This document discusses ectropion and entropion of the eyelids. It describes the anatomy of the eyelids and various types and causes of ectropion and entropion. Signs, symptoms, evaluation, and treatment options are provided for different types including congenital, involutional, cicatricial, and paralytic ectropion as well as entropion. Surgical procedures for correcting ectropion and entropion such as horizontal lid shortening, medial canthal tendon plication, and tarsal fracture are explained.

1. ECTROPION AND ENTROPION
Dr. Nitish Narang

2. ANATOMY OF EYELIDS:-
 SKIN- thin,stretches with age & there is usually
excess available for a full thickness skin graft.
 ORBICULARIS MUSCLE:-

3.  UPPER EYELID ANATOMY:-

4. LOWER EYLID ANATOMY:-

5.  ECTROPION- It is an outward turning of the eyelid
margin .
 TYPES:-
1)Congenital
2) Involutional
3) Paralytic
4) Cicatricial
5) Mechanical
*Involutinal ectropion is more common, while congenital
ectropion is very rare.

7. SYMPTOMS
 Lower lid ectropion -> Inferior punctum displaced away
from globe -> Epiphora/ Excoriation of skin around lid.
 Chronic conjunctivitis -> Irritation/ discomfort.
 Lagophthalmos & corneal exposure.
 Lid laxity & loss of orbicularis tone eliminates the
lacrimal pump mechanism—FLACCID CANALICULAR
SYNDROME.
 KERATINISATION of exposed conjunctiva

8. SIGNS:
 Lid margin is outrolled and depending on outrolling
ectropion can be classified as under:
- Grade I –only punctum is everted
- Grade II –lid margin is everted and palpebral
conjunctiva is visible
- Grade III –fornix is also visible

9. CASE WORK UP
 SNAP BACK TEST:-
 Pull the lower lid down and away from globe for
several seconds and wait. Without the patient
blinking, note the length of time required before the
lower lid returns to its original position; the lid, in
fact, may not return to its original position at all.
MILD – takes some time
MODERATE – goes back slowly without blink
SEVERE – doesnot go back even after a blink

11. MEDIAL CANTHAL LAXITY TEST:-
 Pull the lower lid laterally away from the medial
canthus and measure displacement of medial
punctum; the greater the distance measured, the
greater the laxity.
 Normally, the displacement should only be 0-1 mm.
The medial canthal laxity test is graded
from 0-IV, with a grade of 0 indicating
normal laxity and a grade of IV indicating
severe laxity.

12. LATERAL CANTHAL LAXITY TEST:-
 Pull the lower lid medially away from the lateral
canthus and measure displacement of the lateral
canthal corner; the greater the distance measured,
the greater the laxity.
 Normally, the displacement should only be 0-2 mm.
The lateral canthal laxity test is graded
from 0-IV, with a grade of 0 indicating
normal laxity and a grade of IV indicating
severe laxity.

13.  Schirmer's test: to rule out dry eye.
 Fluorescein test of cornea: to assess the corneal
damage.
 Slit lamp examination
 Assessment of Bell’s phenomenon.
 Examination of 7th cranial/facial nerve.

14. MEDICAL THERAPY
 Provide medical therapy if surgical therapy is not
warranted or not possible.
 Symptomatic therapy with artificial tear ointment or
drops;
 Lower lid taping.
 If there is chronic dacryocystitis, performing a
dacryocystorhinostomy alone or in combination with
an ectropion procedure may produce better results
than treating the ectropion alone.

15.  If the conjunctiva is markedly keratinized, use a
lubricating ointment or mild steroid ointment several
days or weeks prior to ectropion repair.
 Corneal epithelial defects and prior herpes simplex
infection are relative contraindications to use of
steroid-containing ointments.

16.  Instruct patients with tearing and incipient ectropion
or early punctal ectropion to wipe the eyelids in a
direction up and in (toward the nose) to avoid
worsening medial ectropion.
 With cicatricial ectropion following trauma or lid
surgery, digital massage may help stretch the scar.
If not, consider steroid injection into the scar.

17.  External paste-on upper lid weights are available
and are useful for patients who have seventh nerve
palsy. Lid weights can be approximately matched
for different skin colours.
 A double-sided tape is used to apply the lid weight.
Removing the lid weight at night may avoid irritation
of the lid skin. External lid weights are not a good
option in patients with upper lid dermatochalasis or
poor manual dexterity.

18. CONGENITAL ECTROPION:-
 Occurs as an isolated finding.
 Associated with blepharophimosis syndrome or
icthyosis.
 Caused by vertical insufficiency of the anterior
lamellae of the eyelid – if severe can cause chronic
epiphora and exposure keratitis.
 Topical lubrication and short term patching of both
eyes is required.
 If severe and symptomatic it is treated surgically
with horizontal tightening of lateral canthal tendon
and vertical lengthening of the anterior lamellae
using a full thickness sutures.

