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© 2009 American College of Veterinary Ophthalmologists
Veterinary Ophthalmology
(2009)
12
, 4, 221–226
Blackwell Publishing Inc
Feline entropion: a case series of 50 affected animals (2003–2008)
David L. Williams and Joon-Young Kim
Department of Veterinary Medicine, University of Cambridge, Cambridge CB3 0ES, UK
Abstract
Aim
To evaluate the signalment, clinical signs, and etiopathogenesis of entropion in 50 cats.
Methods
Signalment and history of 50 cases of entropion in cats presented to a referral
ophthalmology clinic. Animals were examined with direct and indirect ophthalmoscopy
and slit-lamp biomicroscopy. Animals were treated surgically with a Hotz-Celsus
procedure and results of surgery were evaluated between 4 and 22 weeks.
Results
Sixteen cats were young (mean age 4.1 ± 3.6 years) with pre-existing irritative
ocular surface conditions such as conjunctivitis, corneal ulceration or sequestrum.
Twenty-six cats were relatively older (mean age 11.3 ± 2.2 years) with involutional
entropion with or without enophthalmos, presumed to result from a reduction in orbital
tissue. Five cats were Persians with entropion associated with brachycephalic facial
anatomy, whereas three were entire young adult male Maine Coones with in-turning
associated with excessive facial ‘jowl’ tissue. Surgical treatment was curative in the
majority of cases after one surgery although an increased amount of eyelid tissue was
required to be removed for correction compared with similar surgery in the dog.
Discussion
This study has shown that entropion in cats may be caused in young animals
as a result of continued blepharospasm related to irritative causes such as conjunctivitis
or corneal ulceration or in older animals with lid laxity or globe enophthalmos. Lid
in-turning was also seen in Persian and Maine Coone breeds.
Key Words:
cat, conjunctivitis, entropion, eyelid, irritation
Address communications to:
D. L. Williams
Tel.: 07 939 074682
Fax: 44 1223 232977
e-mail:
doctordlwilliams@aol.com or
dlw33@cam.ac.uk
INTRODUCTION
Entropion, lid in-turning, is common in dogs and widely
documented in the veterinary literature with reports on the
condition in different breeds of dog
1,2
with varying anatomical
peculiarities
3,4
and with a number of different surgical
techniques used to correct the lid defect.
5,6
Yet in the cat the
condition is hardly reported and while it has been noted in
general reviews of ocular disease in this species,
7,8
sizeable
studies of case series have not been published. The fourth
edition of Professor Gelatt’s
Magnum Opus
Veterinary
Ophthalmology devotes a mere 18 lines to the condition,
9
whereas Barnett and Crispin’s Beautiful Atlas gives a page of
information on the condition but considers it ‘an uncommon
problem in the cat.’
10
A survey of Medline shows 41 published
articles on canine entropion but only 14 including informa-
tion on feline entropion with only one of these, that of
Weiss,
11
is a case series focusing solely on lid in-turning in
the cat. This paucity of data does not, however, accurately
reflect the prevalence of entropion in the cat. Here we
report 50 cases of feline entropion, seen over the past 5 years
in young cats, in older animals and in specific breeds, the
Persian and the Maine Coone. Both of these breeds have
eyelid in-turning associated with specific facial anatomical
features while the entropion in young cats is generally linked
with persistent ocular surface irritation such as conjunctivitis
and keratitis. In the older animal the entropion appears
associated with lid laxity as is seen in geriatric humans or
enophthalmos with lid in-turning as a secondary feature. In
these ways feline entropion differs quite substantially from
the condition in dogs, where tarsal plate deformities seen in
several breeds,
1
excess facial skin in breeds such as the Shar
Pei
12
or drooping of facial tissue
3
are important causes of lid
in-turning.
MATERIALS AND METHODS
Animals
The 50 animals reported herein were examined at either
the Department of Veterinary Medicine, Queen’s Veterinary
222
williams and kim
© 2009 American College of Veterinary Ophthalmologists,
Veterinary Ophthalmology
,
12
, 221–226
School Hospital, University of Cambridge (14 cases) or in a
series of first opinion clinics for which the senior author
provides an ambulatory ophthalmology referral service
(36 cases).
