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Q
Entropion Ectropion
1
What does the term 
mean?
A
Entropion Ectropion
2
What does the term 
mean?
It means the eyelid margin is 
turning inward
What does the term 
mean?
Q
Entropion Ectropion
3
What does the term 
mean?
It means the eyelid margin is 
turning inward
What does the term 
mean?
It means the eyelid margin is 
turning outward
A
Entropion Ectropion
4
What does the term 
mean?
It means the eyelid margin is 
turning inward
Q
Entropion Ectropion
5
?
?
?
?
?
?
Categories
The Plastics book identifies six general causes of entropion 
and/or ectropion. What are they? (Note that while most apply to 
both entropion and ectropion, a few apply only to one or the other.)
A
Entropion EctropionCategories
6
Congenital
Involutional
Paralytic
Cicatricial
Mechanical
Acute Spastic
The Plastics book identifies six general causes of entropion 
and/or ectropion. What are they? (Note that while most apply to 
both entropion and ectropion, a few apply only to one or the other.)
Q
Congenital
Involutional
Paralytic
Cicatricial
Mechanical
Acute Spastic
Entropion EctropionCategories
7
?
?
?
?
?
?
Of the six, which can result in entropion?
A
Congenital
 Involutional
 
 Cicatricial
 
 Acute Spastic
Entropion Ectropion
8
Categories
Of the six, which can result in entropion?
Congenital
Involutional
Paralytic
Cicatricial
Mechanical
Acute Spastic
Q
Congenital
 Involutional
 
 Cicatricial
 
 Acute Spastic
Entropion Ectropion
9
Categories
Of the six, which can result in ectropion?
?
?
?
?
?
?
Congenital
Involutional
Paralytic
Cicatricial
Mechanical
Acute Spastic
A
Congenital Congenital
 Involutional Involutional
 Paralytic
 Cicatricial Cicatricial
 Mechanical
 Acute Spastic
Entropion Ectropion
10
Categories
Of the six, which can result in ectropion?
Congenital
Involutional
Paralytic
Cicatricial
Mechanical
Acute Spastic
Congenital Congenital
 Involutional Involutional
 Paralytic
 Cicatricial Cicatricial
 Mechanical
 Acute Spastic
Entropion Ectropion
11
Categories
Congenital
Involutional
Paralytic
Cicatricial
Mechanical
Acute Spastic
Let’s drill down on cicatricial changes
Cicatricial Ectropioncn
Q
12
In a nutshell, what is the pathogenesis of…
--Cicatricial ectropion? 
Cicatricial Ectropioncn
A
13
In a nutshell, what is the pathogenesis of…
--Cicatricial ectropion? Scarring of the lid’s anterior lamella causes it (the anterior 
lamella) to shorten, which in turn causes the lid margin to turn outward
Cicatricial Ectropioncn
Q
14
In a nutshell, what is the pathogenesis of…
--Cicatricial ectropion? Scarring of the lid’s anterior lamella causes it (the anterior 
lamella) to shorten, which in turn causes the lid margin to turn outward
--Cicatricial entropion? 
Cicatricial Ectropioncn
A
15
In a nutshell, what is the pathogenesis of…
--Cicatricial ectropion? Scarring of the lid’s anterior lamella causes it (the anterior 
lamella) to shorten, which in turn causes the lid margin to turn outward
--Cicatricial entropion? Scarring of the lid’s posterior lamella causes it (the posterior 
lamella) to shorten, which in turn causes the lid margin to turn inward
Cicatricial Ectropioncn
16
In a nutshell, what is the pathogenesis of…
--Cicatricial ectropion? Scarring of the lid’s anterior lamella causes it (the anterior 
lamella) to shorten, which in turn causes the lid margin to turn outward
--Cicatricial entropion? Scarring of the lid’s posterior lamella causes it (the posterior 
lamella) to shorten, which in turn causes the lid margin to turn inward
Note this subtle-but-crucial difference!
Cicatricial Ectropioncn
17
In a nutshell, what is the pathogenesis of…
--Cicatricial ectropion? Scarring of the lid’s anterior lamella causes it (the anterior 
lamella) to shorten, which in turn causes the lid margin to turn outward
--Cicatricial entropion? Scarring of the lid’s posterior lamella causes it (the posterior 
lamella) to shorten, which in turn causes the lid margin to turn inward
Note this subtle-but-crucial difference! This one too!
Cicatricial Ectropioncn
Q
18
‘Anterior lamella’? ‘Posterior lamella’? How many layers does an eyelid have?
Well, the lids have a number of layers (the precise count depends on whether it’s an upper vs lower lid , 
as well as the distance from the margin at which one does the counting). However, from a surgical 
perspective, at the level of the tarsal plates it’s useful to think of them as having two--an anterior lamella, 
and a posterior lamella.
What structures comprise each lamella?
Anterior: Skin and orbicularis muscle
Posterior: Tarsal plate and conjunctiva
In a nutshell, what is the pathogenesis of…
--Cicatricial ectropion? Scarring of the lid’s anterior lamella causes it (the anterior 
lamella) to shorten, which in turn causes the lid margin to turn outward
--Cicatricial entropion? Scarring of the lid’s posterior lamella causes it (the posterior 
lamella) to shorten, which in turn causes the lid margin to turn inward
Cicatricial Ectropioncn
Q/A
19
‘Anterior lamella’? ‘Posterior lamella’? How many layers does an eyelid have?
Well, the lids have a number of layers (the precise count depends on whether it’s an upper vs lower lid , 
as well as the distance from the margin at which one does the counting). However, from a surgical 
perspective, at the level of the tarsal plates it’s useful to think of them as having two--an anterior lamella, 
and a posterior lamella.
What structures comprise each lamella?
Anterior: Skin and orbicularis muscle
Posterior: Tarsal plate and conjunctiva
four words
four other words
In a nutshell, what is the pathogenesis of…
--Cicatricial ectropion? Scarring of the lid’s anterior lamella causes it (the anterior 
lamella) to shorten, which in turn causes the lid margin to turn outward
--Cicatricial entropion? Scarring of the lid’s posterior lamella causes it (the posterior 
lamella) to shorten, which in turn causes the lid margin to turn inward
Cicatricial Ectropioncn
A
20
‘Anterior lamella’? ‘Posterior lamella’? How many layers does an eyelid have?
Well, the lids have a number of layers (the precise count depends on whether it’s an upper vs lower lid , 
as well as the distance from the margin at which one does the counting). However, from a surgical 
perspective, at the level of the tarsal plates it’s useful to think of them as having two--an anterior lamella, 
and a posterior lamella.
What structures comprise each lamella?
Anterior: Skin and orbicularis muscle
Posterior: Tarsal plate and conjunctiva
In a nutshell, what is the pathogenesis of…
--Cicatricial ectropion? Scarring of the lid’s anterior lamella causes it (the anterior 
lamella) to shorten, which in turn causes the lid margin to turn outward
--Cicatricial entropion? Scarring of the lid’s posterior lamella causes it (the posterior 
lamella) to shorten, which in turn causes the lid margin to turn inward
Cicatricial Ectropioncn
A
21
‘Anterior lamella’? ‘Posterior lamella’? How many layers does an eyelid have?
Well, the lids have a number of layers (the precise count depends on whether it’s an upper vs lower lid , 
as wellas the distance from the margin at which one does the counting). However, from a surgical 
perspective, at the level of the tarsal plates it’s useful to think of them as having two—an anterior 
lamella, and a posterior lamella.
What structures comprise each lamella?
Anterior: Skin and orbicularis muscle
Posterior: Tarsal plate and conjunctiva
In a nutshell, what is the pathogenesis of…
--Cicatricial ectropion? Scarring of the lid’s anterior lamella causes it (the anterior 
lamella) to shorten, which in turn causes the lid margin to turn outward
--Cicatricial entropion? Scarring of the lid’s posterior lamella causes it (the posterior 
lamella) to shorten, which in turn causes the lid margin to turn inward
Cicatricial Ectropioncn
Q
22
‘Anterior lamella’? ‘Posterior lamella’? How many layers does an eyelid have?
Well, the lids have a number of layers (the precise count depends on whether it’s an upper vs lower lid , 
as well as the distance from the margin at which one does the counting). However, from a surgical 
perspective, at the level of the tarsal plates it’s useful to think of them as having two—an anterior 
lamella, and a posterior lamella.
What structures comprise each lamella?
Anterior: ?
Posterior:
In a nutshell, what is the pathogenesis of…
--Cicatricial ectropion? Scarring of the lid’s anterior lamella causes it (the anterior 
lamella) to shorten, which in turn causes the lid margin to turn outward
--Cicatricial entropion? Scarring of the lid’s posterior lamella causes it (the posterior 
lamella) to shorten, which in turn causes the lid margin to turn inward
Cicatricial Ectropioncn
A
23
‘Anterior lamella’? ‘Posterior lamella’? How many layers does an eyelid have?
