Ectropion is an eversion or outward turning of the eyelid margin. Ectropion may be classified as congenital, involutional, paralytic, cicatricial, or mechanical. Involutional ectropion is caused by horizontal eyelid laxity of the medial and/or lateral canthal tendons. Cicatricial ectropion can be caused by shortening of the anterior and/or middle lamella. Paralytic ectropion can be caused by CN VII paralysis or palsy resulting in loss of orbicularis muscle tone. Lastly, mechanical ectropion can be caused by gravity, mass effect of a tumor, fluid accumulation, herniated orbital fat, or poorly fitted spectacles. The patient may experience symptoms due to ocular exposure, inadequate lubrication, and corneal disease. An individual is at increased risk with age, eyelid rubbing, excessing eyelid pulling or manipulation, skin conditions involving the lid, injury, or previous surgery.
The eyelid is composed of seven tissue layers unique to this facial region. Superficial to deep the layers include skin, subcutaneous tissue, muscles of protraction/orbicularis, orbital septum, orbital fat, muscles of retraction, tarsus, and conjunctiva. The skin along the eyelid, in relation to the other skin, is much thinner.
Multiple nerves supply the eyelid. The superior lid nerves are the infratrochlear, supratrochlear, supraorbital, and lacrimal nerves of V1. The nerves of the lower eyelid are the infratrochlear and infraorbital nerve of V2.
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. The blood supply to the lower and upper lids is created by anastomoses of the lateral and medial palpebral arteries. These arteries branch off the lacrimal artery and ophthalmic artery.
Symptoms include foreign body sensation, hyperemia, epiphora, exposure keratitis, and corneal ulceration. Anterior lamellar shortening often is the primary cause of cicatricial ectropion, and associated disorders should be addressed and treated before surgery. Patients with congenital, paralytic, mechanical, or involutional often require different treatments. It is once again important to identify the etiology before surgical intervention. Medial tendon laxity and punctual ectropion will require additional procedures to correct.
Patients who cannot tolerate the procedure should not undergo a correction. Medical management of the underlying etiology should be controlled first, and then surgical correction can be considered. If inflammation or infection are not controlled, the prognosis is worse, higher risk of complications, and can often progress.
The following equipment is needed: No. 15 Bard-Parker blade, Westcott scissors, 0.5 forceps, and cautery (monopolar or bipolar), 4-0 silk suture, 6-0 vicryl suture, 5-0 vicryl suture, corneal shield, and antibiotics ointment.
An ophthalmologist or surgeon trained in oculofacial plastic surgery is required.
The patient should have been properly examined before surgical intervention and deemed appropriate for surgery by an ophthalmologist or surgeon trained in oculofacial plastic surgical procedures. The patient needs to be educated about the associated risks and benefits of the intervention, including alternative therapies available. All possible complications should be discussed. Lastly, any questions from the patient need to be answered.
There are multiple procedures done depending on the etiology of the ectropion. The essential steps for the following will be listed: cicatricial, involutional, medial, and lateral tarsal strop with a medial spindle for ectropion repair with punctal eversion.
Medial Ectropion Repair
Lateral Tarsal Strip with Medial Spindle
Infection, bleeding, pain, poor cosmesis, corneal abrasion, suture dehiscence or erosion, retrobulbar hematoma, lower eyelid retraction, and canthal dystopia are all possible complications.
The goal is to return the eyelid margin and punctum to their proper anatomic positions. This treatment protects the eye from injury and reduces the exposure/dry eye symptoms in the patient. Surgical management is the only definitive treatment.
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