What is an entropion and how do you fix it?

Entropion is a malposition resulting in inversion of the eyelid margin. The morbidity of

the condition is a result of ocular surface irritation and damage. Successful management
of this condition depends on appropriate classification and a procedural choice that
adequately addresses the underlying abnormality.

Snap-back test
o Perform this test by pulling the lower lid away and down from the
globe for several seconds. If the lid resumes position, note the time
required for the lid to return to its original position without the patient
blinking.
o The snap-back test provides a good idea of relative lower lid laxity.
Lids with normal laxity immediately spring back to original position;
the longer this takes, the more laxity is present.
o Assign grades on a scale from 0-4 (0 = normal laxity, 4 = severe
laxity).
Medial canthal laxity test
o Perform this test by pulling the lower lid laterally from the medial
canthus. Measure displacement of the medial punctum. Greater
distance equates to more laxity. Normal displacement ranges from only
0-1 mm.
o Assign grades on a scale from 0-4 (0 = normal laxity, 4 = severe
laxity).
Lateral canthal laxity test
o Perform this test by pulling the lower lid medially from the lateral
canthus. Measure displacement of the lateral canthal corner. Greater
distance equates to more laxity. Normal displacement ranges from only
0-2 mm.
o Assign grades on a scale from 0-4 (0 = normal laxity, 4 = severe
laxity).
Schirmer test
o Because entropion is only one of several differential diagnoses of
epiphora, having a measure of the degree of eye dryness is important.
The Schirmer test is used to assess tear production and provides such a
measure
o Tiny filter paper tabs are inserted in the lower lids and removed after a
few minutes. The dampened area is measured in millimeters.
Fluorescein cornea test
o This test is essential when looking for signs of corneal damage.
o It can detect damage from lashes or lid skin rubbing on the cornea.
Lacrimal system irrigation
o Check for lacrimal system blockage.
o If the system is blocked, a dacryocystorhinostomy (alone or in
combination with an entropion procedure) would possibly be better
than treating the entropion alone.
Slit-lamp examination
o This examination is especially good for checking corneal status.
o The test also checks for evidence of dryness.
Presence or absence of Bell phenomenon test
o Instruct patient to attempt eye closure while the examiner holds lids
open.
o If eyes move up, the test indicates a positive result for Bell
phenomenon.
Orbicularis muscular tone check

o
o

Check orbicularis muscular tone if the patient exhibits evidence of

ocular muscle spasm caused by postoperative irritation, essential
blepharospasm, or hemifacial spasm.
Ask the patient to squeeze eyes shut. Note how much worse the
entropion is immediately after opening.
Grade the strength from 0-4 (0 = no paralysis, 1 = weak, 2 = normal, 3
= overactive, 4 = spastic).

If surgical therapy is unwarranted or impossible, patients with lower lid entropion should
be treated medically. Symptomatic therapy can be achieved using artificial tear ointment
or drops. Moisture shields are also helpful. Additionally, the lower lid can be taped down
slightly, everting the lid and lashes from the eye using specially designed or normal skin
tape.
For temporary spastic entropion (eg, from postoperative ocular surgery), botulinum toxin
(BOTOX) injections to the lower lid can be considered. The author usually administers
3 injections of 5 units BOTOX laterally, centrally, and medially. Effects usually start in
2 days and last 3-6 months. If the inciting event disappears, BOTOX injections can be a
permanent cure.
The same BOTOX therapy can also be a useful adjunct in reoperations or surgical
treatments, especially in patients in whom orbicularis tone is 3-4 or higher.

