Close
New

Medscape is available in 5 Language Editions – Choose your Edition here.

 

Ectropion Clinical Presentation

  • Author: Edsel Ing, MD, FRCSC; Chief Editor: Hampton Roy, Sr, MD  more...
 
Updated: Apr 15, 2016
 

History

With the exception of patients with acute facial nerve palsy, patients may have ectropion for months or even years before they seek medical attention.

Patients often complain of irritated or red eyes with tearing. They may constantly wipe their eyes, thereby exacerbating lid laxity and the ectropion.

Advanced age may suggest the patient has involutional ectropion.

Eye drop instillation with chronic eversion of the lower lid can lead to involutional ectropion.

A history of facial burns, lid surgery, or lid trauma is usually easily confirmed on cursory examination and may suggest cicatricial ectropion.

In patients with cicatricial ectropion and periocular skin rash, a history of facial skin cancer and topical and systemic medication use should be ascertained (see Causes).

Facial nerve palsy can cause ectropion. Acute facial nerve palsy is consistent with Bell palsy. Chronic, insidious progressive facial nerve palsy may indicate a mass lesion. For patients with facial nerve palsy, the caregiver should be asked if nocturnal lagophthalmos occurs. These patients especially require slit lamp examination of the cornea and testing of corneal sensation.

Next

Physical

Gestalt examination of the visage may reveal a connective tissue disorder, prior surgical scars or burns, cancerous skin conditions, parotid mass, or the physiognomy for floppy eyelid syndrome. All of these findings may be important in ectropion evaluation.

Documentation of visual acuity and examination of the cornea and the conjunctiva are part of any complete oculoplastic examination. Corneal exposure, corneal ulceration, and conjunctival keratinization may accompany ectropion.

Because of gravity, ectropion usually involves the lower lid and is described as punctal, medial, lateral, or tarsal (complete). Laxity-related ectropion typically begins medially; with time, the central lid margin and the lateral lid may evert.

Both the distraction test and the snap-back test are usually performed for abnormal horizontal lid laxity. Anterior lid distraction of more than 6-8 mm from the globe suggests horizontal lid laxity. If the lower lid is pulled inferiorly, the lid should quickly return to its previous position. If not, this may be interpreted as an abnormal snap-back test result. The patient should not be allowed to blink the eyelid back into position.

If cicatricial ectropion is suspected, superiorly displace the lower lid margin. If the lower lid margin does not extend 2 mm above the inferior limbus, then cicatricial ectropion should be considered. In patients with skin erythema and cicatricial ectropion, skin cancer or a medication-induced skin rash should be excluded.

Typically, the puncta should not be visible, unless the lid is everted. If this is not the case, punctal ectropion is present.

Chronic punctal ectropion may result in punctal phimosis.

Chronic ectropion may cause keratinization of the lid margin and the palpebral conjunctiva.

In patients with complete tarsal ectropion, a white line in the inferior fornix is often present, indicating a disinserted capsulopalpebral fascia.

In patients with suspected paralytic ectropion, the following should be documented:

  • Corneal integrity
  • Corneal sensation
  • Presence or absence of Bell phenomenon
  • Degree of lagophthalmos - To estimate nocturnal lagophthalmos, the patient should gently close the eyelids when in the supine position.
  • Disparity between spontaneous and voluntary lid closure

With a lower motor neuron seventh nerve palsy (eg, Bell palsy), the ipsilateral brow and the lower facial musculature are weak. With an upper motor neuron seventh nerve palsy, brow-elevation is relatively spared due to the bilateral innervation of the upper face.

In patients with suspected facial nerve palsy, orbicularis oris dysfunction can be tested for by asking them to show their teeth rather than smile. Compare the elevation of the angles of the lips; ptosis of the lateral lip on the affected side is often present.

If a slow-onset or nonresolving seventh nerve palsy is seen, perform the following:

  • Palpate the parotid gland for tumor.
  • Exclude prior malar skin cancer.
  • Check the patient's hearing to exclude a cerebellopontine angle tumor.
  • Perform a slit lamp examination for uveitis, which may suggest a disease process, such as sarcoidosis or Lyme disease.

Inferior scleral show should be distinguished from ectropion, especially in patients with prominent globes. Horizontal eyelid tightening will exacerbate the scleral show of a proptotic eye, because the shortest arc between the canthi lies inferior to the cornea.

