Sir,

Lower lid entropion is commonly associated with several age-related structural changes.1, 2 Small tarsal plate is a less well known factor in its pathogenesis.2 We describe a young patient in which significantly small tarsal plates were responsible for development of bilateral recurrent entropion, which proved difficult and challenging to manage.

Case report

An 18-year-old Caucasian female was referred with bilateral recurrent lower lid entropion (Figure 1) for the past 3 years. Previously she had everting sutures and lower lid retractor advancement at another hospital that failed. There was no conjunctival cicatrisation or forniceal shortening. The remaining ocular examination was normal. She had no features of congenital ectodermal dysplasia and no other associated craniofacial anomaly.

Figure 1
figure 1

(a and b) Right and left eye photographs showing lower lid entropion.

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Bilateral lower lid hard palate grafts were performed. Intra-operatively the height of tarsal plates was measured as 2.5 mm in lower lids and 5.5 mm in upper lids (Figure 2). Resolution of the entropion was achieved and remained for 6 months before recurrence. The previous grafts were then augmented with auricular cartilage grafts. Four months later the entropion recurred; mild blepharospasm and horizontal lower lid laxity were noted bilaterally. Bick's procedures with everting sutures were performed. She had another recurrence after 2 months, which was managed with intra-orbicularis injections of Botulinum toxin. She has had no further recurrence for the past 4 months.

Figure 2
figure 2

(a) Left lower eye lid photograph illustrating the tarsal plate height of 2.5 mm. (b) Right upper eye lid photograph displaying the tarsal plate height of 5.5 mm.

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Comment

The average height of the tarsus in females is 8.54 mm in upper and 5.84 mm in lower lids.2 Atrophy of the tarsal plate is known to cause involutional entropion.2, 3 Small tarsal plates in our patient contributed to the development of the entropion which manifested later with increased orbicularis tone and over-riding of orbicularis components. Clinically, this manifested at the age of 15 years and may well be related to the growth spurt during puberty. This case highlights a small tarsal plate as a causative factor for recurrent entropion in a young patient, which, to the best of our knowledge, has not yet been reported. The management of such patients is complex and may require a systematic approach.