EYELID MALPOSITION - ECTROPION

GENERAL CONSIDERATIONS

Ectropion is an outwardly turned (everted) or sagging eyelid - usually the lower lid. Normally, the upper and lower eyelids close tightly, protecting the eye from damage and preventing tear evaporation. If the edge of one eyelid turns outward, the two eyelids cannot meet properly and tears are not spread over the eyeball. The wet, inner conjunctival surface is exposed and visible. This may lead to crusting of the eyelid, mucous discharge, pain, irritation, burning, a gritty, sandy feeling, and redness of the eyelid and conjunctiva with light sensitivity. The sagging leaves the eye exposed and dry, and as a result excessive tearing is common with ectropion. More severe and prolonged cases can also result in scar-induced closure of the punctum (the opening of the tear drainage system) exacerbating the tearing. Ectropion can cause serious ocular inflammation, resulting in damage to the eye, particularly the cornea - with potential ulceration. Ectropion can be diagnosed on routing eye exam. Special tests are usually not required.

There are seven different types of ectropion: involutional (age-induced horizontal elongation of the eyelid), cicatricial (tumor, scar, or trauma induced contracture of the outer layers of the skin and muscle in the outer layers of the eyelid), paralytic (resulting from a 7 th cranial nerve palsy such as Bell's Palsy), punctal (eversion of the medial portion of the eyelid - where resides the punctal opening of the tear drainage system), mechanical (eversion of the lower lid due to the weight of a tumor or inflammation), congenital (ectropion evident in a child at or soon after birth), and mixed mechanism (a combination of two or more causes - usually involutional and cicatricial).

SURGICAL TREATMENT

Treatment of ectropion is surgical. These procedures are performed on an outpatient basis and under local anesthesia except in congenital cases and those that require tear drainage intubation - requiring general anesthesia. Prior to surgery symptoms can be reduced by the use of topical ointments (such as Lacrilube at bedtime) and topical eyedrops (such as Refresh during daytime hours). Surgical treatment for ectropion depends on the underlyng cause.

Involutional ectropion is treated with horizontal eyelid shortening (either the Bick procedure or lateral tarsal strip procedure). These procedures involve a skin incision at the outer corner of the eyelid, shortening the eyelid, and reattachment of the eyelid or the tarsal portion of the eyelid to the underlying tissues at the outer canthus (the lateral angle of the eyelid).

Cicatricial ectropion is treated with placement of a full thickness free skin graft in the area of scar-induced contracture. Most commonly the source of this graft is the skin from the upper eyelid or from behind the ear.

Most paralytic ectropion cases are treated with horizontal eyelid shortening. Only in the most severe paralytic cases do we consider the more invasive approaches with implants (gold weights, magnets, silicone rods, surgical springs) or surgical eyelid closure.

Punctal ectropion is treated via a tissue excision on the back surface of the eyelid several millimeters below the punctum thereby turning in the punctum. If the punctum has become stenotic (reduced in size), enlargement of the punctum (puncto/canaliculoplasty) with silicone (Quickert) intubation may also be required.

Mechanical ectropion is more simply managed by elimination of its cause and possible placement of eyelid rotational sutures - without requiring an incision.

Congenital ectropion is often secondary to eyelid laxity. Mild cases may not require treatment. More severe or persistent cases require horizontal eyelid shortening (see involutional ectropion).

Mixed mechanism ectropion is treated by the application of the surgical modalities applicable to the two causal types of ectropion.

AFTER SURGERY

A surgical dressing is required in cicatricial cases where skin grafting is utilized. In all other cases no dressing is required. Antibiotic ointment is used for the first 10 days postoperatively. Sutures are removed 7 - 10 days postoperatively.

RISKS AND COMPLICATIONS

Minor bruising or swelling may be expected and will likely disappear in one to two weeks. Bleeding and infection, which are potential risks with any surgery, are very uncommon. As with any medical procedure, there may be other inherent risks that should be discussed with Dr. Kohn.

CONCLUSIONS

Ectropion surgery is highly successful with low risk and negligible down time. Dr. Kohn has performed several thousand ectropion repairs with a 99% success rate for these procedures. Most patients experience immediate resolution of the problem once surgery is completed with little if any postoperative discomfort. After your eyelids heal, your symptoms should be improved and the risk of corneal scarring, infection, and loss of vision should be significantly reduced.