Well, the lids have a number of layers (the precise count depends on whether it’s an upper vs lower lid , 
as well as the distance from the margin at which one does the counting). However, from a surgical 
perspective, at the level of the tarsal plates it’s useful to think of them as having two—an anterior 
lamella, and a posterior lamella.
What structures comprise each lamella?
Anterior: Skin and orbicularis muscle
Posterior:
In a nutshell, what is the pathogenesis of…
--Cicatricial ectropion? Scarring of the lid’s anterior lamella causes it (the anterior 
lamella) to shorten, which in turn causes the lid margin to turn outward
--Cicatricial entropion? Scarring of the lid’s posterior lamella causes it (the posterior 
lamella) to shorten, which in turn causes the lid margin to turn inward
Cicatricial Ectropioncn
A
24
‘Anterior lamella’? ‘Posterior lamella’? How many layers does an eyelid have?
Well, the lids have a number of layers (the precise count depends on whether it’s an upper vs lower lid , 
as well as the distance from the margin at which one does the counting). However, from a surgical 
perspective, at the level of the tarsal plates it’s useful to think of them as having two—an anterior 
lamella, and a posterior lamella.
What structures comprise each lamella?
Anterior: Skin and orbicularis muscle
Posterior: ?
In a nutshell, what is the pathogenesis of…
--Cicatricial ectropion? Scarring of the lid’s anterior lamella causes it (the anterior 
lamella) to shorten, which in turn causes the lid margin to turn outward
--Cicatricial entropion? Scarring of the lid’s posterior lamella causes it (the posterior 
lamella) to shorten, which in turn causes the lid margin to turn inward
Cicatricial Ectropioncn
A
25
‘Anterior lamella’? ‘Posterior lamella’? How many layers does an eyelid have?
Well, the lids have a number of layers (the precise count depends on whether it’s an upper vs lower lid , 
as well as the distance from the margin at which one does the counting). However, from a surgical 
perspective, at the level of the tarsal plates it’s useful to think of them as having two—an anterior 
lamella, and a posterior lamella.
What structures comprise each lamella?
Anterior: Skin and orbicularis muscle
Posterior: Tarsal plate and conjunctiva
In a nutshell, what is the pathogenesis of…
--Cicatricial ectropion? Scarring of the lid’s anterior lamella causes it (the anterior 
lamella) to shorten, which in turn causes the lid margin to turn outward
--Cicatricial entropion? Scarring of the lid’s posterior lamella causes it (the posterior 
lamella) to shorten, which in turn causes the lid margin to turn inward
Cicatricial Ectropioncn
26
Eyelid lamellae
Cicatricial Ectropioncn
Q
27
‘Anterior lamella’? ‘Posterior lamella’? How many layers does an eyelid have?
Well, the lids have a number of layers (the precise count depends on whether it’s an upper vs lower lid , 
as well as the distance from the margin at which one does the counting). However, from a surgical 
perspective, at the level of the tarsal plates it’s useful to think of them as having two--an anterior lamella, 
and a posterior lamella.
What structures comprise each lamella?
Anterior: Skin and orbicularis muscle
Posterior: Tarsal plate and conjunctiva
In a nutshell, what is the pathogenesis of…
--Cicatricial ectropion? Scarring of the lid’s anterior lamella causes it (the anterior 
lamella) to shorten, which in turn causes the lid margin to turn outward
--Cicatricial entropion? Scarring of the lid’s posterior lamella causes it (the posterior 
lamella) to shorten, which in turn causes the lid margin to turn inward
What about beyond the tarsal plates, ie, above it in the 
upper lid, and below it in the lower? How many lamella 
are conceptualized in these locations? 
Three: Anterior, middle and posterior
What structures comprise each of these three lamellae 
beyond the tarsal plates?
--The anterior lamella doesn’t change; it’s still skin and 
orbicularis
--The newly-arisen middle lamella is composed of the 
eyelid retractors and orbital septum , as well (in the 
lower lid) of the eyelid fat pads
--Beyond the location of the tarsal plate, the plate itself 
isn’t part of the posterior lamella (duh), so in these 
areas the posterior lamella consists only of the conj
Cicatricial Ectropioncn
A
28
‘Anterior lamella’? ‘Posterior lamella’? How many layers does an eyelid have?
Well, the lids have a number of layers (the precise count depends on whether it’s an upper vs lower lid , 
as well as the distance from the margin at which one does the counting). However, from a surgical 
perspective, at the level of the tarsal plates it’s useful to think of them as having two--an anterior lamella, 
and a posterior lamella.
What structures comprise each lamella?
Anterior: Skin and orbicularis muscle
Posterior: Tarsal plate and conjunctiva
In a nutshell, what is the pathogenesis of…
--Cicatricial ectropion? Scarring of the lid’s anterior lamella causes it (the anterior 
lamella) to shorten, which in turn causes the lid margin to turn outward
--Cicatricial entropion? Scarring of the lid’s posterior lamella causes it (the posterior 
lamella) to shorten, which in turn causes the lid margin to turn inward
Middle lamella
What about beyond the tarsal plates, ie, above it in the 
upper lid, and below it in the lower? How many lamella 
are conceptualized in these locations? 
Three: Anterior, middle and posterior
What structures comprise each of these three lamellae 
beyond the tarsal plates?
--The anterior lamella doesn’t change; it’s still skin and 
orbicularis
--The newly-arisen middle lamella is composed of the 
eyelid retractors and orbital septum , as well (in the 
lower lid) of the eyelid fat pads
--Beyond the location of the tarsal plate, the plate itself 
isn’t part of the posterior lamella (duh), so in these 
areas the posterior lamella consists only of the conj
Cicatricial Ectropioncn
Q
29
‘Anterior lamella’? ‘Posterior lamella’? How many layers does an eyelid have?
Well, the lids have a number of layers (the precise count depends on whether it’s an upper vs lower lid , 
as well as the distance from the margin at which one does the counting). However, from a surgical 
perspective, at the level of the tarsal platesit’s useful to think of them as having two--an anterior lamella, 
and a posterior lamella.
What structures comprise each lamella?
Anterior: Skin and orbicularis muscle?
Posterior: Tarsal plate and conjunctiva
In a nutshell, what is the pathogenesis of…
--Cicatricial ectropion? Scarring of the lid’s anterior lamella causes it (the anterior 
lamella) to shorten, which in turn causes the lid margin to turn outward
--Cicatricial entropion? Scarring of the lid’s posterior lamella causes it (the posterior 
lamella) to shorten, which in turn causes the lid margin to turn inward
beyond the tarsal plates
^
Middle lamella
What about beyond the tarsal plates, ie, above it in the 
upper lid, and below it in the lower? How many lamella 
are conceptualized in these locations? 
Three: Anterior, middle and posterior
What structures comprise each of these three lamellae 
beyond the tarsal plates?
--The anterior lamella...?doesn’t change; it’s still skin 
and orbicularis
--The newly-arisen middle lamella is composed of the 
eyelid retractors and orbital septum , as well (in the 
lower lid) of the eyelid fat pads
--Beyond the location of the tarsal plate, the plate itself 
isn’t part of the posterior lamella (duh), so in these 
areas the posterior lamella consists only of the conj
Start here
Cicatricial Ectropioncn
A
30
‘Anterior lamella’? ‘Posterior lamella’? How many layers does an eyelid have?
Well, the lids have a number of layers (the precise count depends on whether it’s an upper vs lower lid , 
as well as the distance from the margin at which one does the counting). However, from a surgical 
perspective, at the level of the tarsal plates it’s useful to think of them as having two--an anterior lamella, 
and a posterior lamella.
What structures comprise each lamella?
Anterior: Skin and orbicularis muscle!
Posterior: Tarsal plate and conjunctiva
In a nutshell, what is the pathogenesis of…
--Cicatricial ectropion? Scarring of the lid’s anterior lamella causes it (the anterior 
lamella) to shorten, which in turn causes the lid margin to turn outward
--Cicatricial entropion? Scarring of the lid’s posterior lamella causes it (the posterior 
lamella) to shorten, which in turn causes the lid margin to turn inward
beyond the tarsal plates
^
Middle lamella
What about beyond the tarsal plates, ie, above it in the 
upper lid, and below it in the lower? How many lamella 
are conceptualized in these locations? 
Three: Anterior, middle and posterior
What structures comprise each of these three lamellae 
beyond the tarsal plates?
--The anterior lamella...doesn’t change; it’s still skin 
and orbicularis
--The newly-arisen middle lamella is composed of the 
eyelid retractors and orbital septum , as well (in the 
lower lid) of the eyelid fat pads
--Beyond the location of the tarsal plate, the plate itself 
isn’t part of the posterior lamella (duh), so in these 
areas the posterior lamella consists only of the conj
Cicatricial Ectropioncn
Q
31
‘Anterior lamella’? ‘Posterior lamella’? How many layers does an eyelid have?
Well, the lids have a number of layers (the precise count depends on whether it’s an upper vs lower lid , 
as well as the distance from the margin at which one does the counting). However, from a surgical 
perspective, at the level of the tarsal plates it’s useful to think of them as having two--an anterior lamella, 
and a posterior lamella.
What structures comprise each lamella?
