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ORIGINAL ARTICLE
Year : 2018  |  Volume : 10  |  Issue : 2  |  Page : 39-43

Complicated lower lid ectropions presenting to tertiary care hospital in Sub-Himalayan Region of Himachal Pradesh and their management


1 Department of Ophthalmology, Dr. RP Government Medical College Kangra at Tanda, Sadarpur, Himachal Pradesh, India
2 Department of Pharmacology, Dr. RP Government Medical College Kangra at Tanda, Sadarpur, Himachal Pradesh, India

Date of Web Publication7-Mar-2019

Correspondence Address:
Dr. Gaurav Sharma
Department of Ophthalmology, Dr. RP Government Medical College Kangra at Tanda, Sadarpur, Himachal Pradesh
India
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DOI: 10.4103/sjopthal.sjopthal_18_18

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  Abstract 


Introduction: Ectropions of the lower lid area are of diverse etiology. They may be involutional, mechanical, paralytic, or cicatricial. The patients have lot of discomfort due to exposure and epiphora. Some of them also develop complications like infectious keratitis that are vision threatening as well. Cicatricial ectropions, severe ectropions with tissue laxity are sometimes difficult to manage. In this study, we intend to describe techniques we have used for the management of selected complicated cases of Ectropions. Aim and Objectives: The aim of the study is to describe the complicated cases of ectropions presenting to a tertiary care hospital in Sub-Himalayan region of Himachal Pradesh, India, and the various techniques used in their management. Materials and Methods: Cases of complicated ectropions fulfilling the inclusion and exclusion criterion which presented to the department of ophthalmology were included in the study. The patients were subjected to detailed history and clinical examination according to a predesigned pro forma. They were divided into four subtypes and managed surgically. Results: Horizontal lid shortening with or without blepharoplasty was performed in the cases of involutional ectropions and showed good outcome in all cases. There was no significant lid notching postoperatively. The cicatricial ectropion cases were managed surgically using Z plasty in all but one case of generalized cicatricial ectropion where skin grafting using postauricular graft was used. Postoperatively, the patients improved symptomatically, and cosmetic outcome was also acceptable. Conclusions: Horizontal shortening with or without blepharoplasty if performed meticulously is a good procedure providing excellent results; however, the site for pentagon excision and the amount of resection required needs to be decided, along with any medial or lateral canthal tendon stabilization. Cicatricial ectropions unless are generalized or very severe managed well with Z plasty, however, it is very important to understand the dynamics of the scar before deciding the site and dimensions of the Z plasty. Full-thickness skin graft is sometimes the only option for generalized cicatricial ectropions.

Keywords: Complicated ectropions, horizontal shortening, Z plasty


How to cite this article:
Sharma G, Sawaraj S. Complicated lower lid ectropions presenting to tertiary care hospital in Sub-Himalayan Region of Himachal Pradesh and their management. Sudanese J Ophthalmol 2018;10:39-43

How to cite this URL:
Sharma G, Sawaraj S. Complicated lower lid ectropions presenting to tertiary care hospital in Sub-Himalayan Region of Himachal Pradesh and their management. Sudanese J Ophthalmol [serial online] 2018 [cited 2019 Jul 15];10:39-43. Available from: http://www.sjopthal.net/text.asp?2018/10/2/39/253679




  Introduction Top


Ectropion is a malposition of the lid in which the eyelid is rolled outward. This leads to punctum being pulled away from is apposition to the globe, causing epiphora. In addition, due to constant exposure, secondary changes take place in the palpebral conjunctiva which results in lot of discomfort to the patients. Sometimes, in severe ectropions, patients may develop corneal complications including keratitis. Ectropions of lower lid are of diverse etiology. They may be involutional, mechanical, paralytic, or cicatricial. Sometimes, ectropions may pose difficult problems in management. Cicatricial ectropions, severe ectropions with tissue laxity are sometimes difficult to manage. These require a more careful evaluation and assessment. The most appropriate technique to be used needs to be tailored for each individual patient and type of the ectropion. Various techniques have been described such as lateral tarsal strip, horizontal lid shortening, horizontal shortening with blepharoplasty, and Lazy T. For cicatricial ectropions procedures such as V/Y plasty, Z plasty, and grafting have been employed. The correct procedure for any case depends on the type, severity and location of the ectropion as well as on medial and lateral canthal laxity. Therefore, it cannot be said that one procedure is superior to others. In this study, we intend to describe techniques for the management of selected complicated cases of ectropions.

Aim and objectives

The study aims to describe the complicated cases of ectropions presenting to Dr. RPGMC, Kangra at Tanda and the various techniques used in their management.


  Materials and Methods Top


Complicated ectropions fulfilling the inclusion and exclusion criterion which presented to department of ophthalmology were included in the study. The patients were subjected to detailed history and clinical examination according to a predesigned pro forma.

Inclusion criterion

  1. Involutional ectropions with marked tissue laxity
  2. Medial cicatricial ectropions
  3. Previous surgical interventions performed
  4. Severe ectropions with generalized scars.