19.  Congenital eyelid eversion- complete eversion of
the upper eyelids seen occasionally.
 Possible causes include inclusion conjunctivitis ,
anterior lamellar inflammation or shortage or Down
syndrome.

20. ICHTHYOSIS WITH
ECTROPION
TOTAL LID EVERSION

21. TREATMENT:
 Hotz-type operation –the skin edges are sutured to
lower lid retractors and lower border of tarsus.
 Indication: Frank lower lid ectropion with inversion
of lid margin in a child who is persistently
photophobic and gets recurrent attacks of
conjunctivitis which don’t resolve in first 2 years of
life

22. METHOD
 Pick excess skin and orbicularis, mark this as
ellipse in medial part of eyelid, excise the ellipse.
 Suture the lower lid skin edges to retractor and
lower border of the tarsal plate with interrupted 6-0
absorbable sutures. Do the procedure bilaterally

23. INVOLUTIONAL ECTROPION:-
 This is the most common form.
 Affects the lower lid of elderly patients
 Causes epiphora and in long standing cases the
tarsal conjunctiva may become chronically
inflammed ,thickened and keratinized .

24. INVOLUTIONAL ECTROPION

25. PATHOGENESIS:-
 Horizontal lid laxity- caused by age related
stretching of the tarsus and palpebral ligaments .
 Medial canthal tendon laxity
 lateral canthal tendon laxity .
 Disinsertion of lower lid retractors .

26. HORIZONTAL LID SHORTENING BY FULL-
THICKNESS WEDGE EXCISION:-
 If horizontal lid laxity exists without significant
lateral canthal or medial canthal tendon laxity.
 Preferred site is lateral 1/3rd
 It is useful if the lateral canthal angle contour and
position are normal.
 First full thickness lid incision is made at right angle
to the lid margin, extending to the lower border of
tarsal plate.
 Tarsal plate edges are approximated using 2-3 long
acting 6-0 absorbable sutures.
 Additional 6-0 marginal sutures are passed through
the gray line and lash line and tied – the ends are
left long.

28. KUHNT-SYMANOWSKI
PROCEDURE( Horizontal
lid shortening &
blepharoplasty):-
 A subciliary incision is cut
through skin 2 mm below the
lashes, from the inferior
punctum to the lateral canthal
angle.
 At the lateral canthus the
incision is continued obliquely
downward in a natural skin
crease for a distance of
10mm and the skin flap is
undermined to the level of the
orbital rim.
 Rest surgery is same as
previously described
 Indication- generalised
horizontal lid laxity with
excess skin.

29. EXCISION OF DIAMOND OF TARSOCONJUNCTIVA
 Probe is passed into the inferior canaliculus.
 A diamond-shaped segment of tarsus and conjunctiva is
resected directly below the punctum, 2mm from lid margin.
 One arm of a 6-0 absorbable suture is passed through the
superior apex of the diamond from the conjunctival surface
to emerge within the wound.
 The other end of the suture is passed through the
conjunctiva and lower lid retractors at the inferior apex of
the diamond and again emerges within the wound.
 As the suture is tied, the medial lid margin and punctum are
rotated inward.
 Indication- ectropion of the lower lacrimal punctum without
significant horizontal lid laxity.

31. MEDIAL DIAMOND EXCISION PLUS HORIZONTAL LID SHORTENING
(“BRYON SMITHS LAZY-T”)
 A full-thickness incision uptil lower tarsal edge is made
through the lid margin 4 mm lateral to the punctum.
 Redundant lid excised as a full-thickness pentagon
lateral to the first incision. This is repaired first followed
by closure of diamond.
 Indication – treatment of choice for medial ectropion
with punctal eversion associated with predominantly
medial horizontal lid laxity.

32. PLICATION OF ANTEROR LIMB OF MEDIAL
CANTHAL TENDON
 AIM: Is to give support to the medial canthal tendon.
 A wire probe is placed into the inferior canaliculus to mark
its precise location.
 A horizontal skin incision is made below the canaliculus,
starting at the medial canthus and extending to below the
inferior punctum.
 A 5-0 nonabsorbable suture is passed through the medial
edge of the tarsal plate and then through the anterior limb
of the medial canthal tendon.
 The suture is tightened sufficiently to stabilize the canthal
angle in its normal position.
 INDICATION – mild medial canthal tendon laxity.

34. MEDIAL CANTHAL TENDON PLICATION-
POSTERIOR LIMB
 The posterior limb of the medial canthal tendon is
reformed by suturing the medial end of the lower
tarsal plate to the periosteum of the medial orbital
wall.
 INDICATION- a mild medial involutional or paralytic
ectropion with a relatively anterior positioned
punctum associated with some medial canthal
tendon laxity affecting the posterior limb more than
the anterior limb,i.e.it should not be possible to pull
the lid very far laterally.

