Ectropion Lower Eyelid Reconstruction 

Updated: Sep 26, 2017
Author: Mounir Bashour, MD, PhD, CM, FRCSC, FACS; Chief Editor: Arlen D Meyers, MD, MBA 

Overview

Background

Lower lid ectropion is a very common condition in older persons. Frequency increases steadily with age.[1] 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.

See the image below.

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.

Epidemiology

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.[2]

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.[3] 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.

A study by Michels et al indicated that risk factors for either entropion or ectropion of the eyelid include dehiscence of the eyelid retractors, presence of a "white line," orbital fat prolapse in the cul-de-sac, decreased excursion and increased distraction of the lower eyelid, and increased laxity of the eyelid (as measured by the snapback test). Eyelids with ectropion were reported to have less elasticity than those with entropion.[4]

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. The images below demonstrate these relationships through horizontal and sagittal sectioning of the orbit.

Sagittal section through orbit. Sagittal section through orbit.
Horizontal section through orbit. Horizontal section through orbit.

Contraindications

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

 

Workup

Other Tests

See the list below:

  • Snap-back test

    • Pull the lower lid down and away from globe for several seconds and wait. Without the patient blinking, note the length of time required before the lower lid returns to its original position; the lid, in fact, may not return to its original position at all.

    • The snap-back test provides a good measure of relative lower lid laxity. A healthy lid should spring back into original position immediately; the longer that the lid takes to return to the original position, the more laxity that is present.

    • The snap-back test is graded from 0-IV, with a grade of 0 indicating normal laxity and a grade of IV indicating severe laxity.

  • Medial canthal laxity test

    • Pull the lower lid laterally away from the medial canthus and measure displacement of medial punctum; the greater the distance measured, the greater the laxity.

    • Normally, the displacement should only be 0-1 mm.

    • The medial canthal laxity test is graded from 0-IV, with a grade of 0 indicating normal laxity and a grade of IV indicating severe laxity.

  • Lateral canthal laxity test

    • Pull the lower lid medially away from the lateral canthus and measure displacement of the lateral canthal corner; the greater the distance measured, the greater the laxity.

    • Normally, the displacement should only be 0-2 mm.

    • The lateral canthal laxity test is graded from 0-IV, with a grade of 0 indicating normal laxity and a grade of IV indicating severe laxity.

  • Schirmer test: Note how dry the eyes are because ectropion is only one of several conditions among the differential diagnoses of epiphora. A filter paper is applied to the fornix, and the amount of moisture on the strip is noted and compared to the contralateral side.

  • Fluorescein test of cornea: Fluorescein is applied to the cornea and the corneal surface is analyzed with a black light to assess corneal changes or laceration.

Diagnostic Procedures

See the list below:

  • Slit lamp examination: The corneal status must be evaluated preoperatively to assess abrasion or evidence of dryness. Also, check for evidence of lagophthalmos.

  • Presence or absence of Bell phenomenon: Instruct the patient to attempt to close the eyes while the examiner is holding the patient's lids open; if the eye moves up, a positive Bell phenomenon is present.

  • Status of seventh nerve: 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 because of the bilateral innervation of the upper face. In patients in whom facial nerve palsy is suggested, test for orbicularis oris dysfunction by asking the patient to show the teeth rather than smile. Compare the elevation of the angles of the lips; often, ptosis of the lateral lip on the affected side is present.

 

Treatment

Medical Therapy

Provide medical therapy if surgical therapy is not warranted or not possible.

  • Symptomatic therapy can be achieved using artificial tear ointment or drops; moisture shields are also helpful. In addition, the lower lid can be taped back into position using either specially designed or normal skin tape. If the lacrimal system is blocked, performing a dacryocystorhinostomy alone or in combination with an ectropion procedure may produce better results than treating the ectropion alone.

  • If the conjunctiva is markedly keratinized, use a lubricating ointment or mild steroid ointment several days or weeks prior to ectropion repair. Corneal epithelial defects and prior herpes simplex infection are relative contraindications to use of steroid-containing ointments.

