CASE REPORT

Bali Journal of Ophthalmology (BJO) 2019, Volume 3, Number 1: 10-13

P-ISSN. 2581-1258, E-ISSN.2581-1266

Right lower lid entropion in a 79-year-old female:

a case-report

A.A.A. Putri Prematura Sri Anasary1*, I Gusti Ngurah Made Sugiana1

ABSTRACT

Introduction: Entropion is a condition in which eyelid margin revealed right lower lid entropion and bilateral pseudophakia.
turns inward. Four types of entropion including spastic, cicatricial, Surgical correction was done to tighten the orbicularis oculi
congenital, and involutional. Involutional entropion prevalence has muscle, along with appropriate postoperative treatment adjuncts
been reported to be 2.1% and increases with advancing age. such as analgesics and antibiotics. Surgical approach was chosen in
Case: A 79-year-old female complained of foreign body sensation favor of its lower recurrence rate.
with tearing in the right eye for the last one year. She had a history Conclusion: After surgical procedure and four days followup, the
of cataract surgery on both eyes. Ophthalmology examination patient was released with good prognosis prediction.

Keywords: entropion, involutional, eye, palpebra disease, ophtalmology

Cite This Article: Anasary, A.A.A.P.P.S., Sugiana, I.G.N.M. 2019. Right lower lid entropion in a 79-year-old female: a case-report. Bali
Journal of Ophthalmology 3(1): 10-13. DOI: 10.15562/bjo.v3i1.42

1
Sanjiwani General Hospital, INTRODUCTION Gianyar in November 2019. A 79-year-old female
Gianyar- Bali presented to eye policlinic with foreign body
Entropion is an inward rotation of the eyelid sensation in the right eye that had been going for a
margin.1 Etiological classification of entropion year. She would often blink and rub her eyes from
comprising spastic due to inflammation, cicatricial the discomfort. In the past 2 and 3 months prior to
with a posttrauma scar, congenital in children, and the visit she underwent cataract surgical treatment
involutional affecting majority elderly aged over for the left and right eye, respectively. Despite the
60 years.1 Involutional entropion is found in 2.1% excellent outcome on her visual acuity, she found
of 25,000 patients aged above 60 years and there the grittiness in both of her eyes unbearable. She
is an inclining trend with advancing age. Bilateral denied any history of wearing spectacles and ocular
manifestation is three times more likely than trauma. There was not any notable past medication
unilateral. The higher prevalence in females (2.4%) use other than postoperative medication for
than males (1,9%) reflects gender predilection of cataracts. History of other systemic diseases such as
entropion. Upper lid involvement is predominantly hypertension and diabetes was denied.
cicatricial etiology, while lower lid involvement is Patient was fully alert and otherwise well general
related to involutional type.1,2 appearance with vital signs as follows: blood pressure
Involutional entropion is closely related to aging. 120/70 millimeters of mercury, pulse 78 beats per
Tissue atrophy and weakening of capsulopalpebral minute, respiration rate16 breaths per minute, and
*Coresponding to: fascia or eyelid muscle retractor mainly contribute temperature 36.2oC. General physical examination
A.A.A. Putri Prematura Sri Anasary; to the disease mechanism. Once losing its elasticity, of head, neck, thorax, abdomen, and extremity was
Sanjiwani General Hospital, the tarsal plate hence in turn together with the lid within normal limit. Ophthalmologic examination
Gianyar- Bali; margin.3-5 Consequently, this leads to posteriorly revealed right and left visual acuity of 6/9.5 and
prematuraa@gmail.com directing eyelashes towards the globe. Continuous 6/12, respectively. There was tearing in both eyes
friction results in conjunctival inflammation and without conjunctival injection, clear cornea, round
abrasion. The patient may complain of foreign pupil measuring 3 mm in diameter, isocoria,
body sensation, redness, tearing, and discharge. bilateral positive pupillary light reflex, implanted
Conjunctival hyperemia and eyelid laxity constitute intraocular lens, and intraocular pressure 17.3
supporting physical findings.3,6,7 millimeters of mercury in both eyes. Right lower lid
Received : 2019-04-12
entropion (Figure 1) resulted in positive snapback
CASE REPORT test. We assessed her with ODS pseudophakia with
Accepted : 2019-05-21
Published: 2019-06-01 We report a case from Rumah Sakit Sanjiwani, OD inferior entropion.