Anterior: Skin and orbicularis muscle!
Posterior: Tarsal plate and conjunctiva?
In a nutshell, what is the pathogenesis of…
--Cicatricial ectropion? Scarring of the lid’s anterior lamella causes it (the anterior 
lamella) to shorten, which in turn causes the lid margin to turn outward
--Cicatricial entropion? Scarring of the lid’s posterior lamella causes it (the posterior 
lamella) to shorten, which in turn causes the lid margin to turn inward
beyond the tarsal plates
^
Middle lamella
What about beyond the tarsal plates, ie, above it in the 
upper lid, and below it in the lower? How many lamella 
are conceptualized in these locations? 
Three: Anterior, middle and posterior
What structures comprise each of these three lamellae 
beyond the tarsal plates?
--The anterior lamella...doesn’t change; it’s still skin 
and orbicularis
--The newly-arisen middle lamella is composed of the 
eyelid retractors and orbital septum , as well (in the 
lower lid) of the eyelid fat pads
--Beyond the location of the tarsal plate, the plate itself 
isn’t part of the posterior lamella (duh), so in these 
areas the posterior lamella…?onsists only of the conj Next
Cicatricial Ectropioncn
A
32
‘Anterior lamella’? ‘Posterior lamella’? How many layers does an eyelid have?
Well, the lids have a number of layers (the precise count depends on whether it’s an upper vs lower lid , 
as well as the distance from the margin at which one does the counting). However, from a surgical 
perspective, at the level of the tarsal plates it’s useful to think of them as having two--an anterior lamella, 
and a posterior lamella.
What structures comprise each lamella?
Anterior: Skin and orbicularis muscle!
Posterior: Tarsal plate and conjunctiva!
In a nutshell, what is the pathogenesis of…
--Cicatricial ectropion? Scarring of the lid’s anterior lamella causes it (the anterior 
lamella) to shorten, which in turn causes the lid margin to turn outward
--Cicatricial entropion? Scarring of the lid’s posterior lamella causes it (the posterior 
lamella) to shorten, which in turn causes the lid margin to turn inward
beyond the tarsal plates
^
Middle lamella
What about beyond the tarsal plates, ie, above it in the 
upper lid, and below it in the lower? How many lamella 
are conceptualized in these locations? 
Three: Anterior, middle and posterior
What structures comprise each of these three lamellae 
beyond the tarsal plates?
--The anterior lamella...doesn’t change; it’s still skin 
and orbicularis
--The newly-arisen middle lamella is composed of the 
eyelid retractors and orbital septum , as well (in the 
lower lid) of the eyelid fat pads
--Beyond the location of the tarsal plate, the plate itself 
isn’t part of the posterior lamella (duh), so in these 
areas the posterior lamella… consists only of the conj
Cicatricial Ectropioncn
Q
33
‘Anterior lamella’? ‘Posterior lamella’? How many layers does an eyelid have?
Well, the lids have a number of layers (the precise count depends on whether it’s an upper vs lower lid , 
as well as the distance from the margin at which one does the counting). However, from a surgical 
perspective, at the level of the tarsal plates it’s useful to think of them as having two--an anterior lamella, 
and a posterior lamella.
What structures comprise each lamella?
Anterior: Skin and orbicularis muscle!
Posterior: Tarsal plate and conjunctiva!
In a nutshell, what is the pathogenesis of…
--Cicatricial ectropion? Scarring of the lid’s anterior lamella causes it (the anterior 
lamella) to shorten, which in turn causes the lid margin to turn outward
--Cicatricial entropion? Scarring of the lid’s posterior lamella causes it (the posterior 
lamella) to shorten, which in turn causes the lid margin to turn inward
beyond the tarsal plates
^
Middle lamella: ?
What about beyond the tarsal plates, ie, above it in the 
upper lid, and below it in the lower? How many lamella 
are conceptualized in these locations? 
Three: Anterior, middle and posterior
What structures comprise each of these three lamellae 
beyond the tarsal plates?
--The anterior lamella...doesn’t change; it’s still skin 
and orbicularis
--As for the newly-arisen middle lamella…?it is 
composed of the eyelid retractors and orbital septum, 
as well as (in the lower lid) the eyelid fat pads
--Beyond the location of the tarsal plate, the plate itself 
isn’t part of the posterior lamella (duh), so in these 
areas the posterior lamella… consists only of the conj
Finally!
Cicatricial Ectropioncn
Q/A
34
‘Anterior lamella’? ‘Posterior lamella’?How many layers does an eyelid have?
Well, the lids have a number of layers (the precise count depends on whether it’s an upper vs lower lid , 
as well as the distance from the margin at which one does the counting). However, from a surgical 
perspective, at the level of the tarsal plates it’s useful to think of them as having two--an anterior lamella, 
and a posterior lamella.
What structures comprise each lamella?
Anterior: Skin and orbicularis muscle!
Posterior: Tarsal plate and conjunctiva!
In a nutshell, what is the pathogenesis of…
--Cicatricial ectropion? Scarring of the lid’s anterior lamella causes it (the anterior 
lamella) to shorten, which in turn causes the lid margin to turn outward
--Cicatricial entropion? Scarring of the lid’s posterior lamella causes it (the posterior 
lamella) to shorten, which in turn causes the lid margin to turn inward
beyond the tarsal plates
^
Middle lamella: ?
What about beyond the tarsal plates, ie, above it in the 
upper lid, and below it in the lower? How many lamella 
are conceptualized in these locations? 
Three: Anterior, middle and posterior
What structures comprise each of these three lamellae 
beyond the tarsal plates?
--The anterior lamella...doesn’t change; it’s still skin 
and orbicularis
--As for the newly-arisen middle lamella…it is 
composed of the eyelid retractors and orbital septum, 
as well as (in the lower lid) the eyelid fat pads
--Beyond the location of the tarsal plate, the plate itself 
isn’t part of the posterior lamella (duh), so in these 
areas the posterior lamella… consists only of the conj
two diff wordstwo words
Cicatricial Ectropioncn
A
35
‘Anterior lamella’? ‘Posterior lamella’? How many layers does an eyelid have?
Well, the lids have a number of layers (the precise count depends on whether it’s an upper vs lower lid , 
as well as the distance from the margin at which one does the counting). However, from a surgical 
perspective, at the level of the tarsal plates it’s useful to think of them as having two--an anterior lamella, 
and a posterior lamella.
What structures comprise each lamella?
Anterior: Skin and orbicularis muscle!
Posterior: Tarsal plate and conjunctiva!
In a nutshell, what is the pathogenesis of…
--Cicatricial ectropion? Scarring of the lid’s anterior lamella causes it (the anterior 
lamella) to shorten, which in turn causes the lid margin to turn outward
--Cicatricial entropion? Scarring of the lid’s posterior lamella causes it (the posterior 
lamella) to shorten, which in turn causes the lid margin to turn inward
beyond the tarsal plates
^
What about beyond the tarsal plates, ie, above it in the 
upper lid, and below it in the lower? How many lamella 
are conceptualized in these locations? 
Three: Anterior, middle and posterior
What structures comprise each of these three lamellae 
beyond the tarsal plates?
--The anterior lamella...doesn’t change; it’s still skin 
and orbicularis
--As for the newly-arisen middle lamella…it is 
composed of the eyelid retractors and orbital septum, 
as well as (in the lower lid) the eyelid fat pads
--Beyond the location of the tarsal plate, the plate itself 
isn’t part of the posterior lamella (duh), so in these 
areas the posterior lamella… consists only of the conj
Middle lamella: Eyelid retractors, orbital septum
Cicatricial Ectropioncn
Q
36
‘Anterior lamella’? ‘Posterior lamella’? How many layers does an eyelid have?
Well, the lids have a number of layers (the precise count depends on whether it’s an upper vs lower lid , 
as well as the distance from the margin at which one does the counting). However, from a surgical 
perspective, at the level of the tarsal plates it’s useful to think of them as having two--an anterior lamella, 
and a posterior lamella.
What structures comprise each lamella?
Anterior: Skin and orbicularis muscle!
Posterior: Tarsal plate and conjunctiva!
In a nutshell, what is the pathogenesis of…
--Cicatricial ectropion? Scarring of the lid’s anterior lamella causes it (the anterior 
lamella) to shorten, which in turn causes the lid margin to turn outward
--Cicatricial entropion? Scarring of the lid’s posterior lamella causes it (the posterior 
lamella) to shorten, which in turn causes the lid margin to turn inward
beyond the tarsal plates
^
What about beyond the tarsal plates, ie, above it in the 
upper lid, and below it in the lower? How many lamella 
are conceptualized in these locations? 
Three: Anterior, middle and posterior
What structures comprise each of these three lamellae 
beyond the tarsal plates?
--The anterior lamella...doesn’t change; it’s still skin 
and orbicularis
--As for the newly-arisen middle lamella…it is 
composed of the eyelid retractors and orbital septum, 
as well as (in the lower lid) the eyelid fat pads
--Beyond the location of the tarsal plate, the plate itself 
isn’t part of the posterior lamella (duh), so in these 
areas the posterior lamella… consists only of the conj
three words
Middle lamella: Eyelid retractors, orbital septum
Cicatricial Ectropioncn
A
37
‘Anterior lamella’? ‘Posterior lamella’? How many layers does an eyelid have?
