entropion and ectropion

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Overview

Background

Ectropion and entropion are common maladies of the eyelid margin that can directly affect ocular function and patient comfort; surgical repair is commonly performed.

Ectropion (out-turning of the eyelid) can present with keratoconjunctivopathy, infection, and dermatitis, among other signs and symptoms. Tearing is a common presentation, whether the punctum is everted (resulting in a tear outflow problem) or not (as in reflex tearing from irritation and exposure keratoconjunctivopathy). Combined-mechanism tearing is not unusual in these cases.

Ectropion is classified into the following categories on the basis of etiology:

  • Congenital ectropion – This is due to a developmental vertical foreshortening of anterior lamellar tissue, resulting in eversion of the lid margin
  • Cicatricial ectropion – This results from vertical foreshortening caused by acquired scarring or inflammation and may coexist with involutional horizontal lengthening of the lid margin due to chronic vertical traction; treatment in these cases is directed at lengthening the lid vertically with midface lifting or skin grafts or flaps; concomitant repair of any horizontal component is similar to repair of involutional ectropion
  • Mechanical ectropion – This is due to a mass effect on the eyelid (eg, from a tumor), which pulls the lid margin away from the globe; it is managed through treatment of the underlying causative factor (eg, tumor excision)
  • Involutional ectropion – This is due to horizontal laxity of the eyelid, leading to stretching of the lid or dehiscence of its attachments at the medial or lateral canthus, with resultant out-turning of the lid margin.
  • Entropion (in-turning of the eyelid) presents as an irritated eye with foreign-body sensation caused by inwardly rotated eyelashes and eyelid skin. The eye is red from keratoconjunctivopathy. Affected individuals often devise home remedies, such as taping the lid down to the cheek to rotate it away from the globe for comfort.

    Like ectropion, entropion is classified into distinct categories on the basis of etiology, as follows:

    • Congenital entropion – Commonly affecting the lower lids, this is a roll of pretarsal skin that abuts the lashes and rotates them inward; it is quite common in persons of Asian descent and usually resolves as the face matures; if it does not, excision of the skin roll with suture closure is used as a remedy, with minimal scarring and little aesthetic downside
    • Cicatricial entropion – This results from scarring of the palpebral conjunctival or tarsoconjunctival tissue, leading to inward rotation of the lid margin; worldwide, trachoma is the most common cause, with others including chemical burns, cicatrizing diseases, and trauma; treatment involves addressing the underlying problem with immunosuppression (in the case of ongoing cicatrizing disease) or scar release and grafting; suture rotation repair of the lid margin, with or without lid fracturing techniques, may be appropriate for less severe forms of the disease or cases where the availability of supplies and practitioners is limited
    • Involutional entropion – This results from a triad of conditions, (1) dehiscence of the lower-lid retractors from the inferior tarsal border, (2) horizontal lid laxity, and (3) relative enophthalmos of the globe; the effect of relative enophthalmos is best appreciated by having the patient lie in the supine position, which typically elicits the transient entropion as the globe sinks into the eye socket.
    • Indications

      Common indications for ectropion repair include the following:

      • Documented ectropion with chronic eye irritation despite topical lubrication
      • Exposure keratopathy
      • Chronic keratoconjunctivopathy
      • Tearing related to outflow (punctal ectropion or tear pump dysfunction)
      • Tearing related to reflex (chronic irritation)
      • Chronic dermatitis from tear irritation of periocular skin

      Common indications for entropion repair include the following:

      • Keratoconjunctivopathy due to lash/skin-globe touch
      • Ocular irritation

      Contraindications

      Contraindications to surgical repair of either entropion or ectropion are usually based on the medical condition of the affected patient.

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