eMedicine Specialties > Plastic Surgery > Eyelids

Blepharoplasty, Lower Lid Ectropion Surgery: Workup

Author: Mounir Bashour, MD, CM, FRCS(C), PhD, FACS, Assistant Professor of Ophthalmology, McGill University; Clinical Assistant Professor of Ophthalmology, Sherbrooke University; Medical Director, Cornea Laser and Lasik MD
Contributor Information and Disclosures

Updated: Jul 7, 2009

Workup

Other Tests

  • Snap-back test
    • Pull lower lid away and down from globe for several seconds and wait to see how long before it returns to original position without the patient blinking (if it does at all).

      The snap-back test.

      The snap-back test.

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      The snap-back test.

      The snap-back test.

    • This test result gives a good idea of relative lower lid laxity. In normal lids, it should spring back into original position immediately; the longer it takes, the more laxity is present.

      Lower lid laxity obvious after snap-back test.

      Lower lid laxity obvious after snap-back test.

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      Lower lid laxity obvious after snap-back test.

      Lower lid laxity obvious after snap-back test.

    • Grade 0-IV (0 = normal, IV = severe laxity): This scale is subjective and comes with clinical experience.
      • Grade 0 - normal lid that returns to position immediately on release
      • Grade IV - never returns to position and continues to hang down in frank ectropion after the snap-back test
      • Grade I - approximately 2-3 sec
      • Grade II - 4-5 sec
      • Grade III - >5 sec but does return to position with blinking
  • Medial canthal laxity test
    • Pull lower lid laterally away from medial canthus and measure displacement of medial punctum; the greater the distance, the more the laxity.
    • Normally, displacement should be only 0-1 mm.
    • Grade 0-IV (0 = normal, IV = severe laxity): This test uses the same scale as the snap-back test; it is also subjective and based on clinical experience.
      • Grade I - approximately 2 mm displacement
      • Grade II - approximately 3 mm
      • Grade III - >3 mm
      • Grade IV - does not return to baseline
  • Lateral canthal laxity test
    • Pull lower lid medially away from lateral canthus and measure displacement of lateral canthal corner; the greater the distance, the more the laxity.
    • Normally, displacement should be only 0-2 mm (grade 0).
    • Grade 0-IV (0 = normal, IV = severe laxity): This test uses the same scale as tests above.
      • Grade I - 2-4 mm
      • Grade II - 4-6 mm
      • Grade III - >6 mm
      • Grade IV - III and does not return to baseline even after blinking
  • Schirmer test: Having an idea of how dry the eyes are is helpful, as ectropion is only one of several conditions in the differential of epiphora.
  • Fluorescein test of cornea: Perform this test as a baseline for the same reasons one does the Schirmer test.
  • Irrigation of lacrimal system: If the system is blocked, a dacryocystorhinostomy alone or in combination with an ectropion procedure would be better than treating the ectropion alone.
  • Slit lamp examination: Specifically check corneal status and evidence of dryness. Also check for evidence of lagophthalmos.
  • Presence or absence of Bell phenomenon: Patient is told to attempt closure of eyes while examiner is holding lids open; if eye moves up, positive Bell is present.
  • Check status of seventh nerve.
    • With lower motor neuron seventh nerve palsy (eg, Bell palsy), the ipsilateral brow and lower facial musculature are weak. With an upper motor neuron seventh nerve palsy, brow elevation is relatively spared from bilateral innervation of the upper face.
    • In patients with suspected facial nerve palsy, test for orbicularis oris dysfunction by asking the patient to show his or her teeth rather than smile. Compare the elevation of the angles of the lips; there is often ptosis of the lateral lip on the affected side.

More on Blepharoplasty, Lower Lid Ectropion Surgery

Overview: Blepharoplasty, Lower Lid Ectropion Surgery
Workup: Blepharoplasty, Lower Lid Ectropion Surgery
Treatment: Blepharoplasty, Lower Lid Ectropion Surgery
Follow-up: Blepharoplasty, Lower Lid Ectropion Surgery
Multimedia: Blepharoplasty, Lower Lid Ectropion Surgery
References
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References

  1. Piskiniene R. Eyelid malposition: lower lid entropion and ectropion. Medicina (Kaunas). 2006;42(11):881-4. [Medline].

  2. Benger RS, Musch DC. A comparative study of eyelid parameters in involutional entropion. Ophthal Plast Reconstr Surg. 1989;5(4):281-7. [Medline].

  3. Carter SR, Chang J, Aguilar GL, Rathbun JE, Seiff SR. Involutional entropion and ectropion of the Asian lower eyelid. Ophthal Plast Reconstr Surg. Jan 2000;16(1):45-9. [Medline].

  4. 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].

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

  6. Corin S, Veloudios A, Harvey JT. A modification of the lateral tarsal strip procedure with resection of orbicularis muscle for entropion repair. Ophthalmic Surg. Oct 1991;22(10):606-8. [Medline].

  7. Chang L, Olver J. A useful augmented lateral tarsal strip tarsorrhaphy for paralytic ectropion. Ophthalmology. Jan 2006;113(1):84-91. [Medline].

