Ectropion Treatment & Management

Updated: Jul 20, 2018
  • Author: Edsel Ing, MD, MPH, FRCSC; Chief Editor: Hampton Roy, Sr, MD  more...
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Treatment

Medical Care

Lubrication and moisture shields are helpful if significant corneal exposure exists from the ectropion. In patients with corneal exposure, plastic dressings (eg, Tegaderm) are often superior to cloth patches. In some cases, taping the inferolateral canthal skin supertemporally provides temporary relief, especially in patients with new-onset seventh nerve palsy. [4, 5]

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 gently 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.

Although spontaneous recovery from Bell palsy is highly likely, steroid administration early in the disease course may decrease the risk of aberrant regeneration (motor synkinesis). Antivirals for herpes simplex are no longer routinely recommended. [6]

Topical retinoids have been suggested as treatment for ectropion from ichthyosis. [7] Hyaluronic acid gel has been described as a treatment for cicatricial ectropion but has a poor cosmetic result. [8]

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Surgical Care

The correct surgical treatment of ectropion depends on the etiology. [9] 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.

Inverting sutures are described but are usually a temporary or adjunctive method of repair. [10] 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. [11]

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 find it 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 mm posterior to the lateral orbital rim at 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

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.

A purse string suture between the lower eyelid portion of the medial canthal tendon and the caruncle has also been described to correct medial ectropion. [12]

Byron Smith lazy-T procedure

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 (or platinum 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.

In patients with paralytic ectropion, transposition of the contralateral corrugator supercilii has been described to correct the medial component. [13]

A "vertical orbicularis oculi muscle turn-over" procedure can be performed for paralytic ectropion. [14]

Cicatricial ectropion  [15]

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.

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Complications

Surgical complications may include bleeding, hematoma, infection, wound dehiscence, pain, and poor positioning of the tarsal strip.

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Prevention

To decrease progression or recurrence of ectropion, patients should not distract the lower lid when instilling eye drops or blotting tears. Instead of sleeping prone, or on the side of the ectropion, it may be better for the patient to sleep supine.

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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.

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