35. MEDIAL CANTHAL RESECTION
 This is the procedure of choice when marked medial canthal tendon
laxity is present that results in dystopia of the medial canthal angle at
rest.
 A vertical full-thickness cut is made through the lower lid just lateral to
the caruncle to include the canthal tendon and canaliculus
 The conjunctival incision is continued onto the bulbar surface, posterior
to the plica.
 This plane is followed back along the medial orbital wall with blunt-
ended scissors until the posterior lacrimal crest is encountered.
 2 half-circle needles of a 5-0 nonabsorbable sutures are passed
through the periosteum of the posterior lacrimal crest, one at the level
of the medial canthal tendon and one 2 mm higher on the medial orbital
wall.
 Appropriate amount of lid is resected.
 The two ends of the fixation suture are passed through the cut edge of
the tarsal plate. The fixation suture is tied to reform the medial canthal
angle.
 INDICATION- This is the procedure of choice when marked medial
canthal tendon laxity is present that results in dystopia of the medial
canthal angle at rest.

37. • Overriding of preseptal over
pretarsal orbicularis during lid
closure
• Weakness of lower lid retractors
• Horizontal lid laxity
• Canthal tendon laxity

38. TREATMENT
 LID EVERTING SUTURES:-
 Transverse sutures are placed through the lid to
prevent the upward movement of the preseptal
muscle. Everting sutures are placed more obliquely
through the lid to shorten the lower lid retractors &
transfer their pull to the upper border of the tarsus.
 INDICATIONS:- temporary cure(upto 18 months).
Quick ,easy & repeatable procedure especially in
geriatric group can be done bedside.

39. TREATMENT
 SUTURES: To correct the lamella dislocation as
a) Transverse suture to prevent upward movement of
preseptal muscle.
b) Everting sutures to tighten the lower lid retractors
and evert lid margins.
 Indication:
a) Temporary cure for geriatric, during wait for
definitive surgery.
b) Transverse suture when patient forcibly closes lid
and there is an element of spasm.

40. LID EVERTING SUTURES

41. WEISS PROCEDURE:- TRANSVERSE LID SPLIT
& EVERTING SUTURES
 The lid is split transeversely to create a fibrous
tissue scar barrier which prevents the upward
movement of the preseptal muscle combined with
the mechanism of the lid everting sutures which
shorten the lower lid retractors and transfer their
pull to upper border of the tarsus
 INDICATIONS:- long term cure(>18months) with
little horizontal lid laxity

42.  Horizontal incision 4mm below
lash line.
 Perforate the lid with sharp
pointed scissors at medial and
lateral ends of skin incision.
 Cut horizontally through the
whole lid along the line of
incision.
 Identify lower lid retractors.
 Pass 3, 4-0 absorbable sutures
through conjunctiva, lid retractors,
tarsal plate coming out through
1mm below lash line.
 Close the skin with suture
 Tie a double armed sutures under
tension, just to evert lid margin

43. QUICKERT PROCEDURE:-TRANSVERSE LID SPLIT +
EVERTING SUTURES + HORIZONTAL LID
SHORTENING
 Horizontal lid shortening corrects the excess lid
laxity & prevents the lid turning in or out along with
mechanisms of the other 2 procedures.
 INDICATIONS:- long term cure of an entropion with
excess horizontal lid laxity assessed by pulling the
lid away from the globe.

44. QUICKERT PROCEDURE:-TRANSVERSE LID SPLIT +
EVERTING SUTURES + HORIZONTAL LID
SHORTENING

45. JONES PROCEDURE:-PLICATION OF LOWER LID
RETRACTORS
 The lower lid retractors are exposed via a skin
approach,shortened,and the sutures used to create
a barrier to the upward movement of the preseptal
muscle
 INDICATIONS:- recurrence after transverse lid split,
everting sutures & lid shortening procedure.

46.  Make horizontal skin incision at
the lower border of tarsal plate.
 Separate the pretarsal and
preseptal muscles to expose the
inferior edge of the tarsal plate.
 Divide the inferior orbital septum,
the orbital fat lie anterior to lower
lid retractors.
 Pass a 4 ‘0’ absorbable suture
through the skin in centre of the
lid, through lower lid retractors
about 8mm below the tarsus,
through the lower border of the
tarsal plate, and out through the
upper skin edge.
 Tighten this suture and tie it with a
slip knot

47. CICATRICIAL ENTROPION
 Caused by severe scarring of the palpebral
conjunctiva, which pulls the upper or lower lid
margin towards the globe.
 Cicatrizing conjunctivitis, trachoma, trauma
chemical injuries, Stevens-Johnson syndrome.

