Many common patient complaints may stem not from the eye itself but the lids designed to protect it.¹ For example, the chronic exposure of the globe and palpebral conjunctiva due to ectropion—or the malposition of the eyelid turning away from the globe—may contribute to symptoms of excessive tearing (epiphora), dry eye, ocular irritation or a mucoid discharge.^1,2 It may also expose the punctum, causing it to become stenotic, which will lead to further epiphora.¹

Clinicians can often treat mild ectropion, at least initially, with lubrication in the form of artificial tears or ointments, or temporary lid taping.¹ Once it progresses further, however, it’s time to refer patients for surgical intervention.

The Procedure

If the patient has punctal stenosis, enlargement of the punctum is the most reliable method of treatment.³ The three-snip punctoplasty is used to re-open the punctum and then provide the proper drainage channel for tears. The first two snips of the three-snip procedure are performed on the medial and lateral aspects of the vertical portion of the punctum. The third snip joins the ends of the two vertical incisions and results in the excision of the posterior aspect of the tissue.³

If the patient has medial ectropion, the medial portion of the eyelid must be inverted so that it is re-approximated to the globe. This is accomplished by performing a medial spindle procedure. A fusiform (elliptical) excision of the conjunctiva and lower lid retractors is performed just temporal to the punctum. The surgical site is then closed with absorbable suture, imparting an inverting vector force to the lid margin and punctum.⁴ 

The workhorse of ectropion lid repair is the lateral canthal strengthening procedure. It combines both horizontal shortening and a lateral tarsal strip.³ Lateral tightening begins with a canthotomy—splitting of the lower and upper eyelids at the lateral canthus to mobilize the lateral eyelid.^3-5 The canthal tendon is then incised (cantholysis) to completely separate the lower lid.^5,6 The lower eyelid is then held taut to the globe to measure the appropriate amount of the lateral lower eyelid to be excised. Once this portion is excised, the surgeon fashions a tarsal strip on the tarsus of the lower eyelid to prevent epithelial ingrowth. The tarsal strip is then reattached with a suture to the periosteum at the level of the lateral orbital tubricle. The lower lid is then pulled taut against the globe and the lateral canthus is reconstructed with non-dissolvable suture. 

Post-surgery

Comanaging physicians will note that the patient should use ice packs on the eyelids and take over-the-counter pain medication as needed following the procedure. Ophthalmic antibiotic ointment is prescribed three times a day to be used on the eyelids to keep the sutures moist, prevent infection and maximize healing. 

After one week, the sutures used to reconstruct the lateral canthus are removed. The suture used to reconstruct the medial spindle is removed two weeks postoperatively. After two weeks, the antibiotic ointment can be discontinued. 

Dr. Skorin practices ophthalmology at the Mayo Clinic Health System in Albert Lea, Minn.

Dr. Lange is a recent graduate of Pacific University College of Optometry.

1. Tse DT, Neff AG. Ectropion. In: Chen WP, ed. Oculoplastic Surgery: The Essentials. New York: Theime; 2001:55-66.  2. Onofrey BE, Skorin L, Holdeman NR. Lacrimal tests and procedures. Ectropion. In: Ocular Therapeutics Handbook. 3rd Ed. Philadelphia: LWW; 2011:304, 602-605. 3. Nesi FA, Gladstone GJ, Brazzo BG, et al. Ophthalmic and Facial Plastic Surgery. A Compendium of Reconstructive and Aesthetic Techniques. Thorofare, NJ: Slack; 2001:89-99.  4. Lauer SA. Ectropion and entropion. Focal Points: Clinical Modules for Ophthalmologists. AAO. 1994;12(10):1-9.  5. Wesley RE, Klippenstein KA. Ectropion surgery. In: Mauriello JA, ed. Unfavorable Results of the Eyelid and Lacrimal Surgery: Prevention and Management. Woburn, MA: Butterworth-Heinemann; 2000:205-26.