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Visit Expert Consult ( expertconsult.inkling.com ) for videos on topics discussed throughout the text.
Introduction
Ectropion of the eyelid occurs when the lid margin everts or turns away from the eyeball. Lower lid ectropion is a common problem. Patients may complain of irritation or mattering , erythema of the lid margin , or tearing. Three types of lower lid ectropion occur:
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Cicatricial
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Paralytic
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Involutional
Cicatricial ectropion is caused by shortening of the anterior lamella as a result of trauma, medication, or cicatricial skin disease. Shrinking of the skin of the front of the eyelid pulls the eyelid off the eye. Involutional ectropion is caused by horizontal laxity of the eyelid. The lower eyelid is too long or loose and it falls away from the eye. Paralytic ectropion is caused by loss of orbicularis muscle tone, which supports the lower eyelid in its normal position. Associated lower facial paralysis and brow ptosis usually accompany paralytic ectropion. The type and cause of the ectropion are usually obvious from the history and examination. Often, there is more than one etiology of the ectropion occurring simultaneously. For example, facial nerve palsy in a young patient without lid laxity often does not cause ectropion. In an older patient, with preexisting horizontal laxity, the eyelid is ectropic.
After the etiology of the ectropion is identified, a treatment plan can be made. The lateral tarsal strip operation is used to correct horizontal lid laxity. The lower eyelid is shortened at the lateral canthus. This operation is the procedure of choice for repairing involutional eyelid ectropion. Paralytic ectropion is usually treated with the operation, also. Some version of the lateral tarsal strip procedure is probably the most useful operation to learn in all of oculoplastic surgery. In severe cases of ectropion, sutures supporting the cheek may also be required (i.e., a midface lift) to prevent the lid from sagging. Paralytic ectropion is somewhat more complicated to treat than involutional ectropion because corneal exposure and brow ptosis may also require treatment.
Cicatricial ectropion is treated by lengthening the shortened anterior lamella, usually with a full-thickness skin graft . Frequently, a lateral tarsal strip operation is used in conjunction with a full-thickness skin graft to treat any associated lid laxity. Cicatricial ectropion of the upper eyelid may also occur. There is no upper eyelid equivalent for paralytic or involutional ectropion.
Congenital ectropion or eversion of the upper or lower eyelid can occur but is extremely rare. Some texts include a mechanical form of ectropion. This is said to occur when a large tumor forms on the eyelid, pulling the eyelid off the eye. I consider this to be more of a tumor problem than a lid malposition and so have not included discussion of a mechanical ectropion in this chapter. Irritation and mattering can occur if the upper eyelid is extremely lax. This is known as floppy eyelid syndrome . It may be caused by poor eyelid apposition or eversion of the eyelid during sleep. Floppy eyelid syndrome is discussed later in the section on physical examination.
Ectropion is common and easy to diagnose. The mechanisms are understandable, and the cause is recognizable during the history and physical examination. Appropriate treatment can be chosen based on the type of ectropion identified. Surgical correction is successful in most cases.
Anatomic Considerations
Normal Eyelid Anatomy
The normal lower lid rests at the limbus ( Figure 3.1 ; also see Figure 2.1 in Chapter 2 ). There is normally no sclera visible between the lower lid margin and the limbus. The lower eyelid apposes the eye for the entire length of the eyelid. There should be no separation of the posterior lid margin from the eye. In most Caucasian eyelids, the lateral canthus is slightly higher than the medial canthus. Some racial variations occur. The lower lid punctum sits in the tear lake at the conjunctival plica. The next time you look at a patient with the slit lamp, notice that the normally positioned punctum is not visible at the slit lamp without using your finger to slightly evert the punctum. Normal tear drainage will not occur if the punctum is vertical or upright. The normal tear lake should be approximately 0.5 mm high. You will see examples of excessive and inadequate tear lakes during your slit lamp examination.
Abnormal Eyelid Anatomy
Horizontal Eyelid Laxity
The tarsal plates are attached to the bony orbital rims by the lateral and medial canthal tendons. Lengthening of the tendons occurs with age. This increase in the horizontal length of the eyelid is responsible for the eyelid laxity that causes involutional ectropion. The tarsal plates do not lengthen with time. The insertion of the lateral canthal tendon is on the inner aspect of the lateral orbital rim at the Whitnall tubercle. This slightly elevated area of the lateral orbital rim is approximately 10 mm inferior to the frontozygomatic suture. When you reattach the lateral canthal tendon using the lateral tarsal strip procedure, reposition the tendon on the inner aspect of the rim to prevent lid distraction from the globe.
