Eyelid malpositions
Entropion: when the eyelid margin turns inward and the lashes rub
'It feels as though I have a grain of sand in my eye all the time — and it will not go away.' With an entropion the eyelid margin tips inward, and the lashes drag across the cornea with every blink. This is not a question of appearance: what rubs there rubs on the most sensitive surface of the eye. That is why an in-turned lid belongs in an assessment before the cornea takes damage — and not only once vision starts to fade.
What an entropion is
With an entropion the edge of the lid tips inward, towards the eye. The lashes therefore no longer point forward but onto the surface of the eye, and the lid margin itself rests against the eye instead of sweeping cleanly past it. With every blink — and there are several thousand a day — both brush across the cornea and the conjunctiva.
The German name describes it literally: an inward rotation of the eyelid margin. It is usually the lower lid that is affected, often on both sides, and usually in people past sixty. At the start it often shows only at times: the lid turns in after screwing the eyes up firmly or after sleep and rights itself again on its own. Later it stays turned in.
An entropion is one of several malpositions the lid can take up; an overview of the eyelid malpositions we treat is given on the parent page. If the eyelid margin tips not inward but outward, and the moist inner surface of the lid stands visibly away from the eye, you have the counterpart: Ectropion — the eyelid margin tipped outward. Both usually arise from the same age-related slackening and cause similar symptoms, but they need different procedures.
A distinction that is often lost in everyday life: not every rubbing lash comes from an in-turned lid. If the lid margin sits correctly and individual lashes still grow inward, that is called trichiasis — a different finding with a different treatment. The two look almost the same from the outside, and they can be told apart only at the slit lamp.
Symptoms — and why they are more than a nuisance
What those affected describe sounds harmless at first and becomes wearing over time:
- A foreign-body sensation — 'like a grain of sand' that will not rinse out
- Constant watering, often all day long. The wet eye here is not too much moisture but the answer to the rubbing
- Redness, burning and an eye that 'never quite settles'
- Light sensitivity and frequent screwing up of the eyes — which in turn intensifies the spasm of the lid muscle
- Eyelids stuck together in the morning and stringy mucus in the eye
- Blurred vision that improves briefly after blinking — a sign that the corneal surface is no longer smooth
- Pain in the eye that increases over weeks
The reason we take these symptoms more seriously than their harmless ring suggests: the cornea is the clear windscreen of the eye and has no replacement. Constant mechanical rubbing first produces superficial abrasions, which heal over on their own. If the rubbing continues, the surface can become inflamed, and an inflammation can turn into an ulcer — with the risk of a lasting clouding. How quickly something like that escalates, and how you recognise it, is described on the page about it: what an inflamed cornea means and how urgent it is.
A second reason an entropion is often recognised late: its symptoms are almost identical to those of a wetting disorder. Many of those affected use drops for months against a supposedly dry eye, and the drops even help a little — they simply change nothing about the cause. How the two can be told apart, and why an eyelid finding can be behind it, is set out under making sense of the symptoms of a dry eye. Anyone who has been using drops for months without it getting better often has not the wrong preparation but the wrong diagnosis.
Where an entropion comes from
Four routes lead to the same picture, and they differ considerably in treatment. Which one is present in your case is decided by the examination — not by your age and not by how long the symptoms have lasted.
Age-related — the usual case
By far the commonest form. Over the years the fine bands that anchor the lower lid to the bone at the sides slacken; at the same time the fibres that hold the lid in position from below lose their pull. Without that counter-support, the ring-shaped eyelid closing muscle can slip forward over the upper edge of the tarsal plate with every firm screwing-up of the eye and roll the margin inward from there. What is typical, therefore, is a start that comes in bouts: the lid turns in after screwing the eyes up firmly or after sleep, at first rights itself again — and at some point stays that way. It is practically always the lower lid that is affected, often both sides one after the other.
Caused by scarring
Here scar tissue on the inner surface of the lid pulls the margin inward. The causes are injuries and chemical burns, earlier procedures on the lid, radiotherapy to this region, or chronic inflammation and diseases of the conjunctiva. This form can affect the upper lid as well, which hardly happens with the age-related one — and it calls for a different, more involved approach, because the cause lies not in slackening but in a traction that has to be released first. If the scarring arises without a preceding injury, in both eyes and progressing over time, a disease of the conjunctiva is sometimes behind it that has to be treated not at the lid but beyond the eye — we look into that before any procedure and refer specifically for it.