The amount of ectropion was graded using ectropion grading scale proposed by Moe and Linder as follows:[1]

  • 0 – Normal eyelid appearance and function
  • 1 – Normal appearance but symptomatic; eyelid laxity present on examination
  • 2 – Scleral show without eversion of lower eyelid
  • 3 – Ectropion without eversion of lacrimal punctum from lacrimal lake
  • 4 – Advanced ectropion with eversion of lacrimal punctum from lacrimal lake
  • 5 – Ectropion with complications (e.g., conjunctival metaplasia, retraction of anterior lamella, or stenosis of lacrimal system).


The tissue laxity was assessed by the snap backtest and graded from I to IV. The lower lid was pulled away and down from the globe for several seconds and waited to see how it takes to return to original position without blinking. It was graded as shown in [Table 1].
Table: 1: Snap back test

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Medial canthal tendon (MCT) laxity was assessed by pulling the lower lid laterally away from the medial canthus and measuring the displacement of the punctum. Normal displacement should be only 0–1 mm. It was graded as shown in [Table 2].
Table 2: Medial canthal Laxity

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Lateral canthal tendon (LCT) laxity was assessed by pulling the lower lid medially away from lateral canthus corner. The normal displacement should be 0–2 mm. It was graded as shown in [Table 3].
Table 3: Lateral canthal tendon laxity

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They were then classified as noncicatricial and cicatricial ectropions. The surgical management was done according to the type of the ectropion and the techniques included: horizontal shortening, horizontal shortening with blepharoplasty, Z plasty, and skin grafting. The postoperative results were compared for all the techniques used.

Consent

A written informed consent was obtained from all the subjects.

Observation and Results

A total of 10 cases were identified as having a complicated Ectropion. Out of which two were females and eight were males. All cases were classified as shown in [Table 4].
Table 4: Types of Ectropions and the surgical techniques used in the management

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Involutional ectropions with marked tissue laxity

Only those cases of involutional ectropions which had a marked tissue laxity were included in the study. All had grade 4/5 on the severity scale. They included one female and three male subjects. Horizontal shortening with or without blepharoplasty was done for each of these cases, and all the patients had a good postoperative result. The subciliary incision was 2–3 mm below the lash line and started just lateral to the punctum and extended 1–2 mm above the lateral canthus and then downward following the lid crease. The pentagon was made at the site of the maximum ectropion. Great attention was paid to suturing of the wound. Grayline was used as an anatomical landmark to avoid notching. Subciliary incision was sutured with minimal traction, using continuous sutures. Preoperative measurements and gradings are shown in [Table 5] and [Figure 1].
Table 5: Preoperative measurement of the involutional ectropion cases

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Figure 1: (a) Involutional ectropion preoperatively. (b) Involutional ectropion postoperatively

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Postoperative measurement and gradings of the patients, who underwent Horizontal shortening, showed good results with full correction in three cases with Grade 2 remaining in one female. The snap backtest and MCT and LCT laxity were also improved postoperatively in all cases from 50% to 100% as shown in the table above [Table 6].
Table 6: Post-operative measurements in involutional ectropions

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Cicatricial ectropions

The extent and direction of the scar were carefully assessed. In contrast to lateral ectropions the medial ectropions presented greater difficulty in management as the tissues available to work with were much less and also the skin is tethered to the bridge of the nose. In these cases, the incision was given along the scar, and the scarred tissues were excised. Two incisions were made at 60° from the line of excision of the scar to fashion a Z. Dissection was carried out beneath the flaps sufficiently to release all traction forces. On the medial side, the dissection was carried out onto the nasal bridge as tissue was less. This is slightly difficult as skin is tight and tissues are adherent more firmly. Flaps were reversed to make a reverse Z and sutures were applied with 6–0 sutures.

Postoperative grade was 0 for all the cases except for generalized ectropion case which had Grade 2 ectropion postoperatively [Figure 2].
Figure 2: (a) Cicatricial ectropion preoperatively. (b) Cicatricial ectropion postoperatively

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  Discussion Top


A number of surgical techniques have been described in literature for the management of Ectropions. They include Lazy T, Horizontal shortening, horizontal shortening with blepharoplasty, lateral tarsal strip procedure for involution types and V/Y plasty, Z plasty or grafting for cicatricial types. Medial canthal resection was described as an effective long-term procedure for noncicatricial types of medial ectropions by Sullivan and Collin[2] Kam et al. studied the lateral tarsal strip (LTS) and concluded that when the lateral pinch and twist test returns the eyelid to a good position, the LTS alone can suffice for the management of involutional ectropion.[3] Sometimes, we encounter ectropions that are complicated due to severity and extreme tissue laxity. In situ ations, where a primary repair has been undertaken months previously, the anatomy is altered greatly, and here, again the results of conventional procedures may be suboptimal. Medial cicatricial ectropions also are not easy to manage as nose on the medial side with firmly adherent overlying skin makes it difficult to mobile tissues and create flaps. In the present study, we have specifically included such cases and used three different techniques in the management of such ectropions, namely horizontal shortening with or without blepharoplasty, Z plasty with shortening, and retroauricular skin grafting, with horizontal shortening.