Midfacial Hypoplasia: The Negative Vector Eyelid
The bony architecture of the inferior orbital rim provides support for the lower eyelid. Individual and racial variations occur. Patients with higher cheekbones or prominent malar bones tend to have less ectropion. Asian patients tend to have a flat face with more prominent malar bones. Black patients tend to have less prominent malar bones. The bony architecture of Caucasian patients is intermediate. Patients with the so-called hypoplastic midface or maxilla have an inferior orbital rim that is somewhat posterior in relationship to the eyeball ( Figure 3.2 ). These patients tend to have less support for the lower lid and often have a low resting lower eyelid position. These patients are more susceptible to ectropion and further lower eyelid retraction. Another term for the hypoplastic maxilla is hemiproptosis . I like this term because it emphasizes the fact that the inferior half of the eye is more anterior than the orbital rim. Tightening of the lower lid in a patient with hemiproptosis may cause the eyelid to slide under the eye, creating lower eyelid retraction. Be careful when tightening any lower eyelid in a patient with hemiproptosis. The relationship of the maxilla to the inferior rim should be considered in patients undergoing lower eyelid blepharoplasty in order to avoid the complication of eyelid retraction or “rounding” of the lower eyelid. You will see later that hemiproptosis is also referred to as a negative vector eyelid , especially in the context of lower eyelid cosmetic surgery. Patients with a negative vector eyelid are prone to lower eyelid retraction after lower blepharoplasty.
Anterior Lamellar Shortening
The skin, orbicularis muscle, and orbital septum are normally flexible enough that quick spontaneous movements of the eyelids can occur. You are already familiar with the terms anterior lamella (skin and muscle) and posterior lamella (tarsus and conjunctiva). Shortening of the anterior lamella can cause a cicatricial ectropion ( Figure 3.3 ). Lengthening of the shortened lamella by medical treatment or adding a full-thickness skin graft is the treatment for cicatricial ectropion . As you know, scarring of the posterior lamella also causes a cicatricial entropion.
Middle Lamella
The term middle lamella has been used to describe the tissues between the anterior and posterior lamellae of the eyelid inferior to the tarsal plate. These tissues include the orbital septum, preaponeurotic fat, and lower lid retractors. Scarring of the middle lamella may tether the eyelid, which causes cicatricial ectropion, lid retraction, or even cicatricial entropion, depending on how the scar tissue forms. This middle lamella scarring occurs most commonly after eyelid trauma or surgery. There is no middle lamella in the pretarsal portion of the eyelid.
Paralysis of the Orbicularis Muscle
The resting tone of the orbicularis muscle supports the tarsal plate and canthal tendons, helping to support the lower eyelid in the normal position. In patients with paralytic ectropion, the resting tone of the orbicularis muscle is reduced or absent ( Figure 3.4 ). Ectropion occurs primarily in older patients who have an underlying element of lid laxity. In younger patients with facial nerve palsy, ectropion generally does not occur, because there is no underlying lid laxity.
Normal lid position and function are necessary for tear drainage. Any type of ectropion may cause tearing as a result of corneal exposure, with resultant reflex tearing, punctal eversion, or loss of the lacrimal pump. Interestingly, many older patients with ectropion do not complain of tearing. This is probably because tear production decreases with age.
At this point you should:
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Know the types of ectropion
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State the anatomic cause for each type of ectropion
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Explain the term hemiproptosis. What are other terms for this condition?
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Understand why younger patients with facial nerve palsy may not have ectropion
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Understand the reasons for tearing resulting from ectropion
History
Symptoms
The history in ectropion is straightforward. You want to understand what bothers the patient about the ectropion. Patients with ectropion usually complain of irritation , redness , or tearing . As the lower eyelid everts, the normally moist conjunctival tissues become exposed to air and dry out. The conjunctiva becomes erythematous. A discharge may develop. The irritation is usually mild, and some patients may choose to ignore recommended treatment for the ectropion. This is in contrast to patients with entropion. When the eyelashes rub against the eye, the irritation is more severe, and patients seldom refuse treatment. For some patients, the main complaint about the ectropion is the erythematous appearance of the lid margin. Tearing may accompany the ectropion. The cause of tearing may be reflex, punctal malposition, or inadequate lacrimal pump function. Younger patients make more tears than older patients. As you would expect then, tearing is more severe in young patients than in older patients. A young patient with mild punctal eversion may complain of severe tearing with tears rolling down the cheek (epiphora), whereas an older patient with complete ectropion may have no complaints related to watering. If tearing is present, you need to pay particular attention to the position of the punctum when you are correcting the eyelid position.
