Summary and objectives Ectropion is an outward turning of the eyelid margin. This usually occurs on the lower eyelids. When the globe is not adequately protected, the eye can become very dry. This dryness can cause symptoms of redness, tearing, and foreign body sensation secondary to exposure of the ocular surface and an inadequate tear film. In extreme cases, the cornea may develop pinpoint epithelial erosions, ulceration, and permanent vision loss. Treatment almost always begins with lubrication with artificial tears, gels, and ointments. Surgical repair is usually necessary to improve eyelid function and permanently protect the eyeball. This article reviews the cause and pathophysiology of ectropion and highlights the role of the interprofessional team in its management. Goals:
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Ectropion is an outward turning of the eyelid margin. This usually occurs on the lower eyelids. When the globe is not adequately protected, the eye can become very dry. This dryness can cause symptoms of redness, tearing, and foreign body sensation secondary to exposure of the ocular surface and an inadequate tear film. In extreme cases, the cornea may develop pinpoint epithelial erosions, ulceration, and permanent vision loss. Treatment almost always begins with lubrication with artificial tears, gels, and ointments. Surgical repair is usually necessary to improve eyelid function and permanently protect the eyeball. [1] [2] [3] [4]
Etiology
Many factors can cause instability of the lower eyelid. The most common etiological factor for lower eyelid ectropion is involutional change , caused by horizontal laxity of the eyelid and disinsertion of the lower eyelid retractors. This usually occurs due to aging changes in the lower eyelids and can be made worse by rubbing your eyes.
Paralytic ectropion can occur with facial nerve paralysis. With decreased innervation of the orbicularis muscle, the eyelid may become lax and flaccid and may result in poor protection of the eyeball.
Cicatricial ectropion can be caused by scarring and shortening of the anterior lamella of the lower eyelid skin, which can also occur with aggressive lower eyelid blepharoplasty. Chronic sun exposure can also cause these changes.
Mechanical ectropion can be caused by a mass, such as a tumor, fatty herniation, or lower eyelid edema, that weighs down and pulls the lower eyelid outward. [fifteen]
Epidemiology
The prevalence of involutional ectropion of the lower eyelid in elderly patients has been reported to be as high as 2%. It may be associated with trauma. Morbidity is primarily associated with corneal/conjunctival exposure. [1]
History and physical examination
A complete history and physical examination are required to determine the etiology of lower eyelid ectropion.
It is very important to understand whether the patient has had prior surgery, for example, lower eyelid blepharoplasty, or removal and repair of trauma or cancer of the lower eyelid and/or cheek area. An adequate history will help guide the doctor as to etiologic factors and what to look for on examination. The patient should also be asked about any symptoms related to dry eye, eye rubbing, or eyelid instability. A complete ophthalmic examination is necessary to adequately evaluate the bilateral eyelids as well as the ocular surface and cornea to evaluate for any complications related to ectropion. [1] [6] [7] [8]
Assessment
Lower eyelid ectropion leads to an abnormally positioned lower eyelid. On examination, the lower eyelid margin may appear low, with visualization of the inferior cornea. Normally, the lower eyelid is situated 1 mm to 2 mm above the inferior corneal limbus. With ectropion, the lower eyelid may also visually turn out. In extreme cases, the tarsal conjunctiva may be visible and show signs of chronic conjunctivitis with keratinization of the conjunctiva. The eye may be injected and, in extreme cases leading to exposure keratopathy , the cornea may be dry with pinpoint epithelial erosions and possible ulceration.
Eyelid laxity is also often evident. Lower eyelid distraction can be checked by pulling the lower eyelid down and out to see how far the eyelid can be pulled. A push-back test is performed by pulling the eyelid down and out and counting the number of seconds until it returns to its position against the ocular surface. In extreme cases, it may be necessary to flash them back into position.
During an exam, the periorbital region would also be carefully examined to rule out other causes, such as scarring changes, such as chronic skin changes or a mass. It is also important to examine the contralateral eyelid, as the etiology of the affected ectropic eyelid may also lead to ectropion of the contralateral eyelid. [1] [9] [10]
Treatment/Management
Treatment usually begins with aggressive lubrication of the eyes with artificial tears, gels, and ointments.
If the ocular surface is protected, then there is no urgent need to protect the eyelid. However, if the ocular surface is compromised, for example in a patient with facial paralysis, the cornea can rapidly decompensate and corneal scarring can develop leading to permanent vision loss.
Treatment is based on correcting the underlying etiology that leads to ectropion. For example, with involutional changes, the lateral canthal tendon may be loose and disinserted. In this situation, a lateral tarsal strip surgical procedure with lateral canthotomy and inferior cantholysis can be performed to completely disinsert the canthus. A small wedge can then be removed from the lateral lower eyelid. The lateral lower eyelid is then reattached to the periosteum of the lateral orbital rim to return the lateral canthus into position. By horizontally shortening the eyelid with this procedure and repositioning the canthus, the lower eyelid can be returned to the proper position to effectively protect the eyeball.
In cases of facial paralysis, with compromised orbicular function, a lateral tarsal strip procedure may also be beneficial, as well as a lateral tarsorrhaphy to connect the lateral upper eyelid to the lateral lower eyelid.
In other cases, for example with cicatricial ectropion from aggressive lower eyelid blepharoplasty and excessive skin removal or scarring from chronic skin changes, the anterior lamella may be too short vertically. In these cases, it may be necessary to replace the skin, usually through the use of a full-thickness skin graft. Ipsilateral or contralateral upper eyelid skin can be used as a donor, if available, or preauricular or postauricular skin can be used. In these cases, it is not uncommon to perform a lateral tarsal strip in addition to a full-thickness skin graft. In cases of scar tissue formation leading to scar ectropion, for example after trauma to the cheek, it may be necessary to dissect and release the scar formation to free the lower eyelid and allow it to return to its proper position. A temporary tarsorrhaphy or Frost tarsorrhaphy may be necessary to connect and elevate the eyelids during the initial healing phase after surgical repair.
It is common for bilateral lower eyelids to have asymmetrical but affected eyelids, for example with involutional ectropion , both lower eyelids may be affected, but to different degrees. Bilateral lower eyelid repair may be necessary to improve both lower eyelids and provide a symmetrical result. [1]
Differential diagnosis
- Basal cell carcinoma
- Bell’s palsy
- Floppy eyelid syndrome
- Ichthyosis
- Neuro-ophthalmic examination
- Neuro-ophthalmic history
- Squamous cell carcinoma, eyelid.
Improving healthcare team outcomes
Ectropion is best managed by an interprofessional team that includes the pharmacist and nurse. Treatment usually begins with aggressive lubrication of the eyes with artificial tears, gels, and ointments. If the ocular surface is protected, then there is no urgent need to protect the eyelid. However, if the ocular surface is compromised, for example in a patient with facial paralysis, the cornea can rapidly decompensate and corneal scarring can develop leading to permanent vision loss.
Surgery is often performed to repair ectropion, but the results are not ideal. Dry eyes and poor aesthetics remain two important postoperative complications that lead to poor quality of life. [eleven]