48. POST TRACHOMA SCAR
POST LIME INJURY

49. TREATMENT
 TARSAL FRACTURE:- the tarsus is fractured
horizontally & hinged into eversion with everting
sutures.

50. POSTERIOR LAMELLAR GRAFT:-
 The tarso-conjunctiva is lengthened with a graft
inserted near the lid margin to allow eversion.
 INDICATIONS:- severe Cicatricial entropion;
entropion with lid retraction of more than about
1.5mm below the limbus
 Recurrence of entropion after tarsal fracture
procedure

51. UPPER LID ENTROPION- ANTERIOR LAMELLAR
REPOSITION
 The anterior lamella of skin & muscle is
repositioned & sutured to the tarsus at a higher
level & also sutured to the aponeurosis with the
skin closure sutures.
 INDICATIONS:- mild upper lid entropion.

52. UPPER LID ENTROPION- ANTERIOR LAMELLAR
REPOSITION

53. TARSAL WEDGE RESECTION
 An anterior lamellar reposition & lid margin split is
combined with the excision of a wedge of tarsal
plate.
 INDICATIONS:- marked upper lid entropion with a
thickened tarsus, no keratinisation of the marginal
tarso-conjunctiva & with eyelids able to meet on
forced lid closure.

54. LAMELLAR DIVISION +/- MUCOUS MEMBRANE
GRAFT
 The lid is split into an anterior lamella & posterior
lamella. The posterior lamella is advanced & held in
position with sutures passed through the lid. The
raw anterior tarsal surface can be allowed to
granulate but heals quicker if covered with a
mucous membrane graft.
 INDICATIONS: marked upper lid entropion with a
thin tarsus

55. TRABUT PROCEDURE:-ROTATION OF
TERMINAL TARSUS
 The tarsus is cut & the lower portion rotated
through 180°. The posterior lamella is advanced to
make a new lid margin.
 INDICATIONS:- upper lid entropion with metaplastic
changes involving the lower posterior tarsal surface
which is in contact with the cornea.

56. POSTERIOR LAMELLAR GRAFT:-
 The tarsus is divided , the terminal fragment
everted & a graft sutured between the everted
terminal tarsal fragment & the recessed conjunctiva
& lid retractors.
 INDICATIONS:- entropion associated with severe
lid retraction such that the lid margins will not meet
on forced lid closure.

57. TARSAL EXCISION
 The tarsus is excised & the conjunctiva & lid
retractors are recessed & held wit sutures passed
through the lid. The raw posterior lid surface rapidly
becomes conjuntivalised.
 INDICATIONS:- entropion associated with severe
lid retraction & a small scarred tarsus when a
corneal graft is not planned

58. AURICULAR CARTILAGE GRAFT
 To lengthen the posterior lamella of the upper or
lower lid when rigidity is required but the lid margin
is intact.
 For reconstruction of the lid margin a graft of tarsal
plate or nasal septal cartilage with its attached
mucosa is preferable

59. SPASTIC ENTROPION
 Due to increased muscular tone, the lower lid
orbicularis shifts superiorly “overriding” the inferior
tarsal border.
 Trauma, lid surgery or inflammation.
 Sometimes seen in association with
blepharospasm.

60. TREATMENT
 The irritation/entropion cycle is to be broken.
 Taping of the inturned eyelid to evert the
margin,cautery, or various suture techniques afford
temporary relief for most patients
 But usually involutional changes are present in the
eyelid so additional surgical repair may be needed.
 Botulinum type A(botox) can be used to paralyze
the overriding preseptal orbicularis muscle.

61. COMPLICATIONS
 Persistent entropion – minimized with good
preoperative planning
 Overcorrection- for cictricial entropion immediately
post operative, patient should be overcorrected
 Eyelid retraction- result of excessive horizontal
tightening of the tarsus or excessive advancement
of the capsulopalpebral fascia.
 Hematoma
 Keratopathy- from conjunctival
sutures/lagopththalmos(severe lid
retraction)/posterior lamellar graft

62.  Symblepharon- as a result of injury to bulbar
conjunctiva in posterior lamella manipulation.
 Granuloma formation.
 Ptosis- injury to levator nerve fibres,eyelid necrosis.
 Eye lash loss & eyelid necrosis- due to damage to
marginal vascular arcade.

63. SYSTEM FOR ACQUIRED ECTROPION

64. SYSTEM FOR ACQUIRED LOWER LID ENTROPION

65. SYSTEM FOR ACQUIRED UPPER LID ENTROPION

66. REFERENCES
 J.R.O.COLLIN – a manual of systematic eyelid surgery
 AMERICAN ACADEMY OF OPHTHLMOLOGY
 JACK KANSKI & BRAD BOWLING – clinical
ophthalmology
 MYRON YANOFF & DUKER
 THE YALE GUIDE OF OPHTHALMIC SURGERY