Management of Ectropion and Floppy Eyelids

Abstract

Ectropion is defined as an eversion of the upper or lower eyelid away from the globe. Classes of ectropion include involutional, cicatricial, paralytic, and mechanical. Ectropic eyelids develop from horizontal eyelid laxity, medial canthal tendon laxity, vertical skin tightness, neuromuscular dysfunction, and lower eyelid retractor disinsertion. Ocular complications associated with ectropic eyelids include corneal exposure and scarring, conjunctivitis, ocular discomfort, photophobia, epiphora, and decreased vision. The entire face and eye should be carefully examined when a patient presents with ectropion. A systemic approach enables the physician to more fully understand the underlying disease process and best therapeutic approach. Ectropion can be quantified by pulling the central portion of the lid anteriorly and measuring the number of millimeters from the anterior cornea to the apex of the eyelid. Ectropion etiology can be elucidated by evaluating for horizontal eyelid laxity, orbicularis dysfunction, vertical skin tightness, and lower eyelid retractors disinsertion. Horizontal eyelid laxity is typically a result of lateral or medial canthal tendon stretching. Laxity of the canthal tendons produces a redundancy in the eyelid tissues, resulting in ectropion, often referred to as an involutional ectropion. Lateral canthal tendon status can be determined by gently pulling the eyelid nasally. The inferior crus of the tendon can then be palpated to evaluate for dehiscence. The medial canthal tendon can be evaluated by pulling laterally and noting the displacement of the inferior punctum. The severity of canthal tendon laxity should be quantified prior to any surgical intervention. 8-2-1 Lateral Canthal Tendon Laxity and the Lateral Tarsal Strip Procedure. Although a variety of methods have been advocated for treatment of lateral canthal tendon laxity, we prefer the lateral tarsal strip, introduced by Anderson. This procedure corrects the underlying anatomic abnormality, does not require reapproximation of the eyelid margin, and is relatively easy to perform. The lateral canthal region is injected with lidocaine 2% mixed with 1:100,000 epinephrine using a 27- or 30-gauge needle. After ensuring appropriate anesthesia, Stevens scissors are used to create a lateral canthotomy and exposure of the lateral orbital rim.