Entropion

• Inversion or inward rolling of the eyelid margin, such that hair-bearing skin can rub against cornea.
• Cause:
  • Primary entropion often breed related - probably inherited.
  • Secondary entropion may be caused by painful corneal conditions that result in enophthalmos or abnormal skin folds, eg older Cocker Spaniel English Cocker Spaniel , Chow Chow Chow Chow.
• Signs: corneal irritation, pigmentary keratitis, epiphora, keratitis Keratitis , and possible corneal ulceration Ulcerative keratitis.
• Treatment: several surgical techniques available.
• Prognosis: good.
  Print off the owner factsheet on Entropion Entropion to give to your client.

• Corneal discomfort due to trigeminal pain (blepharospasm, photophobia and excessive lacrimation).
• May be bilateral.
• Tearing or mucoid ocular discharge.

• 2-6 months old.
• Puppies (2-6 weeks).

• Middle aged to old.

• Bulldog Bulldog.
• Labrador Retriever Retriever: Labrador.
• Chow Chow Chow Chow.
• Irish Setter Irish Setter.
• Bloodhound Bloodhound.
• St Bernard St Bernard.
• English Springer Spaniel English Springer Spaniel.
• Cocker Spaniel English Cocker Spaniel.
• Shar Pei Chinese Shar Pei.
• English Cocker Spaniel English Cocker Spaniel.
• Yorkshire Terrier Yorkshire Terrier.
• Poodle.
• Pug Pug.
• Pekingese Pekingese.
• Norwegian Elkhound.
• Mastiff Mastiff.

• Surgery required. Some cases require referral.

• Genetic predisposition in facial conformation and eyelid support.

Specific

• In brachycephalic breeds, tension on the medial canthal ligament, coupled with nasal folds and abnormal facial anatomy, results in rolling in of the medial canthus and the upper and lower eyelids medially.
• In giant breeds with heavy facial skin or excessive facial folds, laxity of the lateral canthal ligament causes upper lid, and lateral lower lid, entropion.
• In older Cocker Spaniels upper lid sagging causes entropion and trichiasis Trichiasis.

• Primary entropion - anatomical.
• Secondary entropion - alteration in anatomical confirmation due to secondary factor.

• Anatomical entropion → corneal irritation, keratitis Keratitis → corneal ulceration Ulcerative keratitis.

• Cicatrical: scarring of eyelid → entropion.
• Spastic: secondary to a painful corneal condition which results in retraction of the globe and muscular spasm in the orbicularis oculi muscle. This form can occur in all ages.
• Atonic: older individuals, especially English Cocker Spaniel . A loss of elasticity in the skin on the top of the head results in the palpebral fissures slipping down the face. The upper lid tends to roll inwards causing entropion/trichiasis, while the lower lid droops downwards (ectropion Ectropion ). These individuals are worse when tired or if the head is lowered.
• Secondary to facial folds: usually middle-aged Chow Chow (especially males) . Subdermal fat deposits in the folds of skin around the eyelids → 360° entropion .
• Seconday to weight loss: loss of orbital fat can result in entropion.

• Most cases of primary entropion present before 6 months of age. Occasionally, some cases present >12 months.
• Entropion in the Shar Pei can present as early as 2 weeks. It may be so severe that the breeder believes the pup's eyes have not yet opened.

• Ocular pain.
• Wet eye.
• Corneal ulceration Ulcerative keratitis.
• Red eye.

• Ocular pain. Increased blinking or sensitivity around eye.

• Ocular discharge.
• Redness of eye.

• Corneal opacity if secondary corneal damage.

• Blepharospasm.
• Fluorescein staining Fluorescein test will enable any corneal ulceration to be detected.

• Excessive lacrimation .
  Need clinical appraisal without restraint or sedation. Topical anesthesia Therapeutics: eye removes corneal pain so accurate assessment of the anatomical basis of the entropion can be made.

• Corneal vascularization due to irritation .
• Corneal ulceration Ulcerative keratitis.
• Photophobia.

• Distichiasis Distichiasis - hairs may be visible .
• Combined entropion/ectropion ('Diamond eye') Combined entropion / ectropion.
• Prominent nasal folds/trichiasis (especially brachycephalics Trichiasis ).
• Blepharitis Blepharitis. May be due to a generalized skin condition or as an extension of a conjunctivitis Conjunctivitis.
• Corneal ulceration of other etiology, eg foreign body, scratch, etc Ulcerative keratitis.

• Trichiasis Trichiasis.
• Ectopic cilia Ectopic cilia.
• Ectropion Ectropion.

• Hordeolum (external stye). A staphylococcal infection of eyelid gland can cause painful abscesses and blepharospastic entropion.

• Surgery.
  Liquid paraffin injection into eyelids must not be used because granulomas may form
• Early permanent reconstructive entropion sugery. (Not recommended as to allow maturation of facial conformation.)
  Recommend postponing permanent surgery until adulthood as some mild cases resolve spontaneously.
• Lid tacking Eyelid: temporary tacking sutures for entropion.

• A skin/muscle (Hotz-Celsus) resection Eyelid: Hotz-Celsus procedure for entropion.
• Strips of skin and or orbicularis muscle are removed adjacent to the entropion lid margin and the wound closed. The lid margin is thus rolled away from the cornea.
• An elliptical section of the upper lid skin containing hair is removed to treat trichiasis/atonic entropion. The incision extends from 0.5-1 mm and 15-20 mm from the lid. The open wound heals by secondary intention, with little hair growth to irritate the cornea. The size of the eyelid flap assists correction of the upper eyelid entropion and compensates for the redundant forehead skin folds.
• Temporary eversion by the use of vertical mattress sutures may be sufficient in puppies, especially in the Shar Pei.
• This is necessary to break the blepharospastic-corneal irritation sysle and prevent corneal ulceration.

  Secondary

  • Cicatrical: a Y-to-V plasty is the best approach.
  • Atonic: a 'face-lift' procedure involving removal of an oval-shaped piece of excess skin from the top of the head has been used in Shar Peis, but the condition may recur with time. Procedure outlined by Stades inJournal of the American Animal Hospital Association23, p 603 gives good results.

• Surgery plus treatment for corneal ulceration Ulcerative keratitis.

• For corneal damage following surgical procedure.
• Fluorescein staining.
• Recurrence of entropion.

Monitoring

• For success of surgical correction.
  It is better to under-correct and repeat surgery at a later date.

• Good, if surgery undertaken before irreversible corneal damage.

• Restoration of normal lid: globe apposition.
• Absence of corneal pain.
• Healing of corneal ulceration within 3-10 days of appropriate treatment.

• Excessive excision in the Hotz-Celsus procedure → ectropion Ectropion.
• Insufficient excision in the Holz-Celsus procedure → entropion remains.
• Problems related to corneal ulceration.

Refereed papers

• Recent references from PubMed and VetMedResource.
• Dice P F & Cooley P L (1988) The use of contact lenses to treat corneal diseases in small animals. Semin Vet Med Surg 3 (1), 46-51 PubMed.
• Johnson B W, Gerding P A, McLaughlin S A et al (1988) Non-surgical correction of entropion in Shar Pei puppies. Vet Med 83 (5), 482-483 EurekaMag.
• Miller W W & Albert R A (1988) Canine entropion. Comp Cont Ed Pract Vet 10 (4), 431-438 VetMedResource.
• Stades F C (1987) A new method for surgical correction of upper eyelid trichiasis/entropion-operation method. JAAHA 23 (6), 603-6 VetMedResource.