eMedicine Specialties > Ophthalmology > Lid

Ectropion

Edsel Ing, MD, FRCSC, Assistant Professor, Department of Ophthalmology & Vision Sciences, University of Toronto: Consulting Staff, Toronto East General Hospital

Updated: Nov 11, 2009

Introduction

Background

Ectropion is an abnormal eversion (outward turning) of the lid margin away from the globe. Without normal lid globe apposition, corneal exposure, tearing, keratinization of the palpebral conjunctiva, and visual loss may result.

Ectropion usually involves the lower lid and often has a component of horizontal lid laxity.

Treatment is individualized based on the appropriate identification of the etiology.¹

Medial cicatricial ectropion in a patient with extensive basal cell carcinoma.

Complete (tarsal) paralytic ectropion in a patient with an ipsilateral parotid tumor.

Pathophysiology

The pathophysiology depends on the type of ectropion and is discussed within this article.

Mortality/Morbidity

The primary morbidity is associated with corneal/conjunctival exposure. Tearing may also cause significant patient complaints.

Race

No racial predilection has been described.

Sex

No sexual predilection has been described.

Age

Ectropion can affect patients of any age but is most commonly seen in older adults.

Clinical

History

• Patients may have a lid deformity 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).
• For patients with facial nerve palsy, the caregiver should be asked if nocturnal lagophthalmos occurs. These patients should also be examined for corneal problems.

Physical

• Gestalt examination of the visage may reveal a connective tissue disorder, prior surgical scars or burns, cancerous skin conditions, 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.
• 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, a form of floppy eyelid syndrome).

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.
• 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. 
• Antineoplastic agents (eg, docetaxel) and epidermal growth factor receptor inhibitors (eg, erlotinib, cetuximab) have been reported to cause cicatricial ectropion.
• Mechanical tumors may occur with lid tumors, such as neurofibromas that evert the lower lid.
• Acute idiopathic bilateral lower lid ectropion has been described. An uncommon case of bilateral upper lid ectropion from blepharospasm has also been described.

Differential Diagnoses

Treatment

Medical Care

• Lubrication and moisture shields are helpful if significant corneal exposure exists from the ectropion. In patients with corneal exposure, plastic dressings are often superior to cloth patches. In some cases, taping the lateral canthal skin supertemporally provides temporary relief, especially in patients with new-onset seventh nerve palsy.^2,3
• If the conjunctiva is markedly keratinized, a lubricating ointment should be used several days or weeks prior to ectropion repair. Corneal epithelial defects and prior herpes simplex infection are a relative contraindication to steroid-containing ointments.
• Patients with tearing and incipient ectropion or early punctal ectropion should be instructed to wipe the eyelids in a direction up and in (toward the nose) to avoid worsening medial ectropion.
• With cicatricial ectropion following trauma or lid surgery, digital massage may help stretch the scar. If not, steroid injection into the scar should be considered.
• In patients with seventh nerve palsy, external paste-on upper lid weights are available and can be matched approximately for different skin colors.
  • A double-sided tape is used to apply the lid weight.
  • Removing the lid weight at night may avoid irritation of the lid skin.
  • The external lid weights are not a good option in patients with upper lid dermatochalasis or poor manual dexterity.
• The use of steroids for Bell palsy remains controversial, because such a high likelihood of spontaneous recovery exists.
  • Steroid use early in the disease course may decrease the risk of subsequent aberrant regeneration (eg, crocodile tears).
  • Acyclovir in combination with prednisone has been shown to be of greater benefit than prednisone alone in Bell palsy.

