Conditions: Lower Ectropion & Entropion

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Lower Eyelid Ectropion

Lower eyelid ectropion is an eyelid malposition in which the lower eyelid margin is turned away from its normal position in contact with the eye. The condition is commonly age-related but can also occur in patients with skin problems e.g. severe eczema, following an injury/burn, or in patients with a facial palsy. The ectropion leads to overflow tearing of the eye (epiphora) and discomfort. This can lead to a vicious cycle of secondary events and needs to be addressed early. Epiphora may lead to irritation and contraction of the skin of the lower eyelid that further worsens the ectropion. In addition, the patient tends to continually wipe the lower eyelid, which in turn results in eyelid stretching that further worsens the lower eyelid ectropion. If the condition is neglected, the conjunctiva on the inside surface of the eyelid becomes exposed and eventually thickened. The patient's eye may show associated dryness.

A chronic age-related lower eyelid ectropion with drying of the exposed
conjunctiva on the inside surface of the eyelid

Management

The treatment of the ectropion depends on the underlying cause. Most patients undergo surgery to tighten the eyelid at the outer aspect of the eyelids (a lateral tarsal strip procedure). Some patients with shortening of the skin of the eyelids require a skin graft. This can be taken from the upper eyelid, from behind the ear or from the upper inner arm.

	Ectropion of the inner aspect of the lower eyelid causing constant overflow tearing		Postoperative appearance following a skin graft reconstruction and a suture fixation to the lacrimal crest

	A lower eyelid cicatricial ectropion following an injury		The appearance following a lower eyelid skin graft reconstruction

Lower Eyelid Entropion

Lower eyelid entropion is an eyelid malposition in which the lower eyelid margin is turned inwards against the globe causing discomfort from contact between the eyelashes and the surface of the eye. An entropion is usually involutional (age-related) and the majority are therefore seen in older patients.

A lower eyelid entropion

Management

In the case of acute spastic entropion, the treatment is directed to the provoking stimulus e.g. in growing eyelashes, blepharitis, dry eye. Although a bandage contact lens or botulinum toxin injections may improve symptoms temporarily, these are rarely justified. The use of lower lid tape can be advised for use in primary care while the patient is waiting to be seen by an ophthalmologist.

Surgical management

These procedures are commonly used to manage this eyelid problem:

These procedures are usually performed under local anaesthesia with or without mild sedation.

Everting sutures are offered to all older patients at the initial consultation and are used exclusively for the following patients:

Everting sutures have been commonly regarded as a temporary form of treatment but many patients achieve a permanent result with the sutures alone. If the entropion recurs they are offered a repeat procedure or a more definitive surgical procedure. The sutures are very quick and simple to insert in a clinic setting and provide instant relief for the patient.

Lower eyelid everting sutures

For all other patients, a lower eyelid retractor advancement combined with a lateral tarsal strip procedure is performed in the operating theatre. This is a very convenient operation for the patient as no sutures need to be removed. It does, however, leave a sore tender lumpy area at the outer corner of the lower eyelid for a few weeks before this settles.

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