Continuing Education Activity

Ectropion is an eversion or outward turning of the eyelid margin leading to loss of the natural apposition of the eyelid to the globe. Ectropion may be classified as congenital, involutional, paralytic, cicatricial, or mechanical. Patients with ectropion report symptoms of corneal exposure, irritation, or epiphora due to ocular exposure, inadequate lubrication due to disruption of the tear film, and corneal disease. Medical management of underlying pathophysiologic processes and symptom control should be optimized before attempting surgical repair of the lesion. This activity describes the relevant anatomy, etiology, presentation, and surgical treatment of ectropion while highlighting the role of the interprofessional team in optimizing patient outcomes.

Objectives:

• Classify the different subtypes of ectropion with respect to underlying etiology.
• Articulate the common signs and symptoms of ectropion.
• Compare and contrast the surgical treatment of ectropion subtypes.
• Apply effective interprofessional team processes for prehospital and hospital care services to enhance clinical outcomes for patients undergoing surgical ectropion repair.

Introduction

Ectropion is an eversion, or outward turning, of the eyelid margin leading to loss of the normal apposition of the eyelid to the globe. Ectropion may be classified as congenital, involutional, paralytic, cicatricial, or mechanical.[1] 

Involutional ectropion is caused by horizontal eyelid laxity of the medial or lateral canthal tendons. The shortening of the anterior or middle lamella can cause cicatricial ectropion. Paralytic ectropion can be caused by seventh or facial cranial nerve paralysis or palsy, resulting in loss of orbicularis oculi muscle tone. Lastly, mechanical ectropion can be caused by gravity, the mass effect of a tumor, fluid accumulation, herniated orbital fat, or poorly fitted spectacles.[2][3][4] 

The patient with ectropion may experience symptoms of corneal exposure, irritation, or epiphora due to ocular exposure, inadequate lubrication due to disruption of the tear film, and corneal disease. In addition, risks for developing ectropion are increasing age, eyelid rubbing, excessive eyelid pulling or manipulation, contact lens use, eyelid injury, skin conditions involving the lid, or previous surgery of the eyelids or orbit.

Medical management of the underlying etiology of the ectropion should be attempted before consideration of surgical correction. However, surgical ectropion repair is the only definitive management of the condition.

Anatomy and Physiology

The eyelid is composed of 7 tissue layers unique to this facial region. Superficial to deep, the layers are skin, subcutaneous tissue, muscles of protraction including the orbicularis oculi, orbital septum, orbital fat, muscles of retraction, tarsus, and conjunctivae. The skin of the eyelid is much thinner than the skin found elsewhere in the body.[5]

Multiple nerves supply the eyelid. The superior lid is innervated by the infratrochlear, supratrochlear, supraorbital, and lacrimal nerves of the ophthalmic division of the trigeminal nerve (cranial nerve V division V1). The innervation of the lower eyelid is via the infratrochlear and infraorbital nerve of the maxillary division of the trigeminal nerve (cranial nerve V division V2).[6]

The arterial supply of the eyelids is composed of the internal carotid artery by way of the ophthalmic artery and its supraorbital and lacrimal branches and the external carotid artery via the angular and temporal branches of the facial artery. Anastomoses of the lateral and medial palpebral arteries create the blood supply to the upper and lower eyelids. These arteries are branches of the lacrimal and ophthalmic arteries.[7]

Indications

Symptoms of ectropion may include foreign body sensation, hyperemia, epiphora, exposure keratitis, and corneal ulceration. Anterior lamellar shortening is often the primary cause of cicatricial ectropion; any associated connective tissue or other medical disorders must be addressed, controlled, and stabilized before definitive surgical correction is considered.

Patients with congenital, paralytic, mechanical, or involutional ectropion often require different surgical treatments to correct the ectropion and restore normal lower lid position and function. Accurately identifying the etiology before planning any surgical intervention is essential. For example, medial tendon laxity and ectropion of the punctum will require specific procedures to correct, in addition to the eyelid repositioning surgery.[8]

Contraindications

Medical management of the underlying etiology of the ectropion should be attempted before consideration of surgical correction. If inflammation or infection is not controlled before surgical intervention, the prognosis worsens, as there is a higher risk of complications and disease progression. Patients who cannot tolerate general anesthesia or who cannot tolerate a local anesthetic for medical or psychological reasons should not undergo surgical correction.

Equipment

The following equipment is needed for the procedure: Bard-Parker scalpel equipped with a No. 15 blade, Westcott tenotomy scissors, 0.5 mm forceps, monopolar or bipolar cautery, 4-0 silk suture, 5-0 and 6-0 polyglycolic acid (Vicryl) suture, corneal shield, and antibiotic ophthalmic ointment, in addition to a standard oculoplastic instrument tray.