Surgical Care

• The correct surgical treatment of ectropion depends on the etiology.
  • Horizontal lid laxity is often seen with ectropion and usually can be corrected with a lateral tarsal strip procedure.
  • Mild-to-moderate cases of medial ectropion may respond to a medial conjunctival spindle procedure.
  • Tarsal ectropion requires reinsertion of the lower lid retractors.
  • Augmentation of the anterior lamellae (along with excision of any cicatrix) is required for cicatricial ectropion.
• The use of a corneal protector during oculoplastic procedures is recommended. The surgeon must be wary of the remote possibility of flash burns whenever oxygen is on the surgical field. Failure to do so may transform an elective lid repair into a much more complicated problem.
• Ensuring patient comfort during surgery is important. Because most cases of ectropion involve the lower lid, supplemental infraorbital nerve block is a useful adjunct to direct injection and subconjunctival injection.
• Temporary tarsorrhaphy can be performed to protect the cornea if an oculoplastic surgeon is unavailable, but most surgeons do not advocate extensive, permanent tarsorrhaphies.
• Electrocautery at the junction of conjunctiva and lower margin of the tarsus is not commonly advocated. It is usually only a temporary measure.
• Suture repair is a temporary method of repair that is not advocated. Double-armed chromic sutures are passed through the inferior border of the tarsus, emerging at the skin surface near the orbital rim.
• Congenital ectropion
  • Ensure corneal lubrication. If the condition does not resolve after a few days, consider placing lid margin sutures. A lateral tarsorrhaphy may be required if suture techniques do not work, but be careful of iatrogenic amblyopia. More severe cases of congenital ectropion may need a skin flap or graft.
  • Ichthyosis is a well-described cause of congenital ectropion. It is sometimes managed conservatively with lubrication, but skin grafts may be required.
• Lateral tarsal strip: Horizontal lid laxity is a component of most ectropion cases, especially involutional ectropion. Numerous methods are available for correcting horizontal lid laxity. Older methods include wedge resections and the Kuhnt-Szymanowski procedure. Whenever feasible, a lateral canthal tightening procedure is preferred. Surgery at the lateral canthus avoids the possibility of lid notching with noncanthal procedures and decreases the risk of trichiasis. The most common variation of lateral canthal tightening is the lateral tarsal strip procedure.
  • The lateral canthus can be clamped prior to canthotomy (although the author does not believe it is necessary if cautery is available). Inferior cantholysis is then performed with Westcott scissors. The lower lid should now be freely mobile.
  • If excess lid skin is present, it can be draped over the lateral canthus, and an appropriate triangle of full-thickness lid is excised.
  • Traditionally, about 3 mm of the lateral lid is split at the gray line with either sharp Westcott scissors or a 15 blade. (The author does not believe it is necessary to split the lid.)
  • The meibomian orifices of the lateral strip are trimmed away.
  • The lateral conjunctiva is scraped to avoid epithelial inclusion cysts.
  • To secure the lateral strip of tarsus to the periosteum, 2 sutures (or a single horizontal mattress suture) can be placed about 4-5 mm posterior to the lateral orbital rim near the Whitnall tubercle (at or above the level of the inferior pupil). Suitable sutures with small semicircular needles include 5-0 Vicryl on a P2 needle or 4-0 Prolene on a PS-5 needle.
  • Retracting the upper lid supertemporally and placing a Q-tip at the lateral canthus to palpate the inner lateral orbital rim may help.
  • Before tying the suture, remove the corneal shield.
  • The orbicularis layer can be closed with 6-0 Vicryl. The skin can be closed with 6-0 plain gut. A stitch through the lateral-most gray line of the upper and lower lateral lid will help to keep the lateral canthus "sharp."
  • If the patient requires topical drops (eg, glaucoma therapy) postoperatively, do not retract the lower lid for the first month during drop instillation.
  • It is not uncommon for patients to complain of discomfort at the lateral canthus several weeks following this procedure.
• Transconjunctival ectropion repair has been described.
• Kuhnt-Szymanowski (Smith modification): When marked inferior dermatochalasis accompanies ectropion and the lateral canthal tendon is not dehisced, an inferior subciliary blepharoplasty skin incision can be combined with pentagonal wedge excision of the orbicularis and posterior lamellae. Precise closure is required to prevent a lid notch.
• Tarsal ectropion
  • This complete eversion of the lower lid occurs when disinsertion of the capsulopalpebral fascia from the inferior tarsal border is present.
