Lower Lid Ectropion Blepharoplasty Workup

  • Author: Mounir Bashour, MD, CM, FRCS(C), PhD, FACS; Chief Editor: Lars M Vistnes, MD, FRCSC, FACS   more...
 
Updated: Feb 2, 2012
 

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). See the image below. 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. See the image below. 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.
Proceed to Treatment & Management
 
 
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.

Specialty Editor Board

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.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Jorge I de la Torre, MD, FACS  Professor of Surgery and Physical Medicine and Rehabilitation, Chief, Division of Plastic Surgery, Residency Program Director, University of Alabama at Birmingham School of Medicine; 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.

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.

References

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Ectropion with keratinization of the lower lid.
The snap-back test.
Lower lid laxity obvious after snap-back test.
Preparing the lateral tarsal strip.
The 4-0 Vicryl suture is paced through the tarsal strip in a horizontal mattress fashion.
The suture is tied to the periosteum of the lateral orbital rim and tightened.
 
 
 
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