Etiologic Factors
Look for causes of anterior lamellar shortening (see Figure 3.3 )
A history of trauma or cicatricial skin disease may explain why a patient has cicatricial ectropion . Previous excision of skin cancer or repair of a laceration in the periocular area may cause anterior lamellar shortening. The most common cause of anterior lamellar shortening is actinic damage in fair-skinned Caucasian patients. These patients have far fewer wrinkles than expected for their age (you cannot have wrinkles without some laxity). Rarely, a patient may have a cicatricial skin disease, such as ichthyosis, that may cause the eyelid skin to shorten. Eye medications can result in a contact dermatitis with shrinkage of the skin and ectropion. This is common with glaucoma drops. Changing glaucoma medications often improves the dermatitis and cures the ectropion.
Is there any history of facial nerve paralysis?
Even a patient who has no obvious facial asymmetry may recollect a resolved Bell palsy . This mild orbicularis weakness may combine with horizontal laxity to cause paralytic ectropion .
Physical Examination
Location and Severity
The purpose of the physical examination is to identify the presence, location, and severity of the ectropion, as well as the underlying etiology. Any eversion of the lid margin off the eyeball is considered ectropion. The lid distraction may be mild and relatively asymptomatic. Only the punctum may be everted, with tearing as the complaint rather than ectropion. The ectropion may be lateral or medial or involve the entire lower eyelid. The ectropion may be severe with the entire lid everted to the degree that the eyelid is turned inside out. This condition is known as tarsal ectropion ( Figure 3.5 ).
Etiology
Are Cicatricial Changes Present?
The etiology of the ectropion is usually apparent. The first questions to ask are Is the ectropion cicatricial? Is there scar tissue pulling the eyelid away from the eyeball? Look for any specific scarring of the periocular area that would indicate previous accidental or surgical trauma. Look to see if the patient has tight skin on the whole face. Some patients, despite their age, may have tight skin with very few wrinkles. These patients may have generalized skin shrinkage as a cause of the cicatricial ectropion. Cicatricial ectropion is less common than involutional ectropion (see Figure 3.3 ).
Is There Facial Asymmetry?
If there are no cicatricial changes, ask the question Is there evidence of facial asymmetry suggesting paralytic ectropion? Patients with facial nerve palsy have associated flattening of the nasolabial fold and coexisting brow ptosis. Patients with paralytic ectropion have significant laxity of the involved lower eyelid. Be sure to check for evidence of corneal exposure that would require additional medical or surgical treatment aside from repair of the paralytic ectropion (see Figure 3.4 ). The additional procedures used in the management of facial nerve palsy are covered in Chapter 9 .
Horizontal Eyelid Laxity
If the ectropion is not cicatricial and not paralytic, it must be involutional. Involutional ectropion occurs in older patients with eyelid laxity ( Figure 3.6 ). The eyelid laxity can be demonstrated by the eyelid distraction test and the eyelid snap test .
Eyelid Distraction Test
The eyelid distraction test is performed by manually pulling the eyelid away from the eyeball. The lower lid should not move more than 6 mm off the eyeball ( Figure 3.7 ).
Eyelid Snap Test
The eyelid snap test is performed by pulling the lower eyelid inferiorly toward the inferior orbital rim. An eyelid without lower eyelid laxity will spring back into position without a blink. The lax lower eyelid will remain away from the eye for a period of time. The amount of laxity can be grossly quantified by asking the patient to blink and counting the number of blinks required to return the lid to normal position. I note in the chart something like, “eyelid returns with two blinks.” The eyelid distraction and eyelid snap tests are very helpful ( Figure 3.8 ). The amount of laxity is directly related to the treatment, which involves shortening the eyelid with a lateral tarsal strip operation. Remember that involutional ectropion is one of the most common oculoplastic conditions.
Considerations for Treatment
The aim of the last portion of the physical examination is to determine what treatment is required to repair the ectropion. In patients with cicatricial ectropion, the position and severity of the scarring should be estimated. The location and size of the full-thickness skin graft required to lengthen the anterior lamellar shortage can be estimated. In general, the horizontal length of the graft should extend slightly beyond the areas of involved scarring. You should also estimate if lid laxity is present. In most cases, an eyelid tightening procedure (almost always a lateral tarsal strip procedure) is used in conjunction with a full-thickness skin graft.