Caused by spasm
An irritated eye screws itself shut, the screwing-up turns the lid in, the in-turned lid rubs and irritates still more: a circle that drives itself. Typical after eye operations, with severe inflammation or after a dressing has been worn for some time. If the irritation is treated, the malposition sometimes resolves again — provided the tissue has not already slackened anyway. If that does not break the circle, though, it does not stop at waiting: as long as the lashes rub, the eyelid position is corrected here too.
Congenital — rare
In babies and small children a true entropion is rare. More common, and usually more harmless, is an extra fold of skin on the lower lid that presses the lashes against the eye; it often grows out on its own. Persistent watering, light sensitivity or a child who is constantly screwing up one eye should still be looked at — children do not complain of a foreign-body sensation, they simply avoid it.
The two often come together: a slackened lid margin and a chronically inflamed one that keeps the irritation going. Where that is the case we treat the inflammation as well, otherwise the eye stays red even after a technically successful correction — what that involves is described on the page about the chronically inflamed lid margin and its treatment.
Why the correction is not a cosmetic question
With some eyelid findings the first question is whether it is about sight at all or about appearance. With entropion that question is already answered, and answered not by the impression in the mirror but by what is happening at the cornea.
A lash dragging on the cornea is a constant mechanical load on the most sensitive surface of the eye. The cornea has no blood vessels, it has to stay clear to do its job — and while it repairs superficial damage reliably, it does not do so without limit. Repeated abrasions can turn into an inflammation, the inflammation into an ulcer, the ulcer into a scar. If that scar lies in the line of sight, vision stays permanently worse. That last step is the only one in the chain that cannot be undone — and the only reason we advise correction with this finding rather than waiting.
For the cost question this gives a simpler answer than many expect: a malposition whose lashes rub the cornea is treatment of illness. Where the indication is documented, the correction runs through basic health insurance (OKP), with the deductible and co-payment as with any other procedure. What that means in detail is set out further down in the section on costs.
How we examine the lid
The examination takes longer than a routine follow-up, because it has to answer two questions at once: how the lid sits — and what the cornea has already taken from it.
- Eyelid position at rest and in movement. We do not only look at the lid; we also ask you to screw your eyes up firmly and open them again. Many entropions show themselves only then — sitting relaxed, the lid appears to sit correctly.
- Tension of the lid ligaments. A gentle pull on the lower lid shows how far the tissue has slackened and how quickly the lid margin returns to the eye. That test helps decide which procedure is the right one.
- Lashes and lid margin at the slit lamp. The direction and number of the rubbing lashes, the state of the lid margin, the openings of the eyelid glands, the position of the tear punctum. This is also where entropion separates from trichiasis.
- Staining of the cornea. A dye makes abrasions and defects visible that stay invisible without it. That is the finding which decides the urgency — not the account of the symptoms.
- Inner lid surface and tear film. With the lid turned over we assess the conjunctiva for scars and scar traction — the difference between the age-related and the scarring form. Along with the tear film and whether eyelid closure is complete.
- History. Previous lid operations, injuries, chemical burns, radiotherapy, skin conditions, blood-thinning medicines, a tendency to noticeable scars.
By the end of this appointment you know three things: which form is present, whether the cornea has already taken damage, and whether a correction is due or a follow-up is enough.
What helps in the short term — and what solves it for good
Both have their place, and the order matters. Conservative measures relieve the symptoms and protect the cornea while an appointment is still pending. They do not change the position of the lid.
What bridges the time until the procedure
- Wetting. Moistening drops during the day, an eye ointment at night. They make the film between lash and cornea glide more easily and noticeably relieve the foreign-body sensation. With frequent use, preservative-free preparations are more comfortable.
- Taping. A narrow strip of tape pulls the lower lid slightly down and outward towards the cheek, so that the lid margin no longer rests against the eye. A usable stopgap — one we show you before you try it at home: applied wrongly, the pull prevents complete eyelid closure and dries the eye out further.
