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ECTROPION-ENTROPION: A TALE OF A LAX LID Leonid Skorin, Jr., OD, DO, MS, FAAO, FAOCO

I. Ectropion: Malposition of the eyelid where the lid falls away or is pulled away from its normal apposition to the globe.

II. Classification of Ectropion A. Congenital Ectropion 1. Rare 2. Vertical shortening of anterior lamella (skin and orbicularis oculi muscle) 3. Seen in: blepharophimosis syndrome Down syndrome 4. Treat with lubrication, surgery in more severe cases 5. Upper eyelid eversion: bilateral more common in blacks Down syndrome multiparous mothers birth trauma 6. Treat: self-limited. Lubrication, moisture chambers, pressure patches B. Involutional Ectropion 1. Etiology: horizontal eyelid laxity lateral canthal tendon laxity medial canthal tendon laxity loss of tarsoligamentous elasticity shortened external skin/muscle orbicularis muscle tone loss 2. Evaluation a. Horizontal lid laxity (1) Distraction test: lower lid can be pulled away from globe by 10mm or more (2) Snap back test - normal: lid “snaps back” quickly - mild laxity: slow return - moderate laxity: incomplete return unless patient blinks - severe laxity: incomplete return even after blink b. Medial canthal tendon laxity (1) Pull lid laterally: punctum should not move laterally more than 2mm c. Lateral canthal tendon laxity (1) Rounded appearance of lateral canthus (2) Pull lid medially: should not move medially more than 2mm 3. Treatment a. Temporary management (1) Lubrication (2) Lateral aspect of lower eyelid can be taped upwards (3) Tape eyelids closed at night

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b. Surgical (1) Lateral canthal strengthening: full-thickness wedge of eyelid at lateral canthus is removed and the lateral canthus reattached to orbital periosteum. (2) Horizontal shortening and blepharoplasty (Kuhnt-Szymanowski): excision of a pentagon of full-thickness lid laterally and a lateral triangle of redundant skin. (3) Medial spindle: excise posterior lamellar fusiform wedge of conjunctiva, retractors and tarsus. Close with absorbing sutures. (4) Lazy-T procedure: excise pentagon of full-thickness lid and medial spindle. 4. Floppy eyelid syndrome a. Horizontal laxity of the upper eyelid b. Seen in obese males c. Upper lid everted during sleep causing mechanical abrasion and chronic papillary conjunctivitis d. Treat: horizontal lid tightening C. Cicatricial Ectropion 1. Etiology: vertical tightness of eyelid skin thermal or chemical burn mechanical trauma laser resurfacing, chemical peel surgery, lower lid blepharoplasty longstanding involutional ectropion 2. Evaluation a. Place thumb beneath lateral canthus, push lid laterally and superiorly, excessive tension on lid margin indicates contraction b. Upward distraction test: tethering to inferior orbital rim c. Mouth opening: will pull down on lower eyelid 3. Treatment a. Release scar bands b. Z-plasty c. Skin graft (1) Upper eyelid (2) Postauricular (3) Preauricular (4) Supraclavicular D. Inflammatory Ectropion 1. Etiology a. Dermatologic conditions (1) Acne rosacea (2) Atopic dermatitis, eczema (3) Herpes zoster infections (4) Actinic damage (5) Ichtyosis 2. Treatment a. Allergic reagent should be stopped Skorin/Page 3 of 5

b. Steroid ointments or injections c. Surgical correction as for cicatricial ectropion E. Mechanical Ectropion 1. Etiology a. Eyelid tumor b. Eyelid and periocular edema c. Orbital fat herniation d. Malignant orbital lymphoma e. Low-riding poorly-fitted eyeglasses 2. Treatment a. Directed at the cause F. Paralytic Ectropion 1. Etiology a. Facial: 7th cranial nerve palsy Bell’s palsy Parotid gland surgery Acoustic neuroma 2. Evaluation a. Distinguish between upper motor (stroke, tumor) and lower motor (Bells’ palsy) neuron lesion b. Bell’s palsy: complete unilateral involvement of face c. BAD syndrome: lacks Bell’s phenomenon has corneal anesthesia dry eye 3. Treatment a. Conservative (1) Lubrication (2) Taping the eyelids (3) Moisture chamber (4) Punctal plugs (5) Extended-wear bandage contact lens (6) Botulinum toxin injection into levator to cause ptosis b. Medical: treat underlying Bell’s palsy (1) Oral prednisone: 60 to 80mg/day for 5 days then taper over next 5 days (2) Acyclovir 400mg: 5 times daily for 10 days c. Surgery (1) Lateral canthal strengthening (2) Tarsorrhaphy: suturing upper and lower eyelids together (3) Passive upper eyelid animation: gold weight (4) Dynamic eyelid animation: palpebral spring

III. Entropion: Eyelid margin turns in against the globe.

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IV. Classification of Entropion A. Congenital Entropion 1. Rare, familial 2. Improper development of the retractor aponeurosis insertion into the lower border of the tarsal plate 3. Distinguish from epiblepharon a. Seen in Asians b. Overriding of orbicularis oculi and skin 4. Treatment: tarsal fixation (Hotz) B. Spastic Entropion 1. Etiology a. Ocular irritation or inflammation b. Benign essential blepharospasm (BEB) 2. Evaluation a. Complete ophthalmic exam b. History for BEB 3. Treatment a. Ocular irritation: lubrication Ocular inflammation: steroid b. BEB: Botulinum toxin injections C. Involutional Entropion 1. Etiology: horizontal lid laxity Disinsertion of lower eyelid retractors (capsulopalpebral ligament) Preseptal orbicularis muscle override 2. Evaluation a. Snap back test b. Orbicularis override test - Patient squeezes eyes closed - Observe for superior migration of preseptal orbicularis c. Poor eyelid tone d. Lower eyelid margin stays below limbus e. Deep inferior fornix f. White line below inferior tarsal border: detached capsulopalpebral fascia 3. Treatment a. Conservative (1) Tape eyelid away from globe (2) Bandage soft contact lens (3) Botulinum toxin injection b. Surgical (1) Transverse rotation sutures 3 dissolvable sutures passed through lid from conjunctival side out and through skin and tied

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(2) Base-down triangle resection - If no horizontal lid laxity present - Excision of tarsoconjunctival triangular wedge of tissue - Re-approximate with dissolvable sutures (3) Jones procedure - Lower lid retractor tightening - Lateral canthal strengthening D. Cicatricial Entropion 1. Etiology a. Trachoma b. Cicatricial pemphigoid c. Stevens-Johnson syndrome d. Dermatologic conditions 2. Evaluation a. Digital eversion test - Inhibit blinking, pull down lid - Involutional: remains in proper vertical orientation - Cicatricial: resumes inward rotation; shrinkage or retraction of the posterior lamella 3. Treatment a. Mild: tarsal fracture; full-thickness incision middle of tarsal plate b. Severe: mucous membrane graft; spacer into posterior lid lamella