classification

1. ECTROPION
DR. RAKSHYA
BASNET
2ND YEAR

2. CONTENT
• Basic Anatomy
• Definition
• Classification
• Clinical features
• Etiopathogenesis
• Patient evaluation
• Management
• Complications of surgery

3. Skin and subcutaneous tissue
Muscles of protraction
Orbital septum
Orbital fat
Muscles of retraction
Tarsus
Conjunctiva
ANATOMY

4. EYE LID ANATOMY
GROSS DIVISION:
Anterior lamella-skin, orbicularis
oculi
Middle lamella- orbital septum,
orbital fat
Posterior lamella-tarsus,
conjunctiva

5. MAJOR EYELID RETRACTORS
• Upper lid- levator palpebrae superioris muscle with its aponeurosis,
Muller's muscle
• Lower lid- capsulopalpebral fascia and inferior tarsal muscle

6. CANTHAL TENDONS
• cutting, stretching or disinsertion of either of tendons causes horizontal
eyelid laxity
• horizontal eyelid instability is frequently the result of lateral canthal
lengthening

7. ECTROPION ; DEFINITION
• eversion of eyelid or when lid rolls out away from
globe

8. KEY FEATURES:
• Eyelid margin and lash drive are turned away from cornea
• Conjunctival surface is exposed, which can lead to keratinisation of
epithelium
• Corneal exposure results in foreign body sensation, corneal dryness
and ulceration

9. Associated features
• Photophobia
• Epiphora
• Conjunctival infection
• Decreased vision
• Ocular surface pain

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

11. CLASSIFICATION
•Congenital ectropion
•Acquired ectropion
Involutional ectropion
Cicatricial ectropion
Paralytic ectropion
Mechanical ectropion

12. INVOLUTIONAL CICATRICIAL
PARALYTIC MECHANICAL

13. CONGENITAL ECTROPION
Rare condition
Due to shortage of skin in eyelids
Usually associated with
• Blepharophimosis syndrome
• Downs syndrome
Euryblepharon : anti-mongoloid slant because of inferiorly displaced
lateral canthal tendon, widened fissures of lateral eyelid with lid
margin not touching globe

14. Senile or involutional
• which is caused by a horizontal lid laxity, lateral and medial canthal
tendon laxity
• lengthening of medial and lateral canthal tendons with ageing
changes
• most common type of ectropion and has a continuous pathological
process that is aggravated by conjunctivitis and epiphora

15. Cicatricial ectropion
• occurs when there is deficiency of anterior lamella tissue (including skin)
on eyelid
• Contracture of skin pulling lid away from globe
• may result from -thermal or chemical injury
-skin conditions or
-contracture by chronic (involutional, mechanical)
ectropian
-surgical trauma

16. Unilateral or bilateral, depending on cause
Unilateral ectropion due to
traumatic scarring
Bilateral ectropion due to
severe dermatitis

17. Paralytic ectropion
-when orbicularis muscle and facial nerve function disrupted

18. Occurs secondary to Facial nerve palsy
LMN:
• Bell’s palsy
• Ramsey-Hunt Syndrome (Herpes Zoster)
• Parotid tumour or infiltration
• Cerebello-pontine angle lesion
UMN:
• Stroke/AVM
• Tumors
• Infection

19. COMPLICATIONS OF PARALYTIC
ECTROPION
• Exposure keratopathy due to lagophthalmos
• Watering caused by malposition of inferior lacrimal punctum
• Failure of lacrimal pump mechanism
• Increase in tear production from corneal exposure

20. Mechanical ectropion
• occurs when a tractional force is applied to lid by a discrete
lesion
• Caused by-eyelid tumors
-herniated orbital fat
-extravasation of fluid into eyelids
-traction on anterior lamella by eyeglasses

21. PATHOGENESIS OF ECTROPION

22. • Initial sign of a lower lid ectropion is inferior punctal eversion
this leads to a vicious cycle of secondary events
Eversion of inferior punctum
exposure and drying of punctum
stenosis
Epiphora
excoriation and contracture of skin of lower eyelid that further
exacerbates ectropion

23. Patient tends to continually wipe tears
Eyelid and medial canthal tendon laxity that further exacerbates
lower eyelid ectropion
• If condition is neglected, tarsal conjunctiva becomes exposed and
eventually thickened and keratinized
• Lower lid ectropion often results in a corneal epitheliopathy,
especially in inferior third of cornea

24. 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
PATIENT EVALUATION

25. 4. Presence of a horizontal lid laxity
-Eyelid snapback test
-distraction test
5.Medial canthal tendon laxity
-lateral distraction test
6.Lateral canthal tendon laxity
-medial distraction test

26. Eyelid snapback test:
Pull the eyelid inferiorly

27. Grade 0-IV (0 = normal, IV = severe laxity).
• Grade 0 - normal lid that returns to position immediately on release
• Grade I - approximately 2-3 sec
• Grade II - 4-5 sec
• Grade III - >5 sec but does return to position with blinking
• Grade IV - never returns to position and continues to hang down in
frank ectropion after snap-back test