  • Instruct patients with tearing and incipient ectropion or early punctal ectropion 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, consider steroid injection into the scar.

  • External paste-on upper lid weights are available and are useful for patients who have seventh nerve palsy. Lid weights can be approximately matched 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. External lid weights are not a good option in patients with upper lid dermatochalasis or poor manual dexterity.

Surgical Therapy

The correct surgical treatment of ectropion depends on the etiology. Horizontal lid laxity is often observed with ectropion and can usually be corrected with a lateral tarsal strip procedure. Mild-to-moderate cases of medial ectropion may respond to a medial conjunctival spindle procedure. However, tarsal ectropion requires reinsertion of the lower lid retractors, and an augmentation of the anterior lamellae (along with excision of any cicatrix) is required for cicatricial ectropion.[5, 6]

The author recommends the use of a corneal protector during oculoplastic procedures. The surgeon must be wary of the remote possibility of flash burns whenever oxygen is on the surgical field. Failure to use a corneal protector may transform an elective lid repair into a much more complicated problem.

Ensuring patient comfort during surgery is important. Since most cases of ectropion involve the lower lid, supplemental infraorbital nerve block is a useful adjunct to direct injection and subconjunctival injection.

Tarsorrhaphy

This procedure can be performed as a temporary fix for corneal exposure; however, the author believes better surgical alternatives are usually available.

Electrocautery

Electrocautery at the junction of conjunctiva and lower margin of the tarsus is not commonly advocated, as this procedure is usually only a temporary measure.

Hyaluronic acid gel injection repair

In our experience, hyaluronic acid gel is a nonsurgical, minimally invasive, and safe technique that improves cicatricial ectropion, but with a poor cosmetic result that limits its use. This treatment could be considered only in patients who decline surgery or are poor surgical candidates, as the aesthetic result would not be acceptable to many.[7]

Suture repair

Double-armed chromic sutures are passed through the inferior border of the tarsus, emerging at the skin surface near the orbital rim; the Leicester modified suture technique is described here.[8] In some cases, this repair can give good and lasting results, but this author does not advocate this method of repair as it is usually temporary.

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; however, be careful to avoid iatrogenic amblyopia. More severe cases of congenital ectropion may require a skin flap or graft.

Ichthyosis is a well-described cause of congenital ectropion, and although it is sometimes managed conservatively with lubrication, skin grafts may be required.[9]

Lateral tarsal strip

Horizontal lid laxity is a component of most ectropion cases, especially involutional ectropion. Numerous methods for correcting horizontal lid laxity exist. Older methods include wedge resections and the Kuhnt-Szymanowski procedure. Whenever feasible, however, the author prefers a lateral canthal-tightening procedure. 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, as follows:

  • The lateral canthus can be clamped prior to canthotomy. Then perform inferior cantholysis with Westcott scissors. The lower lid should then be freely mobile.

  • If excess lid skin is present, drape the skin over the lateral canthus and excise an appropriate triangle of full-thickness lid.

  • Split about 3 mm of the lateral lid at the gray line with either sharp Westcott scissors or a 15 blade.

  • Trim away the meibomian orifices of the lateral strip.

  • Scrape the lateral conjunctiva 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 (ie, 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 superotemporally and placing a cotton swab at the lateral canthus to palpate the inner lateral orbital rim may be helpful.

  • 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 suture. A stitch through the lateral-most gray line of the upper and lower lateral lid helps to keep the lateral canthus sharp.

  • If the patient requires topical drops (eg, glaucoma therapy) postoperatively, instruct the patient not to retract the lower lid during drop instillation for the first month.

It is not uncommon for patients to experience prolonged discomfort at the lateral canthus following the lateral tarsal strip procedure.