Lateral tarsal strip

Horizontal lid laxity is a component of most entropion cases, especially involutional
entropion. Whenever feasible, the author prefers a lateral canthal-tightening procedure.
Surgery at the lateral canthus avoids the possibility of lid notching with noncanthal
procedures and decreases the risk of trichiasis. The most common variation of lateral
canthal tightening is the lateral tarsal strip procedure.
The lateral canthus can be clamped prior to canthotomy; then perform inferior cantholysis
with Westcott scissors. The lower lid should then be freely mobile. Excess lid skin can be
draped over the lateral canthus. Excise an appropriate triangle of full-thickness lid.
Approximately 3 mm of the lateral lid then is split at the gray line with sharp Westcott
scissors or a No-15 blade. Trim away meibomian orifices of the lateral strip. Scrape the
lateral conjunctiva to avoid epithelial inclusion cysts.
To secure the lateral strip of tarsus to the periosteum, 2 sutures (or a single horizontal
mattress suture) can be placed approximately 4-5 mm posterior to the lateral orbital rim
near the Whitnall tubercle (at or above the level of the inferior pupil). Suitable sutures
with small semicircular needles include 5-0 Vicryl on a P2 needle or 4-0 Prolene on a PS5 needle. Retracting the upper lid supertemporally and placing a cotton-tipped applicator
at the lateral canthus to palpate the inner lateral orbital rim may help.
Before tying the suture, remove the corneal shield. The orbicularis layer can be closed
with 6-0 Vicryl, and the skin can be closed with 6-0 plain gut. A stitch through the
lateral-most gray line of the upper and lower lateral lid helps keep the lateral canthus
sharp.
If the patient requires topical drops (eg, glaucoma therapy) postoperatively, do not retract
the lower lid for the first month during drop instillation.
Patients often complain of prolonged discomfort at the lateral canthus following this
procedure.

Severe entropion with retractor disinsertion

This complete inversion of the lower lid occurs when the capsulopalpebral fascia is
disinserted from the inferior tarsal border. In addition to horizontal lid tightening, reinsert
the retractors (ideally from a skin approach).
A double-armed 5-0 chromic suture can be used to reattach the capsulopalpebral fascia to
the inferior tarsus in running fashion.
Cicatricial entropion
An enhanced tarsal strip (ie, tarsal strip with a posterior lamellas spacer graft) may help
correct some degree of cicatricial ectropion. Spacer grafts may be obtained from the
upper lid (tarsus), roof of the mouth (hard palate), nasal septal cartilage, buccal mucosa,
or banked sclera. A superior traction suture decreases risk of recurrent cicatrix
postoperatively. All these areas can and have been used; the best area is likely the one
that is most similar to the existing tissue, ie, the tarsoconjunctival plate from the upper
lid.
Congenital entropion
The surgeon should try to differentiate this extremely rare condition from epiblepharon,
which is much more common. Epiblepharon is corrected easily with an elliptical
orbicularis-skin excision and interrupted 6-0 gut skin closure
Postoperative Details
For lid sutures, the author prefers an antibiotic steroid combination (eg, Maxitrol
[neomycin, polymyxin, bacitracin]) administered three times per day. Applying cold
compresses to the eyelids every 15 minutes (as tolerated) while awake decreases bruising
and swelling. Frozen peas in a plastic bag are a useful alternative to traditional cloth
compresses.
The author generally does not prescribe narcotics postoperatively. The patient is asked to
use oral acetaminophen 325-650 mg every 4 hours as needed. Patients are asked to avoid
aspirin-containing products
Complications
Complications are primarily related to corneal damage and can involve corneal
breakdown, ulcer formation, epiphora, and pain. Surgical complications may include
bleeding, hematoma, infection, wound dehiscence, pain, and poor positioning of the tarsal
strip.
Entropion surgery often has a poorer outcome than ectropion surgery and more
recurrences. Frequency of surgical failure can be greatly reduced by carefully looking at
the etiology of the entropion. Augmentation with BOTOX for overacting orbicularis,
augmentation with a spacer graft for patients with short posterior lamellae, and
reinsertion of inferior retractors all can be helpful, either singly or in combination.
TT 3. What is an ectropion and how do you fix it?
Ectropion is an abnormal eversion (outward turning) of the lid margin away from the
globe. Without normal lid globe apposition, corneal exposure, tearing, keratinization of
the palpebral conjunctiva, and visual loss may result.

Ectropion usually involves the lower lid and often has a component of horizontal lid
laxity.

Patients may have a lid deformity for months or even years before they seek
medical attention.
Patients often complain of irritated or red eyes with tearing. They may
constantly wipe their eyes, thereby exacerbating lid laxity and the ectropion.
Advanced age may suggest the patient has involutional ectropion.
Eye drop instillation with chronic eversion of the lower lid can lead to
involutional ectropion.
A history of facial burns, lid surgery, or lid trauma is usually easily confirmed
on cursory examination and may suggest cicatricial ectropion.
In patients with cicatricial ectropion and periocular skin rash, a history of facial
skin cancer and topical and systemic medication use should be ascertained (see
Causes).
For patients with facial nerve palsy, the caregiver should be asked if nocturnal
lagophthalmos occurs. These patients should also be examined for corneal
problems.

