This document summarizes various periorbital malpositions and involutional changes including ectropion, entropion, and symblepharon. Ectropion is outward turning of the eyelid and has several types including involutional, cicatricial, and paralytic. Entropion is inward turning and can be involutional, acute spastic, or cicatricial. Symblepharon is an adhesion between conjunctival surfaces caused by inflammation, infection, or trauma. The document discusses examination, risk factors, pathophysiology, and management options for each condition including surgical procedures and medical treatment.

1. PERIOCULAR MALPOSITIONS AND
INVOLUTIONAL CHANGES
PRESENTER: DR.MUGABI BARNABAS
MUKAABYA
MODERATOR:DR.LUSOBYA REBECCA
20TH/04/2023

2. OUTLINE
• ECTROPION
• History and examination
• Risk factors
• Pathophysiology
• Types of ectropion
• ENTROPION
• Special tests
• Types of ectropion
• SYMBLEPHARON
• Definitoin
• Etiology
• Pathophysiology
• Management
• Complications
• prognosis

3. ECTROPION
Outward turning of the eyelid margin and classified as
• congenital
• Involutional
• cicatricial
• paralytic
• Mechanical
Most cases seen in a general ophthalmology practice are involutional

4. ECTROPION
• History and Examination
• History of the presenting condition
• General medical history.
• A detailed ocular exam including:
₋ visual acuity
₋ ocular motility
₋ slit-lamp examination
₋ testing of tearing and protective mechanisms should be performed

5. ECTROPION
• Physical examination
• Facial architecture
• Facial nerve palsy
• Eyelid laxity
• Eyelid pathology
• Punctal ectropion
• Ocular surface

6. ECTROPION
• Risk factors
• Age (gravity, loss of elasticity)
• Eyelid rubbing
• Repeated eyelid pulling (ex. contact-lens use)
• Floppy eyelid syndrome
• Long term use of eye drops
• Skin conditions which involve the eyelid
• Trauma
• Prior Eyelid Surgery

7. ECTROPION
• Pathophysiology
• In involutional ectropion,
the tarsoligamentous sling
becomes lax.
• In paralytic ectropion, orbicularis
muscle tone is weak or absent due
to facial nerve palsy.

8. ECTROPION
• Pathophysiology
• In cicatricial ectropion, the anterior
or middle lamellae are shortened due
to scarring.
• Midfacial hypoplasia results in both
decreased lower eyelid support and
increased propensity for lower eyelid
retraction

9. ECTROPION
• Involutional ectropion
• Results from horizontal eyelid laxity
in the medial or lateral canthal tendons
or both.
• Leads to loss of eyelid apposition to the
globe and eversion of the eyelid margin
• Chronic conjunctival inflammation with
hypertrophy and keratinization
• usually occurs in the lower eyelid

10. ECTROPION
• Involutional ectropion
• Management
• Horizontal eyelid tightening
• In the lateral tarsal strip procedure,
the tarsus is sutured directly to the
lateral orbital rim periosteum
• Repair of medial canthal laxity is more
challenging than repair of horizontal
lower eyelid laxity

11. ECTROPION
• Involutional ectropion
• Management
• Medial spindle procedure
• In cases of mild medial ectropion
with punctal eversion
• The procedure involves a horizontal
fusiform excision of conjunctiva and
eyelid retractors 4 mm inferior to the
puncta, followed by inverting sutures
for closure

12. ECTROPION
• Management
• Repair of lower eyelid retractors

13. ECTROPION
• Cicatricial Ectropion
• Cicatricial ectropion of the upper or
lower eyelid occurs when there is a
deficiency of skin
• chronic inflammation of the eyelid
from dermatologic conditions such
as rosacea, atopic dermatitis,…
• Management consists of:
• addressing the under lying cause
• conservative medical protection of the cornea.

14. ECTROPION
• Cicatricial Ectropion
• Management…
• 3-step procedure:
Vertical cicatricial traction is surgically released through an anterior
approach.
The eyelid is horizontally tightened.
The anterior lamella is vertically augmented by means of a midface-l
ift, full-t hickness skin graft, or adjacent tissue transfer, and the eyelid
is placed on superior traction with a suture.

