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.