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Involutional ectropion: etiological factors and therapeutic management

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Abdulaziz S. AlHarthi
Abdulaziz S. AlHarthi
Abdulaziz S. AlHarthi
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Abstract

Purpose Involutional Ectropion is commonly prevalent disorder of eyelid malposition caused by age-related degeneration of the periocular tissues. This study conducted to provide a summary and review of surgical practice for the management of lower eyelid involutional ectropion and enlist various causative factors that explain the pathogenesis. Methods The review of literature on risk factors and surgical approaches for involutional lower eyelid ectropion, searched on PubMed from 1980 onwards. Result Multiple factors contribute to horizontal and vertical lower eyelid involutional ectropion. Several surgical practices have been described over the last years to address these factors. Lateral tarsal strip is the most used and effective surgery to treat horizontal laxity. Conclusion Knowledge of various contributing factors and surgical procedures will enable to design the most effective therapeutic management for lower eyelid involutional ectropion. surgical approaches are individualized depending on preoperative clinical evaluation of possible causative factors and concerning the predominant location of the ectropion will result in a high success rate.
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Int Ophthalmol (2023) 43:1013–1026
https://doi.org/10.1007/s10792-022-02475-3
REVIEW
Involutional ectropion: etiological factors andtherapeutic
management
AbdulazizS.AlHarthi
Received: 7 May 2022 / Accepted: 20 August 2022 / Published online: 2 September 2022
© The Author(s), under exclusive licence to Springer Nature B.V. 2022
Keywords Involutional lower eyelid ectropion·
Punctal ectropion· Horizontal laxity· Vertical laxity·
Medial laxity· Procedures
Introduction
The lower eyelid is divided into three lamellae con-
sisting of seven structural layers: the anterior lamella
comprises of skin and protractors muscle, medial
lamella comprises of orbital septum and orbital fat,
and the posterior lamella comprises of retractors, tar-
sal plat, and conjunctiva. In normal position, the free
margin of the lower eyelid should rest at the corneal
limbus with no gap between the lid and globe. The
eyelid is maintained in this position by supporting
structures in the eyelid layers. Lower lid has protec-
tive role and contributes to tear film flow. Abnormal
eyelid anatomy may cause eyelid malposition [1].
Ectropion is an eyelid malposition in which there is
loss of normal eyelid apposition to the ocular surface
with eversion or outward turning of the eyelid margin.
Ectropion in lower lid may be classified into various
subtypes as involutional, paralytic, cicatricial, congeni-
tal, or mechanical. Involutional ectropion is the most
common subtype seen in ophthalmology practice that
occurs in old individuals. The pathogenesis of this con-
dition is associated with increasing age being caused
mainly by increased horizontal eyelid laxity in the lat-
eral or medial canthal tendons or both and weakness of
muscle tone. The patient may experience intermittent
Abstract
Purpose Involutional Ectropion is commonly preva-
lent disorder of eyelid malposition caused by age-
related degeneration of the periocular tissues. This
study conducted to provide a summary and review of
surgical practice for the management of lower eyelid
involutional ectropion and enlist various causative
factors that explain the pathogenesis.
Methods The review of literature on risk factors
and surgical approaches for involutional lower eyelid
ectropion, searched on PubMed from 1980 onwards.
Result Multiple factors contribute to horizontal and
vertical lower eyelid involutional ectropion. Several
surgical practices have been described over the last
years to address these factors. Lateral tarsal strip is
the most used and effective surgery to treat horizontal
laxity.
Conclusion Knowledge of various contributing fac-
tors and surgical procedures will enable to design
the most effective therapeutic management for lower
eyelid involutional ectropion. surgical approaches
are individualized depending on preoperative clinical
evaluation of possible causative factors and concern-
ing the predominant location of the ectropion will
result in a high success rate.
A.S.AlHarthi(*)
Ophthalmology Department, College ofMedicine,
Majmaah University, 11952Al-Majmaah, SaudiArabia
e-mail: dr.abdulaziz.alharthi@gmail.com
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
ResearchGate has not been able to resolve any citations for this publication.
