DR. pavan

ECTROPION

DefinitionClassificationEtiologyEtiopathogenesisClinical featuresPatient evaluationDifferent surgeries for ectropionCopmlications of surgery

Eyelid ectropion is an eyelid malposition in which the eyelid margin is turned out from its normal apposition to the globe.

This more frequently affects the lower eyelid.

Upper eyelid ectropion is uncommon

Introduction

1. Involutional ectropion 2. Cicatricial ectropion 3. Paralytic ectropion 4.Mechanical ectropion

Classification 1– congenital2-- aquired

INVOLUTIONAL CICATRICIAL

PARALYTIC MECHANICAL

photophobia

Epiphora Keratinisation of conj epithelium Corneal exposure-FB sensation,corneal dryness,corneal ulceration,exposure keratitis

Features of ectropion

A patient with a bilateral complete tarsal ectropion with keratinization of the chronically exposed conjunctiva.

1. Senile or involutional which is caused by a horizontal lid laxity

lengthening of medial and lateral canthal tendons with ageing changes,

it is the most common type of ectropion and has a continuous pathological process that is aggravated by conjunctivitis and epiphora.

PATHOPHYSIOLOGY

2. When the anterior lamella is shortened either postoperatively, trauma (burns or injuries), or ulceration, the resultant cicatricial ectropion will take place.

3. Supporting of the lower eyelid in its normal position depending on the orbicularis oculi muscle tone and loss of this support will lead to paralytic ectropion as in case of facial nerve palsy.

4. Mechanical ectropion is caused by eversion of the lower lid by a tumor or a mass.

5. Congenital ectropion is a rare condition due to shortage of skin as in congenital ichthyosis or blepharophimosis. N in downs syndrome.

•The initial sign of a lower lid ectropion is inferior punctal eversion •lead to a vicious cycle of secondary events •Eversion of the inferior punctum exposure and drying of the punctum stenosis Epiphora excoriation and contracture of the skin of the lower eyelid that further exacerbates the ectropion.•patient tends to continually wipe the tears

eyelid and medial canthal tendon laxity that further exacerbatesthe lower eyelid ectropion. •If the condition is neglected, the tarsal conjunctiva becomes exposed and eventually thickened and keratinized. •Lower lid ectropion often results in a corneal epitheliopathy, especially in the inferior third of the cornea

Patient evaluation

It should be directed towards recognition of the ectropion and its severity . 1. Severity of ectropion: • Mild : The lower punctum is everted • Moderate : The tarsal conjunctiva is exposed • Severe : The lower fornix is exposed

2. Extent of ectropion: Medial or lateral or involving the entire lower eyelid.

3. Presence of any traumatic or surgical scar tissue.

4. Presence of a horizontal lid laxity. Which is demonstrated by: a. Eyelid snap test: Pull the eyelid inferiorly. • If the eyelid springs to its normal position without a blink it means no lid laxity. • If it remains away from the eye for a time; it means a lax lid. Then the degree of lid laxity will be determined by the Number of blink required to bring the lid on contact to the eye. b. Lateral distraction test: By pulling the eyelid laterally from the eye, the punctum can be drawn lateral to medial limbus, suggest medial canthal tendon laxity

5. Signs of lower facial nerve palsy as brow ptosis, lid retraction with incomplete blink, lagophthalmos and absence of nasolabial fold.

6. Weakness of the preseptal orbicularis oculi is tested by closure of eyelids.

7. Examination of corneal sensation is a must

(A) A patient with a punctal ectropion. (B) A “Snap” test being performed. (C) Positive “snap” test: the eyelid fails to return to the globe without a blink

Medial canthal tendon laxity demonstrated with a lateral distraction test

Preoperative assessment

Postition of maximal ectropion

Medial canthal tendon laxityLateral canthal tendon laxity

Horizontal lid laxity

choice of surgery depends on

Degree of ectropionLocation of ectropionDegree of horrizontal laxityLaxity of medial n lateral tendonTone of orbicularis musclePresence of any mechanical forcesAny cicatrical causeGeneral health of patient