Diagnostic and therapeutic techniques
After the taking of a full signalment and history, each animal
underwent a full ophthalmic examination involving direct
and indirect ophthalmoscopy (using a Welch Alynn direct
ophthalmoscope and Keeler Vantage indirect ophthalmoscope,
Keeler, Windsor, UK) and examination with slit-lamp bio-
microscopy (initially using SL-15 slit lamp, Kowa, and latterly
Hawkeye slit lamp, Dioptrix, France). Photographic docu-
mentation was achieved using a Coolpix 4500 digital camera
and the Hawkeye slit lamp. Lid conformation was evaluated
before and after application of local anesthetic (1% Minims
Tetracaine, Chauvin Pharmaceuticals, Romford, UK) to the
ocular surface.
Diagnostic samples in cases of conjunctivitis were obtained
as previously reported
13
and subjected to polymerase chain
reaction for the diagnosis of feline herpesvirus, feline
Chlamydophila and feline Mycoplasma.
14
Surgery was performed under anesthesia with propofol
induction and maintenance with gaseous anesthesia after
endotracheal intubation using isoflurane in 100% oxygen.
The Hotz-Celsus procedure was used to remove a tarsal
strip of skin everting the lid as previously reported.
6
RESULTS
The signalment and clinical signs of the animals examined
are detailed in Table 1. Twenty-six animals were older cats
with a mean age of 11.3 ± 2.2 years. Twenty-one of these
animals had involutional entropion without an obvious cause
for lid in-turning either unilaterally (Fig. 1a) or bilaterally
(Fig. 1b). Five cats in this group had varying degrees of
enophthalmos evident presumed to be caused by a reduction
in orbital fat although in no cases would owners allow a
magnetic imaging study to quantify this and B-mode
ultrasonography was not sufficiently precise to allow accurate
evaluation of the depth of the retrobulbar space. In 11 of
these older cases trichiasis was evident with significant
worsening of the lid in-turning through spastic entropion
(Fig. 2a). Although there was some amelioration of entropion
with local anesthetic, the trichiasis still remained as a
problem giving persistent blepharospasm. Four cats had a
previous history of conjunctivitis, although none in this
group had ongoing inflammatory ocular surface disease at
the time of presentation.
Sixteen cats were young with an average age of 4.1 ±
3.6 years and in these animals irritative foci such as persistent
conjunctivitis, unilateral (Fig. 3a) or bilateral (Fig. 3b),
corneal ulceration (Fig. 4) or sequestrum (Fig. 5). Three
Figure 1. (a) Unilateral entropion with enophthalmos in a 15-year-old
domestic long haired cat (case 24). (b) Bilateral entropion with
enophthalmos and blepharospasm in a 10-year-old domestic
Short haired cat (case 28).
Figure 2. Entropion with enophthalmos shown by the protruding
third eyelid and with substantial resultant trichiasis in a 13-year-old
domestic Short haired cat (case 20).
© 2009 American College of Veterinary Ophthalmologists,
Veterinary Ophthalmology
,
12
, 221–226
feline entropion
223
animals were diagnosed with FHV-1-related conjunctivitis
by PCR and two were diagnosed as infected with feline
chlamydophila. Treatment with topical acyclovir was instituted
for the former cases while the latter were treated with topical
chlortetracycline and doxycycline
per os
. In one case distichiasis
was present (Fig. 6). Initial observations appeared to show
only an entropion associated with idiopathic irritation
(Fig. 6a) while eversion of the lid demonstrated the presence
of a small number of distichial lashes (Fig. 6b). Five cases were
Persian cats in which the brachycephalic facial characteristics
led to lid in-turning with trichiasis and abrasion of lid hairs
on the ocular surface, further worsening blepharospastic lid
in-turning. Three cats were male entire Maine Coones in
which the large ‘jowls’ of these adult males caused lid in-
turning and trichiasis (Fig. 7a–c).