Lateral Tarsal Strip Procedure for Involutional Ectropion: A Retrospective Analysis of 85 Cases and A Comprehensive Literature Review
Article
  • Sep 2021
Purposes To evaluate the postoperative effect of the lateral tarsal strip (LTS) procedure in treating lower eyelid involutional ectropion. Methods A retrospective study was performed on 85 eyelids in 67 patients with involutional ectropion who underwent LTS procedure. Pre- and postoperative lower eyelid laxity and ocular symptoms as well as perioperative complications were evaluated. Snap back test was performed to evaluate the elasticity of LCT loosening and a lower lid distraction test was performed to evaluate the degree of severity before surgery. Ocular surface diseases were evaluated by the Ocular Surface Disease Index (OSDI), and symptoms including conjunctivitis, corneal ulcer, dry eye syndrome, and ocular pain were recorded. All patients were evaluated within 1 week and during the follow-up period of 4.2±8.3 months. We reviewed the studies that also investigated the surgical effect of the LTS procedure in the literature from 1979 to 2019. Results The success rate was 95%. Only four eyelids required a second surgical intervention. 73 (86%) eyelids had an excellent position after surgery, 9 (11%) only little improvement, and three had no improvement. No significant difference was found in the postoperative effects between different degrees of ectropion (p > 0.05). No statistical correlation was found between surgical improvements and the ectropion severity (P > 0.05). Fifty-two out of 85 eyes had no discomfort after the surgery. Mild complications included epiphora in 13 eyes (3 cases caused by lacrimal punctum eversion), ocular pain in 12 eyes, wound hemorrhage in 12 eyes, and edema in 9 eyelids immediately after surgery, in which 91.2 % (n=21) disappeared within 1 week and did not need any further treatment. Conclusions The lateral tarsal strip procedure can provide an aesthetically pleasing result for correcting the mild to moderate lower eyelid ectropion while maintaining decent eyelid function.
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A New Surgical Method for Medial Ectropion Repair: Fixing the Lower Eyelid Retractor to the Back of the Tarsal Plate
Article
  • Aug 2020
Involutional ectropion is a disease in which the eyelids are everted outwards, and because the eyelids move away from the eyeballs, the ocular surface and conjunctiva are exposed causing inflammation, pain, photophobia, foreign body sensation, epiphora, and blurred vision. It is thought to be caused by horizontal and vertical laxity. Various surgical methods have reportedly been used to correct involutional ectropion. Shortening the lower eyelid retractor (LER) is an indispensable surgical operation for medial ectropion. When the LER is shortened, it is usually fixed to the lower edge of the tarsal plate. Herein we describe a new type of surgery that has now been performed on 6 eyes in 4 patients. The procedure involves separating the conjunctiva from the tarsal plate, inserting the LER between the conjunctiva and the tarsal plate, and then fixing it to the back of the tarsal plate. In all 6 eyes, the lower eyelid now contacts the eyeball, and morphological improvements were achieved. This new surgical method is a useful way to raise the tarsal plate.
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A theory of unified pathogenesis for tarsal ectropion and involutional entropion
Article
  • Jun 2020
  • J FR OPHTALMOL
Tarsal ectropion and involutional entropion are two frequent age-related lower eyelid malpositions with a mirrored clinical presentation. The recent anatomical confirmation of two layers of lower eyelid retractors makes it possible to conceive of the role of each of these layers in the stability of the two palpebral lamellae and their involvement in the pathogenesis of these two malpositions. This study proposes a theory of common pathogenesis involving an involutional change in only the lower lid retractors, leading to the description of two new clinical-anatomical entities.
