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Ectropion is an outward turning of the eyelid margin. Patients may experience symptoms due to ocular exposure and inadequate lubrication. Definitive management is surgical. Medical management is temporizing but can improve symptoms while waiting for surgery.

Disease Entity

ICD-9 374.10 Ectropion, unspecified
ICD-10 H02.109 Unspecified ectropion of unspecified eye, unspecified eyelid

Disease

Ectropion is an outward turning of the eyelid margin. It primarily involves the lower lid. Upper eyelid eversion can occur in Floppy Eyelid Syndrome.

Etiology

There are four main types of ectropion: involutional, cicatricial, mechanical, and paralytic.

Involutional ectropion is caused by increased horizontal laxity of the lower eyelid and disinsertion of the lower eyelid retractors.
Cicatricial ectropion is caused by shortening of the anterior lamella, which is comprised of the skin and orbicularis muscle.
Paralytic ectropion is caused by decreased orbicularis muscle tone supporting the lower eyelid.
Additionally, mechanical ectropion can occur when a mass, such as a tumor, displaces the lower eyelid margin.

Congenital ectropion can occur rarely, and may be seen in association with other congenital defects such as blepharophimosis syndrome or euryblepharon.

Risk Factors

Age (gravity, loss of elasticity)
Eyelid rubbing
Repeated eyelid pulling (ex. contact-lens use)
Floppy eyelid syndrome
Long term use of eye drops
Skin conditions which involve the eyelid
Trauma
Prior Eyelid Surgery

General Pathology

Ectropion can be classified as:

Involutional (most common)
Paralytic
Cicatricial
Mechanical
Congenital (very rare)

Pathophysiology

In involutional ectropion, the tarsoligamentous sling supporting the eyelid by attachment to the orbital rim via the medial and lateral canthal tendons becomes lax. In paralytic ectropion, orbicularis muscle tone is weak or absent due to facial nerve palsy. In cicatricial ectropion, the anterior or middle lamellae are shortened due to scarring. Midfacial hypoplasia, where the inferior obital rim is located relatively posterior to the eyeball, results in both decreased lower eyelid support and increased propensity for lower eyelid retraction

History

In addition to abnormal position of the lid, patients experience tearing, irritation/grittiness/foreign body sensation, red eye, and mucoid discharge. Symptoms are caused by ocular exposure ,inadequate closure and lubrication. Inquire about habitual eye rubbing, which may accompany symptoms of itch from ocular allergy or ocular surface disease.

Physical examination

Facial architecture:
Examine the bony architecture of the lower orbital rim and midface position. Patients with hypoplastic midface, also known as hemiproptosis, will have an inferior orbital rim located posteriorly relative to the globe.
Facial nerve palsy:
Inspect the face and test facial muscle strength to assess for paralysis.
Eyelid laxity:
To test for horizontal laxity, place a thumb beneath the lateral canthus and push the eyelid laterally and superiorly. If the lid margin does not roll back into position, suspect a cicatricial component. In involutional cases, the ectropion typically disappears with this maneuver. The eyelid distraction test is done by pulling the lid away from the globe. Normal lid distraction is between 2-3 mm. If it is more than 5mm, there is substantial laxity. In cases of cicatricial ectropion, the eyelid malposition will often become accentuated by asking the patient to look upwards and to open his or her mouth at the same time; the maneuver places the anterior lamella on maximum stretch.
Eyelid pathology:
Examine the eyelid margin under magnification to look for signs of chronic blepharitis, palpebral conjunctival hypertrophy and keratinization, conjunctival scarring, and to rule out suspicious changes such as loss of lashes (madarosis), ulceration, or infiltration.
Punctal ectropion:
Assess the position of the lower punctum which may rotate away with medial laxity and no longer make contact with the ocular surface and tear lake.
Ocular surface:
Examine the cornea for epithelial changes secondary to exposure.

Differential diagnosis

Eyelid malignancy
Eyelid retraction secondary to proptosis (e.g. thyroid eye disease), excessive tissue removal with lower blepharoplasty, or inferior rectus recession without disinsertion of the lower lid retractors.
Floppy Eyelid Syndrome
Lamellar Ichthyosis
Facial Nerve Palsy

Management

Definitive management is surgical. Medical management is temporizing but can improve symptoms while awaiting surgery.

Deferral of surgery should be considered in 2 groups of patients. Ectropion induced by long term use of eye drops such as dorzolamide and brimonidine may resolve with discontinuation, if feasible. Patients suffering from inflammatory skin conditions involving the eyelid may have improvement or reversal of ectropion with improved control of inflammation.

Medical therapy

Lubrication of the ocular surface
Horizontal taping of the eyelid

Surgery

Lower eyelid laxity: the lower eyelid is horizontally tightening by a lateral tarsal strip or similar procedure.

Lower eyelid retractor disinsertion: the Jones procedure of reattaches retractors to the tarsus.

Punctal ectropion: the medial spindle procedure reapposes the everted punctum.

Cicatricial ectropion often requires lengthening of the anterior lamella by a skin graft.

Paralytic ectropion requires horizontal tightening and correction of punctal ectropion. With facial nerve paralysis, corneal exposure and brow ptosis may also need to be addressed.

Mechanical ectropion from facial ptosis may often require surgical elevation of the mid face (such as a suborbicularis oculi fat lift), or a face lift in conjunction with lower lid tightening.

In some cases of heavy facial tissues or recurrence, periosteal fixation may not be successful and therefore require additional fixation using bone plates or bone tunnels to which the lower lid can be suspended.

Complications

Ectropion surgery is considered safe and effective. Recurrence does occur occasionally after several years requiring a repeat surgery.

Like any eyelid surgery there is always a possibility of local post-operative bleeding or infection but these are generally minor. Injury to the cornea is possible but uncommon with careful technique.

Additional Resources

ASOPRS Information on Ectropion

References

Orbit, Eyelids, and Lacrimal System, Section 7. Basic and Clinical Science Course. San Francisco: American Academy of Ophthalmology; 2009.
American Academy of Ophthalmology Focal Points: Ectropion and Entropion, Volume 12, Number 10, 1994.
Hegde V, Robinson R, Dean F, et al. Drug-induced ectropion: what is best practice? Ophthalmology 2007;114:362-366.
Durairaj VD, Horsley MB. Resolution of pityriasis rubra pilaris-induced cicatricial ectropion with systemic low-dose methotrexate. Am J Ophthalmol 2007;143:709-710.
Nerad JA. Techniques in Ophthalmic Plastic Surgery: A Personal Tutorial. Philadelphia: Saunders, 2010. Print.