What is Ectropion?
Ectropion is a condition where the edge of the eyelid turns outward, usually happening with the lower eyelids. When this happens, the eyeball isn’t properly shielded, causing the eye to turn very dry. This dryness can lead to symptoms such as having red eyes, overflowing tears, and a feeling of something being stuck in the eye. This happens because the surface of the eye is exposed excessively and the moist film of tears is insufficient.
In severe situations, the front part of the eye, known as the cornea, can develop tiny surface wounds, ulcers, and could potentially lead to permanent loss of vision. The first step in treatment is usually using products like artificial tears, gels, and ointments to keep the eye moist. Often, surgery is needed to correct the eyelid’s function and to permanently safeguard the eyeball.
What Causes Ectropion?
There are many factors that can make the lower eyelid unstable. The most common cause of the lower eyelid rolling or turning outwards, a condition called ectropion, is due to natural changes as we get older. This happens when the eyelid becomes loose and the muscles that support the lower eyelid become detached. These changes can be worsened by habits like rubbing the eyes.
Ectropion can also happen due to a facial muscle paralysis. When the muscles around the eye do not get enough nerve signals, the eyelid can become loose and floppy. This can lead to poor protection of the eyeball.
Scarring and shortening of the front surface of the lower eyelid skin can also cause ectropion. This can happen after an aggressive cosmetic procedure on the lower eyelid known as blepharoplasty. Chronic sun exposure can also cause similar changes.
A heavy object, like a tumor or herniated fat, or swelling of the lower eyelid can pull the lower eyelid outwards, causing what’s called mechanical ectropion.
Risk Factors and Frequency for Ectropion
Involutional lower lid ectropion is a condition that can occur in up to 2% of older adults. It is sometimes linked to an injury. The main risk that comes with this condition involves exposure of the cornea or conjunctiva, which are parts of the eye.
Signs and Symptoms of Ectropion
Doctors need to perform a detailed examination and obtain a complete medical history to understand the cause of lower eyelid ectropion, a condition where the lower eyelid turns outward. It’s crucial to know if the patient has undergone any previous surgeries, such as lower eyelid blepharoplasty, or if they’ve experienced any trauma or cancer removal related to the lower eyelid or cheek area. This will guide the doctor in determining the cause and what to look out for during the examination. The patient should also provide information about symptoms related to dry eye, constant eye rubbing, or eyelid instability. A comprehensive eye exam is needed to properly examine both eyelids and the ocular surface and cornea to check for potential complications related to the condition.
Testing for Ectropion
Lower eyelid ectropion refers to a condition where the lower eyelid is not positioned properly. During a check-up, the doctor may notice that the lower eyelid is lower than it should be, even taking the form of sticking outward. The lower eyelid usually rests about 1 to 2 millimeters above the bottom edge of the cornea. The dislocation can be to an extent where the inner lining of the eyelid, called the ‘tarsal conjunctiva,’ becomes visible, and may show signs of chronic inflammations, leading to thickening of the conjunctiva.
The patient’s eye may appear red and, in severe cases, it may lead to a condition called ‘exposure keratopathy.’ Exposure keratopathy refers to the cornea becoming dry with tiny dots of cell damage, which may turn into ulcers if not treated properly. Another common sign of ectropion is that the eyelid may seem abnormally loose or lax. The doctor may check this ‘laxity’ by gently pulling the eyelid down and away from the eye and observing to see how far it gets pulled. Another test, called the ‘snap-back test,’ is done by pulling the eyelid down and out, then letting go and counting how many seconds it takes for the eyelid to snap back to its normal position. In extreme cases, a patient may need to blink to get the eyelid back to its place.
Different aspects of the area around the eye, also known as the ‘periorbital’ area, need to be checked closely to rule out other potential causes such as chronic skin changes, or the presence of a mass. Additionally, the doctor might also examine the other eyelid as the factors causing ectropion in one eyelid might affect the other eyelid too.
Treatment Options for Ectropion
Treatment for ectropion, a medical condition where the eyelids turn outward, often starts with heavily lubricating the eyes using eye drops, gels, and ointments to keep them moist. This is important when the protective layer of the eye, known as the cornea, is at risk or damaged. For instance, in a patient suffering from facial palsy, the cornea can deterioriate quickly and if it scars, could result in permanent vision loss.
The treatment approach mainly focuses on addressing the root cause of ectropion. If the condition is due to natural aging (also called involutional changes), it may involve a surgical procedure called a lateral tarsal strip. In this procedure, the surgeon makes a cut in the outer corner of the eye (lateral canthotomy), releases the lower corner of the eye (lower cantholysis), removes a small wedge from the lower eyelid, and then reattaches the lower eyelid to the bone at the outer edge of the eye socket (the lateral orbital rim). This procedure tightens the eyelid, allowing it to cover the eye properly and to provide protection. A similar procedure could also be beneficial in cases of facial palsy, where the muscles controlling the eyelid don’t function properly.
In other situations, like when ectropion is caused by aggressive eyelid surgery (blepharoplasty) leading to excessive skin removal, or from scarring due to chronic skin changes, the skin of the eyelid may not be long enough vertically. For those cases, skin grafting might be necessary. This involves adding skin from the same eye area, or from behind the ear to the eyelid. Along with the skin graft, a lateral tarsal strip might also be performed. Furthermore, if scar tissue caused by trauma is pulling the lower eyelid down, it might be necessary to surgically release the scar tissue to allow the eyelid to return to its proper position. In the initial healing phase after the surgery, temporary stitches might be placed to hold and lift the eyelids, a procedure known as tarsorrhaphy or Frost tarsorrhaphy.
Lastly, it’s not uncommon for the condition to affect both lower eyelids, but to varying degrees. Therefore, a bilateral lower eyelid repair, which is a procedure to correct both lower eyelids, may be performed to improve the condition in both eyes and to achieve a balanced look.
What else can Ectropion be?
Here are some medical conditions and procedures related to eye and skin health:
- Basal cell carcinoma (a type of skin cancer)
- Bell palsy (a condition that causes sudden weakness in facial muscles)
- Floppy eyelid syndrome (a disorder of the eyelids)
- Ichthyosis (a group of skin disorders causing dry, scaly skin)
- Neuro-ophthalmic examination (an assessment of vision-related nerve functions)
- Neuro-ophthalmic history (past health information related to the nerves involved in vision)
- Squamous cell carcinoma, eyelid (a form of skin cancer that can affect the eyelids)