Various deffrent surgeries areConjunctival cauteryMedial spindle resectionSpindle with wedge resectionMedial canthal tendon plicationLateral wedge resectionMedial canthal resectionLateral tarsal strip procedureZ plastyV-y plastySkin graftRetractors reinsertion to tarsal plate

Involutional ectropion can be further classified into the following subtypes:

1. Punctal ectropion2. Medial ectropion without horizontal eyelid laxity3. Medial ectropion with horizontal eyelid laxity4. Medial ectropion with medial canthal tendon

laxity5. Ectropion of the whole length of the lower eyelid6. Complete tarsal ectropion

Retropunctal Cautery In early stage, simple to apply

Surgical procedureUsing a disposable cautery device, deep burns are applied to

the conjunctiva 3 to 4 mm below the punctum. The effect on the punctal position is observed and titrated by

the number of burns applied and the depth of the burn.Antibiotic ointment is instilled into the eye

Postoperative care Antibiotic drops are instilled into the eye three times per day

for a week.

Punctal Ectropion

Punctal eversion of the right lower eyelid.

Inferiorpunctum

Medial Spindle Procedure ( Medial Conjunctivoplasty) Where the punctal ectropion is more pronounced, a medial

spindle procedure is performed.

Means spindle shaped conj n sub conj tissue is removed

Dilate the punctum with a Nettleship dilator at the same time, as this is often stenosed.

It is not appropriate to perform destructive procedures on the punctum,as it may resume its normal appearance and function once it has been repositioned against the globe.

Medial Ectropion Without Horizontal Eyelid Laxity

Alternatively, a perforated punctal plug, or a Crawford bi-canalicular or monocanalicular stent can be placed temporarily to maintain patency of the punctum.

If a stenosed punctum needs to be surgically enlarged, it is preferable to do this using a Kelly punch.

The conjunctiva is lifted just below the inferior punctum using Paufique forceps.

A diamond-shaped excision of conjunctiva is performed using Westcott scissors.

Surgical procedure

• A further cut is made from the opposite side while keeping hold of the conjunctiva with the forceps.

• A diamond-shaped tissue defect remains.

• A diagrammatic representation of the location of the diamond-shaped excision of conjunctiva. Bowman probe has been inserted into the inferior canaliculus to protect this during the conjunctival resection

Treatment of medial ectropion

Mild

Severe Lazy-T procedure

Medial conjunctivoplasty

a b

Medial Spindle Procedure with a Medial Wedge Resection (lazy T procedure)

The wedge resection is positioned to remove thickened keratinized conjunctiva.

It is important that sufficient eyelid is left medial to the resection to enable vertical mattress sutures to be placed across the eyelid margin without risking damage to the punctum or to the inferior canaliculus.

Medial Ectropion with Horizontal Eyelid Laxity

A wedge resection is performed just lateral to the position of the medial spindle. The wedge resection closure is performed after the closure of the medial spindle.

A moderate degree of lateral punctal displacement is well tolerated

Where the degree of medial canthal tendon laxity is very pronounced, however, this can be addressed with a medial canthal resection procedure.

Medial Ectropion with Medial Canthal Tendon Laxity

Medial Canthal Resection

The extent of the excision in a medial canthal resection isdemonstrated. The deep suture placement for a medial canthal resection procedureis illustrated .

A conjunctival incision is made between the caruncle and the plica semilunaris.

A double-armed 5/0 Ethibond suture on a 1/2-circle needle is passed through the medial aspect of the tarsus and through the periosteum of the posterior lacrimal crest.

The suture is tied and the medial aspect of the eyelid is repositioned against the globe.

The choice of procedure for a more extensive lower eyelid ectropion depends on a consideration of the following factors:

1. The degree of rounding of the lateral canthus

2. The presence of excess lower eyelid skin3. The degree of horizontal eyelid laxity4. The degree of upper eyelid laxity5. The general health of the patient

Ectropion of Whole Length of the Lower Eyelid with Lateral Canthal Tendon Laxity

Lateral Wedge Resection (Modified Kuhnt Szymanowski)

A) A skin–muscle flap is raised and a lateral wedge resection performed. B) The wedge resection is repaired. C) The skin muscle flap is drawn laterally and the excess skin and muscle

are resected as a base-down triangle. D) The lateral skin wound and the subciliary incision wound are closed

with 7/0 Vicrylsutures.

