Inspection
On inspection, the patient has an eversion of the Right lower eye-lid margin.
Check for!
Facial Signs:
Signs of Facial nerve palsy – retraction of the upper eyelid and brow ptosis (at times mimicking narrowing of the palpebral aperture
Scar mark/s – appearance, color.
Mass causing eversion of the eyelid.
Midface hypoplasia
Eyelid Signs
Punctum - Eversion
Worsening of eversion on the opening of the mouth (cicatricial)
Horizontal and vertical palpebral fissure height
lagophthalmos,
amount of lid retraction
Lashes – loss of lashes, trichiasis
Loss of acute angle of the lateral canthus
Assess whether the ectropion is affecting the whole of the eyelid or any specific segment.
Conjunctiva –
Inflammation,
thickening and Keratinization of the conjunctiva,
shortening of fornices
Cornea –
Exposure keratopathy
corneal vascularization
Look for other conditions caused by ocular/periocular trauma.
Palpation
Assess lid Laxity:
Horizontal Lid laxity – snap back test – the central part of the eyelid is pulled 8mm or more from the globe – it is positive if there is failure of the eyelid to snap back to its normal position on release without the first blink of the patient.
Lateral canthal tendon laxity – results in a change of the usual sharp appearance of lateral canthus to a more rounded one. Moreover, the lateral canthus can be pulled medially more than 2mm.
Medial Canthal Tendon laxity – exhibited by pulling the lower eyelid laterally and observing the position of the inferior punctum. Under normal conditions, the punctum is not displaced 1-2 mm. However, a movement of 5 mm indicates significant laxity of the medial canthal tendon.
Palpate the Scar for:
Extent of scar
Thickness of scar
Texture of scar
Scar maturity.
Facial architecture: Palpate the lower orbital rim to rule out hemi-proptosis.
Tests for ocular surface condition
Fluorescein stain
Tear film breakup time.
Schirmer test
Tests for lacrimal system patency
Dye disappearance test.
Jones Tests
Questions:
What are the causes of ectropion?
Involutional ectropion - increased horizontal laxity of the lower eyelid and disinsertion of the lower eyelid retractors.
Cicatricial ectropion - of the anterior lamella of the eyelid, comprised of the skin and orbicularis muscle.
Paralytic ectropion - decreased orbicularis muscle tone supporting the lower eyelid.
Mechanical ectropion can occur when a mass, such as a tumor, displaces the lower eyelid margin.
What are the risk factors for the development of ectropion?
The risk factors for the development of ectropion are as follows.
More common
Age (gravity, loss of elasticity)
Eyelid rubbing
Trauma
Less common
Repeated eyelid pulling (ex. contact-lens use)
Floppy eyelid syndrome
Long-term use of eye drops
Skin conditions which involve the eyelid
Prior Eyelid Surgery
What are the general principles of surgical treatment of ectropion?
Cause | Treatment |
Lower eyelid laxity | Horizontal tightening by lateral tarsal strip or a similar procedure |
Disinsertion of retractors of lower eyelid | Jones procedure to reattach the retractors to the inferior border of tarsal plate |
Punctal Ectropion | Medial spindle procedure to reappose the everted punctum |
Cicatricial ectropion | Lengthening of the anterior lamella by a skin graft |
Paralytic Ectropion | Horizontal tightening and correction of punctal ectropion. In extensive cases, a facelift may also be required. |
What are the usual complications of Ectropion surgery?
Although ectropion surgery is relatively safe and effective, recurrences do occur and are often temporally associated. There is the possibility of local post-operative bleeding or infection. There is a remote possibility of injury to the cornea.
How do we treat involutional ectropion?
The management depends on whether the ectropion is generalized or present only medially.
Generalized Ectropion: Usually, repair of horizontal lid laxity is enough to correct the condition best achieved by Lateral Tarsal Strip Procedure, especially when the lateral canthus has become rounded and allows for tear egress laterally. However, if there is an area of misdirected lashers or keratinized conjunctiva, a pentagon transconjunctival excision may be carried out; however, if there is medial canthal laxity, the tendon needs to be stabilized before horizontal shortening to avoid dragging of the punctum laterally, rendering it non-function.
Medial Ectropion: a diamond medial conjunctival diamond excision (medial spindle procedure), may be used to treat mild cases. This procedure can be combined with a tarsal strip, lateral canthal sling, or pentagon excision if significant horizontal laxity coexists.
Punctal ectropion: if there is pure punctal ectropion without much eyelid involvement, Ziegler cautery may be considered.
What are the treatment options for ectropion associated with Facial nerve palsy?
Temporary Measures:
As about 90% of cases of Bells’ Palsy are reversible, temporary measures may be initiated to protect the cornea and prevent corneal exposure.