Treatment of these animals was by a standard Hotz-Celsus
technique, which resolved the lid in-turning after a single
operation in the vast majority of cases (Fig. 2b). Two younger
T
able 1. Signalment and clinical signs of entropion in 50 cats
Case Breed Age (years) Sex Eye Ophthalmic examination details
1 Dsh 0.8 fe ou Persistent conjunctivitis and blepharitis with self trauma and entropion of all four lids
2 Dsh 1.5 fn ou Conjunctivitis and ocular irritation with subsequent entropion of all four lids
3 Burmese 0.6 fe os Distichiasis with persistent irritation and subsequent entropion
4 Dsh 1.0 mn ou FHV-1-related conjunctivitis with irritation and subsequent entropion
5 Dsh 1.2 fn os FHV-1-related conjunctivitis with irritation and subsequent entropion
6 Dsh 1.8 mn ou Chlamydophila-related conjunctivitis with irritation and subsequent entropion
7 Dsh 3.6 fn os Persistent corneal ulceration with irritation and subsequent entropion
8 Dsh 5.3 mn ou Corneal sequestrum with irritation and subsequent entropion
9 Dsh 7.8 fn ou Corneal sequestrum with irritation and subsequent entropion
10 Dsh 4.5 mn os Corneal ulceration and early sequestrum formation with irritation and entropion
11 Dsh 2.1 fn ou Mycoplasma-related conjujnctivitis with irritation and subsequent entropion
12 Dsh 5.4 me od Post-trauma entropion
13 Dsh 6.4 mn od Idiopathic ocular irritation with sequestrum formation and entropion
14 Exotic Shorthair 5.4 fn ou Chlamydophila-related conjunctivitis with irritation and subsequent entropion
15 Burmese 7.5 mn ou Idiopathic conjunctivitis with irritation and subsequent entropion
16 Burmese 3.4 mn ou FHV-1-related conjunctivitis with irritation and subsequent entropion
17 Dsh 12.2 fn ou Mild enophthalmos with loss of retrobulbar tissue and lower lid entropion
18 Dsh 10.2 fn ou Moderate enophthalmos with subsequent lower lid entropion
19 Dsh 10.2 fn ou Mild enophthalmos with loss of retrobulbar tissue and lower lid entropion
20 Dsh 13.0 fn ou Mild enophthalmos with trichiasis and subsequent lower lid entropion
21 Dsh 15.0 mn ou Substantial enophthalmos with trichiasis and lower lid entropion
22 Dsh 12.4 mn ou Lid laxity with normal globe position but significant lower lid entropion
23 Dsh 14.3 mn ou Lid laxity with mild lower lid entropion
24 Dsh 15.2 mn ou Lid laxity with moderate lid entropion and resultant trichiasis
25 Dsh 8.4 mn ou Lid laxity with substantial lid entropion and resultant trichiasis
26 Dsh 9.5 fn ou Lid laxity with mild lower lid entropion
27 Dsh 8.3 fn ou Lid laxity with mild lower lid entropion
28 Dsh 10.2 fn ou Lid laxity with moderate lid entropion and resultant trichiasis
29 Dsh 11.5 fn ou Lid laxity with moderate lid entropion and resultant trichiasis
30 Dsh 13.2 fn ou Lid laxity with trichiasis and significant lower lid entropion
31 Dsh 12.2 fn ou Lid laxity with moderate lower lid entropion and early trichiasis
32 Dsh 8.7 mn ou Mild lower lid entropion
33 Dsh 9.6 mn ou Mild lower lid entropion
34 Dsh 10.5 mn ou Moderate lower lid entropion with some early trichiasis
35 Dsh 7.5 fe ou Moderate idiopathic lower lid entropion with normal globe position
36 Dsh 12.2 fn ou Lid laxity with trichiasis and significant lower lid entropion
37 Dsh 13.1 mn ou Lid laxity with trichiasis and significant lower lid entropion
38 Dsh 12.0 fn ou Mild lower lid entropion
39 British Blue 7.5 me ou History of previous conjunctivitis but current entropion of all lids
40 Exotic Shorthair 8.6 fn ou History of previous conjunctivitis but current entropion of all lids
41 Colourpoint 9.2 fe ou History of previous conjunctivitis but current entropion of all lids
42 Siamese 8.4 fn ou History of previous conjunctivitis but current entropion of all lids
43 Persian 4.6 mn ou Brachycephalic face with lower lid trichiasis and subsequent entropion
44 Persian 6.7 fn ou Brachycephalic face with lower lid trichiasis and subsequent entropion
45 Persian 5.2 fn ou Brachycephalic face with trichiasis and subsequent entropion
46 Persian 3.9 mn ou Brachycephalic face with trichiasis and subsequent entropion
47 Persian 8.5 fn ou Brachycephalic face with trichiasis and subsequent entropion
48 Maine Coone 0.8 me ou Lower lid entropion with pronounced jowls
49 Maine Coone 1 me ou Lower lid entropion with pronounced jowls more pronounced in right eye
50 Maine Coone 1.5 me ou Lower lid entropion with pronounced jowls
224
williams and kim
© 2009 American College of Veterinary Ophthalmologists,
Veterinary Ophthalmology
,
12
, 221–226
cats (cases 4 and 7) and three older cats (cases 30, 36 and 37)
required a further operation while two Maine Coone cats
(cases 48 and 49) required further surgery. A greater amount
of lid skin was needed to be removed for adequate correction
in the majority of cats than would be the case in a similar
condition in the dog. It appeared that long-term resolution
of the eyelid in-turning was best achieved with surgery,
which in the immediately post-operative period resulted
in a mild ectropion. Within one week this out-turning had
resolved to leave a perfectly apposed lid margin and ocular
surface. A surgery resulting in perfect apposition in the
immediate post-operative period, as occurred with the five
cases noted above, led to long-term failure with recurrent
mild entropion and the need to perform a second resection
of eyelid skin.