Physical

Gestalt examination of the visage may reveal a connective tissue disorder, prior
surgical scars or burns, cancerous skin conditions, or the physiognomy for
floppy eyelid syndrome. All of these findings may be important in ectropion
evaluation.
Documentation of visual acuity and examination of the cornea and the
conjunctiva are part of any complete oculoplastic examination. Corneal
exposure, corneal ulceration, and conjunctival keratinization may accompany
ectropion.
Because of gravity, ectropion usually involves the lower lid and is described as
punctal, medial, lateral, or tarsal (complete). Laxity-related ectropion typically
begins medially; with time, the central lid margin and the lateral lid may evert.
Both the distraction test and the snap-back test are usually performed for
abnormal horizontal lid laxity.
o Anterior lid distraction of more than 6-8 mm from the globe suggests
horizontal lid laxity.
o If the lower lid is pulled inferiorly, the lid should quickly return to its
previous position. If not, this may be interpreted as an abnormal snapback test result. The patient should not be allowed to blink the eyelid
back into position.
If cicatricial ectropion is suspected, superiorly displace the lower lid margin. If
the lower lid margin does not extend 2 mm above the inferior limbus, then
cicatricial ectropion should be considered. In patients with skin erythema and
cicatricial ectropion, skin cancer or a medication-induced skin rash should be
excluded.
The puncta should not be visible, unless the lid is everted. If this is not the case,
punctal ectropion is present.
Chronic punctal ectropion may result in punctal phimosis.
Chronic ectropion may cause keratinization of the lid margin and the palpebral
conjunctiva.
In patients with complete tarsal ectropion, a white line in the inferior fornix is
often present, indicating a disinserted capsulopalpebral fascia.

In patients with suspected paralytic ectropion, the following should be

documented:
o Corneal integrity
o Corneal sensation
o Presence or absence of Bell phenomenon
o Degree of lagophthalmos - To estimate nocturnal lagophthalmos, the
patient should gently close the eyelids when in the supine position.
o Disparity between spontaneous and voluntary lid closure
With a lower motor neuron seventh nerve palsy (eg, Bell palsy), the ipsilateral
brow and the lower facial musculature are weak. With an upper motor neuron
seventh nerve palsy, brow-elevation is relatively spared due to the bilateral
innervation of the upper face.
In patients with suspected facial nerve palsy, orbicularis oris dysfunction can be
tested for by asking them to show their teeth rather than smile. Compare the
elevation of the angles of the lips; ptosis of the lateral lip on the affected side is
often present.
If a slow-onset or nonresolving seventh nerve palsy is seen, perform the
following:
o Palpate the parotid gland for tumor.
o Exclude prior malar skin cancer.
o Check the patient's hearing to exclude a cerebellopontine angle tumor.
o Perform a slit lamp examination for uveitis, which may suggest a
disease process, such as sarcoidosis or Lyme disease.
Inferior scleral show should be distinguished from ectropion, especially in
patients with prominent globes. Horizontal eyelid tightening will exacerbate the
scleral show of a proptotic eye, because the shortest arc between the canthi lies
inferior to the cornea.
Patients with involutional ectropion of the lower lid may also have involutional
changes of the upper eyelid. Failure to recognize this prior to horizontal
tightening of the lower lid may result in the upper lid prolapsing over the lower
lid margin with the lower lid lashes rubbing the palpebral conjunctiva of the
upper lid (ie, a form of floppy eyelid syndrome).

Causes

Ectropion may be congenital or acquired.

o Congenital ectropion is rare and usually involves the lower lid. The
cause often is a vertical deficiency of the anterior lamella.
o Congenital ectropion is rarely an isolated anomaly. It may be associated
with blepharophimosis syndrome, microphthalmos, buphthalmos,
orbital cysts, Down syndrome, and ichthyosis (collodion baby).
o Occasional congenital ectropion cases are on a paralytic basis.
Acquired ectropion may be involutional, paralytic, cicatricial, or mechanical.
Involutional ectropion is the most common form of ectropion.
A major factor is horizontal lid laxity, usually due to age-related weakness (most
patients are elderly) of the canthal ligaments and the pretarsal orbicularis.
Patients with involutional ectropion have been suggested to have an age-normal
or larger than normal tarsal plate, which may mechanically overcome normal or
decreased orbicularis tone, in conjunction with canthal tendon laxity.
Patients with an anophthalmic socket may have involutional ectropion due to
chronic pressure of the ocular prosthesis.
Disinsertion of the capsulopalpebral fascia may lead to severe tarsal ectropion.
Paralytic ectropion may occur with seventh nerve palsy from diverse causes,
such as Bell palsy, cerebellopontine angle tumors, herpes zoster oticus, and
infiltrations or tumors of the parotid gland.