Personnel

An ophthalmologist, oculoplastic, facial plastic, or plastic surgeon is required, and a surgical assistant is helpful. This procedure can be performed under local anesthesia in many cases. However, complex cases or certain patients may benefit from intravenous sedation or general anesthesia; an anesthetist is also required in such cases.

Preparation

The patient should have been adequately evaluated and examined before surgical intervention and deemed appropriate for surgery by an appropriately qualified surgeon. Patients should be educated about the risks and benefits of the intervention, including available alternative therapies. All possible complications should be discussed. Lastly, any questions from the patient need to be answered to their satisfaction.

Technique or Treatment

The etiology of the ectropion dictates the surgical approach chosen, and the repair is tailored to each specific patient based on preoperative examination. The essential steps for the following will be listed: cicatricial, involutional, medial, and lateral tarsal strip with a medial spindle for ectropion repair with punctal eversion.[9][10][11][12]

Cicatricial Ectropion Repair

1. Administration of topical anesthetic and local anesthetic
2. Corneal shield placement
3. Traction sutures placed in the gray or lash line of the eyelid 
4. Subciliary incision
5. Dissection to release scarring until the posterior lamella returns to the normal anatomical position
6. Perform tarsal strip for horizontal lid tightening 
7. Measure or draw a template of the area requiring graft
8. Mark and transfer template to the donor site (often postauricular or upper eyelid skin is used)
9. Closure of donor site skin incision 
10. Debridement of the dermis aspect of the graft of any extraneous subcutaneous tissue
11. Suture graft into the wound bed
12. Close the lateral canthal skin if horizontal lid tightening was performed
13. Removal of corneal shield
14. Frost suture, if required

Involutional Ectropion Repair

1. Administration of topical anesthetic and local anesthetic
2. Corneal shield placement 
3. Lateral canthal incision with canthotomy and inferior cantholysis 
4. Split the anterior and posterior lamella of the lateral lower lid
5. Remove the skin, muscle, and conjunctiva to form a tarsal strip
6. Retract the lid laterally to the rim to estimate the amount of tarsus required; excise the redundancy
7. Anchor the strip to the periosteum of the lateral rim
8. Excise any redundant anterior lamellar tissue
9. Closure of skin incision
10. Removal of corneal shield

Medial Ectropion Repair

1. Administration of topical anesthetic and local anesthetic
2. Corneal shield placement
3. Evert the lid margin with traction suture or Bowman probe
4. Excise an ellipse of the conjunctiva and lower lid retractor muscles
5. Excise a portion of the lateral caruncle if performing caruncular recruitment
6. Pass a double-armed suture through the lower lid retractors, then the apex near the punctum, and then the apex inferiorly, finally passing the suture out through the full thickness of the eyelid
7. Pass a double-armed suture through the lower lid retractors followed by the medial tendon beneath the caruncle; the second arm is then passed through the apex near the punctum incorporating the tendon and caruncle.
8. If performing caruncular recruitment, both suture arms are then passed through the full thickness of the eyelid
9. Perform lateral tarsal strip if required
10. Tie the sutures to invert the punctum appropriately
11. Remove corneal shield

Lateral Tarsal Strip with Medial Spindle

1. Infiltrate local anesthetic at the lateral canthus, lateral lower eyelid, internal aspect of the lateral orbital rim, and conjunctivae of the inferior medial fornix
2. Lateral canthotomy
3. Lateral inferior crus cantholysis
4. Excise a diamond-shaped area of conjunctiva and lower eyelid retractors below the punctum
5. Close the conjunctiva and lower lid retractors
6. Determine the length of the strip
7. Denude the epithelium
8. Split the anterior and posterior lamellae
9. Disinsert the lower eyelid retractors and conjunctiva from the strip
10. Excise the anterior lamella from the strip to remove lash follicles
11. Attach the strip to the periosteum of the inner aspect of the lateral orbital rim
12. Reform the sharp angle of the lateral canthus
13. Close the skin

Complications

Possible complications of ectropion repair include but are not limited to infection, bleeding, pain, poor cosmesis, corneal abrasion, suture dehiscence or erosion, retrobulbar hematoma, lower eyelid retraction, and canthal dystopia.[13]

Clinical Significance

Ectropion repair aims to return the eyelid margin and punctum to their proper anatomic positions. This treatment protects the eye from injury and reduces exposure and dry eye symptoms. Surgical management is the only definitive treatment.[14][13]

Enhancing Healthcare Team Outcomes

Care should be coordinated between physicians, nurses, pharmacists, and other healthcare professionals. Medical management can typically be accomplished by an ophthalmologist, optometrist, or general clinician experienced in handling ocular conditions. Surgical care can be performed by an ophthalmologist or a surgeon specializing in facial and ocular plastic surgery. Patient safety and the best possible outcome should always be considered, and patients should undergo any treatment that may harm or worsen their outcomes. Before initiating any treatment, an in-depth discussion about risks and benefits should be conducted with the patient.