BASICS
DESCRIPTION
• Outward turning/eversion of the upper eyelid margin.
• Types:
– Congenital.
– Involutional (most common).
– Paralytic.
– Cicatricial.
EPIDEMIOLOGY
Incidence
Bells palsy—25 per 100,000.
Prevalence
Involutional ectropion—increases with age.
RISK FACTORS
• Increased skin sun sensitivity.
• Lighter iris color.
• Diabetes.
• Hypertension.
• Stroke.
• Smoking.
PATHOPHYSIOLOGY
• Involutional—horizontal eyelid laxity.
• Cicatricial—skin contracture secondary to inflammatory or infiltrative dermatitis, tumor, previous eyelid, or facial surgery
• Paralytic—Bell’s palsy, herpes zoster, parotid gland surgery, surgery involving the 7th nerve.
• Allergic—contact dermatitis.
Pediatric Considerations
Congenital—Blepharophimosis, Downs, Ichthyosis, congenital eyelid eversion, facial dysmorphic syndromes.
ETIOLOGY
• Drug toxicity, eyedrops or systemic.
• Severe cellulitis.
COMMONLY ASSOCIATED CONDITIONS
• Bells—Lyme
DIAGNOSIS
HISTORY
• Foreign body sensation.
• Redness.
• Tearing.
• Mucous secretion.
• 7th nerve palsy.
• Previous surgery—cosmetic, ENT, neurosurgery, MOHS.
PHYSICAL EXAM
• Outturning of eyelid margin, pull away of eyelid from globe.
• Lagophthalmos.
• Hyperemia/keratinization of conjunctival epithelium.
• Retractor disinsertion.
• Superficial punctuate keratitis.
• Horizontal eyelid laxity.
• Lacrimal punctal eversion and atresia.
• Inability to push lower eyelid up to normal position (cicatricial).
• Signs of 7th nerve palsy (paralytic)—check orbicularis squeezing tone.
• Bells Palsy—signs of herpes zoster (Ramsay Hunt), signs of sarcoid (Heerfordt’s).
DIAGNOSTIC TESTS & INTERPRETATION
Lab
• Bells palsy—Lyme titers.
• Congenital eversioninclusion conjunctival swab.
DIFFERENTIAL DIAGNOSIS
• Thyroid ophthalmopathy.
• Floppy eyelid syndrome.
TREATMENT
MEDICATION
First Line
• Ocular lubrication.
• Artificial tears, gel, ointment.
Second Line
• Ocular antibiotic/steroid ointment to lower eyelid skin (1)[C].
• Bells palsy.
– Corticosteroids.
– Possible antivirals (2)[C].
• Lyme—antibiotic tx
• Herpes zoster—antiviral tx, possible corticosteroids.
ADDITIONAL TREATMENT
General Measures
• Warm compresses.
• Temporary taping of eyelid.
• Possible cyanoacrylate at lateral canthus.
Issues for Referral
Ophthalmologist for cornea monitoring 1 week.
Additional Therapies
• Cicatricial—massage.
• Palsy—massage, TENS unit.
COMPLEMENTARY & ALTERNATIVE THERAPIES
• Hyaluronic acid filler injection.
SURGERY/OTHER PROCEDURES
• Involutional—horizontal tightening, medial spindle.
• Paralytic—same, upper lid gold weight, wait months before surgical repair to allow for spontaneous improvement unless cornea threatened (3)[C].
• Cicatricial—above, full thickness skin graft, flap, or midface suspension.
ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
• Bells palsy—ophthalmologist in few days.
• Involutional ectropion—2 weeks.
PROGNOSIS
• Surgery may be needed if cornea affected or very symptomatic.
• Involutional.
• Paralytic—may resolve depending on etiology.
COMPLICATIONS
Corneal abrasion, ulcer, scarring, perforation.
REFERENCES
1. Libau J, Schulz A, Arens A, Tilkorn H, Schwipper V. Management of lower lid ectropion. Dermatologic Surgery 2006;32:1050–1056.
2. De Almeida J, et al. Combined corticosteroid and antiviral treatmentfor Bells palsy. A systematic review and meta-analysis. JAMA 2009;985–993.
3. Mehta R. Sugical treatment of facial paralysis. Clin Exp Otorhinolaryngol 2009;2:1–5.
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
