Continuing Education Activity

Ectropion is an eversion or outward turning of the eyelid margin leading to loss of the natural apposition of the eyelid to the globe. Ectropion may be classified as congenital, involutional, paralytic, cicatricial, or mechanical. This activity describes the pathophysiology, etiology, presentation, and treatment of lower eyelid ectropion

Objectives:

• Identify the anatomical structures involved in the pathophysiology of ectropion.
• Describe the causes of lower eyelid ectropion.
• Review the clinical significance of ectropion treatment.
• Explain interprofessional team strategies for improving care coordination and communication to advance the evaluation and treatment of ectropion and improve outcomes.

Introduction

Ectropion is an eversion or outward turning of the eyelid margin leading to loss of the normal apposition of the eyelid to the globe. Ectropion may be classified as congenital, involutional, paralytic, cicatricial, or mechanical. Involutional ectropion is caused by horizontal eyelid laxity of the medial and/or lateral canthal tendons. Cicatricial ectropion can be caused by the shortening of the anterior and/or middle lamella. Paralytic ectropion can be caused by CN VII paralysis or palsy resulting in loss of orbicularis oculi muscle tone. Lastly, mechanical ectropion can be caused by gravity, mass-effect of a tumor, fluid accumulation, herniated orbital fat, or poorly fitted spectacles. The patient may experience symptoms of corneal exposure, irritation, or epiphora due to ocular exposure, inadequate lubrication, and corneal disease. An individual is at increased risk with age, eyelid rubbing, excessing eyelid pulling or manipulation, contact lens use, skin conditions involving the lid, injury, or previous surgery.

Anatomy and Physiology

The eyelid is composed of seven tissue layers unique to this facial region. Superficial to deep, the layers are: skin, subcutaneous tissue, muscles of protraction/orbicularis oculi, orbital septum, orbital fat, muscles of retraction, tarsus, and conjunctiva. The skin along the eyelid, in relation to the other skin in the body, is much thinner.

Multiple nerves supply the eyelid. The superior lid is innervated by the infratrochlear, supratrochlear, supraorbital, and lacrimal nerves of V1. The innervation of the lower eyelid is via the infratrochlear and infraorbital nerve of V2.

The arterial supply of the eyelids is composed of the internal carotid artery by way of the ophthalmic artery and its supraorbital and lacrimal branches, and the external carotid artery via the angular and temporal branches of the facial artery. The blood supply to the upper and lower lids is created by anastomoses of the lateral and medial palpebral arteries. These arteries branch off the lacrimal artery and ophthalmic artery.

Indications

Symptoms of ectropion include foreign body sensation, hyperemia, epiphora, exposure keratitis, and corneal ulceration. Anterior lamellar shortening is often the primary cause of cicatricial ectropion, and and associated connective tissue (or other medical) disorders should be addressed and treated before surgery. Patients with congenital, paralytic, mechanical, or involutional ectropion often require different treatments. It is once again important to identify the etiology before surgical intervention. Medial tendon laxity and ectropion of the punctum will require specific procedures to correct, in addition to the eyelid repositioning surgery.

Contraindications

Patients who cannot tolerate the procedure should not undergo a correction. Medical management of the underlying etiology should be controlled first, and then surgical correction can be considered. If inflammation or infection is not controlled, the prognosis is worse, as there is a higher risk of complications and the problem can often progress.

Equipment

The following equipment is needed: No. 15 Bard-Parker blade, Westcott scissors, 0.5mm forceps, and cautery (monopolar or bipolar), 4-0 silk suture, 6-0 Vicryl suture, 5-0 Vicryl suture, corneal shield, and antibiotic ophthalmic ointment, in addition to a standard oculoplastic instrument tray.

Personnel

An ophthalmologist, oculoplastic, facial plastic, or plastic surgeon is required and a surgical assistant is helpful. This procedure can be performed under local anesthesia in many cases, however rextensive cases or certain patients may benefit from intravenous sedation or general anesthesia. In such cases an anesthetist is also required.

Preparation

The patient should have been properly examined before surgical intervention and deemed appropriate for surgery by an appropriately qualified surgeon. The patient needs to be educated about the associated risks and benefits of the intervention, including alternative therapies available. All possible complications should be discussed. Lastly, any questions from the patient need to be answered.