- An appointment for the follow-up, not just for the waiting. Where we wait, the waiting gets a date: a lid that turns in only at times belongs in a follow-up — staining of the cornea shows a deterioration before you notice it. If the symptoms get worse before then, the earlier appointment applies and not the one arranged.
What we expressly do not recommend: pulling out the rubbing lashes at home. They grow back shorter and with a sharper tip, and scratch more afterwards than they did before.
The surgical correction — the actual standard
An in-turned eyelid margin can be set back permanently only by surgery. The procedure is done as a rule as an outpatient under local anaesthetic; you are awake and responsive, feel the prick of the anaesthetic and after that usually a sensation of pressure or pulling. The sutures are of very fine material, usually removed after about a week.
With the age-related form the principle is always the same, even though the technique follows the findings: the slackened tissue is tightened and anchored again, the missing support from below is restored, and the lid margin is set so that it points outward once more. On the lower lid the incision lies close beneath the lash line; a natural crease in which it could disappear — unlike on the upper lid — does not exist there. How much is tightened follows from the measurement beforehand: too little, and the margin goes on turning in; too much, and it tips the other way and stands away from the eye. Either would be a mistake, and avoiding both is the real part of the work.
With the scarring form that is not enough. As long as scar tissue is pulling on the inner surface of the lid, tightening on its own achieves little; here that pull has to be released first and the inner surface rebuilt. That is more involved, occasionally staged, and the underlying disease belongs in the treatment too. The order here is not negotiable: We operate only once the inflammation on the inner surface of the lid has settled. A procedure during the active phase can worsen the scarring rather than release it — that is why we wait here even when the symptoms are pressing. The exception is again the cornea: if the surface takes damage and protection and moistening are not enough, we operate earlier. With the spasm-related entropion, by contrast, treating the irritation comes first — if the malposition resolves with that, no procedure is needed.
We do not promise a result that lasts. What is corrected is the position of the lid, not the ageing of the tissue: where the slackening is very marked, the margin can tip again after years, and a corrective procedure is then needed. How stable it looks in your case we tell you after the examination — before it, it would be a guess.
What the correction can achieve, what it cannot — and what risks it carries
What it is meant to achieve: The lid margin points outward again, lashes and margin no longer touch the cornea, the rubbing stops — and the chafed surface gets the rest it needs to heal.
What it does not achieve — and we would rather say this beforehand than afterwards:
- The foreign-body sensation does not end with the procedure. The eyelid position is corrected immediately; the irritated corneal surface needs days to weeks after that.
- A corneal scar that has already formed does not disappear. The procedure prevents the next one; it does not take away the one that is there.
- A dry eye is not put right by it. If there is also a disturbance of the tear film, it remains and goes on being treated.
- Ageing does not stop. The tissue goes on slackening, and after years the margin can tip again.
- An exactly symmetrical result cannot be promised; small differences between the two eyes often remain.
The risks include swelling and bruising over one to two weeks, temporarily dry or irritated eyes, altered sensation along the scar and a visible scar beneath the lash line. Added to that is the point that belongs with this finding in particular: a lid margin that sits too loosely at first goes on turning in, one that is too tight tips the other way and stands away from the eye — instead of the inward turn you then have the counterpart described further up, and a corrective procedure is needed. Less common are post-operative bleeding, infection and problems with wound healing; very rare are serious complications up to and including an impairment of vision. No procedure on the eye is without risk, and we discuss these points openly with you beforehand.
If you would like to have this assessed, you can do so by phone on +41 44 500 69 00, Mon–Fri 08:00–12:00 / 13:00–17:30, or book an appointment online for the eyelid consultation.
After the procedure
The follow-up treatment is unspectacular, and that is exactly how it should go. What to expect:
- Swelling and bruising at their worst in the first few days, often unequal between the sides, then settling over one to two weeks. Cooling helps most in the first forty-eight hours.
- Drops and ointment as instructed — usually an ointment for the wound and moistening drops for the surface. Exactly which and for how long, we tell you when we write the prescription.
- Suture removal as a rule after around a week, together with the first follow-up check of the eyelid position and the cornea.
- Do not rub, do not press, even when it itches. No eye make-up until the wound has closed; contact lenses only once expressly cleared.