Well, the lids have a number of layers (the precise count depends on whether it’s an upper vs lower lid , 
as well as the distance from the margin at which one does the counting). However, from a surgical 
perspective, at the level of the tarsal plates it’s useful to think of them as having two--an anterior lamella, 
and a posterior lamella.
What structures comprise each lamella?
Anterior: Skin and orbicularis muscle!
Posterior: Tarsal plate and conjunctiva!
In a nutshell, what is the pathogenesis of…
--Cicatricial ectropion? Scarring of the lid’s anterior lamella causes it (the anterior 
lamella) to shorten, which in turn causes the lid margin to turn outward
--Cicatricial entropion? Scarring of the lid’s posterior lamella causes it (the posterior 
lamella) to shorten, which in turn causes the lid margin to turn inward
beyond the tarsal plates
^
What about beyond the tarsal plates, ie, above it in the 
upper lid, and below it in the lower? How many lamella 
are conceptualized in these locations? 
Three: Anterior, middle and posterior
What structures comprise each of these three lamellae 
beyond the tarsal plates?
--The anterior lamella...doesn’t change; it’s still skin 
and orbicularis
--As for the newly-arisen middle lamella…it is 
composed of the eyelid retractors and orbital septum, 
as well as (in the lower lid) the eyelid fat pads
--Beyond the location of the tarsal plate, the plate itself 
isn’t part of the posterior lamella (duh), so in these 
areas the posterior lamella… consists only of the conj
Middle lamella: Eyelid retractors, orbital septum,
eyelid fat pads (lower lid)
Cicatricial Ectropioncn
38
Cicatricial Ectropioncn
Eyelid lamellae below the tarsal plate in the lower lid
Congenital Congenital
 Involutional Involutional
 Paralytic
 Cicatricial Cicatricial
 Mechanical
 Acute Spastic
Entropion Ectropion
39
Categories
Congenital
Involutional
Paralytic
Cicatricial
Mechanical
Acute Spastic
Cicatricial Ectropion
Let’s look at cicatricial ectropion in more detail
 Common causes of cicatricial ectropion:
 Trauma
 Burn
 Iatrogenic 
 Actinic skin changes
 Inflammatory disease
 Rosacea
Q
40
Cicatricial Ectropion
 Common causes of cicatricial ectropion:
 Trauma
 Burn
 Iatrogenic 
 Actinic skin changes
 Inflammatory disease
 Rosacea
A
41
Cicatricial Ectropion
42
Cicatricial Ectropion
Cicatricial ectropion
 Managing cicatricial ectropion of the lower lid 
involves three steps:
1) Release/relax…
2) Lengthen… 
3)
Q
43
(finish the thought)
Cicatricial Ectropion
 Managing cicatricial ectropion of the lowerlid 
involves three steps:
1) Release/relax…the traction caused by the cicatrix
2) Lengthen…the lid vertically (with a FTSG)
3)
A
44
Cicatricial Ectropion
 Managing cicatricial ectropion of the lower lid 
involves three steps:
1) Release/relax…the traction caused by the cicatrix
2) Lengthen…
3) 
Q
45
(ditto)
Cicatricial Ectropion
 Managing cicatricial ectropion of the lower lid 
involves three steps:
1) Release/relax…the traction caused by the cicatrix
2) Lengthen…the lid vertically (with a FTSG)
3)
A
46
(full-thickness skin graft)
Cicatricial Ectropion
 Managing cicatricial ectropion of the lower lid 
involves three steps:
1) Release/relax…the traction caused by the cicatrix
2) Lengthen…the lid vertically (with a FTSG)
3) Shorten…
Q
47
(ditto)
Cicatricial Ectropion
 Managing cicatricial ectropion of the lower lid 
involves three steps:
1) Release/relax…the traction caused by the cicatrix
2) Lengthen…the lid vertically (with a FTSG)
3) Shorten…the lid horizontally (with a lateral tarsal strip)
A
48
Cicatricial Ectropion
49
Cicatricial Ectropion
Cicatricial ectropion: Pre- and post-repair
 Managing cicatricial ectropion of the lower lid 
involves three steps:
1) Release/relax…the traction caused by the cicatrix
2) Lengthen…the lid vertically (with a FTSG)
3) Shorten…the lid horizontally (with a lateral tarsal strip)
Q
^?
50
upper
Cicatricial Ectropion
Which of these steps are involved in repair of UPPER lid cicatricial ectropion?
 Managing cicatricial ectropion of the lower lid 
involves three steps:
1) Release/relax…the traction caused by the cicatrix
2) Lengthen…the lid vertically (with a FTSG)
3) Shorten…the lid horizontally (with a lateral tarsal strip)
A
two ^
51
upper
^
Which of these steps are involved in repair of UPPER lid cicatricial ectropion?
1 and 2, but not 3: The upper lid generally does not suffer horizontal laxity, 
so tightening is not required
Cicatricial Ectropion
Congenital Congenital
 Involutional Involutional
 Paralytic
 Cicatricial Cicatricial
 Mechanical
 Acute Spastic
Entropion Ectropion
52
Categories
Congenital
Involutional
Paralytic
Cicatricial
Mechanical
Acute Spastic
Cicatricial Entropion
Now let’s look at cicatricial entropion
 In another nutshell, what is the pathogenesis of 
cicatricial entropion? 
Q
53
Cicatricial Entropion
 In another nutshell, what is the pathogenesis of 
cicatricial entropion? How does this lead to 
cornea problems?
Vertical tarsoconjunctival contracture  
in-rotation of the lid margin
three words
two-words two words
Q/A
54
start with this one
Cicatricial Entropion
 In another nutshell, what is the pathogenesis of 
cicatricial entropion? How does this lead to 
cornea problems?
Vertical tarsoconjunctival contracture  
in-rotation of the lid margin
Q/A
55
two-words two words
next
Cicatricial Entropion
 In another nutshell, what is the pathogenesis of 
cicatricial entropion? How does this lead to 
cornea problems?
Vertical tarsoconjunctival contracture  
in-rotation of the lid margin
Q/A
56
two words
finally
Cicatricial Entropion
 In another nutshell, what is the pathogenesis of 
cicatricial entropion? How does this lead to 
cornea problems?
Vertical tarsoconjunctival contracture  
in-rotation of the lid margin
A
57
Cicatricial Entropion
 In another nutshell, what is the pathogenesis of 
cicatricial entropion? How does this lead to 
cornea problems?
Vertical tarsoconjunctival contracture  
in-rotation of the lid margin 
in-rotation of the eyelashes cornea problems
Q
58
two-words one word
answer these simultaneously
Cicatricial Entropion
 In another nutshell, what is the pathogenesis of 
cicatricial entropion? How does this lead to 
cornea problems?
Vertical tarsoconjunctival contracture  
in-rotation of the lid margin 
in-rotation of the eyelashes cornea problems
A
59
Cicatricial Entropion
 In another nutshell, what is the pathogenesis of 
cicatricial entropion? How does this lead to 
cornea problems?
Vertical tarsoconjunctival contracture  
in-rotation of the lid margin 
in-rotation of the eyelashes cornea problems
Q
60
‘In-rotation of the eyelashes’? Why not just say ‘trichiasis’?
Because trichiasis is not present
Huh? But the lashes are touching the cornea--isn’t that the definition of trichiasis?
No, it isn’t. Trichiasis is defined as the inward-rotation of lashes that originate from 
a normally-positioned lid margin. In any form of entropion (ie, not just cicatricial), 
the position of the lid margin is rotated inward, and therefore not normal. Thus, the 
term trichiasis, while often employed, is technically incorrect.
Cicatricial Entropion
 In another nutshell, what is the pathogenesis of 
cicatricial entropion? How does this lead to 
cornea problems?
Vertical tarsoconjunctival contracture  
in-rotation of the lid margin 
in-rotation of the eyelashes cornea problems
A
61
‘In-rotation of the eyelashes’? Why not just say ‘trichiasis’?
Because trichiasis is not present
Huh? But the lashes are touching the cornea--isn’t that the definition of trichiasis?
No, it isn’t. Trichiasis is defined as the inward-rotation of lashes that originate from 
a normally-positioned lid margin. In any form of entropion (ie, not just cicatricial), 
the position of the lid margin is rotated inward, and therefore not normal. Thus, the 
term trichiasis, while often employed, is technically incorrect.
Cicatricial Entropion
 In another nutshell, what is the pathogenesis of 
cicatricial entropion? How does this lead to 
cornea problems?
Vertical tarsoconjunctival contracture  
in-rotation of the lid margin 
in-rotation of the eyelashes cornea problems
Q
62
‘In-rotation of the eyelashes’? Why not just say ‘trichiasis’?
Because trichiasis is not present
Huh? But the lashes are touching the cornea--isn’t that the definition of trichiasis?