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Modification of the Lazy-T Procedure for Correction of Punctal Ectropion
Article
  • Nov 2018
The Lazy-T procedure is used to correct moderate-to-severe punctal ectropion in the lower eyelid. It includes full-thickness wedge resection of the medial lower eyelid and horizontal tarso-conjunctival diamond excision inferior to the lower punctum. However, the skin wound vertical to the relaxed skin tension lines is often conspicuous and horizontal excision of a part of the tarsus may impair function of the meibomian gland. In this study, the authors developed a modified Lazy-T procedure, which includes subciliary incision, pentagonal tarso-conjunctival resection, and medial spindle excision for submerging the vertical wound after suturing the pentagonal tarso-conjunctival resection under the skin flap and minimizing damage to the tarsus. The modified Lazy-T procedure was applied in 4 eyelids of 3 patients and achieved good anatomical results with cosmetically acceptable postoperative appearances and no remarkable complication.
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The Use of a Double Suture and Conjunctival Cuts in the Lateral Tarsal Strip: A New Approach to Involutional Ectropion
Article
  • Oct 2018
Purpose: To describe the use of a double suture and conjunctival cuts in the lateral tarsal strip (LTS) and to evaluate postsurgical outcome in patients with severe involutional ectropion. Methods: A prospective randomized study was conducted on 16 eyelids of 8 patients with symptomatic severe involutional ectropion. The 8 patients were between 62 and 79 years. They were distributed into 2 groups consisting of 4 patients each. The control group was treated with a conventional lateral tarsal strip (C-LTS), the second group underwent a modified lateral tarsal strip (M-LTS). The mean follow-up was 18 months. Success was defined as relief in lid laxity. The recurrence rate was also evaluated. Results: Patients treated with M-LTS showed lower horizontal laxity (3.5 ± 0.2) than patients treated with C-LTS (5.7 ± 0.2). During the 18-month follow-up, a statistically significant difference was found between the 2 groups with P value <0.05. Conclusions: The use of a double suture and conjunctival cuts in the lateral tarsal strip proposed by Meduri showed a reduction of postsurgical ectropion's grade and postsurgical recurrences. This technique could be used for the treatment of patients with a severe ectropion.
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Lateral tarsal strip versus lateral tarsal strip with three-snip punctoplasty for managing epiphora in involutional ectropion
Article
  • Sep 2018
Purpose: To compare the efficacy of two surgical techniques-lateral tarsal strip (canthoplasty) alone, and lateral tarsal strip with three-snip punctoplasty-in reducing epiphora arising from involutional ectropion with partial punctal stenosis. Methods: Fourty patients with involutional ectropion and partial stenosis of the lacrimal punctum were randomly allocated to two treatment groups. Group 1 patients received lateral tarsal strip alone with only non-invasive stenting of the punctum, and group 2 patients received tarsal strip plus three-snip punctoplasty. Subjective assessment of epiphora was achieved via completion of a quality of life (QoL) questionnaire preoperatively and at postoperative month 3. Eyelid position, adverse outcomes and corneal dryness (via Oxford grading scheme) were also assessed postoperatively. Only patients with unilateral problems were included in the study. Results: Forty eyes of 40 patients were included: 20 in each group. The mean ages of group 1 and group 2 patients were 79±11 and 80±9 years, respectively. All patients reported significantly reduced eye watering after surgery, with no significant intergroup difference in subjective outcomes, except that computer usage and night driving (P<0.05), improved in a more significant way in group 2. Eyelid malposition was corrected in all cases, there were no cases of postoperative punctal eversion, and no significant adverse events or complications occurred. Finally, the mean improvements in the dryness/keratitis score (using the Oxford scheme) were comparable between the 2 groups (P=0.34). Conclusion: The study findings indicate that treatment of involutional ectropion with partial punctal stenosis by lateral tarsal strip with three snip punctoplasty does not provide greater reduction in discomfort secondary to epiphora than conventional lateral tarsal strip alone, except for specific situations such as night driving or computer use.