28. (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

29. ability to pull eyelid more than 6mm from globe
Distraction test

30. Lateral distraction test:
-test for medial canthal tendon laxity
-demonstrated by pulling LL laterally and
observing position of punctum
-normally punctum should not be
displaced >1-2 mm
-mild laxity-punctum reaches limbus
-severe laxity-punctum reaches pupil

31. MEDIAL DISTRACTION TEST
• Test for lateral canthal tendon laxity
• Characterized by a rounded appearance of lateral cathus
• Ability to pull LL medially >2mm

32. • 7. Signs of lower facial nerve palsy as brow ptosis, lid retraction with
incomplete blink, lagophthalmos and absence of nasolabial fold
• 8. Weakness of the preseptal orbicularis oculi is tested by closure of
eyelids
• 9. Examination of corneal sensation is a must

33. Skin shortage?
Abnormal Eyelid
Closure?
Lump in Lid?
Cicatricial
Paralytic
Mechanical
No
No
No 
Involutional
Yes
Yes
Yes
MODIFIED ALGORITHM FOR SORTING OUT CAUSE OF
ECTROPION

34. MANAGEMENT

35. NON-OPERATIVE MANAGEMENT
• Lubricants for corneal exposure/ conjunctival keratinization
• Taping lateral canthal skin superotemporally
• Scar (cicatricial) massage, Steroid injection
• Taped lid weights for Facial nerve palsy may improve lagophthalmos
• Advice on wiping tears (up and in toward nose) may reduce exacerbation
of ectropion

36. Preoperative assessment
Postition of maximal ectropion
Medial canthal tendon laxity Lateral canthal tendon laxity
Horizontal lid laxity

37. MANAGEMENT OF INVOLUTIONAL
ECTROPION

38. RETROPUNCTAL CAUTERY
• In early stage, in cases of mild medial ectropion with punctal
malposition
Surgical procedure
• Using a disposable cautery device, deep burns are applied to
conjunctiva 3 to 4 mm below punctum
• effect on punctal position is observed and titrated by number of
burns applied and depth of burn

39. MEDIAL ECTROPION WITHOUT HORIZONTAL
LID LAXITY
Medial Spindle Procedure
(Medial Conjunctivoplasty)
Medial conjunctivoplasty

40. MEDIAL ECTROPION WITH HORIZONTAL LID
LAXITY
Medial Spindle Procedure with a Medial Wedge Resection (lazy T
procedure)
• wedge resection is positioned to remove thickened keratinized
conjunctiva

41. -wedge resection is performed just lateral to position of medial
spindle
-wedge resection closure is performed after closure of the
medial spindle

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

43. COMPLETE TARSAL ECTROPION
Posterior Approach Retractor Reinsertion with
Medial Spindle with Lateral Tarsal Strip
Procedure

44. Treatment of extensive ectropion
Without marked excess skin
With marked excess skin
Horizontal lid shortening
Kuhnt-Szymanowski procedure
a b
a b

45. SURGICAL TREATMENT OF CICATRICIAL
ECTROPION

46. Method depends on severity
Severe cases require transposition flaps
or free skin grafts
Mild localized cases are treated by
excision of scar tissue combined
with ‘Z’-plasty

47. Cicatricial ectropion of LOWER LID -3 step procedure
1. Vertical cicatricial traction surgically released
2. Eyelid is horizontally tightened with lateral tarsal strip procedure
3. Anterior lamella is vertically lengthened via mid-face lift or full
thickness skin grafts
Cicatricial ectropion of UPPER LID -1 step procedure
1. Release of traction & augmentation of vertically shortened
anterior lamella with full thickness skin graft

48. TREATMENT OF PARALYTIC ECTROPION

49. 1.TEMPORARY TREATMENT
• Lubrication with tear substitutes during day
• Botulinum toxin injection
• Temporary tarsorrhaphy in patients with poor Bell’s
phenomenon
Temporary
tarsorrhaphy

50. 2.PERMANENT TREATMENT
-Medial canthoplasty
-Medial wedge resection to correct medial canthal tendon laxity
-Lateral tarsal sling to correct residual ectropion and raise lateral
canthus

51. • Removal of the primary cause
• Correction of significant horizontal lid laxity
TREATMENT OF MECHANICAL ECTROPION

52. • Correction of congenital
ectropion
Horizontal lid shortening
Grafting of anterior
lamella
TREATMENT OF CONGENITAL ECTROPION

53. COMPLICATIONS
• Undercorrection
• Recurrence
• Overcorrection
• Lateral canthal angle dystopia
• Trichiasis
• Canalicular injury
• Corneal abrasion
• Eyelid notching

54. BIBLIOGRAPHY
• AAO series: Orbit, Eyelid and Lacrimal system
• Jack J kanski, Brad Bowling, Clinical Ophthalmology
• Yanoff and Duker Ophthalmology
• Anatomy & Physiology-A.K. Khurana
• Wolff’s anatomy
• Richard Collins book on eyelid surgery

55. THANK
YOU