10 Published by DiscoverSys | Bali Journal of Ophthalmology 2019;

Open3(1):
access:
10-13http://balijournalophth.org
| doi:10.15562/bjo.v3i1.42
 CASE REPORT

palpebral retractor weakness allowing lower tarsal

plate border to turn inward; (3) loss of tarsal plate
rigidity enabling palpebral margin to inturn; and
(4) changes in orbicularis muscle, canthal tendon,
and tarsus promoting horizontal laxity in inferior
palpebra. Tarsal size of male eyelids generally
exceeds that of female, inducing female gender
predilection.
Three other types of entropion with distinct
pathological processes besides the involutional
type have been described. Severe scar formation
and palpebral conjunctiva contraction in cicatricial
entropion pull the eyelid margin inward; spasm
of orbicularis muscle triggered by eye irritation
(including surgery) or blepharospasm in spastic
entropion; and incorrect attachment of retractor
Figure 1. Right lower lid entropion muscle on tarsal plate inferior margin in congenital
entropion. Tamsulosin, a member of alpha-1
receptor blocker group used in benign prostate
hyperplasia treatment, was also found to decrease
Reconstruction surgery was planned for orbicularis muscle tone.5-7
the right inferior palpebra. In-patient care Upon physical finding of eyelash misdirection
was considered unnecessary. She was given secondary to inferior palpebral malposition
postoperative medications with doses as follows: supporting entropion diagnosis, alternative
amoxicillin 500 mg tid, mefenamic acid 500 mg tid, diagnosis of trichiasis in which primary abnormal
and methylprednisolone 8 mg tid. She was required ciliary growth directing to the ocular surface with
to visit the next day after hospital discharge for normal palpebra could then be ruled out.1,2,3 Both
surgical follow-up. Additional eye drop and lenses reflected light in a mirror-like manner
ointment, namely 0.3% Bralifex® a drop six times a indicating intraocular lens use ensuing cataract
day for the right eye and 0.3% gentamicin sulfate surgery of both eyes, therefore confirming
bid applied on surgical wound were prescribed. pseudophakia.
She was advised for another follow-up visit 4 days Both pharmacological and non-pharmacological
afterwards or sooner in case of new complaint. measures were taken. Non-pharmacological aspect
Non-pharmacological management, for instance, of the management emphasized on education, while
by recommending to avoid rubbing eyes, keep the pharmacological aspect reviewed complies to the
wound clean, administer medications accordingly, guideline proposed by the College of Optometrists.
and use protective covers (i.e. glasses, bandage) to Recommended regime encompasses lubricant to
prevent infection. This case was predicted to have a resolve tear deficiency and associated symptoms,
good prognosis. antibiotics administration, chemodenervation by
botulinum toxin injection in orbicularis muscle,
DISCUSSION and temporary use of tape. Pulling lower lid
In this case of a 79-year-old female with foreign and attaching it using tape to the cheeks, with
body sensation in the right eye, we found an tension directing towards temporal and inferior,
inward turning of right inferior palpebral margin. is the most straightforward measure though it
Entropion presents as involutional (spastic, senile), might elicit allergic reaction from prolonged
cicatricial, or congenital type. Foreign body use. Definitive management of entropion needs
sensation could be attributed by eyelid margin surgical intervention aiming to reposition the lid
folding itself, causing misdirected eyelashes to be in outward. Persistence of these conditions call for
contact with cornea or conjunctiva. This friction, in surgical treatment: recurring ocular irritation,
turn, give rise to grittiness, irritation, tearing, itch, bacterial conjunctivitis, tear hypersecretion
and ultimately pain.8 reflex, superficial keratopathy, ulceration risk, and
Involutional entropion commonly targets microbial keratitis. Surgery poses patient to the risk
geriatric population aged over 60 years. Progressive of bleeding, hematoma, infection, pain, and bad
senile change in the eyelid structure chiefly consist tarsal positioning.9
of: (1) orbicularis muscle change leading to preseptal Accurate surgical procedure selection relies
muscle rolling onto pretarsal muscle; (2) inferior on the determination of underlying cause.