  8. Xu JH, Tan WQ, Yao JM. Bipedicle orbicularis oculi flap in the reconstruction of the lower eyelid ectropion. Aesthetic Plast Surg. Mar-Apr 2007;31(2):161-6. [Medline].

  9. Cherubini TD. Entropion and ectropion of the eyelids. Clin Plast Surg. Oct 1978;5(4):583-91. [Medline].

  10. Fox SA. Surgery of senile ectropion and entropion. Ann Ophthalmol. Mar 1972;4(3):217-31. [Medline].

  11. Hartstein ME, Klimek DL. Eyelid Malposition: Update on Entropion and Ectropion. Comprehensive Ophthalmology Update. 2001;2:107-14.

  12. Harvey JT. Voluntary entropion. Can J Ophthalmol. Feb 1985;20(1):19-22. [Medline].

  13. Hayashi A, Maruyama Y, Okada E, Ogino A. Use of a suture anchor for correction of ectropion in facial paralysis. Plast Reconstr Surg. Jan 2005;115(1):234-9. [Medline].

  14. Sisler HA, Labay GR, Finlay JR. Senile ectropion and entropion: a comparative histopathological study. Ann Ophthalmol. Mar 1976;8(3):319-22. [Medline].

  15. Weber PJ, Popp JC, Wulc AE. Refinements of the tarsal strip procedure. Ophthalmic Surg. Nov 1991;22(11):687-91. [Medline].

  16. Weene LE. Bick procedure for correction of senile entropion and ectropion. Ophthalmic Surg. Apr 1977;8(2):40-1. [Medline].

  17. Wesley RE. Ectropion repair. Oculoplastic Surgery. 1995;249-61.

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Further Reading

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Keywords

involutional ectropion, lower lid laxity, blepharoplasty, lower lid ectropion surgery, lower lid ectropion, ectropion, epiphora, ocular irritation, eyelid laxity, punctal ectropion, medial ectropion, generalized ectropion, snap-back test, medial canthal laxity test, lateral canthal laxity test, cicatricial ectropion, lateral tarsorrhaphy, horizontal lid laxity, congenital ectropion, ichthyosis, lateral tarsal strip, LTS, tarsal ectropion, paralytic ectropion, augmented lateral tarsal strip, tarsorrhaphy

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Contributor Information and Disclosures

Author

Mounir Bashour, MD, CM, FRCS(C), PhD, FACS, Assistant Professor of Ophthalmology, McGill University; Clinical Assistant Professor of Ophthalmology, Sherbrooke University; Medical Director, Cornea Laser and Lasik MD
Mounir Bashour, MD, CM, FRCS(C), PhD, FACS is a member of the following medical societies: American Academy of Ophthalmology, American Association for Pediatric Ophthalmology and Strabismus, American College of International Physicians, American College of Surgeons, American Medical Association, American Society of Cataract and Refractive Surgery, American Society of Mechanical Engineers, American Society of Ophthalmic Plastic and Reconstructive Surgery, Biomedical Engineering Society, Canadian Medical Association, Canadian Ophthalmological Society, Contact Lens Association of Ophthalmologists, International College of Surgeons US Section, Ontario Medical Association, Quebec Medical Association, and Royal College of Physicians and Surgeons of Canada
Disclosure: Nothing to disclose.

Medical Editor

Neal R Reisman, MD, JD, Chief of Plastic Surgery, St Luke's Episcopal Hospital; Clinical Professor of Plastic Surgery, Baylor College of Medicine
Neal R Reisman, MD, JD is a member of the following medical societies: American Association of Plastic Surgeons, American College of Surgeons, American Society for Aesthetic Plastic Surgery, American Society of Plastic Surgeons, Lipoplasty Society of North America, Texas Medical Association, and Texas Society of Plastic Surgeons
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Jorge I de la Torre, MD, FACS, Professor of Surgery and Physical Medicine and Rehabilitation, Residency Program Director, Division of Plastic Surgery, University of Alabama at Birmingham; Director, Center for Advanced Surgical Aesthetics
Jorge I de la Torre, MD, FACS is a member of the following medical societies: American Association of Plastic Surgeons, American Burn Association, American College of Surgeons, American Medical Association, American Society for Laser Medicine and Surgery, American Society for Reconstructive Microsurgery, American Society of Maxillofacial Surgeons, American Society of Plastic Surgeons, Association for Academic Surgery, and Medical Association of the State of Alabama
Disclosure: Nothing to disclose.

CME Editor

Nicolas (Nick) G Slenkovich, MD, Director, Colorado Plastic Surgery Center
Nicolas (Nick) G Slenkovich, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Medical Association, American Society of Aesthetic Plastic Surgery, American Society of Plastic Surgeons, and Colorado Medical Society
Disclosure: Nothing to disclose.

Chief Editor

Lars M Vistnes, MD, FRCSC, FACS, Professor of Surgery, Emeritus, Stanford University Medical Center
Lars M Vistnes, MD, FRCSC, FACS is a member of the following medical societies: Royal College of Physicians and Surgeons of Canada
Disclosure: Nothing to disclose.

 
 
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