No, it isn’t. Trichiasis is defined as the inward-rotation of lashes that originate from 
a normally-positioned lid margin. In any form of entropion (ie, not just cicatricial), 
the position of the lid margin is rotated inward, and therefore not normal. Thus, the 
term trichiasis, while often employed, is technically incorrect.
Cicatricial Entropion
 In another nutshell, what is the pathogenesis of 
cicatricial entropion? How does this lead to 
cornea problems?
Vertical tarsoconjunctival contracture  
in-rotation of the lid margin 
in-rotation of the eyelashes cornea problems
A
63
‘In-rotation of the eyelashes’? Why not just say ‘trichiasis’?
Because trichiasis is not present
Huh? But the lashes are touching the cornea--isn’t that the definition of trichiasis?
No, it isn’t. Trichiasis is defined as the inward-directing of lashes that originate from 
a normally-positioned lid margin. In any form of entropion (ie, not just cicatricial), 
the position of the lid margin is rotated inward, and therefore not normal. Thus, the 
term trichiasis, while often employed, is technically incorrect.
Cicatricial Entropion
 In another nutshell, what is the pathogenesis of 
cicatricial entropion? How does this lead to 
cornea problems?
Vertical tarsoconjunctival contracture  
in-rotation of the lid margin 
in-rotation of the eyelashes cornea problems
A
64
‘In-rotation of the eyelashes’? Why not just say ‘trichiasis’?
Because trichiasis is not present
Huh? But the lashes are touching the cornea--isn’t that the definition of trichiasis?
No, it isn’t. Trichiasis is defined as the inward-directing of lashes that originate from 
a normally-positioned lid margin. In any form of entropion (ie, not just cicatricial), 
the position of the lid margin is rotated inward, and therefore not normal. Thus, theterm trichiasis, while often employed, is technically incorrect.
Cicatricial Entropion
 In another nutshell, what is the pathogenesis of 
cicatricial entropion? How does this lead to 
cornea problems?
Vertical tarsoconjunctival contracture  
in-rotation of the lid margin 
in-rotation of the eyelashes cornea problems
65
‘In-rotation of the eyelashes’? Why not just say ‘trichiasis’?
Because trichiasis is not present
Huh? But the lashes are touching the cornea--isn’t that the definition of trichiasis?
No, it isn’t. Trichiasis is defined as the inward-directing of lashes that originate from 
a normally-positioned lid margin. In any form of entropion (ie, not just cicatricial), 
the position of the lid margin is rotated inward, and therefore not normal. Thus, the 
term trichiasis, while often employed, is technically incorrect.
Technically incorrect, sure. But in fairness, many clinicians aren’t this 
persnickety about the term trichiasis--and neither are the BCSC books. 
So this is not the hill you want to die on when taking the Boards.
Cicatricial Entropion
 In another nutshell, what is the pathogenesis of 
cicatricial entropion? How does this lead to 
cornea problems?
Vertical tarsoconjunctival contracture  
in-rotation of the lid margin 
in-rotation of the eyelashes cornea problems
Q
66
‘In-rotation of the eyelashes’? Why not just say ‘trichiasis’?
Because trichiasis is not present
Huh? But the lashes are touching the cornea--isn’t that the definition of trichiasis?
No, it isn’t. Trichiasis is defined as the inward-directing of lashes that originate from 
a normally-positioned lid margin. In any form of entropion (ie, not just cicatricial), 
the position of the lid margin is rotated inward, and therefore not normal. Thus, the 
term trichiasis, while often employed, is technically incorrect.
How does distichiasis differ from trichiasis?
In trichiasis, the lashes are growing from their usual location (albeit in an abnormal 
direction), whereas in distichiasis, lashes are growing from meibomian gland orifices
Is distichiasis congenital, or acquired?
It can be either
Cicatricial Entropion
 In another nutshell, what is the pathogenesis of 
cicatricial entropion? How does this lead to 
cornea problems?
Vertical tarsoconjunctival contracture  
in-rotation of the lid margin 
in-rotation of the eyelashes cornea problems
Q/A
67
‘In-rotation of the eyelashes’? Why not just say ‘trichiasis’?
Because trichiasis is not present
Huh? But the lashes are touching the cornea--isn’t that the definition of trichiasis?
No, it isn’t. Trichiasis is defined as the inward-directing of lashes that originate from 
a normally-positioned lid margin. In any form of entropion (ie, not just cicatricial), 
the position of the lid margin is rotated inward, and therefore not normal. Thus, the 
term trichiasis, while often employed, is technically incorrect.
How does distichiasis differ from trichiasis?
In trichiasis, the lashes are growing from their usual location (albeit in an abnormal 
direction), whereas in distichiasis, lashes are growing from meibomian gland orifices
Is distichiasis congenital, or acquired?
It can be either
three words
Cicatricial Entropion
 In another nutshell, what is the pathogenesis of 
cicatricial entropion? How does this lead to 
cornea problems?
Vertical tarsoconjunctival contracture  
in-rotation of the lid margin 
in-rotation of the eyelashes cornea problems
A
68
‘In-rotation of the eyelashes’? Why not just say ‘trichiasis’?
Because trichiasis is not present
Huh? But the lashes are touching the cornea--isn’t that the definition of trichiasis?
No, it isn’t. Trichiasis is defined as the inward-directing of lashes that originate from 
a normally-positioned lid margin. In any form of entropion (ie, not just cicatricial), 
the position of the lid margin is rotated inward, and therefore not normal. Thus, the 
term trichiasis, while often employed, is technically incorrect.
How does distichiasis differ from trichiasis?
In trichiasis, the lashes are growing from their usual location (albeit in an abnormal 
direction), whereas in distichiasis, lashes are growing from meibomian gland orifices
Is distichiasis congenital, or acquired?
It can be either
Cicatricial Entropion
69
Distichiasis: Lashes arising from MG orifices
Cicatricial Entropion
 In another nutshell, what is the pathogenesis of 
cicatricial entropion? How does this lead to 
cornea problems?
Vertical tarsoconjunctival contracture  
in-rotation of the lid margin 
in-rotation of the eyelashes cornea problems
Q
70
‘In-rotation of the eyelashes’? Why not just say ‘trichiasis’?
Because trichiasis is not present
Huh? But the lashes are touching the cornea--isn’t that the definition of trichiasis?
No, it isn’t. Trichiasis is defined as the inward-directing of lashes that originate from 
a normally-positioned lid margin. In any form of entropion (ie, not just cicatricial), 
the position of the lid margin is rotated inward, and therefore not normal. Thus, the 
term trichiasis, while often employed, is technically incorrect.
How does distichiasis differ from trichiasis?
In trichiasis, the lashes are growing from their usual location (albeit in an abnormal 
direction), whereas in distichiasis, lashes are growing from meibomian gland orifices
Is distichiasis congenital, or acquired?
It can be either
Cicatricial Entropion
 In another nutshell, what is the pathogenesis of 
cicatricial entropion? How does this lead to 
cornea problems?
Vertical tarsoconjunctival contracture  
in-rotation of the lid margin 
in-rotation of the eyelashes cornea problems
A
71
‘In-rotation of the eyelashes’? Why not just say ‘trichiasis’?
Because trichiasis is not present
Huh? But the lashes are touching the cornea--isn’t that the definition of trichiasis?
No, it isn’t. Trichiasis is defined as the inward-directing of lashes that originate from 
a normally-positioned lid margin. In any form of entropion (ie, not just cicatricial), 
the position of the lid margin is rotated inward, and therefore not normal. Thus, the 
term trichiasis, while often employed, is technically incorrect.
How does distichiasis differ from trichiasis?
In trichiasis, the lashes are growing from their usual location (albeit in an abnormal 
direction), whereas in distichiasis, lashes are growing from meibomian gland orifices
Is distichiasis congenital, or acquired?
It can be either
Cicatricial Entropion
 In another nutshell, what is the pathogenesis of 
cicatricial entropion? How does this lead to 
cornea problems?
Vertical tarsoconjunctival contracture  
in-rotation of the lid margin 
in-rotation of the eyelashes cornea problems
Q
72
‘In-rotation of the eyelashes’? Why not just say ‘trichiasis’?
Because trichiasis is not present
Huh? But the lashes are touching the cornea--isn’t that the definition of trichiasis?
No, it isn’t. Trichiasis is defined as the inward-directing of lashes that originate from 
a normally-positioned lid margin. In any form of entropion (ie, not just cicatricial), 
the position of the lid margin is rotated inward, and therefore not normal. Thus, the 
term trichiasis, while often employed, is technically incorrect.
How does distichiasis differ from trichiasis?
In trichiasis, the lashes are growing from their usual location (albeit in an abnormal 
direction), whereas in distichiasis, lashes are growing from meibomian gland orifices
Is distichiasis congenital, or acquired?
It can be either
Cicatricial Entropion
How on earth can an oil gland give rise to an eyelash?
