Causes and risk factors
The most common causes are:
- Senile: aging has tendency to generate soft tissue laxity; the lateral cantal tendon (tendon that is well anchored on the lateral margin of the orbit and defines the lateral angle of the eye through the lateral palpebral commissure and with the shape of the lateral exposure of the bulbar conjunctiva, the lateral white portion of the eye, "lateral scleral triangle) gives way to tension. This results in an increased convexity of the arch of the lower eyelid, which leads to an alteration of the normal tear flow to the tear duct. In addition, the orbicularis muscle of the eye (which is just below the skin layer) is also relaxed, resulting in the failure of structural support to the eyelid. As a result, the eversion of the eyelid greatly increases, and the skin layer also becomes looser, worsening the clinical picture.
- Cicatricial: The scar is by histological structure an inelastic tissue with a tendency to retract with unpredictable intensity. However, a few millimeters of retraction in the eyelid territory are sufficient to cause a marked eyelid distortion.
In some skin diseases (such as rosacea) the whole skin of the face is involved in a chronic inflammatory process with scarring progression over time. As a consequence of the scarring process, the lower eyelid may complicate into scarring ectropion, characterized by a taut, translucent skin furrowed by telangiectasias (small red branching vessels).
Post-traumatic scar retractions are also common to ectropion, particularly at the level of the lower eyelid. This process frequently occurs when the scars are perpendicular to the tarsal rima of the eyelid.
Other less frequent causes of ectropion include tumor outcomes and congenital forms of ectropion (rare).
Which are the symptoms?
Ectropion appears in various stages: beginning with verticalisation of the tear duct, the tear duct changes its vector, detaching itself from the bulbar conjunctiva (first sign) until complete palpebral eversion with exposure of the palpebral conjunctiva (the red posterior surface of the eyelid, which is normally in contact with the eye and not exposed), and exposure of the conjunctival sclera inferior to the cornea (scleral show, exposure of the lower white portion of the eye). In advanced cases, the tear duct, which physiologically drains the tear outflow, is no longer adherent with the eye and consequently the tear outflow is altered with a "hydraulic" and gravitational effect only in this anatomical area. Thus, an accumulation of tear secretion is created that overflows from the palpebral tarsal edge (referred to as "epiphora" in eyelids with preserved motility, "lagophthalmos" in paretic eyelids); therefore, the patient reports an eye that continues to tear all day long. The effect of this discomfort is that the patient tends to rub the eye, risking serious complications, such as keratitis, corneal ulceration, and ocular infection.
- Scleral show
- Eversion of cilia
How is it diagnosed?
Objective examination: tarsal border detached from the eye, scleral show, epiphora (hyperlacrimation), corneal keratitis, mucosization of the tarsal border, verticalization of the tear duct.
How is it treated?
There are different surgical instructions depending on the type and stage of ectropion. In any case, it is an operation that can be performed under local anesthesia, lasting from 15 to 45 minutes in the most complex cases. In the most initial stages, characterized by only the eversion of the tear duct, it is possible to proceed only with an inverted suture, in order to reposition the correct location of the tear duct. In senile ectropions the operation can be performed in different ways, however resulting in a single small scar, confined to the eyelid area. Even in the scarred ectropions we recognize more interventions according to the case observed, from the single surgical detention of the scar tissue to larger reconstructions of the eyelid. Everything is always performed with the aim of preserving the best aesthetics, structure and functionality of the eyelid.