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DR. pavan
 Definition
 Classification
 Etiology
 Etiopathogenesis
 Clinical features
 Patient evaluation
 Different surgeries...
 Eyelid ectropion is an eyelid malposition in which the
eyelid margin is turned out from its normal apposition
to the glo...
 1. Involutional ectropion
 2. Cicatricial ectropion
 3. Paralytic ectropion
 4.Mechanical ectropion
INVOLUTIONAL CICATRICIAL
PARALYTIC MECHANICAL
photophobia
Epiphora
Keratinisation of conj
epithelium
Corneal exposure-FB
sensation,corneal
dryness,corneal
ulceration,ex...
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...
 2. When the anterior lamella is shortened either
postoperatively, trauma (burns or injuries), or
ulceration, the resulta...
 4. Mechanical ectropion is caused by eversion
of the lower lid by a tumor or a mass.
 5. Congenital ectropion is a rare...
•The initial sign of a lower lid ectropion is inferior punctal
eversion
•lead to a vicious cycle of secondary events
•Ever...
It should be directed towards recognition of the ectropion
and its severity .
1. Severity of ectropion:
• Mild : The lower...
4. Presence of a horizontal lid laxity. Which is demonstrated by:
a. Eyelid snap test: Pull the eyelid inferiorly.
• If th...
 5. Signs of lower facial nerve palsy as brow ptosis,
lid retraction with incomplete blink,
lagophthalmos and absence of ...
(A) A patient with a punctal ectropion. (B) A “Snap” test being performed. (C)
Positive “snap” test: the eyelid fails to r...
Preoperative assessment
Postition of maximal ectropion
Medial canthal tendon laxity Lateral canthal tendon laxity
Horizont...
choice of surgery depends on
Degree of ectropion
Location of ectropion
Degree of horrizontal laxity
Laxity of medial n lat...
 Conjunctival cautery
 Medial spindle resection
 Spindle with wedge resection
 Medial canthal tendon plication
 Later...
 Involutional ectropion can be further
classified into the following subtypes:
1. Punctal ectropion
2. Medial ectropion w...
Retropunctal Cautery
 In early stage, simple to apply
Surgical procedure
 Using a disposable cautery device, deep burns ...
Inferior
punctum
Medial Spindle Procedure ( Medial Conjunctivoplasty)
 Where the punctal ectropion is more pronounced, a medial
spindle pr...
 Alternatively, a perforated punctal plug, or a Crawford
bi-canalicular or monocanalicular stent can be placed
temporaril...
 The conjunctiva is lifted
just below the inferior
punctum using Paufique
forceps.
 A diamond-shaped
excision of conjunc...
• A further cut is made from the opposite side while keeping hold of the
conjunctiva with the forceps.
• A diamond-shaped ...
Treatment of medial ectropion
Mild
Severe Lazy-T procedure
Medial conjunctivoplasty
a b
Medial Spindle Procedure with a Medial Wedge
Resection (lazy T procedure)
 The wedge resection is positioned to remove th...
A wedge resection is performed just lateral to the position of the medial spindle.
The wedge resection closure is performe...
A moderate degree of lateral punctal displacement is
well tolerated
 Where the degree of medial canthal tendon laxity is
...
The extent of the excision in a medial canthal resection is
demonstrated.
The deep suture placement for a medial canthal r...
A conjunctival incision is
made between the caruncle
and the plica semilunaris.
A double-armed 5/0
Ethibond suture on a 1/...
 The choice of procedure for a more extensive lower
eyelid ectropion depends on a consideration of the
following factors:...
A) A skin–muscle flap is raised and a lateral wedge resection performed.
B) The wedge resection is repaired.
C) The skin m...
A lateral canthotomy is performed using straight blunt-tipped scissors (surgeon’s
view).
The lower eyelid is then lifted in a superotemporal direction and the inferior crus of
the lateral canthal tendon is cut u...
(A)The anterior and posterior lamellae are split along the gray line using sharp-
tipped scissors.
(B) The gray line has b...
•The tarsal strip is shortened as required
•The tarsal strip is then positioned over the handle of a Paufique forceps with...
 Posterior Approach Retractor Reinsertion with Medial
Spindle with Lateral Tarsal Strip Procedure
•A conjunctival incisio...
Treatment of extensive ectropion
Without marked excess skin
With marked excess skin
Horizontal lid shortening
Kuhnt-Szyman...
Causes of cicatricial ectropion
• Contracture of skin pulling lid away from globe
• Unilateral or bilateral, depending on ...
Treatment of cicatricial ectropion
Method depends on severity
Severe cases require transposition flaps
or free skin grafts...
 Correction of cicatricial
ectropion
 Horizontal tightening
 Fascial sling
 Full thickness skin graft
 Correction of cicatricial
ectropion
 Horizontal tightening
 Fascial sling
 Full thickness skin graft
 Transposition ...
Paralytic ectropion
Exposure keratopathy caused by
lagophthalmos
Caused by facial nerve palsy which,
if severe, may give r...
Treatment Options for Paralytic Ectropion
• Lubrication with tear substitutes
• Botulinum toxin injection
• Temporary tars...
Correction of paralytic
ectropion
 Tarsorrhaphy
 Correction of paralytic
ectropion
 Horizontal lid
tightening
 Correction of
paralytic ectropion
 Fascial sling
Mechanical ectropion
Mechanical lid eversion by tumour
• Removal of the cause, if possible
• Correction of significant hor...
 Congenital
 Rare
 Association with other
anomalies
 Euryblepharon
 Blepharophimosis
 Correction of congenital
ectro...
 Undercorrection
 Recurrence
 Overcorrection
 Lateral canthal angle dystopia
 Trichiasis
 Canalicular injury
 Corne...
