A 68-year-old man presents to the ophthalmology clinic with a 6-month history of progressive irritation and redness of the left eye. He reports constant tearing, foreign body sensation, and mild mucoid discharge. On examination, the lower eyelid margin is turned inward, and the eyelashes are in contact with the cornea. Corneal abrasion is noted on fluorescein staining. The patient has a long-standing history of trachoma. What is the most likely diagnosis?

Explanation

## Diagnosis: Cicatricial Entropion ### Clinical Presentation The patient presents with a classic picture of cicatricial entropion: inward turning of the eyelid margin with lashes touching the cornea, causing corneal abrasion and tearing. The key historical clue is **long-standing trachoma**, which causes conjunctival scarring. ### Pathophysiology of Cicatricial Entropion 1. Chronic inflammation (trachoma, Stevens-Johnson syndrome, ocular cicatricial pemphigoid, chemical burns) leads to conjunctival fibrosis 2. Scar tissue contracts, pulling the eyelid margin inward 3. The tarsal plate rotates medially, inverting the lid margin 4. Eyelashes (trichiasis) rub against the cornea → abrasion, pain, tearing ### Key Distinguishing Features | Feature | Cicatricial | Involutional | Acute Spastic | |---------|-------------|-------------|---------------| | **Onset** | Gradual (chronic inflammation) | Gradual (age-related) | Sudden | | **Age** | Any (depends on cause) | Elderly | Any | | **Etiology** | Trachoma, SJS, pemphigoid, burns | Senile laxity, dehiscence | Orbicularis spasm, pain | | **Conjunctival changes** | Scarring, fornix loss | Normal | Normal | | **Tarsal plate** | Rigid, fibrotic | Lax | Normal | | **Trichiasis** | Present | Absent | Absent | | **Corneal involvement** | Common (abrasion) | Rare | Rare | **High-Yield:** Trachoma is the **leading infectious cause of preventable blindness worldwide** and is endemic in parts of India. Chronic trachoma (TF/TS stages) inevitably progresses to cicatricial entropion if untreated. ### Clinical Pearl **Key Point:** Cicatricial entropion is characterized by loss of the lower conjunctival fornix and conjunctival scarring on slit-lamp examination — findings absent in involutional entropion. ### Management Approach 1. **Acute management:** Lubricants, protective eyewear, bandage contact lens 2. **Definitive treatment:** Surgical correction (Wnt procedure, tarsal rotation, mucous membrane grafting) — more complex than involutional entropion due to scarring [cite:Yanoff & Duker Ophthalmology 5e Ch 7]