Lateral Tarsal Strip Procedure

A lateral canthotomy is performed using straight blunt-tipped scissors (surgeon’s view).

The lower eyelid is then lifted in a superotemporal direction and the inferior crus of the lateral canthal tendon is cut using blunt-tipped Westcottscissors. All residual attachments of the eyelid to the lateral orbital margin are released by cutting all tissues between the skin and the conjunctiva laterally.

(A)The anterior and posterior lamellae are split along the gray line using sharp-tipped scissors.

(B) The gray line has been split.

(C) The lateral tarsal strip is then formed by cutting along the inferior border of the tarsus.

(D)Next, the posterior eyelid margin is excised from the tarsal strip

•The tarsal strip is shortened as required

•The tarsal strip is then positioned over the handle of a Paufique forceps with the conjunctival side exposed and the conjunctiva scraped from thetarsal strip using a no. 15 blade.

• The lid is drawn laterally and the amount of redundant anterior lamella is determined•The lateral tarsal strip has been passed through the loop of suture. The suture needles have then been passed through the strip from below.

Posterior Approach Retractor Reinsertion with Medial Spindle with Lateral Tarsal Strip Procedure

Complete Tarsal Ectropion

•A conjunctival incision is made at the lower border of the tarsus.

•The lower eyelid retractors are dissected free and sutures passed through theretractors as shown in the drawing.

•The lower eyelid retractors are advanced and sutured to the inferior border of the tarsus•The conjunctival wound is closed ensuring that the suture knots are

buried.

Treatment of extensive ectropion

Without marked excess skin

With marked excess skin

Horizontal lid shortening

Kuhnt-Szymanowski procedure

a b

a b

Causes of cicatricial ectropion• Contracture of skin pulling lid away from globe• Unilateral or bilateral, depending on cause

Unilateral ectropion due totraumatic scarring

Bilateral ectropion due to severedermatitis

Treatment of cicatricial ectropion Method depends on severity

Severe cases require transposition flaps or free skin grafts

Mild localized cases are treatedby excision of scar tissuecombined with ‘Z’-plasty

Correction of cicatricial ectropionHorizontal tighteningFascial slingFull thickness skin

graft

Correction of cicatricial ectropionHorizontal

tighteningFascial slingFull thickness skin

graftTransposition graftSplit level graft

Paralytic ectropion

Exposure keratopathy caused by lagophthalmos

Caused by facial nerve palsy which, if severe, may give rise to the following:

• Failure of lacrimal pump mechanism

• Increase in tear production resulting from corneal exposure

Epiphora caused by combination of:

Treatment Options for Paralytic Ectropion

• Lubrication with tear substitutes • Botulinum toxin injection

• Temporary tarsorrhaphy in patients with poor Bell’s phenomenon

• Medial canthoplasty • Medial wedge resection to correct medial canthal tendon laxity• Lateral canthal sling to correct residual ectropion and raise lateral canthus

2.Permanent treatment

1.Temporary treatment

(A) A patient with a chronic right facial palsy and a right lower eyelid ectropion due to a combination of factors. It is paralytic, involutional,cicatricial, and mechanical. (B) The ectropion has been addressed by means of a posterior approach lower lid retractor recession, a lower eyelid skin graft and a lateral tarsal strip procedure, and a medial spindle procedure. The mid-face ptosis has not been addressed in this patient.

Correction of paralytic ectropionTarsorrhaphy

Correction of paralytic ectropionHorizontal lid

tightening

Correction of paralytic ectropionFascial sling

Mechanical ectropion Mechanical lid eversion by tumour

• Removal of the cause, if possible• Correction of significant horizontal lid laxity

Treatment

Congenital Rare Association with other

anomalies Euryblepharon Blepharophimosis

Correction of congenital ectropion Horizontal lid

tightening/shortening Grafting of anterior

lamella

complicationsUndercorrectionRecurrenceOvercorrectionLateral canthal angle dystopiaTrichiasisCanalicular injuryCorneal abrasionEyelid notching

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