Cicatricial ectropion occurs from scarring of the anterior lamella by such

conditions as facial burns, trauma, chronic dermatitis, excessive skin excision
(or laser) with blepharoplasty, or orbital fracture repair with a transcutaneous
approach.
Glaucoma drops (eg, dorzolamide, brimonidine) have been implicated as a cause
of cicatricial ectropion.
Less common causes of cicatricial ectropion include cutaneous T-cell
lymphoma.
Antineoplastic agents (eg, docetaxel) and epidermal growth factor receptor
inhibitors (eg, erlotinib, cetuximab) have been reported to cause cicatricial
ectropion.
Mechanical tumors may occur with lid tumors, such as neurofibromas that evert
the lower lid.
Acute idiopathic bilateral lower lid ectropion has been described. An uncommon
case of bilateral upper lid ectropion from blepharospasm has also been
described.

Medical Care

Lubrication and moisture shields are helpful if significant corneal exposure

exists from the ectropion. In patients with corneal exposure, plastic dressings are
often superior to cloth patches. In some cases, taping the lateral canthal skin
supertemporally provides temporary relief, especially in patients with new-onset
seventh nerve palsy.
If the conjunctiva is markedly keratinized, a lubricating ointment should be used
several days or weeks prior to ectropion repair. Corneal epithelial defects and
prior herpes simplex infection are a relative contraindication to steroidcontaining ointments.
Patients with tearing and incipient ectropion or early punctal ectropion should be
instructed to wipe the eyelids in a direction up and in (toward the nose) to avoid
worsening medial ectropion.
With cicatricial ectropion following trauma or lid surgery, digital massage may
help stretch the scar. If not, steroid injection into the scar should be considered.
In patients with seventh nerve palsy, external paste-on upper lid weights are
available and can be matched approximately for different skin colors.
o A double-sided tape is used to apply the lid weight.
o Removing the lid weight at night may avoid irritation of the lid skin.
o The external lid weights are not a good option in patients with upper lid
dermatochalasis or poor manual dexterity.
The use of steroids for Bell palsy remains controversial, because such a high
likelihood of spontaneous recovery exists.
o Steroid use early in the disease course may decrease the risk of
subsequent aberrant regeneration (eg, crocodile tears).
o Acyclovir in combination with prednisone has been shown to be of
greater benefit than prednisone alone in Bell palsy.

Surgical Care

The correct surgical treatment of ectropion depends on the etiology.

o Horizontal lid laxity is often seen with ectropion and usually can be
corrected with a lateral tarsal strip procedure.
o Mild-to-moderate cases of medial ectropion may respond to a medial
conjunctival spindle procedure.
o Tarsal ectropion requires reinsertion of the lower lid retractors.

