Ectropion

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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.

Contents

Disease Entity

Ectropion

Disease

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

Etiology

Most cases of ectropion are caused by age-related changes in the eyelid tissues which increase laxity.  

Risk Factors

Age (gravity, loss of elasticity)

Eyelid rubbing

Repeated eyelid pulling (ex. contact-lens use)

Floppy eyelid syndrome


General Pathology

Ectropion can be classified as:

- Involutional (most common)

- Paralytic

- Cicatrizing

- Mechanical

- Congenital (very rare)

Pathophysiology

The tarsoligamentous sling which supports the eyelid by attachment to the orbital rim via the medial and lateral canthal tendons becomes lax. 

Clinical examination

Examination reveals outward turning of the eyelid margin.

History

Many patients experience tearing, irritation/grittiness/foreign body sensation, red eye, and mucoid discharge. Symptoms are caused by ocular exposure and inadequate lubrication.

Physical examination

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

- Test for horizontal laxity by placing a thumb beneath the lateral canthus and pushing 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. 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

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

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

Medical therapy

Lubrication

Eyelid hygiene for blepharitis

Horizontal taping of the eyelid

Surgery

Horizontal tightening by lateral tarsal strip procedure.

Medial spindle procedure to correct punctal malposition.

Complications

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

ASOPRS Information on Ectropion

References

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.

Original article contributed by: Michel J. Belliveau, MD
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