In patients with involutional ectropion, the effect of lower eyelid tightening can be estimated at the slit lamp. Using your index finger, pull the eyelid laterally and watch how the eyelid margin fits against the eyeball. In many cases, tightening the eyelid at the lateral canthus returns the punctum to the normal position. If the punctum remains everted, additional treatment of the punctal eversion should be considered in conjunction with the lateral tarsal strip operation. The most useful operation to correct punctal eversion is the medial spindle operation .
Rarely with involutional ectropion, the punctum is everted in the absence of lower eyelid laxity. In these patients, the medial spindle operation alone may be sufficient.
Many texts suggest evaluating the eyelid for the presence of medial canthal tendon laxity. If lateral traction of the lower eyelid displaces the punctum to or beyond the limbus, medial canthal tendon laxity exists. Several procedures have been devised to tighten or plicate the medial canthal tendon. All are complicated by the presence of the lower canaliculus. None of these procedures works consistently well for me. Horizontal lower eyelid tightening with the standard lateral tarsal strip procedure is effective in most of these patients.
In patients with paralytic ectropion, the effect of lower lid tightening can also be estimated during the slit lamp examination. Often, the lateral tarsal strip procedure alone repositions the lower lid nicely. For paralytic ectropion, other factors should be considered as discussed above. Lubricating drops and ointment may be needed to correct corneal exposure. Additional procedures to improve blinking or protect the cornea may be necessary. Consideration should be given to elevating the ptotic eyebrow.
Floppy Eyelid Syndrome
This is a good place to talk about the floppy eyelid syndrome . Patients with this syndrome complain of unilateral or bilateral irritation and ocular injection. On examination, an upper eyelid tarsal papillary conjunctivitis is present. No obvious upper or lower eyelid ectropion may be present. The main diagnostic finding is an enormous amount of upper eyelid laxity, so much so that the eyelid can be folded on itself and easily turned inside out ( Figure 3.9 ). The cause of the irritation is related to poor eyelid apposition to the globe. In some patients there may be nocturnal eversion of the extremely lax upper eyelid and rubbing of the conjunctiva on the pillow. Even more interesting is the fact that the majority of these patients are obese men with obstructive sleep apnea caused by similarly lax tissue in the upper airway. If the sleep apnea has already been recognized, the patient is usually wearing a continuous positive airway pressure mask at night or has had a uveopalatopharyngoplasty to open the upper airway tissues. If the patient does not have a diagnosis of sleep apnea, ask about snoring, especially heavy snoring followed by short periods of apnea. The patient may complain of sleepless nights or daytime fatigue. If any of these symptoms are present, refer your patient to a sleep specialist, and you may save the patient from some serious cardiopulmonary consequences. If your practice is like mine, you will see many patients with floppy eyelid syndrome. The treatment for floppy eyelid syndrome is horizontal lid tightening of the upper eyelid (usually a pentagonal wedge resection). In most cases the lower eyelid requires tightening as well.
At this point you should:
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Know the questions to ask yourself during the physical examination to determine the type of ectropion
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Understand and be able to perform
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The eyelid snap test
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The eyelid distraction test
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Describe the floppy eyelid syndrome
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Treatment of Ectropion
Treatment of Lower Eyelid Involutional Ectropion
As we said, the most common type of ectropion is involutional ectropion. Correction of the lower eyelid laxity using the lower lid–tightening procedure, the lateral tarsal strip operation, corrects the ectropion. The lateral tarsal strip operation is one of the most useful operations in oculoplastic surgery. Make sure that you learn how to do this operation.
Lateral Tarsal Strip Operation
The lateral tarsal strip operation involves shortening the lower lid at the lateral canthus. The lower lid is released from the lateral orbital rim. A tab, or strip, of lower lid tarsus is fashioned and denuded of conjunctival epithelium and skin. The strip is shortened to provide appropriate tension. The strip is then reattached to the inner aspect of the orbital rim. Many patients benefit from 1 to 2 weeks of ointment lubrication before correction of the ectropion if there is conjunctival thickening. The lubrication eliminates some of the roughness of the conjunctival mucosa that is once again against the eye.
To complete a lateral tarsal strip procedure, you:
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Perform a lateral canthotomy
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Perform a cantholysis
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Form the strip
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Shorten the strip
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Reattach the strip
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Trim the redundant anterior lamella
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Close the canthotomy
The steps of the tarsal strip procedure are:
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Prepare the patient.
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Instill topical anesthetic drops.
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Inject a local anesthetic with epinephrine
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Into the lateral canthal skin
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On the inner aspect of the orbital rim against the bone
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Into the lateral third of the lower lid skin and conjunctiva ( Figure 3.10A ).
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