Augmentation of the anterior lamellae (along with excision of any

cicatrix) is required for cicatricial ectropion.
The use of a corneal protector during oculoplastic procedures is recommended.
The surgeon must be wary of the remote possibility of flash burns whenever
oxygen is on the surgical field. Failure to do so may transform an elective lid
repair into a much more complicated problem.
Ensuring patient comfort during surgery is important. Because most cases of
ectropion involve the lower lid, supplemental infraorbital nerve block is a useful
adjunct to direct injection and subconjunctival injection.
Temporary tarsorrhaphy can be performed to protect the cornea if an
oculoplastic surgeon is unavailable, but most surgeons do not advocate
extensive, permanent tarsorrhaphies.
Electrocautery at the junction of conjunctiva and lower margin of the tarsus is
not commonly advocated. It is usually only a temporary measure.
Suture repair is a temporary method of repair that is not advocated. Doublearmed chromic sutures are passed through the inferior border of the tarsus,
emerging at the skin surface near the orbital rim.
Congenital ectropion
o Ensure corneal lubrication. If the condition does not resolve after a few
days, consider placing lid margin sutures. A lateral tarsorrhaphy may
be required if suture techniques do not work, but be careful of
iatrogenic amblyopia. More severe cases of congenital ectropion may
need a skin flap or graft.
o Ichthyosis is a well-described cause of congenital ectropion. It is
sometimes managed conservatively with lubrication, but skin grafts
may be required.
Lateral tarsal strip: Horizontal lid laxity is a component of most ectropion cases,
especially involutional ectropion. Numerous methods are available for
correcting horizontal lid laxity. Older methods include wedge resections and the
Kuhnt-Szymanowski procedure. Whenever feasible, a lateral canthal tightening
procedure is preferred. Surgery at the lateral canthus avoids the possibility of lid
notching with noncanthal procedures and decreases the risk of trichiasis. The
most common variation of lateral canthal tightening is the lateral tarsal strip
procedure.
o The lateral canthus can be clamped prior to canthotomy (although the
author does not believe it is necessary if cautery is available). Inferior
cantholysis is then performed with Westcott scissors. The lower lid
should now be freely mobile.
o If excess lid skin is present, it can be draped over the lateral canthus,
and an appropriate triangle of full-thickness lid is excised.
o Traditionally, about 3 mm of the lateral lid is split at the gray line with
either sharp Westcott scissors or a 15 blade. (The author does not
believe it is necessary to split the lid.)
o The meibomian orifices of the lateral strip are trimmed away.
o The lateral conjunctiva is scraped to avoid epithelial inclusion cysts.
o To secure the lateral strip of tarsus to the periosteum, 2 sutures (or a
single horizontal mattress suture) can be placed about 4-5 mm posterior
to the lateral orbital rim near the Whitnall tubercle (at or above the
level of the inferior pupil). Suitable sutures with small semicircular
needles include 5-0 Vicryl on a P2 needle or 4-0 Prolene on a PS-5
needle.
o Retracting the upper lid supertemporally and placing a Q-tip at the
lateral canthus to palpate the inner lateral orbital rim may help.
o Before tying the suture, remove the corneal shield.
o

The orbicularis layer can be closed with 6-0 Vicryl. The skin can be
closed with 6-0 plain gut. A stitch through the lateral-most gray line of
the upper and lower lateral lid will help to keep the lateral canthus
"sharp."
o If the patient requires topical drops (eg, glaucoma therapy)
postoperatively, do not retract the lower lid for the first month during
drop instillation.
o It is not uncommon for patients to complain of discomfort at the lateral
canthus several weeks following this procedure.
Transconjunctival ectropion repair has been described.
Kuhnt-Szymanowski (Smith modification): When marked inferior
dermatochalasis accompanies ectropion and the lateral canthal tendon is not
dehisced, an inferior subciliary blepharoplasty skin incision can be combined
with pentagonal wedge excision of the orbicularis and posterior lamellae.
Precise closure is required to prevent a lid notch.
Tarsal ectropion
o This complete eversion of the lower lid occurs when disinsertion of the
capsulopalpebral fascia from the inferior tarsal border is present.
o In addition to horizontal lid tightening, reinsert the retractors (ideally
from a conjunctival approach).
o A spindle of redundant conjunctiva, no more than 3 mm in vertical
height, can be excised, if necessary.
o A double-armed 5-0 chromic suture can be used to reattach the
capsulopalpebral fascia to the inferior tarsus in a running fashion.
Medial ectropion: If tearing is the primary problem in patients with punctal
ectropion, a 1-snip or 2-snip inferior punctoplasty may be beneficial. Easily
performed with Vannas scissors and topical anesthetic, punctoplasty restores
continuity between the lacus lacrimali and the medial canthal angle. For mild-tomoderate medial ectropion, a medial conjunctival spindle procedure (excision of
the medial conjunctiva and retractors) can be performed.
o Following anesthetic injection in the medial inferior fornix, the inferior
canaliculus can be guarded with a lacrimal probe.
o A horizontal ellipse or diamond of conjunctiva and underlying lid
retractors is excised inferior to the punctum, approximately 3-4 mm
high and 6-8 mm wide. The base of the wound is cauterized.
o Then, the defect is closed with double-armed 5-0 chromic inverting
suture. This can be accomplished by engaging the inferior lip of the
wound, then the superior lip of the wound; the needle is then redirected
from the inferior lid to the cutaneous surface. Alternatively, buried
interrupted 6-0 polyglactin stitches can be used to close the medial
conjunctival spindle.
The Byron Smith lazy-T procedure is a well-described procedure for repairing
prominent medial ectropion. It combines a lower lid, full-thickness pentagonal
wedge resection, 3-4 mm temporal to the punctum with resection of a medial
triangle of conjunctiva and lower lid retractors (similar to medial conjunctival
spindle).
o Usually, 5-8 mm of lower lid is excised in the pentagonal wedge. When
closed, the incisions resemble a "T" lying on its side, hence the name
lazy T.
o If marked medial canthal laxity is present, medial canthal tendon
plication generally is performed with a lid shortening procedure.
o A lacrimal probe is placed to guard the lower canaliculus. A skin
incision, extending from just medial to the medial canthus to just
temporal to the punctum, is made inferior to the canaliculus.
o A double-armed 5-0 nylon suture is placed from the medial inferior
tarsus to the medial canthal ligament near the anterior lacrimal crest.
o

