Oculoplastics
Adjusting the covers
by Enette Ngoei Senior EyeWorld Staff Writer
Experts explain what to do when a patient develops ectropion
Examples of ectropion
Source: Wendy W. Lee, M.D.
Most commonly seen in the elderly population, ectropion is a condition where the eyelid, more often the lower one, flips outwards, away from the eye. The most common reason this happens is that as people get older, their tissues sag and are no longer tight, explained Robert B. Penne, M.D., director, Oculoplastics & Orbital Surgery Service, Wills Eye Institute, Philadelphia. This is known as involutional ectropion.
However, there are other causes for ectropion like scarring of the skin—whether it is a scar from trauma, a skin problem, or burns that shorten the skin and pull the eyelid away, Dr. Penne said. The last kind of scarring on the skin is a much rarer cause for ectropion, which can occur in either the lower lid or the upper lid, he added.
As a result of ectropion, the patient doesn’t have effective pumping distribution of his or her tears, explained Wendy W. Lee, M.D., Miller School of Medicine, University of Miami, Miami. “When the lid is everted and it’s loose, it doesn’t pump the tears and distribute the tears across the eye effectively. So that leads to irritation, it can lead to tearing, and it can lead to keratinization of the conjunctiva if it’s severe,” she said.
Next step: surgery
If symptoms are mild and a patient just has irritation and dryness, the physician can first try using various artificial tears and either a lubricated ointment or sometimes an antibiotic ointment, Dr. Penne said.
“For most people, though, it ends up being that they need outpatient surgery,” he said.
The lid needs to be tightened surgically and depending on the severity of the condition, there are different ways to tighten the lid, Dr. Lee said. The surgeon could perform a lateral tarsal strip, a lateral canthopexy, or do a retractor insertion.
In the first two procedures, the lateral canthal tendon on the lateral aspect of the eyelid is tightened, Dr. Lee explained. In the lateral canthopexy, the whole body of the tendon is tightened, whereas in the lateral tarsal strip, the surgical focus is on the inferior aspect of the lateral canthal tendon and it’s tightened and put back to its anatomical position inside the lateral orbital rim.
The other thing surgeons sometimes do is take a tuck or tighten the retractors, which are the anchors of the eyelid, Dr. Penne said. “So from the inside of the eyelid, we’ll take a little piece of tissue out and reattach or tighten the retractors of the eyelid as well,” he said.
The typical post-op regimen for eyelid surgery includes patient application of an antibiotic ointment twice a day on the sutures, twice a day in the eye and the patient has to use ice for three days and warm compresses. Post-op follow-up is one week, Dr. Penne said. After that, most patients are typically fine and nothing else needs to be done.
The complication rates are low, he added, with the most common complication being that the lid sags back out or isn’t brought back in during the surgery. In such instances, if the eyelid is not fully corrected, the surgeon may go back to correct it, or prescribe lubrication drops but if that doesn’t work, he or she has to figure out why the surgery hasn’t worked, Dr. Penne advised.
It is possible that the surgeon did not initially recognize that there was some scarring so that the skin is actually pulling the lid out and may have to perform procedures like skin grafts, he explained.
Another possible but very rare complication, as with any surgery is infection, Dr. Penne said. In addition, a very uncommon occurrence is that in trying to bring an eyelid that’s out back in, a surgeon can overcorrect and resulting in the patient developing an entropion, where the eyelid is turned inwards, he said.
As for contraindications, Dr. Lee said it’s always recommended that patients be off of blood thinners for at least 2 weeks. The surgeon has to be cautious about performing surgery on anyone who either can’t stop things such as Coumadin (warfarin sodium, Bristol-Myers Squibb, New York) or even aspirin or Plavix (clopidogrel bisulfate, Bristol-Myers Squibb/Sanofi Pharmaceuticals, New York), Dr. Penne explained. “If they can’t stop those at all, you have to be concerned that they may bleed more and you have to reassess how badly they need the surgery,” he said.
Finally, if a patient is medically too sick to undergo surgery you certainly wouldn’t want to do it. “It’s not a surgery that has a lot of risks except not working,” Dr. Penne added.
Editors’ note: Drs. Penne and Lee have no financial interests related to their comments.
Contact information
Lee: 305-326-6000, wlee@med.miami.edu
Penne: 215-928-3250, dpenne1@comcast.net