Cicatricial ectropion is a relative deficiency of eyelid skin and muscle that results from various causes. These causes are varied and include congenital, traumatic, inflammatory, ultraviolet (UV)-related, infectious, neoplastic, and autoimmune etiologies (Figures 16.1 and 16.2). Diseases causing congenital eyelid skin shortening are discussed separately in Chapter 17.

Traumatic causes of cicatricial ectropion can be seen following eyelid trauma and with skin loss that persists following surgical repair. This is especially true when vertical scars or skin grafts contract (Figure 16.1A and B). Chemical injuries to the eyelids due to acids and more commonly alkali agents are often also associated with ocular injury. On the eyelids, alkali can cause tissue saponification or hydrolysis of lipids and liquefaction of proteins resulting in cell death and tissue loss.³ They can occur as industrial accidents, or even after relatively trivial domestic injuries with household chemicals. Thermal burns are common injuries that can result from hot surfaces, liquids, steam, and open flames (Figure 16.1C), and skin contracture can follow excessive radiotherapy (Figure 16.1D). Burn injuries can cause three levels of injury: superficial hyperemia with reversible vasodilation, deeper areas of ischemia, and deep levels of coagulation or necrosis resulting in contraction and loss of tissue.⁴ Another source of eyelid skin shortening is surgical trauma from excessive removal of skin during lower eyelid blepharoplasty, or from cutaneous scarring following eyelid, orbital, or facial surgery (Figure 16.2B).²,⁵

Inflammatory causes of cicatricial ectropion include contact dermatitis and UV skin damage (Figure 16.2C and D). The eyelids are particularly susceptible to contact dermatitis because their skin is thinner (0.55 mm) than skin in the rest of the face (2.0 mm).⁶,⁷,⁸,⁹ Eyelid contact dermatitis usually results from skin contact to exogenous substances, and two major forms have to be distinguished. The first or allergic contact dermatitis is less common and thus less likely to cause cicatricial ectropion. It usually develops as a form of hypersensitivity reaction to allergenic chemicals like cosmetics, lotions, creams, or topical ophthalmic preparations.¹⁰ The allergenic components in topical eye drops and ointments include either the preservative or the active principle, but it is not always possible to determine whether the offending agent is the active ingredient or the preservative used except with patch testing.⁶,⁷,⁸,⁹ Topical antibiotics usually top the list with tobramycin as the most common allergenic agent, followed by preservatives or nonactive ingredients. Corticosteroids and mydriatics come next. Interestingly, antiglaucoma medications are at the bottom of the list.¹⁰

The second form, or irritant contact dermatitis, is four times more common around the eyes than allergic dermatitis, which is a frequently overlooked cause of lower eyelid ectropion. It can eventually lead to cicatricial ectropion, and usually results from a nonallergenic dose-dependent toxic effect typically resulting from the chronic use of topical eye drops, particularly antiglaucoma medications.⁶,⁷,⁸,⁹

The other inflammatory cause is chronic sun or UV light exposure in fair-skinned individuals. These result in actinic changes, which are more pronounced in the lower eyelids, and are clinically distinct from the normal chronological processes of aging skin.¹¹ Sun-damaged or photoaged skin typically exhibits inflammatory hypertrophy of elastic tissue, with an accumulation of thickened elastic fibers and amorphous elastotic material in the dermis.⁸ With prolonged exposure and diffuse actinic damage to the lower eyelid skin, the skin becomes taut, exerting a downward tractional force on the anterior lamella, pulling the eyelid margin away from the globe and resulting in ectropion (Figure 16.2C and D).²,¹¹,¹²

Cicatricial ectropion has rarely been reported in association with systemic infections like paracoccidioidomycosis.¹³ Upper eyelid cicatricial ectropion may also rarely result from scar contracture in association with a fistulous tract from the frontal sinus, although a more common presentation would be cicatricial retraction rather than ectropion.¹⁴

Benign and malignant eyelid neoplasms may rarely cause cicatricial ectropion (Figure 16.2A)¹⁵,¹⁶,¹⁷,¹⁸,¹⁹; however, a “mechanical” displacement of the eyelid is a more likely mechanism for the ectropion associated with periocular neoplasms.

Several autoimmune dermatologic disorders, like discoid lupus erythematosus and psoriasis, may also cause cicatricial ectropion although other eyelid margin abnormalities like entropion trichiasis and madarosis have also been reported with both conditions.²⁰,²¹ The rash associated with lupus and the plaques associated with psoriasis could result in chronic blepharitis and scarring, eventually ending in ectropion.²⁰,²¹