Ectropion

Ectropion 

Ectropion is when your lower eyelid turns or sags outward, away from your eye, exposing the surface of your inner eyelid.

This condition can cause eye dryness, excessive tearing, and irritation. Ectropion may be due to several factors, including facial paralysis and injury. The most common cause is muscle weakness or slipping due to aging.

If you have symptoms of ectropion, you should seek medical attention. Without treatment, ectropion can lead to serious problems with your cornea, and can even cause blindness.

Eye lubricants can help ease symptoms, but surgery is usually necessary to achieve full correction. Most people who have the surgery experience a positive outcome.

Causes 

Ectropion is usually associated with aging. It can happen as the tissues and muscles of the eyelids become weaker as you get older.

Less common causes of ectropion include:

• a problem with the nerves that control the eyelid – this is often seen in a type of facial paralysis called Bell's palsy
• a lump, cyst or tumour on the eyelid
• damage to the skin around the eyelid as a result of an injury, a burn, a skin condition such as contact dermatitis, or previous surgery

Symptoms

Normally when you blink, your eyelids distribute tears evenly across your eyes, keeping the surfaces of the eyes lubricated. These tears drain into small openings on the inner part of your eyelids (puncta).

If you have ectropion, your lower lid pulls away from your eye and tears don't drain properly into the puncta. The resulting signs and symptoms can include:

• Watery eyes (excessive tearing): Without proper drainage, your tears may pool and constantly flow over your eyelids.
• Excessive dryness: Ectropion can cause your eyes to feel dry, gritty and sandy.
• Irritation: Stagnant tears or dryness can irritate your eyes, causing a burning sensation and redness in your eyelids and the whites of your eyes.
• Sensitivity to light: Stagnant tears or dry eyes can irritate the surface of the cornea, making you sensitive to light.

Diagnosis 

Facial architecture:

Examine the bony architecture of the lower orbital rim and midface position. Patients with hypoplastic midface, also known as hemi proptosis, will have an inferior orbital rim located posteriorly relative to the globe.

Facial nerve palsy:

Inspect the face and test facial muscle strength to assess for paralysis.

Eyelid laxity:

To test for horizontal laxity, place a thumb beneath the lateral canthus and push the eyelid laterally and superiorly. If the lid margin does not roll back into position, suspect a cicatricial component. In involutional cases, the ectropion typically disappears with this maneuver. The eyelid distraction test is done by pulling the lid away from the globe. Normal lid distraction is between 2-3 mm. If it is more than 5mm, there is substantial laxity. In cases of cicatricial ectropion, the eyelid malposition will often become accentuated by asking the patient to look upwards and to open his or her mouth at the same time; the maneuver places the anterior lamella on maximum stretch.

Eyelid pathology:

Examine the eyelid margin under magnification to look for signs of chronic blepharitis, palpebral conjunctival hypertrophy and keratinization, conjunctival scarring, and to rule out suspicious changes such as loss of lashes (madarosis), ulceration, or infiltration.

Punctal ectropion:

Assess the position of the lower punctum which may rotate away with medial laxity and no longer make contact with the ocular surface and tear lake.

Ocular surface:

Examine the cornea for epithelial changes secondary to exposure.