15. ECTROPION
• Cicatricial Ectropion
• Management
• Treatment of cicatricial ectropion
or retraction of the upper eyelid
usually requires only release of
traction and augmentation of the
vertically shortened anterior lamella
with a full- thickness skin graft.
• The postauricular, preauricular, supraclavicular, and medial upper arm
areas are potential donor sites,upper eyelid skin from the fellow eye

16. ECTROPION
• Mechanical Ectropion
• Mechanical ectropion is usually
caused by the gravitational effect
of a bulky eyelid mass.
• Other causes include:
• fluid accumulation
• herniated orbital fat
• poorly fitted spectacles.
• Treatment is focused on addressing the underlying etiology.

17. ECTROPION
• Paralytic Ectropion
• Paralytic ectropion usually follows CN VII paralysis or palsy
• concomitant upper eyelid lagophthalmos
• Poor blinking and eyelid closure
• frequent reports of tearing in these patients.
• Neurologic evaluation may be needed to determine the cause of the
CN VII paralysis.

18. ECTROPION
• Paralytic Ectropion
• In cases resulting from stroke or intracranial surgery, clinical
evaluation of corneal sensation is indicated
• Management
• Lubricating drops
• viscous tear supplementation
• ointments
• taping of the temporal half of the lower eyelid
• moisture chambers can be used.

19. ECTROPION
• Paralytic Ectropion
• Long- term or permanent paralysis
• tarsorrhaphy
• medial or lateral canthoplasty
• suspension procedures
• horizontal tightening procedures are useful.

20. ECTROPION
• Paralytic Ectropion
• A “temporary tarsorrhaphy”:
• Nonabsorbable sutures between the upper and lower eyelid margins.
• injection of botulinum toxin into the levator muscle
• Permanent tarsorrhaphy involves de-epithelialization of the upper
and lower eyelid margins, avoiding the lash follicles.

21. ECTROPION
• Paralytic Ectropion
• Occasionally, a fascia lata or silicone suspension sling of the lower
eyelid may be indicated.
• Vertical elevation of the lower eyelid is useful in reducing exposure of
the inferior cornea.
• recession of the lower eyelid retractors
• spacer graft.
• Surgical midface elevation

22. ENTROPION
• Introduction
• Entropion is an inversion of the eyelid margin.
• Lower eyelid entropion is much more common than upper eyelid
entropion
• unilateral or bilateral

23. ENTROPION
• Classified as:
• congenital
• involutional
• acute spastic
• cicatricial

24. ENTROPION
• Special Tests
• Horizontal lid laxity can be evaluated
with the snap back test.
• Lower lid retractor function is evaluated
by measuring lower lid excursion in downgaze.
• Spastic entropion can be elicited by forcefully
closing the eyelids, causing override of the
pretarsal orbicularis oculi by the preseptal orbicularis.

25. ENTROPION
• Involutional Entropion
• occurs in the lower eyelids
• Causative factors include:
• horizontal laxity of the eyelid
• attenuation or disinsertion of eyelid retractors
• and overriding by the preseptal orbicularis oculi muscle.
• Histologic examination of tarsal plates showed degenerated and
disorganized collagen fibers with abnormal elastogenesis.
• snapback and distraction testing

26. ENTROPION
• Involutional Entropion
• laxity is a result of senescence, with stretching of the eyelid and
canthal tendons
• attenuation of the eyelid retractors in conjunction with preseptal
orbicularis override
• inward rotation of the margin.

27. ENTROPION
• Involutional Entropion
• Several clinical clues may suggest disinsertion of the retractors:
• a white subconjunctival line several millimeters below the inferior
tarsal border
• a deeper- than- normal inferior fornix
• elevation of the lower eyelid
• minimal movement of the lower eyelid on downgaze

28. ENTROPION
• Management:
• a combination of procedures is necessary
• Procedures to repair involutional entropion of the lower eyelid:
• Temporizing measures
• Lubrication and a bandage contact lens
• Rotational suture techniques
• Recurrance if used in isolation

29. ENTROPION
• Management:
• Surgical repair
• Direct repair of lower eyelid retractor defects through a skin incision
or a transconjunctival approach
• a small amount of preseptal orbicularis oculi muscle can be removed
• Reinsertion of the eyelid retractors and limited myectomy of the
orbicularis in conjunction with a lower eyelid shortening procedure

30. ENTROPION
• Acute Spastic Entropion
• Acute spastic entropion arises from ocular irritation or inflammation
• Sustained contraction of the orbicularis oculi muscle leads to inward
rotation of the eyelid margin
• Taping of the entropic eyelid to evert the margin, cautery, or various
rotational suture techniques
• botulinum toxin injection

31. ENTROPION
• Cicatricial Entropion
• cicatricial entropion is caused by vertical tarsoconjunctival
contracture and internal rotation of the eyelid margin
• Conditions that may lead to cicatricial entropion include:
• autoimmune
• inflammatory
• infectious
• surgical
• traumatic

32. ENTROPION
Cicatricial Entropion
• The long-term use of topical glaucoma medications, especially miotics
and prostaglandins
• Distinguishing cicatricial entropion from involutional entropion:
• digital eversion
• inspection of the posterior lamella may reveal scarring of the tarsal
conjunctiva in cases of cicatricial entropion.