Lubrication with high-viscosity substitutes
Ointment and Taping of eyelids during sleep
Botulinum toxin to levator palpebrae superioris to induce ptosis.
Temporary tarsorrhaphy
If Bells’ palsy doesn’t improve by 6-12 months, or there is irreversible damage to the facial nerve, permanent treatments should be considered.
Permanent measures:
Medial Canthoplasty
Lateral canthal sling or Lateral tarsal strip
Levator disinsertion to lower the upper eyelid.
Gold or platinum weight implants for lagophthalmos
lateral tarsorrhaphy
What is the Treatment of cicatricial ectropion?
As the primary cause of cicatricial ectropion is vertical shortening of the anterior eyelid lamella, the correction is focused on lengthening it.
Mild and localized cases are managed by excision of scar tissue combined with lengthening procedures such as Z-plasty. In contrast, severe generalized cases require transposition flaps or free skin grafts.
The skin may be harvested from upper eyelids, pre- or post-auricular areas, and supraclavicular areas.
How do you grade Ciccatricial Ectropion?
Grading of cicatricial ectropion
Grade I- Punctal eversion or a part of posterior lid margin not apposed to the globe.
Grade II- The whole length of the posterior lid margin is not apposed to the globe
Grade III- Palpebral conjunctiva visible.
Grade IV- Fornix is visible
What are the common causes of Cicatricial Ectropion?
Trauma
Burns
Cicatrizing skin tumors
Medications like dorzolamide, brimonidine
Allergies
Skin conditions – ichthyosis
In which eyelid is the involutional ectropion more common and why?
Involutional ectropion is more common because of gravity and smaller and relatively weak tarsal plate.
What is the optimal time for intervention in cases of cicatricial ectropion?
The process of scar maturation, reaching 70-80% tensile strength, typically spans 6 to 12 months. During this time, adjunct treatments like scar massage, silicone gel, steroids, and antimetabolites are essential to prevent hypertrophic scar formation. Early use of these agents post-trauma can lead to more aesthetically pleasing outcomes in the long run, as immature scars are prone to hypertrophy and may result in poor results after scar revision.
What are non-surgical measures taken for management of Cicatricial Ectropion?
Scar massage
The massage should be initiated as early as possible and continued for 6-8 weeks after surgery 2, 3 times a day. This massage caused physical disruption of fibroblast fibers, rendering the wound more pliable and thus resulting in a softer scar.
Pressure therapy
It is considered the standard of care for burn scars. The compression over scar area aggravates the hypoxic state of the scar tissue, thereby increasing degeneration of fibroblasts and collagen.
Silicone gel
Silicone gel decreases capillary activity, vascularity and metabolism of the scar tissue by providing a hydrating environment of the epidermal layer.
Intra-lesional steroids
Intra-lesional injection of long-acting steroid inhibits keratinocyte proliferation, inflammatory compounds and has an anti-angiogenic effect. The dose and regimens vary between 1 to 40 mg/ml at 2–6 weeks’ intervals.
Non-ablative laser resurfacing
Non-ablative fractional laser resurfacing involves the use of a specific type of laser emitting at 1540 nm wavelength. This laser creates columns of thermal damage at specific depths, triggering a therapeutic wound healing response. The response includes the activation of heat shock proteins, myofibroblasts, and increased production of collagen III, ultimately contributing to texture remodeling..
Autologous Fat graft for Cicatricial Ectropion
The technique has been widely used for first and second degree burn scars. Adipose tissue, housing stored fat and a reserve of mesenchymal stem cells, possesses the unique ability for indefinite multiplication of these cells. This property allows them to replace atrophied cells, offering the potential for the restoration of both full mechanical and biological properties.
What are the surgical Measures taken to correct cicatrical Ectropion?
The ectropion can be corrected with a Z-plasty. The central limb of the Z is madealong the line of the scar and the two peripheral limbs at about 60 degrees to this central limb. The flaps are raised and the underlying scar excised. Any residual eversion of the punctum may be treated with retropunctal cautery or tarsoconjunctival excision.
Skin graft
What are the phases of wound healing?
Inflammatory phase: Whenever there is trauma, the inflammatory phase begins, which lasts for 4-6 days. The inflammatory phase is characterized by the presence of local edema, erythema, and pain.
Proliferative phase: The proliferative phase lasts for 4-24 days. The smaller blood vessels begin to increase, and granulation tissue fills the wound. Fibroblasts lay collagen in the wound bed, causing the granulation tissue to strengthen and wound edges begin to contract.
Maturation phase: The maturation phase lasts for 21 days to 2 years. Filled in the wound is strengthened, and scar tissue is formed. The length of the maturation phase varies.
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