Technique

There are multiple procedures possible depending on the etiology of the ectropion, and the repair is tailored to each specific patient based on preoperative examination. The essential steps for the following will be listed: cicatricial, involutional, medial, and lateral tarsal strip with a medial spindle for ectropion repair with punctal eversion.[1]

Cicatricial [2]

1. Administration of topical anesthetic and local anesthetic
2. Corneal shield placement
3. Traction sutures placed in gray or lash line of the eyelid 
4. Subciliary incision
5. Dissection to release scarring until the posterior lamella returns to anatomical position
6. Perform tarsal strip for horizontal lid tightening 
7. Measure or draw a template of the area requiring graft
8. Mark/transfer template to the donor site (often postauricular or upper eyelid skin is used)
9. Closure of donor site skin incision 
10. Debride the dermis aspect of the graft of any extraneous subcutaneous tissue
11. Suture graft into the wound bed
12. Close the lateral canthal skin (if horizontal lid tightening was performed)
13. Removal of corneal shield
14. Frost suture (if required)

Involutional [3]

1. Administration of topical anesthetic and local anesthetic
2. Corneal shield placement 
3. Lateral canthal incision with canthotomy and inferior cantholysis 
4. Split the anterior and posterior lamella of the lateral lower lid
5. Remove the skin, muscle, and conjunctiva to form a tarsal strip
6. Distract lid laterally to the rim to estimate the amount of tarsus required and excise the redundancy
7. Anchor the strip to the periosteum of the lateral rim
8. Excise any redundant anterior lamella 
9. Closure of skin incision
10. Removal of corneal shield

Medial Ectropion Repair [4]

1. Administration of topical anesthetic and local anesthetic
2. Corneal shield placement
3. Evert the lid margin with traction suture and/or Bowman probe
4. Excise an ellipse of the conjunctiva and lower lid retractors
5. Excise a portion of the lateral caruncle (if performing caruncular recruitment)
6. Pass a double-armed suture through the lower lid retractors, the apex near the punctum, and then the apex inferiorly, and out full thickness through the lid.
7. Pass a double-armed suture through the lower lid retractors and then through the medial tendon beneath the caruncle. The second arm is then passed through the apex near the punctum incorporating the tendon and caruncle. Both arms are then passed full thickness through the lid (if performing caruncular recruitment)
8. Perform lateral tarsal strip (if required)
9. Tie the sutures to invert the punctum appropriately
10. Remove corneal shield

Lateral Tarsal Strip with Medial Spindle [2]

1. Infiltrate local anesthetic at the lateral canthus, lateral lower eyelid, internal aspect of the lateral orbital rim, and conjunctiva of the inferior medial fornix
2. Lateral Canthotomy
3. Lateral Inferior crus cantholysis
4. Excise a diamond-shaped area of conjunctiva and lower eyelid retractors below the punctum
5. Close the conjunctiva and lower lid retractors
6. Determine the length of the strip
7. Denude the epithelium
8. Split the anterior and posterior lamellae
9. Disinsert the lower eyelid retractors and conjunctiva from the strip
10. Excise the anterior lamella from the strip to remove lash follicles.
11. Attach the strip to the periosteum of the inner aspect of the lateral orbital rim
12. Reform the sharp angle of the lateral canthus
13. Close the skin

Complications

Infection, bleeding, pain, poor cosmesis, corneal abrasion, suture dehiscence or erosion, retrobulbar hematoma, lower eyelid retraction, and canthal dystopia are all possible complications.[5]

Clinical Significance

The goal is to return the eyelid margin and punctum to their proper anatomic positions. This treatment protects the eye from injury and reduces the exposure/dry eye symptoms in the patient. Surgical management is the only definitive treatment.[6][5]

Enhancing Healthcare Team Outcomes

Care should be coordinated between physicians, nurses, pharmacists and other healthcare professionals. Medical management can typically be done by an ophthalmologist, optometrist, or general clinicians experienced in handling ocular conditions. Surgical care can be performed by an ophthalmologist or surgeon who specialized in facial and ocular plastics. Patient safety and the best possible outcome should always be considered and no patient should undergo any treatment that may harm or worsen their outcome. An in depth discussion about risks and benefits should be performed with the patient prior to iniating any treatment.