  • In addition to horizontal lid tightening, reinsert the retractors (ideally from a conjunctival approach).
  • A spindle of redundant conjunctiva, no more than 3 mm in vertical height, can be excised, if necessary.
  • A double-armed 5-0 chromic suture can be used to reattach the capsulopalpebral fascia to the inferior tarsus in a running fashion.
• Medial ectropion: If tearing is the primary problem in patients with punctal ectropion, a 1-snip or 2-snip inferior punctoplasty may be beneficial. Easily performed with Vannas scissors and topical anesthetic, punctoplasty restores continuity between the lacus lacrimali and the medial canthal angle. For mild-to-moderate medial ectropion, a medial conjunctival spindle procedure (excision of the medial conjunctiva and retractors) can be performed.
  • Following anesthetic injection in the medial inferior fornix, the inferior canaliculus can be guarded with a lacrimal probe.
  • A horizontal ellipse or diamond of conjunctiva and underlying lid retractors is excised inferior to the punctum, approximately 3-4 mm high and 6-8 mm wide. The base of the wound is cauterized.
  • Then, the defect is closed with double-armed 5-0 chromic inverting suture. This can be accomplished by engaging the inferior lip of the wound, then the superior lip of the wound; the needle is then redirected from the inferior lid to the cutaneous surface. Alternatively, buried interrupted 6-0 polyglactin stitches can be used to close the medial conjunctival spindle.
• The Byron Smith lazy-T procedure is a well-described procedure for repairing prominent medial ectropion. It combines a lower lid, full-thickness pentagonal wedge resection, 3-4 mm temporal to the punctum with resection of a medial triangle of conjunctiva and lower lid retractors (similar to medial conjunctival spindle).
  • Usually, 5-8 mm of lower lid is excised in the pentagonal wedge. When closed, the incisions resemble a "T" lying on its side, hence the name lazy T.
  • If marked medial canthal laxity is present, medial canthal tendon plication generally is performed with a lid shortening procedure.
  • A lacrimal probe is placed to guard the lower canaliculus. A skin incision, extending from just medial to the medial canthus to just temporal to the punctum, is made inferior to the canaliculus.
  • A double-armed 5-0 nylon suture is placed from the medial inferior tarsus to the medial canthal ligament near the anterior lacrimal crest.
  • The lacrimal probe is removed and the plication suture tightened enough to prevent lateral excursion of the puncta. Over-tightening the stitch may kink canalicular outflow. The skin incision can be closed with 6-0 fast-absorbing gut suture.
• Paralytic ectropion
  • A tarsal strip procedure is often helpful. At least 5 mm of the lateral lower lid may have to be excised. For more severe paralytic ectropion, an augmented lateral tarsal strip tarsorrhaphy has been described. A long tarsal strip (10-15 mm) is attached to the outer temporal orbital rim, at a point higher than a conventional lateral tarsal strip. A small portion of the upper eyelid anterior lamella is removed to facilitate passage of the long tarsal strip superiorly. With marked paralytic lower lid ectropion, a midface or suborbicularis oculi fat (SOOF) lift is a useful technique.
  • In patients with extreme paralytic ectropion, a fascia lata (or Gortex) sling or temporalis transfer procedure may be required.
  • Upper lid gold weight implantation is a helpful adjunct for patients with lagophthalmos. Usually, a 1.0-1.2 g weight is implanted superior to the tarsus and inferior to the orbicularis. Extrusion of the gold weight occasionally occurs with time. Since the gold weight works by gravity, patients should sleep with their head slightly elevated. The gold weights are not a contraindication for MRI investigation.
• Cicatricial ectropion
  • An enhanced tarsal strip (ie, a tarsal strip without the traditional lateral skin excision) may help correct some degree of cicatricial ectropion.
  • If an enhanced tarsal strip is insufficient, Z-plasties, V-Y plasty, skin grafts, or advancement flaps may be used to lengthen the anterior lamella.
  • Skin grafts may be obtained from the upper lid if dermatochalasis is present; preauricular or postauricular skin is another alternative. If facial skin is unavailable, medial forearm skin can be used. The skin graft should be thinned and buttonholed (for drainage). In patients with moderate lower eyelid cicatricial ectropion and upper eyelid dermatochalasis, the transfer of a bipedicle or monopedicle flap from the upper eyelid combined with canthopexy is an option.
  • A compressive bolster can be placed over the graft to enhance graft survival and to decrease hematoma formation. The bolster is left for 5 days. A superior traction suture decreases the risk of recurrent cicatrix postoperatively.
  • Hyaluronic acid filler and autologous fat injection have been described for selected cases of cicatricial ectropion.