Because embryology. In the first trimester, the meibomian glands and eyelashes 
differentiate from a common pilosebaceous ‘ancestor.’ Given this, it’s easy to see 
how a failure of differentiation could lead to the presence of eyelashes in meibomian 
gland orifi, resulting in congenital distichiasis. And it doesn’t take much to prod the 
progenitor cells in a mature meibomian gland to differentiate into an eyelashfollicle 
and sprout one, resulting in acquired distichiasis.
 In another nutshell, what is the pathogenesis of 
cicatricial entropion? How does this lead to 
cornea problems?
Vertical tarsoconjunctival contracture  
in-rotation of the lid margin 
in-rotation of the eyelashes cornea problems
A
73
‘In-rotation of the eyelashes’? Why not just say ‘trichiasis’?
Because trichiasis is not present
Huh? But the lashes are touching the cornea--isn’t that the definition of trichiasis?
No, it isn’t. Trichiasis is defined as the inward-directing of lashes that originate from 
a normally-positioned lid margin. In any form of entropion (ie, not just cicatricial), 
the position of the lid margin is rotated inward, and therefore not normal. Thus, the 
term trichiasis, while often employed, is technically incorrect.
How does distichiasis differ from trichiasis?
In trichiasis, the lashes are growing from their usual location (albeit in an abnormal 
direction), whereas in distichiasis, lashes are growing from meibomian gland orifices
Is distichiasis congenital, or acquired?
It can be either
Cicatricial Entropion
How on earth can an oil gland give rise to an eyelash?
Because embryology. In the first trimester, the meibomian glands and eyelashes 
differentiate from a common pilosebaceous ‘ancestor.’ Given this, it’s easy to see 
how a failure of differentiation could lead to the presence of eyelashes in meibomian 
gland orifi, resulting in congenital distichiasis. And it doesn’t take much to prod the 
progenitor cells in a mature meibomian gland to differentiate into an eyelash follicle 
and sprout one, resulting in acquired distichiasis.
 In another nutshell, what is the pathogenesis of 
cicatricial entropion? How does this lead to 
cornea problems?
Vertical tarsoconjunctival contracture  
in-rotation of the lid margin 
in-rotation of the eyelashes cornea problems
A
74
‘In-rotation of the eyelashes’? Why not just say ‘trichiasis’?
Because trichiasis is not present
Huh? But the lashes are touching the cornea--isn’t that the definition of trichiasis?
No, it isn’t. Trichiasis is defined as the inward-directing of lashes that originate from 
a normally-positioned lid margin. In any form of entropion (ie, not just cicatricial), 
the position of the lid margin is rotated inward, and therefore not normal. Thus, the 
term trichiasis, while often employed, is technically incorrect.
How does distichiasis differ from trichiasis?
In trichiasis, the lashes are growing from their usual location (albeit in an abnormal 
direction), whereas in distichiasis, lashes are growing from meibomian gland orifices
Is distichiasis congenital, or acquired?
It can be either
Cicatricial Entropion
How on earth can an oil gland give rise to an eyelash?
Because embryology. In the first trimester, the meibomian glands and eyelashes 
differentiate from a common pilosebaceous ‘ancestor.’ Given this, it’s easy to see 
how a failure of differentiation could lead to the presence of eyelashes in meibomian 
gland orifi, resulting in congenital distichiasis. And it doesn’t take much to prod the 
progenitor cells in a mature meibomian gland to differentiate into an eyelash follicle 
and sprout one, resulting in acquired distichiasis.
 In another nutshell, what is the pathogenesis of 
cicatricial entropion? How does this lead to 
cornea problems?
Vertical tarsoconjunctival contracture  
in-rotation of the lid margin 
in-rotation of the eyelashes cornea problems
Q
75
‘In-rotation of the eyelashes’? Why not just say ‘trichiasis’?
Because trichiasis is not present
Huh? But the lashes are touching the cornea--isn’t that the definition of trichiasis?
No, it isn’t. Trichiasis is defined as the inward-directing of lashes that originate from 
a normally-positioned lid margin. In any form of entropion (ie, not just cicatricial), 
the position of the lid margin is rotated inward, and therefore not normal. Thus, the 
term trichiasis, while often employed, is technically incorrect.
How does distichiasis differ from trichiasis?
In trichiasis, the lashes are growing from their usual location (albeit in an abnormal 
direction), whereas in distichiasis, lashes are growing from meibomian gland orifices
Is distichiasis congenital, or acquired?
It can be either
Cicatricial Entropion
How on earth can an oil gland give rise to an eyelash?
Because embryology. In the first trimester, the meibomian glands and eyelashes 
differentiate from a common pilosebaceous ‘ancestor.’ Given this, it’s easy to see 
how a failure of differentiation could lead to the presence of eyelashes in meibomian 
gland orifi, resulting in congenital distichiasis. And it doesn’t take much to prod the 
progenitor cells in a mature meibomian gland to differentiate into an eyelash follicle 
and sprout one, resulting in acquired distichiasis.What sort of event/situation can ‘prod’ a meibomian gland 
to produce acquired distichiasis?
Trauma; chronic inflammation
 In another nutshell, what is the pathogenesis of 
cicatricial entropion? How does this lead to 
cornea problems?
Vertical tarsoconjunctival contracture  
in-rotation of the lid margin 
in-rotation of the eyelashes cornea problems
A
76
‘In-rotation of the eyelashes’? Why not just say ‘trichiasis’?
Because trichiasis is not present
Huh? But the lashes are touching the cornea--isn’t that the definition of trichiasis?
No, it isn’t. Trichiasis is defined as the inward-directing of lashes that originate from 
a normally-positioned lid margin. In any form of entropion (ie, not just cicatricial), 
the position of the lid margin is rotated inward, and therefore not normal. Thus, the 
term trichiasis, while often employed, is technically incorrect.
How does distichiasis differ from trichiasis?
In trichiasis, the lashes are growing from their usual location (albeit in an abnormal 
direction), whereas in distichiasis, lashes are growing from meibomian gland orifices
Is distichiasis congenital, or acquired?
It can be either
Cicatricial Entropion
How on earth can an oil gland give rise to an eyelash?
Because embryology. In the first trimester, the meibomian glands and eyelashes 
differentiate from a common pilosebaceous ‘ancestor.’ Given this, it’s easy to see 
how a failure of differentiation could lead to the presence of eyelashes in meibomian 
gland orifi, resulting in congenital distichiasis. And it doesn’t take much to prod the 
progenitor cells in a mature meibomian gland to differentiate into an eyelash follicle 
and sprout one, resulting in acquired distichiasis.What sort of event/situation can ‘prod’ a meibomian gland 
to produce acquired distichiasis?
Trauma; chronic inflammation
 In another nutshell, what is the pathogenesis of 
cicatricial entropion? How does this lead to 
cornea problems?
Vertical tarsoconjunctival contracture  
in-rotation of the lid margin 
in-rotation of the eyelashes cornea problems
Q
77
When evaluating cicatricial entropion, for what crucial question must an 
adequate answer be determined?
That question is: What is the underlying etiology of the cicatrix—that is, 
what caused the scarring in the first place?
What is the DDx for cicatricial entropion?
Glad you asked…
Cicatricial Entropion
 In another nutshell, what is the pathogenesis of 
cicatricial entropion? How does this lead to 
cornea problems?
Vertical tarsoconjunctival contracture  
in-rotation of the lid margin 
in-rotation of the eyelashes cornea problems
A
78
When evaluating cicatricial entropion, for what crucial question must an 
adequate answer be determined?
That question is: What is the underlying etiology of the cicatrix—that is, 
what caused the scarring in the first place?
What is the DDx for cicatricial entropion?
Glad you asked…
Cicatricial Entropion
 In another nutshell, what is the pathogenesis of 
cicatricial entropion? How does this lead to 
cornea problems?
Vertical tarsoconjunctival contracture  
in-rotation of the lid margin 
in-rotation of the eyelashescornea problems
Q
79
When evaluating cicatricial entropion, for what crucial question must an 
adequate answer be determined?
That question is: What is the underlying etiology of the cicatrix—that is, 
what caused the scarring in the first place?
What is the DDx for cicatricial entropion?
Glad you asked…
Cicatricial Entropion
 In another nutshell, what is the pathogenesis of 
cicatricial entropion? How does this lead to 
cornea problems?
Vertical tarsoconjunctival contracture  
in-rotation of the lid margin 
in-rotation of the eyelashes cornea problems
80
When evaluating cicatricial entropion, for what crucial question must an 
adequate answer be determined?
That question is: What is the underlying etiology of the cicatrix—that is, 
what caused the scarring in the first place?
What is the DDx for cicatricial entropion?
Glad you asked…
Cicatricial Entropion
 Common causes of cicatricial entropion:
 OCP
 SJS
 Trachoma
 Trauma
 Sarcoid
 Iatrogenic (e.g., post Fasanella-Servat)
Q
81
Cicatricial Entropion
 Common causes of cicatricial entropion:
 Ocular cicatricial pemphigoid (OCP)
 Stevens-Johnson syndrome (SJS)
 Trachoma
 Trauma
 Sarcoid
 Iatrogenic
A
82
Cicatricial Entropion
83
Cicatricial entropion
Cicatricial Entropion
84
Cicatricial entropion in OCP
Cicatricial Entropion
 Common causes of cicatricial entropion:
 Ocular cicatricial pemphigoid (OCP)
 Stevens-Johnson syndrome (SJS)
 Trachoma
 Trauma
 Sarcoid
 Iatrogenic
85
If the cause is inflammatory, make sure that process
is completely quiescent before attempting repair!