Published by DiscoverSys | Bali Journal of Ophthalmology 2019; 3(1): 10-13 | doi:10.15562/bjo.v3i1.42 11

 CASE REPORT

Reconstruction for involutional entropion can be

done through repairing capsulopalpebral fascia,
Quickert sutures, modified Quickert sutures with
lateral tarsal strip, and tightening of orbicularis oculi
muscle. Congenital entropion is managed by proper
attachment of capsulopalpebral fascia, epiblepharon
correction if keratopathy co-occurs, and fish-tail
resection. Although spontaneous resolution is
possible, spastic entropion would otherwise benefit
from combined surgical techniques as in horizontal
eyelid shortening or pretarsal and orbicularis
muscle fibers lifting, and vertical skin reduction.
Wies procedure, hammock flap method, modified
tarsotomy method, superior palpebral margin
rotation method through palpebral fold incision
with anterior internal lamellar traction, tarsotomy,
and tarsal overlap without external suture, among
others, provide surgical technique alternatives for
cicatricial entropion.9-13
In this case, correction was done by orbicularis
oculi muscle tightening (Figure 2), yielding
strong muscular wall superficial to periorbital
fat. Subcutaneous administration of 1% lidocaine
containing 0,01% epinephrine to the whole inferior
palpebra was followed by inferior palpebral
dissection from orbicularis oculi by subciliary
incision. Preseptal orbicularis oculi was fixed and
tightened through stitching pretarsal and preorbital
orbicularis oculi with 6-0 non-absorbable suture,
then closing the incision with the same suture.
Aforementioned postoperative medications
(amoxicillin 500 mg tid, mefenamic acid 500 mg tid,
0.3% Bralifex® one drop q4h, 0.3% gentamicin sulfate
Figure 2. Operative technique to tighten orbicularis oculi muscle bid) were prescribed. Bralifex® eye drop contains
aminoglycoside, specifically tobramycin, suitable
for targeting staphylococcus, including S. aureus,
S. epidermidis, and penicillin-resistant strains.
Streptococcus, as well as group A β-hemolytic
strain, few non-hemolytic species, and few S.
pneumoniae. Pseudomonas aeruginosa, Escherichia
coli, Klebsiella pneumoniae, Enterobacter aerogenes,
Proteus mirabillis, Morganella morganii, most
Proteus vulgaris strains, Haemophilus influenzae,
and H. aegyptius, Moraxella lacunata, Acinetobacter
calcoaceticus and some Neisseria species. Amoxicillin
has wide spectrum antibacterial activity against
gram positive and negative bacteria. Bralifex® and
amoxicillin were given to prevent postoperative
infection. Gentamicin sulfate eye ointment
extended the antibacterial activity spectrum to
cover Staphylococcus aureus, Streptococcus pyogenes,
Streptococcus pneumoniae, Enterobacter aerogenes,
Escherichia coli, Haemophilus influenzae, Klebsiella
pneumoniae, Neisseria gonorrhoeae, Pseudomonas
Figure 3. Postoperative day 1 aeruginosa, and Serratia marcescens. Ointment
formulation moisturizes the skin and improves its