Patients with involutional ectropion of the lower lid may also have involutional changes of the upper eyelid. Failure to recognize this prior to horizontal tightening of the lower lid may result in the upper lid prolapsing over the lower lid margin with the lower lid lashes rubbing the palpebral conjunctiva of the upper lid (ie, lid imbrication, which can be seen with floppy eyelid syndrome).

Previous
Next

Causes

Ectropion may be congenital or acquired. Congenital ectropion is rare and usually involves the lower lid. The cause often is a vertical deficiency of the anterior lamella. Congenital ectropion is rarely an isolated anomaly. It may be associated with blepharophimosis syndrome, microphthalmos, buphthalmos, orbital cysts, Down syndrome, and ichthyosis (collodion baby). Occasional congenital ectropion cases are on a paralytic basis.

Acquired ectropion may be involutional, paralytic, cicatricial, or mechanical.

Involutional ectropion is the most common form of ectropion in developed countries.

A major factor is horizontal lid laxity, usually due to age-related weakness (most patients are elderly) of the canthal ligaments and the pretarsal orbicularis. Patients with involutional ectropion have been suggested to have an age-normal or larger than normal tarsal plate, which may mechanically overcome normal or decreased orbicularis tone, in conjunction with canthal tendon laxity.

Patients with an anophthalmic socket may have involutional ectropion due to chronic pressure of the ocular prosthesis.

Disinsertion of the capsulopalpebral fascia may lead to severe tarsal ectropion.

Paralytic ectropion may occur with seventh nerve palsy from diverse causes, such as Bell palsy, cerebellopontine angle tumors, herpes zoster oticus, and infiltrations or tumors of the parotid gland.

Cicatricial ectropion occurs from scarring of the anterior lamella by such conditions as facial burns, trauma, chronic dermatitis, excessive skin excision (or laser) with blepharoplasty, or orbital fracture repair with a transcutaneous approach.

Glaucoma drops (eg, dorzolamide, brimonidine) have been implicated as a cause of cicatricial ectropion.

Less common causes of cicatricial ectropion include cutaneous T-cell lymphoma, pyoderma gangrenosum, and ichthyosis.

Antineoplastic agents (eg, docetaxel) and epidermal growth factor receptor inhibitors (eg, erlotinib, cetuximab) have been reported to cause cicatricial ectropion.

Mechanical ectropion may occur with lid tumors, such as neurofibromas that evert the lower lid. Glasses have been implicated as a "mechanical factor" that causes ectropion.

Acute idiopathic bilateral lower lid ectropion has been described. An uncommon case of bilateral upper lid ectropion from blepharospasm has also been described.

Previous
 
 
Contributor Information and Disclosures
Author

Edsel Ing, MD, FRCSC Associate Professor, Department of Ophthalmology and Vision Sciences, University of Toronto Faculty of Medicine; Consulting Staff, Hospital for Sick Children and Sunnybrook Hospital

Edsel Ing, MD, FRCSC is a member of the following medical societies: American Academy of Ophthalmology, American Association for Pediatric Ophthalmology and Strabismus, American Society of Ophthalmic Plastic and Reconstructive Surgery, Royal College of Physicians and Surgeons of Canada, Canadian Ophthalmological Society, North American Neuro-Ophthalmology Society, Canadian Society of Oculoplastic Surgery, European Society of Ophthalmic Plastic and Reconstructive Surgery, Canadian Medical Association, Ontario Medical Association, Statistical Society of Canada, Chinese Canadian Medical Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Simon K Law, MD, PharmD Clinical Professor of Health Sciences, Department of Ophthalmology, Jules Stein Eye Institute, University of California, Los Angeles, David Geffen School of Medicine

Simon K Law, MD, PharmD is a member of the following medical societies: American Academy of Ophthalmology, Association for Research in Vision and Ophthalmology, American Glaucoma Society

Disclosure: Nothing to disclose.

Chief Editor

Hampton Roy, Sr, MD Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences

Hampton Roy, Sr, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, Pan-American Association of Ophthalmology

Disclosure: Nothing to disclose.

Additional Contributors

Ron W Pelton, MD, PhD Private Practice, Colorado Springs, Colorado

Ron W Pelton, MD, PhD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, AO Foundation, American Society of Ophthalmic Plastic and Reconstructive Surgery, Colorado Medical Society

Disclosure: Nothing to disclose.

