Ectropion

Definition

Ectropion (ek-TROH-pee-on) is a condition in which your eyelid — typically the lower lid — turns out, leaving the inner eyelid surface exposed and prone to irritation. Ectropion occurs mainly in older adults. In severe ectropion, the entire length of the eyelid is turned out. When ectropion is less severe, only one segment of the eyelid sags away from the eye.

Artificial tears can help relieve the symptoms caused by ectropion until you can have surgery to correct the condition.

Symptoms

Normally when you blink, your eyelids distribute tears evenly across your eyes, keeping them lubricated. These tears drain into the little openings on the inner part of your eyelids (puncta). When you have ectropion, your lower lid pulls away from your eye and tears don't drain into the puncta properly, causing a number of signs and symptoms:

• Irritation. Stagnant tears or dryness can irritate your eyes, causing a burning sensation and redness in your eyelids and the whites of your eyes.
• Excessive tearing. Without proper drainage, your tears may pool and constantly flow over your eyelids. Many people with ectropion complain of watery or weepy eyes.
• Excessive dryness. Ectropion can cause your eyes to feel dry, gritty and sandy.

When to see a doctor
If you begin noticing that your eyes are constantly watering or irritated, or your eyelid seems to be sagging or drooping, make an appointment to see your doctor for an evaluation.

If you know that you have ectropion, be alert for symptoms of cornea exposure or ulcers, including rapidly increasing redness, pain, light sensitivity or decreasing vision. If you experience any of these vision-threatening signs and symptoms, seek immediate care in an emergency room.

Causes

Ectropion can have several different causes, including:

• Muscle weakness. As you age, the muscles under your eyes tend to get weaker as the tendons stretch out. These muscles and tendons are responsible for holding your eyelid taut against your eye, so when they relax, the eyelid can begin to droop and turn outward.
• Facial paralysis. When some of the facial nerves and muscles are paralyzed, as with Bell's palsy and some types of tumors, it can affect the eyelid muscles and cause ectropion.
• Scars or skin problems. Scarred skin from facial burns or trauma, such as a dog bite or lacerations, can affect the way that the eyelid rests against the eye.
• Eyelid growths. Benign or cancerous growths on your eyelid can cause the lid to turn outward.
• Previous surgery, radiation or cosmetic procedures. Previous eyelid surgery (blepharoplasty) can cause ectropion to develop later, particularly if too much skin from the eyelid was removed at the time of surgery. Radiation of your eyelid for a cancerous growth can trigger ectropion to develop. Even cosmetic laser skin resurfacing can shrink your eyelid too much, pulling it away from your eye and causing ectropion.
• Rapid weight loss. Sometimes, losing weight very quickly can cause ectropion.
• Congenital ectropion. Rarely, ectropion is present at birth (congenital), when it is usually associated with genetic disorders, such as Down syndrome.

Risk factors

Certain factors increase your risk of developing ectropion:

• Age. The most common cause of ectropion is weakening muscle tissue associated with aging. The older you are, the greater your chances of developing the condition.
• Previous eye surgeries. People who have had eyelid surgery (blepharoplasty) are at higher risk of developing ectropion later.
• Previous cancer, burns or trauma. If you've had spots of skin cancer on your face, facial burns or trauma, you're at higher risk of developing ectropion.

Complications

The most serious complications associated with ectropion are irritation and damage of the cornea. Because ectropion leaves your cornea irritated and exposed, it's more susceptible to drying. This can lead to corneal abrasions and ulcers, which in turn can cause permanent loss of vision. Lubricating eyedrops and ointments can help to protect your cornea and prevent damage until your ectropion is corrected.

Preparing for your appointment

If you suspect you have ectropion, you may start by seeing your primary care doctor. However, you may then be referred to a doctor who specializes in treating eye disorders (ophthalmologist).

Because appointments can be brief and there's often a lot of ground to cover, it's a good idea to arrive prepared. Here's some information to help you get ready, and what to expect from your doctor.

What you can do

• Write down any symptoms you're experiencing, as well as how long it has been since you first noticed these symptoms.
• Bring an older photograph. You may wish to bring a photograph of yourself before your ectropion was noticeable so that your doctor can observe the difference in your eyelid appearance.
• Make a list of all medications, as well as any vitamins or supplements, that you're taking.
• Write down questions to ask your doctor.