- Sport, heavy lifting, sauna and sunbeds should be put off for around two weeks. Office work is often possible again after a few days.
- Keep your follow-up appointments, even when everything looks fine. Whether the lid margin sits cleanly against the eye and the cornea has healed is shown by the slit lamp and not by the mirror.
So do not plan the procedure for the week before an occasion at which you will be photographed — and expect the suture line to be visible at first as a fine reddened line that fades over months.
When you should not wait
An entropion usually develops over months, and the great majority of findings have time for a regular appointment. These signs do not — call us the same day if one of these applies:
- Increasing pain in the eye, not just burning or scratching
- Markedly worse vision, which does not improve after blinking
- Marked light sensitivity, which makes you screw up your eye
- A whitish spot on the otherwise clear cornea
- Purulent discharge or an eye that is rapidly becoming redder
- Contact lenses and an irritated eye — lenses out and call
That combination suggests that the cornea is no longer merely irritated but inflamed, and that is the situation in which weeks become days. Our number: +41 44 500 69 00, Mon–Fri 08:00–12:00 / 13:00–17:30; for findings of this kind we keep short-notice appointments free. Outside consulting hours the ophthalmic emergency service applies.
Not everyone feels damage to the cornea, and that is why pain does not stand on its own in the list above. After a herpes infection of the eye, after operations on the cornea and with long-standing diabetes, sensation in the cornea can be reduced — a larger defect then runs its course almost painlessly. With age-related entropion in particular this affects a substantial proportion of those affected. Anyone in that group goes not by the pain but by what can be seen: clouding, discharge, increasing redness, worse vision.
And so that it comes out right in the other direction as well: an eye that has been scratching and watering for weeks but sees as well as before, shows no whitish spot, is not discharging pus, is not rapidly getting redder and does not hurt more and more, is not an emergency. It is a reason for an appointment in the next few days — not for a trip to the emergency department.
Costs & health insurance
What does the insurer pay for — and what not?
With entropion the cost question is simpler than with some other eyelid findings: if lashes or the lid margin rub on the cornea, the correction is treatment of illness and not an aesthetic service. What that means in practice is set out here.
| Service | Coverage | What this means for you |
|---|---|---|
Ophthalmic assessment of the eyelid findings | Basic insurance (OKP) | You come with symptoms — a foreign-body sensation, watering, a reddened eye — so the assessment is treatment of illness. The deductible and co-payment apply as at any doctor's appointment. That holds even when the examination shows in the end that no procedure is needed. |
Slit-lamp examination with staining of the cornea and documentation of the findings | Same as for the assessment | The finding on which everything else builds: the position of the lid margin and lashes, the state of the cornea. It is at the same time the documentation of the medical indication that carries the procedure. |
Surgical correction of the entropion where there is a medical indication | Basic insurance (OKP) | An inward-turned eyelid margin in contact with the cornea is a functional finding; the procedure is billed accordingly. If your insurer requires cost approval in advance, we submit the findings and the documentation before the appointment and wait for written confirmation. |
Moistening drops and ointments as a stopgap | Varies by preparation | Whether a preparation is covered depends on whether it is on the Federal Specialities List and has been prescribed by a doctor. Some artificial tears patients pay for themselves — we tell you when we write the prescription which is which. |
Follow-up checks, suture removal and aftercare | Same as for the procedure itself | Aftercare follows how the operation is classified. With a medically justified procedure it goes through basic health insurance. |
Aesthetic correction additionally requested on the same part of the lid | Self-pay | If you would like an aesthetic change beyond the correction of the malposition, that part is billed separately. What belongs to which we set down in writing before the procedure, not after it. |
There are deliberately no amounts here: what is involved depends on the findings — an age-related tightening and a reconstruction for scarring are two different procedures — and a figure without an examination would be a guess. Where a cost estimate is needed, you receive it in writing before you have to decide.
A tax point that surprises many: with purely aesthetic procedures VAT is added; with medically indicated treatment it is not. That too is in the cost estimate.
