Discussion
This patient has involutional ectropion of the right lower lid. The outward turning of the lid margin typically occurs in the lower lid (it may occur in the upper lid as well).¹ Because of the risk for severe keratopathy and symblepheron formation––in addition to scarring––we referred her to an oculoplastic surgeon for surgical repair.

Ectropion is more common in patients of non-Asian decent.¹ The condition can occur in patients of all ages and needs to be distinguished from eyelid retraction.¹ There are several causes of ectropion:

• Involutional ectropion is the most common form of ectropion seen in clinical practice.^1,2 It affects the lower lids only and occurs secondary to aging changes in lid anatomy.^1,2 The anatomical changes include disinsertion of the lower lid retractors, laxity of the medial and lateral canthal tendons, and atrophy of the orbicularis muscle.¹ One study found no difference in muscle fiber type in histological sections of patients with involutional ectropion vs. normal patients.³ Onset is gradual and the first sign typically is punctal eversion.² This causes the patient to complain of epiphora secondary to the tears not being able to reach the lower puncta. As the ectropion progresses, the long-term exposure and inflammation of the palpebral conjunctiva causes thickening of the tarsus, resulting in ectropion progression, lagophthalmos, exposure keratopathy and ultimately corneal ulceration.²          
• Congenital ectropion is caused by a shortage of skin in the eyelids.^1,2 This form of ectropion is most commonly associated with Down syndrome, but also is seen in blepharophimosis syndrome or it can be idiopathic.^1,2 Both upper and lower eyelids can be affected.¹
• Paralytic ectropion results from loss of orbicularis muscle tone secondary to stroke, Bell’s palsy, facial nerve trauma, or in association with a central nervous system neoplasm.^1,2 This form of ectropion usually is the most severe from a medical perspective.²
• Cicatricial ectropion is caused by a vertical shortening of the lid skin and orbicularis muscle secondary to skin diseases, scarring from trauma/burns or surgery, or acute allergic skin reactions.^1,2 The onset can be gradual or sudden, depending upon the etiology.²
• Mechanical ectropion is the result of a mass lesion (tumor, conjunctival cyst, edema, and/or scar tissue) pulling on the lower lid, displacing it from the globe.^1,2

Treatment depends upon disease etiology as well as the severity of the signs and symptoms that the patient is experiencing. In patients with mild corneal involvement, artificial tears and careful follow-up evaluations are sufficient.^1,2 Surgery is recommended in severe cases of patient discomfort or corneal involvement.^1,2 Skin grafts are recommended for patients with congenital ectropion.² For patients with involutional ectropion, surgery aimed at repairing the laxity of the lids is recommended.² Patients with a temporary paralytic ectropion should be monitored until resolution of the facial palsy occurs. If the palsy is permanent, surgery is almost always necessary.² Cicatricial and mechanical ectropion management involves treating the underlying cause.²

We referred the patient to an occuloplastic surgeon. Her lid was repaired and now functions normally.

Thanks Steven S. Shehan, O.D., of Saint Marys, Pa., for contributing to this case.

1. Vallabhanath P, Carter SR. Ectropion and entropion. Curr Opin Ophthalmol. 2000 Oct;11(5):345-51.
2. Robinson FO, Collin JR. Ectropion. In: Yanoff M, Duker JS. Ophthalmology. Philadelphia: Mosby; 1999:7.7.1-8.
3. Manners RM, Weller RO. Histochemical staining of orbicularis oculi muscle in ectropion and entropion. Eye (Lond). 1994;8 ( Pt 3):332-5.