eMedicine Specialties > Otolaryngology and Facial Plastic Surgery > Reconstructive Surgery

Lower Eyelid Reconstruction, Ectropion

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 14, 2009

Introduction

Lower lid ectropion is a very common condition in older persons. Frequency increases steadily with age. Defined as an eversion of the eyelid away from the globe, the condition is classified according to its anatomic features as involutional, cicatricial, tarsal, congenital, or neurogenic/paralytic. Surgical approaches are directed toward the underlying etiologic factors.

Sagittal section through orbit.

Sagittal section through orbit.

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Sagittal section through orbit.

Sagittal section through orbit.

Problem

Ectropion is an outward turning of the eyelid margin. It occurs most often in the lower eyelid. The condition may be mild or severe and may involve all or part of the eyelid margin.

Frequency

Ectropion is a very common condition in older persons. It is more frequently found in men than in women, which may be related to men generally having larger tarsal plates than women.

Etiology

Ectropion is most commonly observed as an involutional change associated with horizontal laxity of the involved eyelid. Ectropion may be classified into the following 5 types, ordered in decreasing frequency: involutional (senile), paralytic (neurogenic), cicatricial, mechanical, and congenital.1

Involutional ectropion

Involutional ectropion is the most common form of ectropion. A major factor is horizontal lid laxity, which is usually due to age-related (most patients are older persons) weakness of the canthal ligaments and pretarsal orbicularis.

For many years, physicians have questioned why some patients develop ectropion and others develop entropion, when both conditions seem to share the same etiologic factors. Bashour and Harvey recently answered this question.2  They report the following:

  • Patients with involutional entropion have tarsal plates that are smaller than the normal average for age. Involutional entropion results from the vector mechanical effect of an atrophied or smaller than normal for age partially or fully disinserted tarsal plate being overcome by the normal or increased tone of the preseptal/pretarsal orbicularis muscle.
  • Patients with involutional ectropion have tarsal plates that are larger than the normal average for age. Involutional ectropion results from normal or larger-than-normal for age tarsal plate vector mechanical effects overcoming the normal or decreased tone of the preseptal/pretarsal orbicularis muscle in combination with medial/lateral 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

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

Cicatricial ectropion occurs from scarring of the anterior lamella by conditions such as facial burns, trauma, chronic dermatitis, or excessive skin excision (or laser) with blepharoplasty. Ectropion is not uncommon after orbital fracture repair with a transcutaneous approach. Less common causes of cicatricial ectropion include cutaneous T-cell lymphoma.

Mechanical ectropion

Mechanical ectropion may occur with lid tumors, such as neurofibromas, that evert the lower lid.

Congenital ectropion

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

Pathophysiology

Causal factors leading to ectropion include horizontal laxity of the eyelid (universal), dehiscence of the lower eyelid retractors, vertical shortening of the anterior lamella of the eyelid, paralysis of the orbicularis oculi muscle causing loss of eyelid muscular tone, and neoplasia within the lower eyelid pulling or forcing the eyelid away from the globe.

Presentation

Patients usually present because of epiphora, ocular irritation, or cosmesis.

Generally, the progression observed is from eyelid laxity to punctal ectropion, to medial ectropion, and then to generalized ectropion. If the punctum is everted slightly from the lacus lacrimalis, tears cannot effectively drain into the canalicular system. Also, horizontal eyelid laxity may produce a flaccid canalicular syndrome or poor lacrimal pump so that tears are not siphoned from the lacus lacrimalis, producing epiphora.

This tearing malfunction is aggravated by the chronic ectropion and eyelid retraction that produce lagophthalmos and secondary exposure keratopathy. With time, the exposed conjunctiva thickens and keratinizes, producing further ocular irritation.

Indications

Tearing (epiphora) is probably the most common indication for surgical correction, but ocular irritation and cosmesis are also frequently encountered and may be indications for surgery.

Relevant Anatomy

The orbicularis oculi muscle is the sphincter of the eyelids. It spreads over the eyelids and out onto the forehead, temple, and cheeks. It is divided into orbital and palpebral portions, with the palpebral portion subdivided into preseptal and pretarsal parts.

The pretarsal part is attached laterally to the Whitnall tubercle by the lateral canthal tendon. This tendon (which is actually just a band of connective tissue) is weak in ectropion. Medially, the pretarsal orbicularis forms the anterior crus of the medial canthal tendon that inserts into the frontal process of the maxillary bone. The posterior pretarsal orbicularis inserts into the posterior lacrimal crest. The small strip of pretarsal muscle at the lid margin forms the gray line and is called the Riolan muscle. Images 1-2 demonstrate these relationships through horizontal and sagittal sectioning of the orbit.