Figure 5. (a) Lower lid medial entropion occurring subsequent to
blepharospasm associated with a corneal sequestrum (case 9). (b) Mild
lower lid entropion occurring subsequent to blepharospasm associated
w
ith a corneal sequestrum (case 13).
Figure 3. (a) Domestic Short haired cat with entropion unilaterally
w
ith concurrent severe conjunctivitis (case 5). (b) Domestic
Short haired cat with entropion bilaterally with concurrent chronic
conjunctivitis (case 1).
Figure 4. Lower lid entropion in a cat with a concurrent corneal ulcer
also demonstrating early sequestrum formation after development of
the entropion (case 10).
© 2009 American College of Veterinary Ophthalmologists,
Veterinary Ophthalmology
,
12
, 221–226
feline entropion
225
DISCUSSION
It should not be surprising that cats as well as dogs can
suffer from entropion. Indeed, what is surprising is that
the condition has not been more widely recognized and
reported in the veterinary ophthalmic literature. It might
be considered that the prevalence of the disease is lower in
the cat than in the dog, although determining a prevalence
is impossible without knowing the denominator data regard-
ing the number of animals in the population from which
these animals were taken. Over the same time period the
authors examined 356 dogs with entropion, allowing the
tentative suggestion that dogs may be affected around
seven times as frequently as cats. A recent study document-
ing a surgical approach to entropion in dogs and cats
15
evaluated the technique in 269 dogs and 42 cats, a proportion
of 6.4 to 1, not dissimilar to our relative prevalence of 7.12
to 1. More importantly, canine and feline cases of entropion
differ in their presentation and etiopathogenesis.
A case series such as the current one shows the different
forms of entropion seen in this species. Barnett and Crispin
10
consider feline entropion to occur with anatomical, spastic
or cicatricial etiopathology although their comments in a
text and atlas are understandably not supported by numerical
evidence. In the present series of cases we did not encounter
cicatricial entropion but found that there are two main
etiopathogenic origins of the condition. The first is seen in
younger animals where ocular surface irritation from con-
junctivitis, corneal ulceration or corneal sequestrum causes
lid in-turning. In one case distichiasis was noted (Fig. 6). It
might be asked whether corneal ulceration or the effect of
the lid in-turning was the cause, although it was considered
in the animals here given the history taken from the owners
that it was local irritation that first caused the blepahrospasm
and next the lid in-turning. It might well be suggested that
Figure 6. (a) Entropion with trichiasis in a 6-month-old Burmese cat
(case 3). (b) Eversion of the lid in the cat in Fig. 6a reveals the distichia
initially causing the blepharospasm leading to entropion.
Figure 7. (a) One-year-old entire Maine Coone cat showing entropion
associated with pronounced facial ‘jowls’ (case 49). (b) Entropion,
predominantly of the right eye although occurring in both, in the son
of the cat in Fig. 7a (case 50) again showing the pronounced ‘jowls’
resulting in the lid in-turning.
226
williams and kim
© 2009 American College of Veterinary Ophthalmologists,
Veterinary Ophthalmology
,
12
, 221–226
one lesion accentuates the other in a vicious circle. In the
present authors’ opinion this has to remain a conjecture.
The second form of the condition occurs in older animals
and here it seems that lid laxity or tension with or without
enophthalmos, presumed to be from a loss of retrobulbar
tissue in older cats, is the primary problem that results in
entropion with subsequent trichiasis (Fig. 2). Entropion in
the dog is related to anatomical abnormalities of the lid tarsal
plate, lid length or lateral ligament laxity, or to facial skin
abnormalities in breeds such as the Shar Pei when young or
Cocker Spaniels when older. Entropion in the cat appears
quite different from that in the dog with in-turning associated
predominantly either with persistent ocular surface irritation
and blepharospasm in young animals and increased lid tension
or enophthalmos in older individuals.
The finding of entropion in brachycephalic breeds such as
the Persian has been anecdotally noted previously,
8
although
this was in a review article and without the details of specific
cases noting signalment and ocular signs. Barnett and Crispin
consider anatomical entropion ‘is most commonly seen in the
Persian cat...in which it may be present from an early age
and usually involves the lower eyelid and particularly the
medial aspect of the eyelid initially.’ We have not seen this in
our present study, which serves to show the limitations of a
case series from one clinician, even when it contains 50 animals.