12 Published by DiscoverSys | Bali Journal of Ophthalmology 2019; 3(1): 10-13 | doi:10.15562/bjo.v3i1.42

 CASE REPORT

recovery rate. Postoperative pain was addressed population. Ophthalmic Plastic and Reconstructive
with mefenamic acid.14,15 Surgery. 2011;27(5):317–20.
4. Tse DT. Entropion. In: Tse DT. Color Atlas of Ophthalmic
Majority of entropion cases have good prognosis. Surgery: Oculoplastic Surgery. Pennsylvania: J. B.
Management efficacy is determined by underlying Lippincott Company. 1992;101–12.
cause and degree of disease severity. Despite low 5. Bashour M, Harvey J. Causes of involutional ectropion
surgical recurrence rate reported by evidence, and entropion - age-related tarsal changes are the
key. Ophthalmic Plastic and Reconstructive Surgery.
future follow-up visits warrant prompt recognition 2000;16(2):131–41.
of recurrence.16 6. Deka A, Saikia SP. Lower lid entropion correction
with botulinum toxin injection. Oman J Ophthalmol.
CONCLUSION 2010;3(3):158-159.
7. Michels KS, Czyz CN, Cahill KV, Foster JA, Burns JA,
Entropion is defined as inward turning of palpebral Everman KR. Age-matched, case-controlled comparison
margin, which could result in misdirected cilia of clinical indicators for development of entropion and
ectropion. J Ophthalmol. 2014;2014:231487.
towards the ocular surface. Development of 8. Riordan-Eva P, Whitcher JP. Vaughan & Asbury
conjunctivitis, keratitis, and corneal ulcer as its Oftalmologi Umum. Edisi ke-17. Jakarta: EGC; 2008.
complication could be prevented with appropriate 9. The College of Optometrists. Clinical management
treatment. Given that there are various surgical and guidelines entropion [Internet]. 2017 [cited 2020 Feb 10].
Available from: https://www.college-optometrists.org/
non-surgical treatment choices, consideration of guidance/clinical-management-guidelines/entropion.
underlying cause and any existing surgical indication html.
is essential for making treatment decision. 10. Sakamoto Y, Nakajima H, Imanishi N, Okumoto T, Kato T,
Kishi K. A hammock flap: a modified backflip flap for the
surgical correction of cicatricial entropion. J Plast Reconstr
CONFLICT OF INTEREST Aesthet Surg. 2015;68(5):738-40.
None. 11. Nakauchi K, Mimura O. Fish tail resection for treating
congenital entropion in Asians. Clin Ophthalmol.
2012;2012:831-6.
FUNDING 12. Long JA. Oculoplastic Surgery. Philadelphia: Elsevier;
2009.
All authors responsible for financing this manuscript 13. Yaumil R. Diagnosis dan tatalaksana entropion. 2018;45(2):
privately. 151-5.
14. Drug label information of tobramycin eye drop
[Internet]. 2012 [cited 2020 Feb 10]. Available from:
ETHIC https://www.accessdata.fda.gov/drugsatfda_docs/
label/2012/050541s024lbl.pdf.
This case report was already accepted by the ethic
15. Drug label information of gentamicin sulfate eye
comitee of Sanjiwani General Hospital. ointment [Internet]. 2018 [cited 2020 Feb 10]. Available
from: https://www.accessdata.fda.gov/drugsatfda_docs/
REFERENCES label/2018/050612s021lbl.pdf.
16. Hendriati, Sherly M. Hasil Operasi Entropion Involusional
1. Ilyas S. Ilmu Penyakit Mata. Edisi ke-3. Jakarta: Fakultas di Rumah Sakit Dr. M. Djamil Padang. Jurnal Kesehatan
Kedokteran Universitas Indonesia; 2009. Andalas. 2018; 7.
2. Cristopher L, Ioannis G. Diagnosis and management of
involutional entropion [Internet]. 2016 [cited 2020 Feb
10]. Available from: https://www.aao.org/eyenet/article/
diagnosis-management-of-involutional-entropion.
3. Damasceno RW, Osaki MH, Dantas PE, Belfort R Jr.
Involutional entropion and ectropion of the lower eyelid:
prevalence and associated risk factors in the elderly

Published by DiscoverSys | Bali Journal of Ophthalmology 2019; 3(1): 10-13 | doi:10.15562/bjo.v3i1.42 13