ECTROPION

Introduction

Ectropion is an outward turning of the eyelid margin exposing the inner eye surface. Lower eyelid involvement is more common. It varies from mild to severe cases. Mild cases have involvement of only a part of eyelid while some severe cases involve the whole of lower eyelid.

• Age: Ectropion can occur in people of any age group but is most commonly seen in older age groups. 1.2% of ages 60-69 years, 6.7% of ages 70-79 years and 16.7% of those aged 80 years or older

• Gender:  Affected Male: Female ratio is 5:3.

Classification & Types
There are two major types of ectropion depending on its cause, they are congenital and acquired.

Congenital ectropion:
Congenital ectropion occurs due to defects at birth. They usually occur in association with other birth defects like Down syndrome. Occasional paralysis can be associated with congenital ectropion.

Acquired ectropion:
They are of following types:

• Involutional Ectropion: Most commonly found  type of ectropion. It occurs due to the eye muscle weakness., gradually progressing with increasing age.
  
• Paralytic ectropion: Occurs in association with paralysis of the facial  nerves and muscles.
  
• Mechanical Ectropion: Benign or cancerous growths on eyelid can cause mechanical ectropion.
  
• Cicatrical ectropion:  Scarring of the eyelid tissue and muscles be cause of various reasons like Previous surgeries, excessive exposure to radiations in cancer/cosmetic treatment, burns, trauma etc.

Causes & Risk factors

• Eyelid surgeries increase the risk of causing ectropion.
  
• People, who have developed some forms of cancer; have facial trauma or burns are at increased risk of getting affected.
  
• Old age is also another risk factors.
  

Symptoms and Signs

• Watering of eyes
• Dryness of eyes
• Drooping eyelids
• Irritation, burning and redness of the affected eye
• Decreased vision and increased sensitivity of eyes to exposure to light

Diagnosis

Patient history: Eyelid surgery, eyelid trauma, facial skin cancer, facial palsy or facial burns is interrogated for. Skin diseases (past/present) should be asked for.

Physical examination:

• Careful facial examination is essential as it can reveal the presence of previous scars, surgeries or tumor which could be the cause of ectropion.
• Muscle strength is assessed. Snap- back test is performed by pulling the lower eye lid below
• Corneal and conjunctival examinations are carried out to detect any other abnormalities.

Prognosis

The chances of recovery after treatment are good in ectropion. Most people are relived of symptoms of ectropion post surgical treatment.

Treatment Options

Most of the ectropion cas requires surgical treatment but medicinal treatment is useful in some cases.

Medical treatment:

• Artificially lubrication of  the eyes: With the use of  eyedrops and moisture shield to reduce  eye irritation and dryness. It helps in cases having conjunctival keratinization to lubrication the eyes before  surgical treatment.
• Massaging the scar tissue may help in stretching the scar in cases of cicatrical ectropion.
• Steroid injections into scar tissue can also help to stretch the scar tissue but its use is contarversial for its effevctiveness.

Surgical treatment:

Most of the surgical procedures for ectropion can be performed on OPD (Outpatient department) basis and require only local.

• For Congenital ectropion: Surgery to strengthen the eyelid muscles. Some severe cases may require a skin graft.
• For involutional ectropion:The cases of involutional ectropion usually muscle weakness and so a little portion of the affected lower eyelid is removed to tighten the eyelid muscles.
• For cicatrical ectropion:Cicatrical ectropion usually require surgical treatment with skin grafts. The graft is taken from upper eyelid or form behind the ear and rarely from medial forearm.
• For Paralytic ectropion:At least 5 mm of the lateral lower lid is excised. Additionally, external paste-on upper eyelid weights can be used if required. A double side tape may be used to paste these weights. The weights have to be removed at night to decrease eye irritation.

Post surgical care: 

• An eye patch for 1 day after the surgery.
• Antibiotic eye drops or ointment to avoid secondary infections.
• Painkillers used to relive his pain. Aspirin should be avoided to prevent bleeding.
• Cold compresses for reducing the swelling

Auxillary Management:

The patient should be advised to take special care wiping his tears. He should wipe the eyes in upward direction and towards the nose to prevention further increasing of prevailing symptoms.

Complications of treatment: 

Usually complications are seen in surgical treatment.

They are as follows:

• Hemorrhage post surgery.
• Secondary infection.
• Hematoma formation.
• Swelling of the eye lids.

Complications of Disease

• Corneal and conjunctival injuries
• Corneal ulcers
• Conjunctival Keratinisation (Loss of moisturein epithelial cells)
• Loss of eye sight
• Other eye infections
• Epiphora (overproduction and over flowof tears)

References

Fezza JP. Nonsurgical treatment of cicatricial ectropion with hyaluronic acid filler. Plast Reconstr Surg. Mar 2008;121(3):1009-14.