The finding of entropion in Maine Coone cats (Fig. 7a,b),
associated with the prominent jowl or cheek tissue seen in
young entire adult male cats is, to our knowledge, a new
finding. Related females did not have the marked facial
features of the males and hence were not affected by entropion.
In all these cases where entropion is severe, the point at
which trichiasis occurs seems a critical one whereby irritation
leads to increased blepharospasm and lid in-turning and
further irritation. This is seen in the dog also, but appears
particularly problematic in the cats in this series.
It is widely known that entropion can be corrected in many
cases with resection of a skin strip, the so-called Hotz-Celsus
procedure.
5,6
In the cats presented here the amount of skin
requiring removal to effect a permanent repair was some-
what greater than in similar surgery in the dog. While in the
dog a good apposition of eyelid margin with ocular surface at
the close of surgery is sufficient to give a good long-term
result, it would appear that in the cat a mild ectropion at the
end of surgery results in a good long-term correction while
a perfect apposition of lid margin with the ocular surface as
the animal recovers from anesthetic can lead to a recurring
entropion in the weeks after surgery. Primary surgery was
not adequately corrective in two of the three Maine Coone
cats where a greater amount of skin needed to be removed
than would be required in the majority of cats in this study.
CONCLUSION
It might seem surprising that a relatively common condition
such as entropion in the cat has, to date, been so poorly
documented. Indeed, it may be the fact that this is not an
unusual abnormality that has led to this lack of reporting.
Having evaluated these 50 cases, however, we see entropion
in the cat as quite a different condition from that in the dog,
one with different causes and a modification of the surgical
treatment required for long-term correction. It is hoped
that this article will encourage veterinarians to recognize
and treat feline entropion more successfully than previously.
REFERENCES
1. Miller WM, Albert RA. Canine entropion.
Compendium of Continu-
ing Education
1988;
10
: 431–438.
2. Willis AM, Martin CL, Stiles J
et al
. Brow suspension for treatment
of ptosis and entropion in dogs with redundant facial skin folds.
Journal of the American Veterinary Medical Association
1999;
214
:
660–662.
3. Stades FC. A new method for surgical correction of upper eyelid
trichiasis–entropion: operation method.
Journal of the American
Animal Hospital Association
1987;
23
: 603–606.
4. Robertson BF, Roberts SM. Lateral canthus entropion in the dog,
part 1: comparative anatomic studies.
Veterinary and Comparative
Ophthalmology
1995;
5
: 151–156.
5. Van der Woerdt A. Adnexal surgery in dogs and cats.
Veterinary
Ophthalmology
2004;
7
: 284–289.
6. Lackner PA. Techniques for surgical correction of adnexal disease.
Clinical Techniques in Small Animal Practice
2001;
16
: 40–50.
7. Priester WA. Congenital ocular defects.
Journal of the American
Veterinary Medical Association
1972;
160
: 1504–1509.
8. Narfstrom K. Hereditary and congenital ocular disease in the cat.
Journal of Feline Medicine and Surgery
1999;
1
: 135–141.
9. Stiles J, Townsend WM. Feline ophthalmology. In:
Veterinary Oph-
thalmology
, 4th edn. (ed. Gelatt KN). Blackwell Publishing, Ames,
IA, 2007; 1096.
10. Barnett KC, Crispin SM.
Feline Ophthalmology: an Atlas and Text
.
W.B. Saunders Co Ltd, London, 1998; 48.
11. Weiss CW. Feline entropion.
Feline Practice
1980;
10
: 38–45.
12. Muller GH. Skin disease in the Shar Pei.
Veterinary Clinics of North
America Small Animal Practice
1990;
20
: 1655–1670.
13. Maggs DJ, Lappin MR, Reif JS
et al
. Evaluation of serologic and
viral detection methods for diagnosing feline herpesvirus-1
infection in cats with acute respiratory tract or chronic ocular disease.
Journal of the American Veterinary Medical Association
1999;
214
:
502–507.
14. Sykes JE, Allen JL, Studdert VP
et al
. Detection of feline calicivirus,
feline herpesvirus 1 and Chlamydia psittaci mucosal swabs by
multiplex RT-PCR/PCR.
Veterinary Microbiology
2001;
81
: 95–
108.
15. Read RA, Broun HC. Entropion correction in dogs and cats using
a combination Hotz-Celsus and lateral eyelid wedge resection:
results in 311 eyes.
Veterinary Ophthalmology
2007;
10
: 6–11.
