What are the treatment options for ectropion?

Treatment Options for Ectropion

The treatment of ectropion should follow a stepwise approach, beginning with conservative measures for mild cases and progressing to surgical intervention for more severe or refractory cases. 1

Conservative Management

• Ocular lubrication is the first-line treatment for all patients with ectropion to protect the ocular surface and should be maintained long-term if lagophthalmos is present 1
• Preservative-free topical lubricants are strongly recommended, with options including:
  • Carboxymethylcellulose 0.5-1%
  • Carmellose sodium
  • Hyaluronic acid
  • Petrolatum ointment at night (especially for nocturnal lagophthalmos) 1
• Lipid-containing eye drops are particularly effective in improving symptoms when meibomian gland dysfunction is present 1
• Eyelid emollients and massage (vertical lid massage and stretching) can improve lagophthalmos and ectropion based on case reports 1

Medical Therapy

• Topical agents may be helpful but can cause irritation in some patients 1
• Oral retinoids are recommended as second-line therapy in combination with topical agents for moderate-to-severe ectropion to reduce severity and prevent further worsening 1
• Caution: Oral retinoids may induce ophthalmic side effects such as dry eyes, requiring careful monitoring 1

Surgical Management

Surgical intervention is indicated when:

• Conservative measures fail to provide adequate relief
• Corneal exposure or epiphora persists
• There is evidence of keratinization of the palpebral conjunctiva 1, 2

Surgical Techniques Based on Ectropion Type:

1. For Involutional Ectropion (44.2% of cases) 3:

   • Pentagonal excision
   • Kuhnt-Symanowski procedure
   • Medial wedge excision
   • Lazy-T procedure
   • Lateral canthal sling 3

2. For Cicatricial Ectropion (25% of cases) 3:

   • Z-plasty
   • Local flaps
   • Full-thickness skin grafting
   • Combination approaches 3

3. For Paralytic Ectropion (30.8% of cases) 3:

   • Tarsorrhaphy
   • Support and tightening procedures for the lower eyelid 3

4. For Severe or Recurrent Cases:

   • The superotemporal skin transposition (STS) technique combined with a lateral tarsal strip or Bick procedure has shown promising results 4
   • The tarsal belt procedure, which uses a trans-tarsal mattress non-absorbable suture anchored to the periosteum of the lateral orbital rim, has shown 100% success rates for involutional and cicatricial ectropion 5

5. For Medial Ectropion:

   • Fixing the lower eyelid retractor to the back of the tarsal plate has shown morphological improvements 6

Eyelid Skin Grafting:

• Third-line therapy to be considered only when symptomatic corneal exposure or epiphora persists despite adequate conservative treatments 1
• Timing is crucial - should ideally be undertaken before keratinization of the palpebral conjunctiva occurs 1
• Graft options include:
  • Autologous full-thickness skin grafts
  • Split-thickness skin grafts
  • Oral buccal mucosa (when skin is unavailable) 1
• Potential complication: Relapse may occur rapidly, requiring continued topical therapy 1

Follow-up Care

• Regular ophthalmic examination is recommended, with frequency varying from monthly to once or twice a year 1
• Assessment should include:
  • Age-appropriate vision assessment
  • Slit lamp or portable assessment of the ocular surface
  • Cycloplegic refraction to exclude significant refractive errors 1
• Monitor for recurrence, as approximately 20% of patients with severe ectropion may need additional surgery 3

Special Considerations

• Bilateral ectropion with documented corneal damage requires prompt surgical intervention to prevent progressive corneal epithelial breakdown and increased risk of corneal ulceration 2
• In congenital ichthyosis, finding suitable donor sites for skin grafting can be challenging, with case reports of successful use of penile foreskin when other sites are affected by the disease 7

Treatment Success Rates

• Approximately 80% of patients achieve satisfactory functional and cosmetic outcomes with a single surgical procedure 3
• The tarsal belt procedure has shown success rates of 100% for involutional and cicatricial ectropions, 90% for lid retraction, and 87.5% for paralytic ectropions 5