References
  1. Gupta B, Parmar B, Raina J, Chawla JS. Acute idiopathic bilateral lower lid ectropion. Indian J Ophthalmol. 2006 Sep. 54(3):212-4. [Medline].

  2. Damasceno RW, Osaki MH, Dantas PE, Belfort R Jr. Involutional entropion and ectropion of the lower eyelid: prevalence and associated risk factors in the elderly population. Ophthal Plast Reconstr Surg. 2011 Sep-Oct. 27(5):317-20. [Medline].

  3. Balogun BG, Adekoya BJ, Balogun MM, Ngwu RV, Oworu O. Ectropion and entropioin in sub-Saharan Africa: how do we difer?. Ann Afr Med. Oct-Dec/2013. 12:193-6.

  4. Fezza JP. Nonsurgical treatment of cicatricial ectropion with hyaluronic acid filler. Plast Reconstr Surg. 2008 Mar. 121(3):1009-14. [Medline].

  5. Schrom T, Habermann A. Temporary ectropion therapy by adhesive taping: a case study. Head Face Med. 2008 Jul 21. 4:12. [Medline]. [Full Text].

  6. Dobson R. Antiviral drugs should not be used to treat Bell's palsy, Cochrane analysis concludes. BMJ. 2009 Oct 7. 339:b4086. [Medline].

  7. Criglow BG, Choate KA, Milstone LM. Topical tazarotene for the treatment of ectropion in ichthyosis. JAMA Dermatol. May 2013. 149:598-600.

  8. Romero R, Sanchez-Orgaz M, Granados M, Arbizu A, Castano A, Romero A. Use of hyaluronic acid gel in the management of cicatricial ectropion: results and complications. Orbit. 2013 Dec. 32(6):362-5. [Medline].

  9. Bedran EG, Pereira MV, Bernardes TF. Ectropion. Semin Ophthalmol. 2010 May. 25(3):59-65. [Medline].

  10. Berry-Brincat A, Burns J, Sampath R. Inverting sutures for tarsal ectropion (the leicester modified suture technique). Ophthal Plast Reconstr Surg. 2013 Sep. 29(5):400-2. [Medline].

  11. Xue CY, Dai HY, Li L, Wang YC, Yang C, Li JH, et al. Reconstruction of Lower Eyelid Retraction or Ectropion Using a Paranasal Flap. Aesthetic Plast Surg. 2012 Jan 25. [Medline].

  12. Czyz CN, Wulc AE, Ryu CL, Foster JA, Edmonson BC. Caruncular fixation in medial canthal tendon repair: the minimally invasive purse string suture for tendinous laxity and medial ectropion. Ophthal Plast Reconstr Surg. 2015 Jan-Feb. 31 (1):34-7. [Medline].

  13. Genther DJ, Kim LR, Loyo MD, Boahene KD. Transposed Corrugator Supercilii Muscle-Tendon Unit Flap for Contralateral Paralytic Medial Ectropion Repair. JAMA Facial Plast Surg. 2016 Mar 17. [Medline].

  14. Osborne SF, Eidsness RB, Carroll SC, Rosser PM. The use of fibrin tissue glue in the repair of cicatricial ectropion of the lower eyelid. Ophthal Plast Reconstr Surg. 2010 Nov-Dec. 26(6):409-12. [Medline].

  15. Anderson RL, Gordy DD. The tarsal strip procedure. Arch Ophthalmol. 1979 Nov. 97(11):2192-6. [Medline].

  16. Bashour M, Harvey J. Causes of involutional ectropion and entropion--age-related tarsal changes are the key. Ophthal Plast Reconstr Surg. 2000 Mar. 16(2):131-41. [Medline].

  17. Ben Simon GJ, Molina M, Schwarcz RM, McCann JD, Goldberg RA. External (subciliary) vs internal (transconjunctival) involutional entropion repair. Am J Ophthalmol. 2005 Mar. 139(3):482-7. [Medline].

  18. Bergeron CM, Moe KS. The evaluation and treatment of lower eyelid paralysis. Facial Plast Surg. 2008 May. 24(2):231-41. [Medline].