A study by Pascali et al suggested that the tarsal belt technique can be more effective than use of the lateral tarsal strip in ectropion correction. Following up on patients over 24 months, it was found that those who underwent tarsal belt surgery showed significantly greater and more stable reduction regarding the distance of the lower lid margin from the interpupillary line than did those who underwent the lateral tarsal strip technique.[10]

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 a 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 one-snip or two-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 into the medial inferior fornix, the inferior canaliculus can be guarded with a lacrimal probe.

  • Excise a horizontal ellipse or diamond of conjunctiva and underlying lid retractors inferior to the punctum, approximately 3-4 mm high and 6-8 mm wide.

  • Close the defect with double-armed 5-0 chromic inverting sutures. This can be accomplished by engaging the inferior lip of the wound, then the superior lip of the wound; then, redirect the needle from the inferior lid to the cutaneous surface.

  • Alternatively, buried interrupted 6-0 polyglactin stitches can be used to close the medial conjunctival spindle.

Byron Smith lazy-T procedure

This well-described procedure for repairing prominent medial ectropion 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 is generally performed with a lid-shortening procedure.

  • Place a lacrimal probe to guard the lower canaliculus. Make a skin incision, extending from just medial to the medial canthus to just temporal to the punctum, inferior to the canaliculus.

  • Place a double-armed 5-0 nylon suture from the medial inferior tarsus to the medial canthal ligament near the anterior lacrimal crest.

  • Remove the lacrimal probe and tighten the plication suture enough to prevent lateral excursion of the puncta. Overtightening the stitch may cause a kink in canalicular outflow. The skin incision can be closed with 6-0 fast-absorbing gut sutures.

Paralytic ectropion

A tarsal strip procedure is often helpful. At least 5 mm of the lateral lower lid may require excision. With lower lid ectropion, suborbicularis oculi fat (SOOF) lifts are also an option.

In patients with extreme paralytic ectropion, a fascia lata (or Gore-Tex) sling or temporalis transfer procedure may be required. An upper lid gold weight implantation is a helpful adjunct for patients with lagophthalmos. Usually, a 1.0- to 1.2-g weight is implanted superior to the tarsus and inferior to the orbicularis. Extrusion of the gold weight occasionally occurs with time as well. Since the gold weight uses gravity, patients should sleep with the head slightly elevated. The gold weights are not a contraindication to 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- to 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. Thin and buttonhole the skin graft (for drainage). Place a compressive bolster 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.

A retrospective study by Choi et al found full-thickness skin grafts to be effective in the treatment of lower eyelid cicatricial ectropion developing secondary to actinic skin, with donor sites including the upper eyelid, supraclavicular skin, postauricular skin, inner brachial skin, axilla, and preauricular skin. The study included 24 patients (29 eyelids), most of whom underwent the graft in conjunction with one or more additional procedures, such as punctoplasty, canthoplasty, and the use of lateral tarsal strips.[11]

Xu et al described a surgical technique for lower eyelid cicatricial ectropion repair using a bipedicle orbicularis oculi muscle or myocutaneous flap from the upper eyelid.[12] A strip of orbicularis oculi muscle or a myocutaneous flap from the upper eyelid with 2 pedicles attached in the medial and lateral canthus is advanced to the lower eyelid to suspend the eyelid and repair the skin defect.

Postoperative Details

For the lid sutures, the author prefers an antibiotic steroid combination, such as Maxitrol (neomycin, polymyxin, bacitracin), 3 times a day.

Applying cold compresses to the eyelids every 15 minutes (as tolerated) while the patient is awake decreases bruising and swelling. Frozen peas in a plastic bag are a useful alternative to traditional cloth compresses.

The author generally does not prescribe narcotics postoperatively. Ask the patient to use acetaminophen 325-650 mg by mouth every 4 hours as needed. Ask the patient to avoid aspirin-containing products if possible.

Follow-up

Patients are usually reviewed on the first postoperative day. Patients then return 5-7 days later for suture removal.

Complications

Complications are primarily related to corneal and conjunctival exposure. 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.

Outcome and Prognosis

Outcome and prognosis are usually excellent.