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Lower eyelid retractor (white-line) advancement to correct tarsal ectropion
Article
  • Apr 2018
Objective To describe a modification of trans-conjunctival, lower eyelid retractor advancement to correct tarsal ectropion. Design A retrospective case review. Participants Consecutive patients with lower eyelid tarsal ectropion. Methods Cases of lower eyelid tarsal ectropion, surgically corrected by advancement of inferior retractor to the lower border of tarsus via a transconjunctival approach, were identified. Lateral tarsal strip was also performed simultaneously in all cases. Results Twenty patients (25 eyelids) were included in this study. There were 19 primary lower eyelid tarsal ectropion and 6 recurrent tarsal ectropion. Complete resolution of tarsal ectropion was achieved in all patients postoperatively. Mean follow-up was 8.4 months (range 1–36 months). There were no cases of overcorrection, recurrent ectropion, suture abscess, wound dehiscence, or inferior fornix shortening after surgery. Conclusions Visualization of the lower eyelid retractor (white-line) and advancement to the inferior border of tarsus through a transconjunctival approach is effective in correcting both primary and recurrent cases of tarsal ectropion. This can be performed through a small conjunctival incision in the middle third of the lower eyelid, without the need for any excision of tissue or suture loop tie on the skin surface.
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Lateral tarsal strip versus Bick’s procedure in correction of eyelid malposition
Article
  • Feb 2018
Objectives: To compare the functional and anatomical outcomes of lateral tarsal strip (LTS) with Bick's procedure in treatment of eyelid malposition. Methods: A retrospective, consecutive case series of patients who underwent LTS and Bick's procedure for all types of involutional lower eyelid malposition, at two centers between January 2012 and 2015. Statistical analyses of differences between groups were performed using the Fisher's exact test to compare non-continuous variables and Mann-Whitney U test for continuous variables. Results: A total of 641 procedures (557 LTS and 84 Bick's) were performed on 504 patients (137 bilateral) by 7 consultants and their trainees. The study cohort included 286 males and 218 females. The mean age was 76.2 years (median 78). The mean follow-up was 13.07 months (median 7, range 0.5-58 months). The indications for surgery included ectropion (43.2%), entropion (39.9%), eyelid laxity (12.3%), floppy eyelid syndrome (2.7%), and others (1.9%). At last follow-up, the LTS group achieved 89.1% anatomical success (total + partial correction) compared to 100% in Bick's group (P < 0.001). Functional improvement was 82% and 95% in LTS and Bick's groups, respectively (P = 0.002). Consultants and trainee doctors achieved comparable outcomes within each group. Complications were relatively minor with no major long-term sequelae, nor any statistically significant difference between the two groups in terms of frequency of adverse events (16.9% vs 14.2%, P = 0.929). The reoperation rate was 9% in the LTS group during the study period, compared to none in the Bick's group (P = 0.001). Conclusions: This study compares the outcomes of the largest reported cohort of eyelid malposition surgery analyzing the two different techniques for lid margin shortening. Bick's procedure achieved statistically significant better anatomical and functional outcomes compared to LTS although the samples were unequal and not randomized.
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Entropion and ectropion repair: a snapshot of surgical practice in the United Kingdom
Article
  • Oct 2017
We aim to provide a snapshot of the current surgical practice for correction of entropion and ectropion, the two most common oculoplastic procedures carried out in the UK, by surveying 135 consultant oculoplastic surgeons via the tool Survey Monkey. Forty-seven (35%) consultants responded. For entropion, 44% of surgeons opted for lateral tarsal strip (LTS) + everting sutures (ES). Other first-line choices included LTS + transcutaneous retractor plication (21%), Quickert’s procedure (14%), ES (7%), and Wies procedure (5%). Important patient-related factors to consider were horizontal lid laxity and retractor dehiscence. Regarding ectropion, LTS was most commonly practiced (35%), followed by LTS + transconjunctival retractor plication (28%), wedge excision (16%), and lateral canthoplasty (5%). The patient-related factors guiding choice were horizontal lid laxity, lateral canthal tendon laxity, and punctal position under traction. Responses found a wide range of preferred surgical techniques in practice. The factors guiding surgical choice were personal audit results (92% stated important/very important), familiarity with the technique (92%), and the technique being favoured by previous trainers (76%), suggesting current practice led by expert opinion, possibly due to a lack of evidence-based literature. This highlights the variety of core oculoplastic surgical techniques practiced and underlines the need for robust trials to guide surgical choice.
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