Thank you
Ectropion
Ectropion
Ectropion
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Ectropion

  1. 1. DR. pavan
  2. 2.  Definition  Classification  Etiology  Etiopathogenesis  Clinical features  Patient evaluation  Different surgeries for ectropion  Copmlications of surgery
  3. 3.  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
  4. 4.  1. Involutional ectropion  2. Cicatricial ectropion  3. Paralytic ectropion  4.Mechanical ectropion
  5. 5. INVOLUTIONAL CICATRICIAL PARALYTIC MECHANICAL
  6. 6. photophobia Epiphora Keratinisation of conj epithelium Corneal exposure-FB sensation,corneal dryness,corneal ulceration,exposure keratitis
  7. 7. A patient with a bilateral complete tarsal ectropion with keratinization of the chronically exposed conjunctiva.
  8. 8.  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.
  9. 9.  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 palsy.
  10. 10.  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.
  11. 11. •The initial sign of a lower lid ectropion is inferior punctal eversion •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
  12. 12. 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.
  13. 13. 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
  14. 14.  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
  15. 15. (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
  16. 16. Preoperative assessment Postition of maximal ectropion Medial canthal tendon laxity Lateral canthal tendon laxity Horizontal lid laxity
  17. 17. 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
  18. 18.  Conjunctival cautery  Medial spindle resection  Spindle with wedge resection  Medial canthal tendon plication  Lateral wedge resection  Medial canthal resection  Lateral tarsal strip procedure  Z plasty  V-y plasty  Skin graft  Retractors reinsertion to tarsal plate
  19. 19.  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
  20. 20. Retropunctal Cautery  In early stage, simple to apply Surgical procedure  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 Postoperative care  Antibiotic drops are instilled into the eye three times per day for a week.
  21. 21. Inferior punctum
  22. 22. 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.
  23. 23.  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.
  24. 24.  The conjunctiva is lifted just below the inferior punctum using Paufique forceps.  A diamond-shaped excision of conjunctiva is performed using Westcott scissors.
  25. 25. • 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
  26. 26. Treatment of medial ectropion Mild Severe Lazy-T procedure Medial conjunctivoplasty a b
  27. 27. Medial Spindle Procedure with a Medial Wedge Resection (lazy T procedure)  The wedge resection is positioned to remove thickened keratinized conjunctiva.  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.
  28. 28. 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.
  29. 29. A moderate degree of lateral punctal displacement is well tolerated  Where the degree of medial canthal tendon laxity is very pronounced, however, this can be addressed with a medial canthal resection procedure.
  30. 30. The extent of the excision in a medial canthal resection is demonstrated. The deep suture placement for a medial canthal resection procedure is illustrated .
  31. 31. 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 is repositioned against the globe.
  32. 32.  The choice of procedure for a more extensive lower eyelid ectropion depends on a consideration of the following factors: 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
  33. 33. 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 base-down triangle. D) The lateral skin wound and the subciliary incision wound are closed with 7/0 Vicryl sutures.
  34. 34. A lateral canthotomy is performed using straight blunt-tipped scissors (surgeon’s view).
  35. 35. 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 scissors. All residual attachments of the eyelid to the lateral orbital margin are released by cutting all tissues between the skin and the conjunctiva laterally.
  36. 36. (A)The anterior and posterior lamellae are split along the gray line using sharp- tipped scissors. (B) The gray line has been split. (C) The lateral tarsal strip is then formed by cutting along the inferior border of the tarsus. (D)Next, the posterior eyelid margin is excised from the tarsal strip
  37. 37. •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.
  38. 38.  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.
  39. 39. Treatment of extensive ectropion Without marked excess skin With marked excess skin Horizontal lid shortening Kuhnt-Szymanowski procedure a b a b
  40. 40. Causes of cicatricial ectropion • Contracture of skin pulling lid away from globe • Unilateral or bilateral, depending on cause Unilateral ectropion due to traumatic scarring Bilateral ectropion due to severe dermatitis
  41. 41. 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
  42. 42.  Correction of cicatricial ectropion  Horizontal tightening  Fascial sling  Full thickness skin graft
  43. 43.  Correction of cicatricial ectropion  Horizontal tightening  Fascial sling  Full thickness skin graft  Transposition graft  Split level graft
  44. 44. Paralytic ectropion Exposure keratopathy caused by lagophthalmos Caused by facial nerve palsy which, if severe, may give rise to the following: • Failure of lacrimal pump mechanism • Increase in tear production resulting from corneal exposure Epiphora caused by combination of:
  45. 45. Treatment Options for Paralytic Ectropion • Lubrication with tear substitutes • Botulinum toxin injection • Temporary tarsorrhaphy in patients with poor Bell’s phenomenon • Medial canthoplasty • Medial wedge resection to correct medial canthal tendon laxity • Lateral canthal sling to correct residual ectropion and raise lateral canthus 2.Permanent treatment 1.Temporary treatment
  46. 46. Correction of paralytic ectropion  Tarsorrhaphy
  47. 47.  Correction of paralytic ectropion  Horizontal lid tightening
  48. 48.  Correction of paralytic ectropion  Fascial sling
  49. 49. Mechanical ectropion Mechanical lid eversion by tumour • Removal of the cause, if possible • Correction of significant horizontal lid laxity Treatment
  50. 50.  Congenital  Rare  Association with other anomalies  Euryblepharon  Blepharophimosis  Correction of congenital ectropion  Horizontal lid tightening/shortening  Grafting of anterior lamella
  51. 51.  Undercorrection  Recurrence  Overcorrection  Lateral canthal angle dystopia  Trichiasis  Canalicular injury  Corneal abrasion  Eyelid notching
  52. 52. Thank you
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