Preparing a list of questions can help make the most of the time with your doctor. For ectropion, some basic questions include:

• What's the most likely cause of my symptoms?
• Are there other possible causes for my symptoms?
• What kinds of tests do I need?
• Is this condition temporary or long-lasting?
• Will ectropion affect my vision?
• What treatments are available, and which do you recommend?
• What types of side effects can I expect from treatment?
• Are there any alternatives to the primary approach that you're suggesting?
• I have other health conditions. How can I best manage them together?
• Are there any restrictions that I need to follow?
• Is there a generic alternative to the medicine you're prescribing me?
• Are there any brochures or other printed material that I can take with me? What websites do you recommend?
• Will the repair of my ectropion be considered a cosmetic procedure by my insurance company, or is it considered a medically necessary procedure?

In addition to the questions that you've prepared, don't hesitate to ask questions during your appointment at any time that you don't understand something.

What to expect from your doctor
Your doctor is likely to ask you a number of questions. Being ready to answer them may reserve time to go over points you want to spend more time on. Your doctor may ask:

• When did you first begin experiencing symptoms?
• Do you have any chronic medical conditions?
• Have you had any previous eye or eyelid surgery?
• Have you had any other eye problems, such as an eye infection?
• Are you taking aspirin or any other medication that thins your blood?
• Have had any radiation to your face for cancer or other problems?
• Are you using any eyedrops?

Tests and diagnosis

Usually, ectropion can be diagnosed with a routine eye exam and physical examination. Your doctor may pull on your eyelids during the exam, or ask you to close your eyes forcefully, in order to assess your eyelid's muscle tone and tightness.

If your ectropion is caused by a scar, tumor or previous surgery, your doctor will examine the surrounding tissue as well. Understanding how other conditions cause ectropion is important in choosing the correct treatment or surgical technique.

Treatments and drugs

Eyedrops and ointments can be used to manage symptoms and protect your cornea until a permanent treatment is done. Most cases of ectropion require surgery.

Scar tissue stretching
This treatment can be considered if your ectropion is caused by a developing scar that's tightening or pulling on your skin. Massaging the scar tissue, injecting it with steroids or doing both may help to modify the scar and relieve the ectropion. However, this method may not be effective.

Surgery
There are several different surgical techniques for ectropion, depending on the cause and the condition of the tissue surrounding your eyelid. Before the surgery, you'll receive a local anesthetic to numb your eye and the area around it. You may be lightly sedated using oral or intravenous (IV) medication to make you more comfortable, depending on the type of procedure you're having and whether or not the surgery is performed in an outpatient surgical clinic.

If your ectropion is caused by muscle and ligament relaxation due to aging, your surgeon will likely remove a small part of your lower eyelid, which tightens the tendons and muscles of the lid. You'll have a few stitches on the outside corner of your eye or just below your lower eyelid. In general, this procedure is relatively simple and will be the only surgery you need.

If you have scar tissue from an injury or previous surgery, the surgeon may need to use a skin graft, taken from your upper eyelid or behind your ear, to help support the lower lid. If you have facial paralysis or significant scarring, the outcome of surgery is less predictable, and more than one procedure may be necessary before your ectropion is completely resolved.

Following your surgery, you may need to wear an eye patch for 24 hours, and then to use an antibiotic and steroid ointment on your eye several times a day for one week. You may also use cold compresses periodically to decrease bruising and swelling, as well as acetaminophen (Tylenol, others) for pain. Avoid drugs containing aspirin, because they can increase the risk of bleeding.

At first your eyelid might feel tight, but as you heal it will become more comfortable. Most people say that their ectropion symptoms are relieved immediately after surgery. You will get your stitches removed about a week after your surgery, and you can expect the swelling and bruising to fade in about two weeks.

Although uncommon, bleeding or infection are possible risks of surgery. You will likely experience temporary swelling, and your lid tissues may be somewhat bruised after surgery.

Lifestyle and home remedies

These lifestyle tips may relieve your discomfort until you have surgery:

• Use eye lubricants. To help protect against vision-threatening cornea damage, use artificial tears and eye ointments to keep your cornea lubricated. Using an eye ointment and a moisture shield, which you wear over your eye, seals in moisture and is particularly useful overnight.
• Wipe your eyes carefully. Constantly wiping watery eyes can make your under-eye muscles and tendons stretch even further, making ectropion worse. If you must wipe your eye, use an up-and-in motion, wiping from the outer eye up and in toward the nose.
• Use skin tape. To temporarily tighten your lower lid and relieve some ectropion symptoms, you can use skin tape on the sides of your eyes. Ask your doctor to demonstrate the correct use and position of skin tape before you try it.