The lacrimal probe is removed and the plication suture tightened

enough to prevent lateral excursion of the puncta. Over-tightening the
stitch may kink canalicular outflow. The skin incision can be closed
with 6-0 fast-absorbing gut suture.
Paralytic ectropion
o A tarsal strip procedure is often helpful. At least 5 mm of the lateral
lower lid may have to be excised. For more severe paralytic ectropion,
an augmented lateral tarsal strip tarsorrhaphy has been described. A
long tarsal strip (10-15 mm) is attached to the outer temporal orbital
rim, at a point higher than a conventional lateral tarsal strip. A small
portion of the upper eyelid anterior lamella is removed to facilitate
passage of the long tarsal strip superiorly. With marked paralytic lower
lid ectropion, a midface or suborbicularis oculi fat (SOOF) lift is a
useful technique.
o In patients with extreme paralytic ectropion, a fascia lata (or Gortex)
sling or temporalis transfer procedure may be required.
o Upper lid gold weight implantation is a helpful adjunct for patients with
lagophthalmos. Usually, a 1.0-1.2 g weight is implanted superior to the
tarsus and inferior to the orbicularis. Extrusion of the gold weight
occasionally occurs with time. Since the gold weight works by gravity,
patients should sleep with their head slightly elevated. The gold
weights are not a contraindication for MRI investigation.
Cicatricial ectropion
o An enhanced tarsal strip (ie, a tarsal strip without the traditional lateral
skin excision) may help correct some degree of cicatricial ectropion.
o If an enhanced tarsal strip is insufficient, Z-plasties, V-Y plasty, skin
grafts, or advancement flaps may be used to lengthen the anterior
lamella.
o Skin grafts may be obtained from the upper lid if dermatochalasis is
present; preauricular or postauricular skin is another alternative. If
facial skin is unavailable, medial forearm skin can be used. The skin
graft should be thinned and buttonholed (for drainage). In patients with
moderate lower eyelid cicatricial ectropion and upper eyelid
dermatochalasis, the transfer of a bipedicle or monopedicle flap from
the upper eyelid combined with canthopexy is an option.
o A compressive bolster can be placed over the graft to enhance graft
survival and to decrease hematoma formation. The bolster is left for 5
days. A superior traction suture decreases the risk of recurrent cicatrix
postoperatively.
o Hyaluronic acid filler and autologous fat injection have been described
for selected cases of cicatricial ectropion.
o

Further Outpatient CarePostoperative care

o
o

For the lid sutures, an antibiotic ointment (eg, polysporin, tobramycin)

can be used.
Applying cold compresses to the eyelids every 15 minutes (as
tolerated) while awake will decrease bruising and swelling. Frozen peas
in a plastic bag are a useful alternative to traditional cloth compresses.
Generally, physicians do not prescribe narcotics postoperatively. The
patient is asked to use acetaminophen (325-650 mg PO q4h prn) to
manage pain. Patients are asked to avoid aspirin-containing products.
Patients can be examined on the first postoperative day, then 5-7 days
later for suture removal.Complications are primarily related to corneal

and conjunctival exposure. As listed above, these complications can involve

conjunctival keratinization, corneal breakdown, epiphora, and pain.

Surgical complications may include bleeding, hematoma, infection, wound

dehiscence, pain, and poor positioning of the tarsal strip.