  19. Caviggioli F, Klinger F, Villani F, Fossati C, Vinci V, Klinger M. Correction of cicatricial ectropion by autologous fat graft. Aesthetic Plast Surg. 2008 May. 32(3):555-7. [Medline].

  20. Chang L, Olver J. A useful augmented lateral tarsal strip tarsorraphy for paralytic ectropion. Ophthalmology. 2006. 113:84-91.

  21. Cook BE Jr, Bartley GB, Pittelkow MR. Ophthalmic abnormalities in patients with cutaneous T-cell lymphoma. Ophthalmology. 1999 Jul. 106(7):1339-44. [Medline].

  22. Frankfort BJ, Garibaldi DC. Periocular cutaneous toxicity and cicatricial ectropion: a potential class effect of antineoplastic agents that inhibit EGFR signaling. Ophthal Plast Reconstr Surg. 2007 Nov-Dec. 23(6):496-7. [Medline].

  23. Hedge V, Robinson R, Dean F, Mulvihill HA, Ahluwalia H. Drug-induced ectropion: what is best practice?. Ophthalmology. 2007. 114:362-6.

  24. Hintschich C. Correction of entropion and ectropion. Dev Ophthalmol. 2008. 41:85-102. [Medline].

  25. Isawumi MA, Adeoti CO, Umar IO, Oluwatimilehin IO, Raji RA. Congenital bilateral eversion of the eyelids. J Pediatr Ophthalmol Strabismus. 2008 Nov-Dec. 45(6):371-3. [Medline].

  26. Jordan DR, Anderson RL. The lateral tarsal strip revisited. The enhanced tarsal strip. Arch Ophthalmol. 1989 Apr. 107(4):604-6. [Medline].

  27. Jordan DR, Bawazeer AM, Pelletier CR. Severe congenital ectropion secondary to lamellar ichthyosis. Can J Ophthalmol. 1998 Feb. 33(1):30-1. [Medline].

  28. Koh S, Hosohata J, Tano Y. Bilateral upper eyelid ectropion associated with blepharospasm. Br J Ophthalmol. 2006 Nov. 90(11):1437-8. [Medline].

  29. Manku K, Leong JK, Ghabrial R. Cicatricial ectropion: repair with myocutaneous flaps and canthopexy. Clin Experiment Ophthalmol. 2006 Sep-Oct. 34(7):677-81. [Medline].

  30. Monaco G, Franceschin S, Cacioppo V, Simonetta S, Ratiglia R. Congenital iris ectropion associated with juvenile glaucoma. J Pediatr Ophthalmol Strabismus. 2009 Jan-Feb. 46(1):35-7. [Medline].

  31. Nowinski TS, Anderson RL. The medial spindle procedure for involutional medial ectropion. Arch Ophthalmol. 1985 Nov. 103(11):1750-3. [Medline].

  32. Oh SR, Korn BS, Kikkawa DO. Orbitomalar suspension wth combined single drill hole canthoplasty. Ophthal Plast Reconstr Surg. Sept 2013. 29:357-60.

  33. Perez-Dieste JM, Catroviejo-Bolbar M. Eyelid ectropion caused by glasses. Mechanical centurion syndrome. Arch Soc Esp Oftalmol. February 2013. 88:80-2.

  34. [Guideline] Salinas RA, Alvarez G, Daly F, Ferreira J. Corticosteroids for Bell's palsy (idiopathic facial paralysis). Cochrane Database Syst Rev. 2010. (3):CD001942. [Medline].

  35. Smith B. The "lazy-T" correction of ectropion of the lower punctum. Arch Ophthalmol. 1976 Jul. 94(7):1149-50. [Medline].

  36. Tse DT, Kronish JW, Buus D. Surgical correction of lower-eyelid tarsal ectropion by reinsertion of the retractors. Arch Ophthalmol. 1991 Mar. 109(3):427-31. [Medline].

  37. Uthoff D, Gorney M, Teichmann C. Cicatricial ectropion in ichthyosis: a novel approach to treatment. Ophthal Plast Reconstr Surg. 1994 Jun. 10(2):92-5. [Medline].

 
Previous
Next
 
Medial cicatricial ectropion in a patient with extensive basal cell carcinoma.
Complete (tarsal) paralytic ectropion in a patient with an ipsilateral parotid tumor.
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.