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Different surgeries for ectropion
Copmlications 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
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.
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
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
•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 exacerbates
the 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
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
Postition of maximal ectropion
Medial canthal tendon laxity Lateral canthal tendon laxity
Horizontal lid laxity
choice of surgery depends on
Degree of ectropion
Location of ectropion
Degree of horrizontal laxity
Laxity of medial n lateral tendon
Tone of orbicularis muscle
Presence of any mechanical forces
Any cicatrical cause
General health of patient
Involutional ectropion can be further
classified into the following subtypes:
1. Punctal ectropion
2. Medial ectropion without horizontal eyelid laxity
3. Medial ectropion with horizontal eyelid laxity
4. Medial ectropion with medial canthal tendon laxity
5. Ectropion of the whole length of the lower eyelid
6. Complete tarsal ectropion
In early stage, simple to apply
Using 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
Antibiotic drops are instilled into the eye three times per day for
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.
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
excision of conjunctiva is
• 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
Severe Lazy-T procedure
Medial Spindle Procedure with a Medial Wedge
Resection (lazy T procedure)
The wedge resection is positioned to remove thickened
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.
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
Where the degree of medial canthal tendon laxity is
very pronounced, however, this can be addressed with
a medial canthal resection procedure.
The extent of the excision in a medial canthal resection is
The deep suture placement for a medial canthal resection procedure
is 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
against the globe.
The choice of procedure for a more extensive lower
eyelid ectropion depends on a consideration of the
1. The degree of rounding of the lateral canthus
2. The presence of excess lower eyelid skin
3. The degree of horizontal eyelid laxity
4. The degree of upper eyelid laxity
5. The general health of the patient
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
D) The lateral skin wound and the subciliary incision wound are closed with 7/0 Vicryl
A lateral canthotomy is performed using straight blunt-tipped scissors (surgeon’s
The lower eyelid is then lifted in a superotemporal direction and the inferior crus of
the lateral canthal tendon is cut using blunt-tipped Westcott
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-
(B) The gray line has been split.
(C) The lateral tarsal strip is then formed by cutting along the inferior border of the
(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 the
tarsal 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
•A conjunctival incision is made at the lower border of the tarsus.
•The lower eyelid retractors are dissected free and sutures passed through the
retractors 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
Causes of cicatricial ectropion
• Contracture of skin pulling lid away from globe
• Unilateral or bilateral, depending on cause
Unilateral ectropion due to
Bilateral ectropion due to severe
Treatment of cicatricial ectropion
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
Correction of cicatricial
Full thickness skin graft
Exposure keratopathy caused by
Caused by facial nerve palsy which,
if severe, may give rise to the following:
• Failure of lacrimal pump
• 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
• Medial canthoplasty
• Medial wedge resection to correct medial canthal
• Lateral canthal sling to correct residual ectropion
and raise lateral canthus
Correction of paralytic
Correction of paralytic
Mechanical lid eversion by tumour
• Removal of the cause, if possible
• Correction of significant horizontal lid laxity
Association with other
Correction of congenital
Grafting of anterior lamella