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Medically reviewed by PD Dr. med. Andrea von Rückmann · Last reviewed
Frequently asked questions
- Not for the lid itself — for the cornea, yes. The lashes and the in-turned lid margin scrape across the surface of the eye with every blink, several thousand times a day. At first that produces only superficial abrasions, which heal over again on their own. If the rubbing persists over weeks and months, the cornea can become inflamed, in an unfavourable course form an ulcer, and in the end be left with a scar. A corneal scar in the line of sight clouds vision permanently, and that part cannot be undone. That is exactly why an entropion is not a finding to sit out. It is not an emergency as long as you see as well as before, no whitish spot is visible on the cornea, nothing is discharging pus, the eye is not rapidly getting redder and the symptoms are not increasing — what counts is the complete list in the section 'When you should not wait', not the pain alone. This is not splitting hairs: anyone whose corneal sensation is poorer — after a herpes infection of the eye, after operations on the cornea or with long-standing diabetes — can have considerable damage without it hurting. Then what can be seen is what counts.
- It can be put right permanently only by surgery — the lid margin does not turn back on its own, and no drops in the world change the position of the lid. That does not mean, though, that every finding belongs in the operating theatre straight away. If the lid turns in only at times, say after screwing the eyes up firmly or in the morning after waking, and the cornea is clear on staining, watching with good wetting is a defensible decision. If the cornea already shows abrasions, by contrast, or the lashes rub constantly, we advise correction rather than waiting. What applies in your case is told by the examination — not by how long the symptoms have lasted.
- Where there is a medical indication, yes: an inward-turned eyelid margin whose lashes rub the cornea is treatment of illness and not an aesthetic service — the correction runs through basic health insurance in that case. The deductible and co-payment apply as with any other procedure. The indication has to be documented: the finding at the slit lamp, the position of the lid margin and lashes, staining of the cornea. If you would also like a purely aesthetic correction on the same lid, that part is billed separately and is self-pay; what belongs to which we set down in writing before the procedure. Whether your insurer requires cost approval in advance is something we settle with you before an appointment is fixed.
- The direction. With an entropion the eyelid margin tips inward, towards the eye — the lashes disappear from view and rub on the cornea. With an ectropion it tips outward, away from the eye — the lid margin stands away, the moist inner surface becomes visible, and the tear punctum loses contact with the eye. The symptoms are confusingly alike: both findings lead to a watering, reddened, irritated eye, and both usually arise from the same age-related slackening of the lid tissue. They are treated differently, which is why the examination at the slit lamp comes first and not self-diagnosis in the mirror.
- The procedure is done as a rule as an outpatient under local anaesthetic. You are awake and responsive; what you feel is the prick of the anaesthetic, and after that usually a sensation of pressure or pulling. Expect around one to two weeks in which the procedure is visible on you: swelling and bruising are at their worst in the first few days, and the fine sutures are usually removed after around a week. Office work is often possible again after a few days; sport, heavy lifting, sauna and sunbeds are better put off for around two weeks. A foreign-body sensation can persist a while longer, until the irritated corneal surface has healed completely — that is the part that often comes as a surprise.
- Yes, that is possible, and we would rather say so beforehand than afterwards. What is corrected is the position of the lid, not the ageing of the tissue: if the slackening is very marked, the lid margin can tip inward again after years, and a corrective procedure is then needed. With forms caused by scarring, stability also depends on whether the underlying disease on the inner surface of the lid stays quiet. That is why you will find no percentages and no promises of durability on this page — what we can tell you is how your tissue looks and what that means for the outlook.
- Two things, and both only buy time. First, wetting: moistening drops during the day, an eye ointment at night, and preservative-free preparations with frequent use. They make the film between lash and cornea glide more easily and noticeably relieve the foreign-body sensation. Second, taping: a narrow strip of tape pulls the lower lid slightly down and outward towards the cheek, so that the lid margin no longer rests against the eye. That is a stopgap, one we show you before you try it yourself at home — applied wrongly, the pull prevents eyelid closure and dries the eye out further. What you should on no account do: pull out the rubbing lashes yourself.
Rubbing lashes are not a condition you get used to.
In the eyelid consultation we establish in a single appointment how the lid sits, whether the cornea has already suffered and whether a correction is due. You decide afterwards — with the findings in front of you.
+41 44 500 69 00 — Mon–Fri 08:00–12:00 / 13:00–17:30. Or book an appointment online.
