Ectropion

From EyeWiki
Original article contributed by: Michel J. Belliveau, MD
All contributors: Cat Nguyen Burkat, MD FACS, Marcus M. Marcet, MD FACS, Michel J. Belliveau, MD and Shubhra Goel, MD
Assigned editor: Cat.N.Burkat,
Review: Assigned status Up to Date by Shubhra Goel, MD on May 3, 2015.
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Ectropion is an outward turning of the eyelid margin. Patients may experience symptoms due to ocular exposure and inadequate lubrication. Definitive management is surgical. Medical management is temporizing but can improve symptoms while waiting for surgery.
Ectropion. A patient with involutional ectropion of the left lower eyelid. Keratinization of the palpebral conjunctiva is present. Image courtesy of Marcus M. Marcet, MD FACS.

Disease Entity[edit | edit source]

Ectropion

Disease[edit | edit source]

Ectropion is an outward turning of the eyelid margin. It primarily involves the lower lid. 

Etiology[edit | edit source]

Most cases of ectropion are caused by age-related changes and is named as involutional . There are changes in the eyelid tissues which increase laxity.  

Risk Factors[edit | edit source]

Age (gravity, loss of elasticity)

Eyelid rubbing

Repeated eyelid pulling (ex. contact-lens use)

Floppy eyelid syndrome

Long term use of eye drops

Skin conditions which involve the eyelid


General Pathology[edit | edit source]

Ectropion can be classified as:

- Involutional (most common)

- Paralytic

- Cicatricial

- Mechanical

- Congenital (very rare)

Pathophysiology[edit | edit source]

In Involutional ectropion, the tarsoligamentous sling which supports the eyelid by attachment to the orbital rim via the medial and lateral canthal tendons becomes lax. Whereas paralytic type is due to weak orbicularis muscle tone and cicatricial is secondary to the shortening of anterior lamella. 

Clinical examination[edit | edit source]

Examination reveals outward turning of the eyelid margin.

History[edit | edit source]

In addition to abnormal position of the lid, patients experience tearing, irritation/grittiness/foreign body sensation, red eye, and mucoid discharge. Symptoms are caused by ocular exposure ,inadequate closure and lubrication. Inquire about habitual eye rubbing, which may accompany symptoms of itch from ocular allergy or ocular surface disease.

Physical examination[edit | edit source]

- Inspection of the face and testing of facial muscle strength to assess for paralytic causes (ex. facial nerve palsy)

- Test for eye lid laxity is important. For horizontal laxity, place a thumb beneath the lateral canthus and push the eyelid laterally and superiorly. If the lid margin does not roll back into position, suspect a cicatricial component. In involutional cases, the ectropion typically disappears with this maneuver. eye lid distraction test is done by pulling the lid away from the globe. Normal lid distraction is between 2-3 mm. If it is more than 5mm, there is substantial laxity. In cases of cicatricial ectropion, the eyelid malposition will often become accentuated by asking the patient to look upwards and to open his or her mouth at the same time; the maneuver places the anterior lamella on maximum stretch.

- Examine the lid margin under magnification to look for signs of chronic blepharitis, palpebral conjunctival hypertrophy and keratinization, conjunctival scarring, and to rule out suspicious changes such as loss of lashes (madarosis), ulceration, or infiltration.

- Assess the position of the lower punctum which may rotate away with medial laxity and no longer make contact with the ocular surface and tear lake.

- Examine the cornea for epithelial changes secondary to exposure 

Differential diagnosis[edit | edit source]

Eyelid malignancy

Eyelid retraction secondary to proptosis (ex. thyroid-associated orbitopathy), excessive tissue removal with lower blepharoplasty, or inferior rectus recession without disinsertion of the lower lid retractors.

Management[edit | edit source]

Definitive management is surgical. Medical management is temporizing but can improve symptoms while waiting for surgery.

Deferral of surgery should be considered in 2 groups of patients. Ectropion induced by long term use of eye drops such as dorzolamide and brimonidine may resolve with discontinuation, if feasible. Patients suffering from inflammatory skin conditions involving the eyelid may have improvement or reversal of ectropion with improved control of inflammation. 

Medical therapy[edit | edit source]

Lubrication

Horizontal taping of the eyelid

Surgery[edit | edit source]

Horizontal tightening by lateral tarsal strip, or similar, procedure.

In cases of additional retractor disinerstion, jones procedure of reattaching the retractors to the tarsus along with lateral tarsal strip works well.

Medial spindle procedure to correct punctal malposition.

Cicatricial ectropion frequently requires lengthening of the anterior lamella by a skin graft.

Complications[edit | edit source]

Ectropion surgery is very safe and very effective. Recurrence does occur occasionally after several years requiring a repeat surgery.

Like any eyelid surgery there is always a possibility of local post-operative bleeding or infection but these are generally minor. Injury to the cornea is possible but uncommon with careful technique.

Additional Resources[edit | edit source]

ASOPRS Information on Ectropion

References[edit | edit source]

Orbit, Eyelids, and Lacrimal System, Section 7. Basic and Clinical Science Course. San Francisco: American Academy of Ophthalmology; 2009.

American Academy of Ophthalmology Focal Points: Ectropion and Entropion, Volume 12, Number 10, 1994.

Hegde V, Robinson R, Dean F, et al. Drug-induced ectropion: what is best practice? Ophthalmology 2007;114:362-366.

Durairaj VD, Horsley MB. Resolution of pityriasis rubra pilaris-induced cicatricial ectropion with systemic low-dose methotrexate. Am J Ophthalmol 2007;143:709-710.