Ectropion Repair
Amina Hussain, MD
DISEASE DESCRIPTION
Ectropion is an eyelid disorder in which the eyelid everts or does not appose the globe sufficiently to provide adequate protection to the ocular surface. The lower lid margin should sit at the level of the inferior limbus with the meibomian gland line abutting the globe. In the absence of this, the ocular surface will not maintain sufficient moisture, leading to ocular surface dysfunction. This can range from mild symptoms of ocular irritation to more serious problems such as conjunctival hypertrophy, keratinization, and even potential vision loss.
Ectropion can be characterized according to its etiology (Figure 9.1):
Involutional ectropion
Most common, due to horizontal laxity of the lower lid and lateral canthal tendon
Cicatricial ectropion
Due to anterior lamellar shortening of the lower lid, leading to a downward vector that pulls the eyelid inferiorly and everts the lid margin
Mechanical ectropion
Due to a mass or process that creates traction on the lower lid
Paralytic ectropion
Due to a facial nerve palsy causing loss of neurogenic tone in the orbicularis oculi muscle
Floppy eyelid syndrome (FES)
Becoming more common due to the increased incidence of obstructive sleep apnea (OSA) and the link between these two conditions.
Results from the degradation of elastin in the tarsus, presumed to be a result of recurrent desaturations causing loss of integrity to the tarsal plate with resultant severe horizontal laxity in the lids
Congenital
Rare and more often associated with blepharophimosis, Down syndrome, or ichthyosis
 FIGURE 9.1. Etiologies of ectropion. A, Involutional. B, Cicatricial following skin cancer removal. C, Mechanical from chronic periorbital edema. D, Paralytic following right facial nerve palsy. E, Floppy eyelid syndrome. F, Congenital. |
MANAGEMENT OPTIONS
It is important to determine the etiology of the ectropion. There may be a role for medical management depending on the underlying cause of the ectropion and the severity of symptoms. Adequate ocular lubrication and moisture retention is paramount to the medical management of all cases of ectropion.
Involutional ectropion
Medical treatment is directed at ocular lubrication.
Surgical treatment is directed at shortening the lower lid and reestablishing its attachment to the lateral orbital rim.
Cicatricial ectropion
Address the cause of the cicatrix.
The cicatrix may be secondary to bilateral skin changes related to sun exposure in predisposed skin types or may be secondary to scarring, postsurgical changes, or disease processes such as skin cancers or inflammatory skin disorders.
Mechanical ectropion
Determine the nature of the mass effect.
If edema or fluid collection is causing an ectropion, it is often better addressed medically than surgically.
Paralytic ectropion
Determine the cause of the seventh nerve palsy.
Some palsies may resolve and will not require surgery. If a palsy does not resolve by itself after several months or if adequate lubrication of the ocular surface cannot be maintained, then surgical options should be considered.
FES
Address any concurrent OSA first because of the associated cardiovascular and cerebral comorbidities. OSA is diagnosed by obtaining a sleep study test and can be medically managed with a continuous positive airway pressure (CPAP) machine.
Recommend avoidance of eyelid rubbing and sleeping either face down or on one side. Sleeping on one’s back is best, if possible.
Ocular allergy drops or refrigerated artificial tears can ameliorate the intense ocular itching that patients experience with FES.
Congenital
Ocular lubrication and protection is often all that is needed for mild cases.
More severe cases may require surgical intervention
INDICATIONS FOR SURGERY
Failure of medical management to alleviate ocular surface dysfunction
Tearing
Ocular irritation
Blurred vision
Exposure keratopathy
Keratinization of palpebral or bulbar conjunctiva
SURGICAL DESCRIPTION
Involutional Ectropion Repair by Lateral Tarsal Strip
Clamp the lateral canthus with a small straight hemostat. Perform a lateral canthotomy using Wescott scissors. Cauterize any bleeding vessels using bipolar or monopolar cautery.
Perform an inferior cantholysis using Wescott scissors. Cauterize any bleeding vessels.
Resect a lateral tarsal wedge to an extent related to the amount of lid laxity noted. Most often, 2 to 3 mm of tarsal resection is sufficient.
Pass a 4-0 double-armed Mersilene suture on a half-circle needle through the cut end of the tarsal plate approximately 1 mm from the superior border. Enter immediately beneath the skin/muscle layer on the anterior surface of the tarsus and exit through the cut end of the tarsal plate. Pass the other arm of the suture in the same manner approximately 2 mm inferior to the first pass.
Pass each arm of the Mersilene suture just inside the lateral orbital rim slightly superior to an imaginary horizontal line extended from the medial canthus (Figure 9.2).
Reform the lateral canthal angle with a 6-0 plain gut or polyglactin suture. Enter through the gray line of the lower lid approximately 1 mm from the cut end of the lid and exit through the cut end of the lid approximately 1 mm below the lid margin. Pass the suture through the upper lid along the same path, except begin at the cut end of the lid and exit at the gray line (Figure 9.3).
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