Follow-up

Further Outpatient Care

• Postoperative care
  • For the lid sutures, an antibiotic ointment (eg, polysporin, tobramycin) can be used. 
  • Applying cold compresses to the eyelids every 15 minutes (as tolerated) while awake will decrease bruising and swelling. Frozen peas in a plastic bag are a useful alternative to traditional cloth compresses.
  • Generally, physicians do not prescribe narcotics postoperatively. The patient is asked to use acetaminophen (325-650 mg PO q4h prn) to manage pain. Patients are asked to avoid aspirin-containing products.
  • Patients can be examined on the first postoperative day, then 5-7 days later for suture removal.

Complications

• Complications are primarily related to corneal and conjunctival exposure. As listed above, these complications can involve conjunctival keratinization, corneal breakdown, epiphora, and pain.
• Surgical complications may include bleeding, hematoma, infection, wound dehiscence, pain, and poor positioning of the tarsal strip.

Multimedia

Media file 1: Medial cicatricial ectropion in a patient with extensive basal cell carcinoma.

Media file 2: Complete (tarsal) paralytic ectropion in a patient with an ipsilateral parotid tumor.

References

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

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

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

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

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

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

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

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

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

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

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Keywords

ectropion, eversion, lid, lower lid, eyelid, corneal exposure, conjunctival exposure, tearing, lid deformity, irritated eyes, red eyes, lid laxity, punctal, medial, lateral, tarsal, cicatricial ectropion, punctal phimosis, paralytic ectropion, nocturnal lagophthalmos, Bell palsy

Contributor Information and Disclosures

Author

Edsel Ing, MD, FRCSC, Assistant Professor, Department of Ophthalmology & Vision Sciences, University of Toronto: Consulting Staff, Toronto East General Hospital
Edsel Ing, MD, FRCSC is a member of the following medical societies: American Academy of Ophthalmology, American College of Physician Executives, American Society of Contemporary Ophthalmology, Canadian Ophthalmological Society, Contact Lens Association of Ophthalmologists, North American Neuro-Ophthalmology Society, and Royal College of Physicians and Surgeons of Canada
Disclosure: Nothing to disclose.

Medical Editor

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 Medical Association, American Society of Ophthalmic Plastic and Reconstructive Surgery, Colorado Medical Society, Utah Medical Association, and Wilderness Medical Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Simon K Law, MD, PharmD, Assistant Professor of Ophthalmology, Jules Stein Eye Institute; Chief of Section of Ophthalmology Surgical Services, Department of Veterans Affairs Healthcare Center, West Los Angeles
Simon K Law, MD, PharmD is a member of the following medical societies: American Academy of Ophthalmology, American Glaucoma Society, and Association for Research in Vision and Ophthalmology
Disclosure: Nothing to disclose.

Managing Editor

Mark T Duffy, MD, PhD, Consulting Staff, Division of Oculoplastic, Orbito-facial, Lacrimal and Reconstructive Surgery, Green Bay Eye Clinic, BayCare Clinic; Medical Director, Advanced Cosmetic Solutions, A BayCare Clinic
Mark T Duffy, MD, PhD is a member of the following medical societies: American Academy of Ophthalmology, American Medical Association, American Society of Ophthalmic Plastic and Reconstructive Surgery, Sigma Xi, and Society for Neuroscience
Disclosure: Allergan - Botox Cosmetic Consulting fee Consulting; Quest medical - lacrimal balloons Honoraria Speaking and teaching; Ortho-Neutrogenia Consulting fee Consulting

CME Editor

Lance L Brown, OD, MD, Ophthalmologist, Affiliated With Freeman Hospital and St John's Hospital, Regional Eye Center, Joplin, Missouri
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, and Pan-American Association of Ophthalmology
Disclosure: Nothing to disclose.

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