Cicatricial Entropion
 Common causes of cicatricial entropion:
 Ocular cicatricial pemphigoid (OCP)
 Stevens-Johnson syndrome (SJS)
 Trachoma
 Trauma
 Sarcoid
 Iatrogenic
Q
86
What is the causative organism in trachoma?
C trachomatis serotypes A,B,C
Where does trachoma rank as a cause of blindness worldwide?
It is the most common cause of infectious blindness
Where in the world is trachoma prevalent?
The Middle East, South Asia, Africa
Is trachoma primarily a follicular, or papillary conjunctivitis?
Follicular
Where do the follicles tend to occur?
On the superior palpebral conj, and the superior limbal region
Cicatricial Entropion
 Common causes of cicatricial entropion:
 Ocular cicatricial pemphigoid (OCP)
 Stevens-Johnson syndrome (SJS)
 Trachoma
 Trauma
 Sarcoid
 Iatrogenic
Q/A
87
What is the causative organism in trachoma?
C trachomatis serotypes A,B,C
Where does trachoma rank as a cause of blindness worldwide?
It is the most common cause of infectious blindness
Where in the world is trachoma prevalent?
The Middle East, South Asia, Africa
Is trachoma primarily a follicular, or papillary conjunctivitis?
Follicular
Where do the follicles tend to occur?
On the superior palpebral conj, and the superior limbal region
Cicatricial Entropion
 Common causes of cicatricial entropion:
 Ocular cicatricial pemphigoid (OCP)
 Stevens-Johnson syndrome (SJS)
 Trachoma
 Trauma
 Sarcoid
 Iatrogenic
A
88
What is the causative organism in trachoma?
C trachomatis serotypes A,B,C
Where does trachoma rank as a cause of blindness worldwide?
It is the most common cause of infectious blindness
Where in the world is trachoma prevalent?
The Middle East, South Asia, Africa
Is trachoma primarily a follicular, or papillary conjunctivitis?
Follicular
Where do the follicles tend to occur?
On the superior palpebral conj, and the superior limbal region
Cicatricial Entropion
 Common causes of cicatricial entropion:
 Ocular cicatricial pemphigoid (OCP)
 Stevens-Johnson syndrome (SJS)
 Trachoma
 Trauma
 Sarcoid
 Iatrogenic
Q
89
What is the causative organism in trachoma?
C trachomatis serotypes A,B,C
Where does trachoma rank as a cause of blindness worldwide?
It is the most common cause of infectious blindness
Where in the world is trachoma prevalent?
The Middle East, South Asia, Africa
Is trachoma primarily a follicular, or papillary conjunctivitis?
Follicular
Where do the follicles tend to occur?
On the superior palpebral conj, and the superior limbal region
Cicatricial Entropion
 Common causes of cicatricial entropion:
 Ocular cicatricial pemphigoid (OCP)
 Stevens-Johnson syndrome (SJS)
 Trachoma
 Trauma
 Sarcoid
 Iatrogenic
A
90
What is the causative organism in trachoma?
C trachomatis serotypes A,B,C
Where does trachoma rank as a cause of blindness worldwide?
It is the most common cause of infectious blindness
Where in the world is trachoma prevalent?
The Middle East, South Asia, Africa
Is trachoma primarily a follicular, or papillary conjunctivitis?
Follicular
Where do the follicles tend to occur?
On the superior palpebral conj, and the superior limbal region
Cicatricial Entropion
 Common causes of cicatricial entropion:
 Ocular cicatricial pemphigoid (OCP)
 Stevens-Johnson syndrome (SJS)
 Trachoma
 Trauma
 Sarcoid
 Iatrogenic
Q
91
What is the causative organism in trachoma?
C trachomatis serotypes A,B,C
Where does trachoma rank as a cause of blindness worldwide?
It is the most common cause of infectious blindness
Where in the world is trachoma prevalent?
The Middle East, South Asia, Africa
Is trachoma primarily a follicular, or papillary conjunctivitis?
Follicular
Where do the follicles tend to occur?
On the superior palpebral conj, and the superior limbal region
Cicatricial Entropion
Why are they blind, ie, what ocular structure is responsible?
The cornea—it is scarred, and covered by a pannus
In a nutshell, what sequence of events leads to corneal opacification?
Repeated infections produce scarification of the superior palpebral conj, 
and the subsequent cicatricial entropion leads to severe trichiasis which 
decimates the corneal surface
 Common causes of cicatricial entropion:
 Ocular cicatricial pemphigoid (OCP)
 Stevens-Johnson syndrome (SJS)
 Trachoma
 Trauma
 Sarcoid
 Iatrogenic
A
92
What is the causative organism in trachoma?
C trachomatis serotypes A,B,C
Where does trachoma rank as a cause of blindness worldwide?
It is the most common cause of infectious blindness
Where in the world is trachoma prevalent?
The Middle East, South Asia, Africa
Is trachoma primarily a follicular, or papillary conjunctivitis?
Follicular
Where do the follicles tend to occur?
On the superior palpebral conj, and the superior limbal region
Cicatricial Entropion
Why are they blind, ie, what ocular structure is responsible?
The cornea—it is scarred, and covered by a pannus
In a nutshell, what sequence of events leads to corneal opacification?
Repeated infections produce scarification of the superior palpebral conj, 
and the subsequent cicatricial entropion leads to severe trichiasis which 
decimates the corneal surface
 Common causes of cicatricial entropion:
 Ocular cicatricial pemphigoid (OCP)
 Stevens-Johnson syndrome (SJS)
 Trachoma
 Trauma
 Sarcoid
 Iatrogenic
Q
93
What is the causative organism in trachoma?
C trachomatis serotypes A,B,C
Where does trachoma rank as a cause of blindness worldwide?
It is the most common cause of infectious blindness
Where in the world is trachoma prevalent?
The Middle East, South Asia, Africa
Is trachoma primarily a follicular, or papillary conjunctivitis?
Follicular
Where do the follicles tend to occur?
On the superior palpebral conj, and the superior limbal region
Cicatricial Entropion
Why are they blind, ie, what ocular structure is responsible?
The cornea—it is scarred, and covered by a pannus
In a nutshell, what sequence of events leads to corneal opacification?
Repeated infections produce scarification of the superior palpebral conj, 
and the subsequent cicatricial entropion leads to severe trichiasis which 
decimates the corneal surface
 Common causes of cicatricial entropion:
 Ocular cicatricial pemphigoid (OCP)
 Stevens-Johnson syndrome (SJS)
 Trachoma
 Trauma
 Sarcoid
 Iatrogenic
A
94
What is the causative organism in trachoma?
C trachomatis serotypes A,B,CWhere does trachoma rank as a cause of blindness worldwide?
It is the most common cause of infectious blindness
Where in the world is trachoma prevalent?
The Middle East, South Asia, Africa
Is trachoma primarily a follicular, or papillary conjunctivitis?
Follicular
Where do the follicles tend to occur?
On the superior palpebral conj, and the superior limbal region
Cicatricial Entropion
Why are they blind, ie, what ocular structure is responsible?
The cornea—it is scarred, and covered by a pannus
In a nutshell, what sequence of events leads to corneal opacification?
Repeated infections produce scarification of the superior palpebral conj, 
and the subsequent cicatricial entropion leads to severe trichiasis which 
decimates the corneal surface
 Common causes of cicatricial entropion:
 Ocular cicatricial pemphigoid (OCP)
 Stevens-Johnson syndrome (SJS)
 Trachoma
 Trauma
 Sarcoid
 Iatrogenic
Q
95
What is the causative organism in trachoma?
C trachomatis serotypes A,B,C
Where does trachoma rank as a cause of blindness worldwide?
It is the most common cause of infectious blindness
Where in the world is trachoma prevalent?
The Middle East, South Asia, Africa
Is trachoma primarily a follicular, or papillary conjunctivitis?
Follicular
Where do the follicles tend to occur?
On the superior palpebral conj, and the superior limbal region
Cicatricial Entropion
 Common causes of cicatricial entropion:
 Ocular cicatricial pemphigoid (OCP)
 Stevens-Johnson syndrome (SJS)
 Trachoma
 Trauma
 Sarcoid
 Iatrogenic
A
96
What is the causative organism in trachoma?
C trachomatis serotypes A,B,C
Where does trachoma rank as a cause of blindness worldwide?
It is the most common cause of infectious blindness
Where in the world is trachoma prevalent?
The Middle East, South Asia, Africa
Is trachoma primarily a follicular, or papillary conjunctivitis?
Follicular
Where do the follicles tend to occur?