Sagittal section through orbit.

Sagittal section through orbit.

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Sagittal section through orbit.

Sagittal section through orbit.



Horizontal section through orbit.

Horizontal section through orbit.

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Horizontal section through orbit.

Horizontal section through orbit.

Contraindications

Surgery to correct ectropion is contraindicated in patients who are unable to tolerate the procedure.

More on Lower Eyelid Reconstruction, Ectropion

Overview: Lower Eyelid Reconstruction, Ectropion
Workup: Lower Eyelid Reconstruction, Ectropion
Treatment: Lower Eyelid Reconstruction, Ectropion
Follow-up: Lower Eyelid Reconstruction, Ectropion
Multimedia: Lower Eyelid Reconstruction, Ectropion
References
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References

  1. Neuhaus RW. Anatomical basis of "senile" ectropion. Ophthal Plast Reconstr Surg. 1985;1(2):87-9. [Medline].

  2. 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].

  3. Sigurdsson H, Baldursson BT. [Case of the month. Ichthyosis with ectropion]. Laeknabladid. May 2009;95(5):357-8. [Medline].

  4. 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].

  5. Adenis JP, Grivet D. Ectropion of the lacrimal point: The shoe lace technique. Eur J Ophthalmol. Mar-Apr 2005;15(2):267-70. [Medline].

  6. Benger RS, Frueh BR. Involutional ectropion: a review of the management. Ophthalmic Surg. Feb 1987;18(2):136-9. [Medline].

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

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

  9. Detorakis ET, Ioannakis K, Kozobolis VP. Corneal topography in involutional ectropion of the lower eyelid: preoperative and postoperative evaluation. Cornea. May 2005;24(4):431-4. [Medline].

  10. Frueh BR, Schoengarth LD. Evaluation and treatment of the patient with ectropion. Ophthalmology. Sep 1982;89(9):1049-54. [Medline].

  11. Hsuan J, Selva D. The use of a polyglactin suture in the lateral tarsal strip procedure. Am J Ophthalmol. Oct 2004;138(4):588-91. [Medline].

  12. Kersten RC, Kulwin DR. Paralytic ectropion of the lower eyelid [letter; comment]. Plast Reconstr Surg. Sep 1995;96(4):991-2. [Medline].

  13. Pidde WJ. Cicatricial ectropion. Can J Ophthalmol. Oct 1976;11(4):350. [Medline].

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

  15. Rosenberg S, Goldfarb M. Management of paralytic ectropion. Ann Ophthalmol. Sep 1981;13(9):1063-5. [Medline].

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

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Further Reading

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Keywords

lower lid ectropion, lower lid laxity, eyelid eversion, involutional, cicatricial, tarsal, congenital, neurogenic, paralytic, lower eyelid reconstruction, eyelid laxity

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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

Richard V Smith, MD, Director of Clinical Affairs, Associate Professor, Department of Otolaryngology, Division of Head and Neck Surgery, Einstein College of Medicine, Montefiore Medical Center
Richard V Smith, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Head and Neck Society, American Laryngological Rhinological and Otological Society, American Medical Association, American Medical Student Association/Foundation, Medical Society of the District of Columbia, New York Academy of Medicine, and Vermont State Medical Society
Disclosure: Nothing to disclose.

Pharmacy Editor

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

Managing Editor

David W Stepnick, MD, Associate Professor, Departments of Plastic Surgery and Otolaryngology-Head and Neck Surgery, Case Western Reserve University School of Medicine, University Hospitals of Cleveland Case Medical Center
David W Stepnick, MD is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Medical Association, American Society for Head and Neck Surgery, and Society of University Otolaryngologists-Head and Neck Surgeons
Disclosure: Nothing to disclose.

CME Editor

Christopher L Slack, MD, Otolaryngology-Facial Plastic Surgery, Private Practice, Associated Coastal ENT; Medical Director, Treasure Coast Sleep Disorders
Christopher L Slack, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Medical Association
Disclosure: Nothing to disclose.

Chief Editor

Arlen D Meyers, MD, MBA, Professor, Department of Otolaryngology-Head and Neck Surgery, University of Colorado School of Medicine
Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Head and Neck Society
Disclosure: Covidien Corp Consulting fee Consulting; US Tobacco Corporation unstricted gift unknown; Axis Three Corporation Ownership interest Consulting; Omni Biosciences Ownership interest Consulting; Sentegra Ownership interest Board membership; Syndicom Ownership interest Consulting; Oxlo  Consulting; Medvoy Ownership interest Management position

 
 
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