Ectropion

Ectropion is outward turning of the eyelid margin, exposing the palpebral conjunctiva and breaking the apposition of the lacrimal punctum to the globe. It nearly always affects the lower lid and causes epiphora, exposure keratopathy, and chronic conjunctival irritation.

• Types:
  • Involutional: horizontal laxity of the lid from stretching of the canthal tendons and lid tissue; the commonest, in older adults.
  • Paralytic: facial nerve (VII) palsy with loss of orbicularis tone; Bell, trauma, surgery, stroke, and tumours of the parotid or cerebellopontine angle.
  • Cicatricial: anterior lamella shortening from burns, trauma, chronic dermatitis, skin cancer, radiation, or previous surgery (blepharoplasty); causes include scarring of lamellar tissue and tethering.
  • Mechanical: lid tumour or oedema pulls the lid down.
  • Congenital: rare, with other anomalies (blepharophimosis syndrome, ichthyosis).
• Chronic exposure can lead to corneal ulceration, perforation, and vision loss.

• Persistent watering (epiphora) worsened by wiping the eye downward, a red and sore eye, discharge, and mucus.
• Eversion of the lid margin, with exposed, thickened, keratinised, red palpebral conjunctiva, eversion of the punctum, and lagophthalmos.
• Paralytic: unilateral lid droop with loss of facial expression, incomplete eye closure, Bell phenomenon, and corneal exposure.
• Cicatricial: skin scarring, lid retraction, and a lid that cannot be pushed into position (vertical shortening).
• Corneal staining inferiorly and ulceration in advanced cases.

• Clinical examination with attention to horizontal lid laxity (distraction test, snap back test), medial and lateral canthal tendon laxity, punctal position, skin scarring (the pinch test and upward lid push), and facial nerve function.
• Fluorescein staining of the cornea and tear break up time.
• Neurological evaluation and imaging (MRI of the brain and cerebellopontine angle, facial nerve) for paralytic ectropion.
• Biopsy of suspicious lid lesions (basal cell carcinoma and others) pulling the lid.
• Exclude dacryocystitis and punctal stenosis as separate causes of epiphora.

• Conservative: preservative free lubricants four to six times daily and ointment at night, moisture chamber goggles, lid taping at night, and treatment of dermatitis (topical corticosteroid, emollients) for cicatricial disease.
• Involutional ectropion (surgery):
  • Lateral tarsal strip to tighten the lower lid horizontally; success exceeds 90 percent.
  • Medial spindle (conjunctivoplasty) for punctal ectropion: a diamond shaped excision of tarsoconjunctiva below the punctum with absorbable sutures to invert the punctum; combined with a lateral procedure for medial and lateral laxity.
  • Medial canthal tendon plication or resuspension for medial laxity.
• Cicatricial ectropion: release of the scar and a full thickness skin graft (from the upper lid, retroauricular, or supraclavicular skin) to lengthen the anterior lamella, with a lateral canthal tightening; lower lid cartilage grafts if the posterior lamella is deficient. Treat the underlying cause such as skin cancer.
• Paralytic ectropion: temporary tarsorrhaphy or botulinum toxin to the levator (2.5 to 5 units for protective ptosis) while waiting for recovery of the facial nerve (up to 6 to 12 months); then upper lid gold weight (0.8 to 1.6 g) implantation, lateral tarsorrhaphy, lower lid tightening or suspension, and facial reanimation for permanent palsy.
• Mechanical ectropion: remove the mass or reduce oedema.
• Postoperative: antibiotic ointment (chloramphenicol 1 percent) for 1 week, skin care, sutures removed at 1 to 2 weeks, and review at 6 weeks.
• Complications: recurrence, overcorrection (entropion), lid retraction, graft contracture, corneal exposure, and wound infection.