Among cases of noncicatricial ectropions, one patient who had extreme laxity, underwent horizontal lid shortening with blepharoplasty. This patient had mild residual ectropion postoperatively; remaining patients had no residual ectropion after surgery. This female was aged 70 years and has lot of tissue laxity therefore despite maximal possible shortening some ectropion persisted. In remaining patients, only horizontal shortening was done and it gave satisfactory results. The problems with horizontal shortening are mainly related to suturing which if not done meticulously may lead to notching of the lid margin. However, if during suturing anatomical landmarks are taken care of the problems can be avoided in majority of the cases. Goel et al. compared transconjunctival retractor plication (TRP) with LTS and polypropylene sling (PS) for involutional lower lid ectropion and found that both are effective for involutional ectropion LTS with TRP was more invasive but more successful. PS was easy to perform on outpatient department basis. However, LTS with TRP is more suitable for lateral ectropions and PS for mild-to-moderate ectropions.[4] For severe ectropions with generalized laxity horizontal shortening with or without blepharoplasty, still remains the best procedure demonstrated in the present study.

Cicatricial ectropions cause problems in management since there are often other underlying problems such as canalicular injuries, fractures with may be malunited or nonunited, and canthal tendon injuries. Hence, most of them are complicated. Among our patients, one patient had sustained injury by bear mauling with severe injuries to forehead, nose, MCT, and underlying fracture of the medial orbital wall. The primary repair had been done in emergency in the field, and the resultant scar ran 15–20 mm downward and laterally from the medial canthus. The pull of this broad scar was being exerted downward pulling the medial lower lid into ectropion. This resulted not only in exposure and epiphora but also the lower medial conjunctiva remaining exposed during lid closure as well. One option for this patient was full thickness skin graft, however with underlying fractures chances of graft uptake were not good. We had demonstrated the effectiveness of Z plasty with medial dissection in cases of medial cicatricial ectropions earlier.[5] A Z Plasty with medial dissection was planned along with repair and fixation of the remaining parts of the MCT. Postoperatively, the ectropion was corrected and lid closure was also complete, and the patient had relief of the epiphora. The dynamics of the scar are very important and must be understood carefully before undertaking the Z plasty. The scar usually creates the pull along its own axis, but sometimes, the pull may be at right angle to the axis of the scar and this pull may be resulting in ectropion. This is illustrated as follows: Thin scar which on contracting is exerting pull along its own axis, while a thick scar [Figure 3] may contract along its width and cause pull at its right axis. The aim should be to rotate the axis to right angles so that the direction of the pull is reversed [Figure 3].
Figure 3: Showing the directions of the pull of a scar

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Another patient had sustained injury from hot oil being spilled over the face and had severe ectropion of lower lid so much so that the lid margin was tethered to the malar region. When he presented to us, he had developed corneal ulcer in his left eye with hypopyon following corneal exposure. Microbiology revealed Methicillin Resistant Staph aureus as the pathogen. The patient was started on fortified antibiotics, cycloplegics but the ulcer continued to progress. An ectropion repair with scar excision and retro-auricular skin graft was planned. Horizontal shortening was also done in addition to the grafting after removal of the scar and freeing the lid margins. Postoperatively, the ectropion was significantly corrected, and the ulcer started healing and responding to treatment. In 1 month, the ulcer was healed fully.


  Conclusions Top


Complicated ectropions require a more detailed assessment and line of the management has to be individualized for each case. Horizontal shortening with or with blepharoplasty if performed meticulously is a good procedure providing excellent results; however, the site for pentagon excision and the amount of resection required needs to be decided, along with any medial or lateral tendon stabilization. Cicatricial ectropions unless are generalized or very severe managed well with Z plasty, however, it is very important to understand the dynamics of the scar before deciding the site and dimensions of the Z plasty. Full-thickness skin graft is sometimes the only option for generalized cicatricial ectropions.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Moe KS, Linder T. The lateral transorbital canthopexy for correction and prevention of ectropion: Report of a procedure, grading system, and outcome study. Arch Facial Plast Surg 2000;2:9-15.  Back to cited text no. 1
    
2.
Sullivan TJ, Collin JR. Medical canthal resection: An effective long-term cure for medial ectropion. Br J Ophthalmol 1991;75:288-91.  Back to cited text no. 2
    
3.
Kam KY, Cole CJ, Bunce C, Watson MP, Kamal D, Olver JM, et al. The lateral tarsal strip in ectropion surgery: Is it effective when performed in isolation? Eye (Lond) 2012;26:827-32.  Back to cited text no. 3
    
4.
Goel R, Sanoria A, Kumar S, Arya D, Nagpal S, Rathie N. Comparison of polypropylene sling with combined transconjunctival retractor plication and lateral tarsal strip for correction of involutional lower eye lid ectropion. Open Ophthalmol J 2017;11:285-97.  Back to cited text no. 4
    
5.
Sharma G, Sharma DK, Tuli R. Z-Plasty for medial cicatricial ectropion our experience. DJO 2016;26:208-9.  Back to cited text no. 5
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]



 

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