On the superior palpebral conj, and the superior limbal region
Cicatricial Entropion
 Common causes of cicatricial entropion:
 Ocular cicatricial pemphigoid (OCP)
 Stevens-Johnson syndrome (SJS)
 Trachoma
 Trauma
 Sarcoid
 Iatrogenic
Q
97
What is the causative organism in trachoma?
C trachomatis serotypes A,B,C
Where does trachoma rank as a cause of blindness worldwide?
It is the most common cause of infectious blindness
Where in the world is trachoma prevalent?
The Middle East, South Asia, Africa
Is trachoma primarily a follicular, or papillary conjunctivitis?
Follicular
Where do the follicles tend to occur?
On the superior palpebral conj, and the superior limbal region
Cicatricial Entropion
In the US, which ethnic group is most likely to be affected?
Native Americans
United States
 Common causes of cicatricial entropion:
 Ocular cicatricial pemphigoid (OCP)
 Stevens-Johnson syndrome (SJS)
 Trachoma
 Trauma
 Sarcoid
 Iatrogenic
A
98
What is the causative organism in trachoma?
C trachomatis serotypes A,B,C
Where does trachoma rank as a cause of blindness worldwide?
It is the most common cause of infectious blindness
Where in the world is trachoma prevalent?
The Middle East, South Asia, Africa
Is trachoma primarily a follicular, or papillary conjunctivitis?
Follicular
Where do the follicles tend to occur?
On the superior palpebral conj, and the superior limbal region
Cicatricial Entropion
In the US, which ethnic group is most likely to be affected?
Native Americans
United States
 Common causes of cicatricial entropion:
 Ocular cicatricial pemphigoid (OCP)
 Stevens-Johnson syndrome (SJS)
 Trachoma
 Trauma
 Sarcoid
 Iatrogenic
Q
99
What is the causative organism in trachoma?
C trachomatis serotypes A,B,C
Where does trachoma rank as a cause of blindness worldwide?
It is the most common cause of infectious blindness
Where in the world is trachoma prevalent?
The Middle East, South Asia, Africa
Is trachoma primarily a follicular, or papillary conjunctivitis?
Follicular
Where do the follicles tend to occur?
On the superior palpebral conj, and the superior limbal region
Cicatricial Entropion
 Common causes of cicatricial entropion:
 Ocular cicatricial pemphigoid (OCP)
 Stevens-Johnson syndrome (SJS)
 Trachoma
 Trauma
 Sarcoid
 Iatrogenic
A
100
What is the causative organism in trachoma?
C trachomatis serotypes A,B,C
Where does trachoma rank as a cause of blindness worldwide?
It is the most common cause of infectious blindness
Where in the world is trachoma prevalent?
The Middle East, South Asia, Africa
Is trachoma primarily a follicular, or papillary conjunctivitis?
Follicular
Where do the follicles tend to occur?
On the superior palpebral conj, and the superior limbal region
Cicatricial Entropion
 Common causes of cicatricial entropion:
 Ocular cicatricial pemphigoid (OCP)
 Stevens-Johnson syndrome (SJS)
 Trachoma
 Trauma
 Sarcoid
 Iatrogenic
Q
101
What is the causative organism in trachoma?
C trachomatis serotypes A,B,C
Where does trachoma rank as a cause of blindness worldwide?
It is the most common cause of infectious blindness
Where in the world is trachoma prevalent?
The Middle East, South Asia, Africa
Is trachoma primarily a follicular, or papillary conjunctivitis?
Follicular
Where do the follicles tend to occur?
On the superior palpebral conj, and the superior limbal region
Cicatricial Entropion
 Common causes of cicatricial entropion:
 Ocular cicatricial pemphigoid (OCP)
 Stevens-Johnson syndrome (SJS)
 Trachoma
 Trauma
 Sarcoid
 Iatrogenic
A
102
What is the causative organism in trachoma?
C trachomatis serotypes A,B,C
Where does trachoma rank as a cause of blindness worldwide?
It is the most common cause of infectious blindness
Where in the world is trachoma prevalent?
The Middle East, South Asia, Africa
Is trachoma primarily a follicular, or papillary conjunctivitis?
Follicular
Where do the follicles tend to occur?
On the superior palpebral conj, and the superior limbal region
Cicatricial Entropion
 Common causes of cicatricial entropion:
 Ocular cicatricial pemphigoid (OCP)
 Stevens-Johnson syndrome (SJS)
 Trachoma
 Trauma
 Sarcoid
 Iatrogenic
Q
103
What is the causative organism in trachoma?
C trachomatis serotypes A,B,C
Where does trachoma rank as a cause of blindness worldwide?
It is the most common cause of infectious blindness
Where in the world is trachoma prevalent?
The Middle East, South Asia, Africa
Is trachoma primarily a follicular, or papillary conjunctivitis?
Follicular
Where do the follicles tend to occur?
On the superior palpebral conj, and the superior limbal region
Cicatricial Entropion
When limbal follicles scar, what classic eponymous exam 
finding results?
Herbert’s pits
When upper-lid tarsal follicles scar, what classic eponymous 
exam finding results?
Arlt’s line
 Common causes of cicatricial entropion:
 Ocular cicatricial pemphigoid (OCP)
 Stevens-Johnson syndrome (SJS)
 Trachoma
 Trauma
 Sarcoid
 Iatrogenic
A
104
What is the causative organism in trachoma?
C trachomatis serotypes A,B,C
Where does trachoma rank as a cause of blindness worldwide?
It is the most common cause of infectious blindness
Where in the world is trachoma prevalent?
The Middle East, South Asia, Africa
Is trachoma primarily a follicular, or papillary conjunctivitis?
Follicular
Where do the follicles tend to occur?
On the superior palpebral conj, and the superior limbal region
Cicatricial Entropion
When limbal follicles scar, what classic eponymous exam 
finding results?
Herbert’s pits
When upper-lid tarsal follicles scar, what classic eponymous 
exam finding results?
Arlt’s line
105
Trachoma: Herbert’s pits
Cicatricial Entropion
 Common causes of cicatricial entropion:
 Ocular cicatricial pemphigoid (OCP)
 Stevens-Johnson syndrome (SJS)
 Trachoma
 Trauma
 Sarcoid
 Iatrogenic
Q
106
What is the causative organism in trachoma?
C trachomatis serotypes A,B,C
Where does trachoma rank as a cause of blindness worldwide?
It is the mostcommon cause of infectious blindness
Where in the world is trachoma prevalent?
The Middle East, South Asia, Africa
Is trachoma primarily a follicular, or papillary conjunctivitis?
Follicular
Where do the follicles tend to occur?
On the superior palpebral conj, and the superior limbal region
Cicatricial Entropion
When limbal follicles scar, what classic eponymous exam 
finding results?
Herbert’s pits
When upper-lid tarsal follicles scar, what classic eponymous 
exam finding results?
Arlt’s line
 Common causes of cicatricial entropion:
 Ocular cicatricial pemphigoid (OCP)
 Stevens-Johnson syndrome (SJS)
 Trachoma
 Trauma
 Sarcoid
 Iatrogenic
A
107
What is the causative organism in trachoma?
C trachomatis serotypes A,B,C
Where does trachoma rank as a cause of blindness worldwide?
It is the most common cause of infectious blindness
Where in the world is trachoma prevalent?
The Middle East, South Asia, Africa
Is trachoma primarily a follicular, or papillary conjunctivitis?
Follicular
Where do the follicles tend to occur?
On the superior palpebral conj, and the superior limbal region
Cicatricial Entropion
When limbal follicles scar, what classic eponymous exam 
finding results?
Herbert’s pits
When upper-lid tarsal follicles scar, what classic eponymous 
exam finding results?
Arlt’s line
108
Trachoma: Arlt’s line
Cicatricial Entropion
 How would you correct cicatricial entropion in 
cases of:
 Mild disease:
 Moderate disease:
 Severe disease:
Q
109
Cicatricial Entropion
 How would you correct cicatricial entropion in 
cases of:
 Mild disease: Anterior lamellar resection
 Moderate disease: Tarsal fracture procedure
 Severe disease: Excise/replace scarred tissues
A
110
Cicatricial Entropion
 How would you correct cicatricial entropion in 
cases of:
 Mild disease: Anterior lamellar resection
 Moderate disease: Tarsal fracture procedure
 Severe disease: Excise/replace scarred tissues
Q
111
Cicatricial Entropion
 How would you correct cicatricial entropion in 
cases of:
 Mild disease: Anterior lamellar resection
 Moderate disease: Tarsal fracture procedure
 Severe disease: Excise/replace scarred tissues
A
112
Cicatricial Entropion
 How would you correct cicatricial entropion in 
cases of:
 Mild disease: Anterior lamellar resection
 Moderate disease: Tarsal fracture procedure
 Severe disease: Excise/replace scarred tissues
Q
113
Cicatricial Entropion
 How would you correct cicatricial entropion in 
cases of:
 Mild disease: Anterior lamellar resection
 Moderate disease: Tarsal fracture procedure
 Severe disease: Excise/replace scarred tissues
A
114
Cicatricial Entropion
	Q
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	A
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