33. ENTROPION
• Cicatricial Entropion
• Management
• careful preoperative evaluation
• lubricating drops and ointments, barriers to symblepharon formation,
and eyelash ablation with lash cautery
• topical and systemic medications until a state of stability is attained.
• The tarsal fracture operation is useful in cases of mild to moderate
cicatricial entropion (marginal entropion)

34. ENTROPION
• Cicatricial Entropion
• Management
• A posterior horizontal tarsal incision is made 2 mm distal to the eyelid
margin.
• Eyelid margin is rotated away from the globe.
• The eyelid position is stabilized with everting sutures.

35. ENTROPION
• Cicatricial Entropion
• Management
• Incase of tarsal scarring:
• In the upper eyelid, tarsoconjunctival and other mucosal grafts are
useful tarsal substitutes.
• In the lower eyelid, autogenous ear cartilage, preserved scleral grafts,
and hard- palate mucosa have been used.

36. SYMBLEPHARON
• Symblepharon is an adhesion between conjunctival surfaces.
• It can occur as a result of inflammation, infection, trauma, or previous
surgery
• Conjunctival Z- plasties
• More extensive symblepharon formation requires a full-t hickness
conjunctival graft or flap, a partial-t hickness buccal mucous
membrane graft, or an amniotic membrane graft.

37. SYMBLEPHARON
• Definition
• Symblepharon is a pathologic condition where the bulbar and
palpebral conjunctiva form an abnormal adhesion to one another.

38. SYMBLEPHARON
• Etiology
• Immune mediated inflammatory conditions include:
• Steven-Johnson Syndrome/Toxic Epidermal Necrolysis
• Ocular cicatricial pemphigoid
• Sarcoid
• Granulomatosis with Polyangiitis
• Chronic Graft-versus-host disease
• Paraneoplastic Mucous Membrane Pemphigoid
• Lichen Planus
• Recessive Dystrophic Epidermolysis Bullosa

39. SYMBLEPHARON
• Etiology
• Infections from both bacteria and viruses
• Trauma
• Congenital symblepharon

40. SYMBLEPHARON
• Pathophysiology
• Symblepharon occurs from an
abnormal healing process after
injury to the conjunctiva.
• loss of epithelial cells from both
the bulbar and palpebral conjunctiva
• an abnormal adhesion between the
bulbar and palpebral conjunctiva.

41. SYMBLEPHARON
• Diagnosis
• History
• dry eyes
• burning sensation
• photophobia
• decreased vision.

42. SYMBLEPHARON
• Diagnosis
• Physical examination
• small adhesion between the two layers of conjunctiva
• fornix of the eye may become obliterated
• cicatricial entropion
• permanent lagophthalmos
• exposure of the cornea.

43. SYMBLEPHARON
• Management
• Medical therapy
• Aims to prevent or decrease symblepharon formation
• to treat the underlying pathology.
• immune modulating therapy
• Steroids and other immuno-suppressive drugs
• preservative free artificial tears and eye lubricants.

44. SYMBLEPHARON
• Management
• Surgery
• tissue grafting to the affected areas, and reconstruction of a normal fornix.
• cicatrix lysis and intraoperative mitomycin C (MMC)
• reconstruction using tissue grafts from either oral mucosal transplantation
and autografting
• Cultivated limbal stem cell transplantation

45. Symblepharon
Oral mucus membrane grafts for total symblepharon
management
surgery
limbal stem cell transplantation

46. SYMBLEPHARON
• Complications
• The adhesion can encroach on the limbus and grow over the cornea,
leading to vision loss.
• The adhesions can also decrease eye movement
• Diplopia
• prevent the normal functioning of the eyelids through mechanical
forces

47. SYMBLEPHARON
• Prognosis
• mild and cause no symptoms or damage to the eye.
• permanent blindness, in others there may be full resolution with
good visual outcome.

48. REFERENCES
• KANSKI
• AAO
• EYEWIKI
• PUBMED ARTICLES