Ectropion occurs when the retractors of the lower lid, the orbicularis muscle and the lateral canthal tendon cease to function as a unit. The normal forces of the lower lid result in the eyelid staying tight against the eye. If you were to pull the eyelid, it should snap back against the eyeball. In an eyelid with ectropion there is laxity of the lower lid. When you pull the eyelid back, it does not snap back quickly. It returns slowly to regain its former position. As this worsens, the loose lid droops.
One of the hallmarks of ectropion is a red line along the lower lid. This becomes swollen with fluid. This is called chemosis. Several other problems occur with ectropion. First is irritation of the eye. If the eye becomes too irritated the cornea can become scratched and broken down leading to infection or corneal ulcer. Second is tearing. Tearing problems secondary to ectropion require surgical repair.
There are a variety of ways to correct ectropion surgically. They all involve recalibrating three forces around the eyes. The first force is a horizontal force provided by the lateral canthal tendon. The second force is a vertical force provided by the retractors of the lower lid. The third force is an inward force provided by the overlying orbicularis oculi muscle. When these three forces are out of balance, the eyelid turns inward. One of the main ways to fix an ectropion is tightening the lateral canthal tendon. This can be done either via a wedge resection of the lateral canthus, (2) a lateral canthal tendon plication, or (3) a lateral tarsal strip. The key to all these procedures is to maintain the lateral canthal angle. In a wedge resection a full thickness pentagonal section of eyelid is removed. It is then repaired in a layered fashion so that the conjunctiva, tarsus, orbicularis, and skin all line up. The lid margins, the gray line, the lash line and the Meibomian orifices all must line up as well.
In a lateral canthal tendon plication a small incision is made underneath the lateral canthus. This is occluded corner of the eye. The lateral canthal tendon is dissected out and a double arm #5-0 Prolene suture placed through the lateral canthal tendon and out through the internal aspect of the lateral orbital rim at the level of the pupil. By placing it in this fashion the eyelid position is maintained with respect to the upper lid and does not result in slanted closure.
In a lateral tarsal strip the lateral canthus is crushed with the hemostat and then a lateral canthotomy is performed. In a lateral last motion an incision is made down to the orbital bone. Then a lateral cantholysis is performed where the orbicularis muscle is cut free from the orbital rim. This gives complete relaxation of the lower lid muscles. A skin muscle flap is then developed over the tarsus and the excess tarsus is trimmed. Then the conjunctival surface of the tarsus is removed using a blade. An incision is made under the tarsus and a double armed #5-0 Prolene suture is then placed through the tarsus and out through the internal aspect of the lateral orbital rim at the level of the pupil. The upper and lower lid may be removed using Westcott scissors for a distance of one centimeter. Double arm #5-0 polysorb suture is then placed in the upper and lower lid margins and then out again through the internal aspect of the lateral orbital rim at the level of the pupil. This brings the upper and lower lids together. This is crucial to keep from developing what is referred to as lid imbrication system, where one lid overrides the other leading to irritation. These sutures are then tied into place and the wound is then closed using interrupted #6-0 mild chromic sutures. These clear sutures do not require removal. The internal Prolene suture is permanent.
By correcting an ectropion the patient regains comfort. Their blink normalizes and their tearing ceases. In good order the appearance of the lower eyelid is restored. This procedure can be combined with other procedures to remove the bags under the lower lid.
Ectropion repair can be performed under local anesthesia with sedation. If necessary, only local can be used. It is typically done in one of our surgery centers, although it can be done in the office without sedation. Postoperatively the patient will have a patch over the eye overnight and will then be placed on pain medicines which may be either Vicodin ES or Tramadol. The next day they will start Tobradex Ointment twice a day. They should use ice every 2 hours while awake for the first 48 hours, then warm compresses for approximately 5 days thereafter, again for every 2 hours. They are able to return to work one day postoperatively. This should not interfere with any of their activities.