Senile Ectropion
Etiopathogenesis, Clinical Evaluation & Surgical Management
Examination question · ~800 words
Define senile ectropion. Discuss its etiopathogenesis, clinical features, evaluation, differential diagnosis, and management with emphasis on surgical correction.
Try to outline your answer mentally before expanding sections below.
Ectropion is outward turning or eversion of the eyelid margin away from the globe, exposing the palpebral conjunctiva and disrupting normal ocular surface protection. Senile or involutional ectropion is the most common type and usually affects the lower lid in elderly patients due to age-related horizontal lid laxity, canthal tendon attenuation, orbicularis weakness, and lower lid retractor dehiscence. It causes epiphora, conjunctival exposure, keratinisation, and exposure keratopathy if untreated.
| Type | Mechanism | Key Feature |
|---|---|---|
| Involutional / senile | Horizontal lid laxity with lower lid retractor attenuation or dehiscence | Commonest type; elderly; usually lower lid; often bilateral |
| Cicatricial | Vertical anterior lamellar shortage due to scar contracture | Post-burn, surgery, trauma, radiotherapy, or chronic skin disease; may affect upper or lower lid |
| Paralytic | Orbicularis weakness due to facial nerve palsy | Ipsilateral facial palsy, lagophthalmos, poor blink, exposure |
| Mechanical | Mass effect from tumour, oedema, or heavy lesion | Usually unilateral with an associated lid or adnexal lesion |
| Congenital | Anterior lamellar excess or lid dysgenesis | Rare; neonatal or childhood presentation |
- Horizontal lid tension is maintained by the medial and lateral canthal tendons and the rigidity of the tarsal plate.
- Lower lid retractors include the capsulopalpebral fascia and inferior tarsal muscle; they are analogous to the levator aponeurosis in the upper lid and maintain lower lid apposition to the globe.
- Pretarsal orbicularis oculi provides active lid closure and contributes to the lacrimal pump.
- Anterior lamella consists of skin and orbicularis; posterior lamella consists of tarsus and conjunctiva.
- Lacrimal pump function requires the lower punctum to remain apposed to the lacrimal lake; ectropion causes punctal malposition and pump failure, producing epiphora.
Senile ectropion is multifactorial. It usually begins medially as punctal ectropion and progresses laterally as horizontal laxity increases.
| Component | Age-Related Change | Consequence |
|---|---|---|
| Horizontal lid support | Stretching of medial and lateral canthal tendons with tarsal laxity | Lower lid sags away from the globe |
| Lower lid retractors | Capsulopalpebral fascia attenuates or detaches | Inferior lid margin tilts outward with anterior rotation of tarsus |
| Orbicularis oculi | Loss of pretarsal muscle tone | Reduced lid apposition and impaired lacrimal pump |
| Skin and anterior lamella | Dermatochalasis and age-related tissue laxity | Exacerbates eversion, especially medially |
| Medial canthal tendon | Medial canthal laxity | Punctal eversion and persistent epiphora |
Symptoms
- Epiphora is the commonest presenting complaint due to punctal eversion and lacrimal pump failure.
- Foreign body sensation, chronic irritation, watering, and mucoid discharge.
- Conjunctival redness and exposure-related discomfort.
- Blurred or reduced vision if exposure keratopathy develops.
- Cosmetic concern and social embarrassment.
Signs
| Sign | Finding | Significance |
|---|---|---|
| Lid eversion | Outward rotation of lower lid margin, initially medial and later diffuse | Primary clinical feature |
| Punctal ectropion | Lower punctum is not apposed to the lacrimal lake | Important cause of epiphora |
| Conjunctival exposure | Injection, chemosis, papillary reaction, chronic keratinisation | Indicates chronic exposure |
| Horizontal lid laxity | Distraction test: lid can be pulled > 6-8 mm from globe | Significant horizontal laxity requiring surgical tightening |
| Poor lid tone | Snap-back test: delayed return of lid after being pulled down | Suggests orbicularis/lid laxity |
| Medial canthal tendon laxity | Medial distraction test: punctum displaced > 2 mm lateral to lacrimal crest | Predicts failure if medial laxity is not addressed |
| Corneal exposure | Fluorescein staining, SPK, filamentary keratitis, exposure keratopathy | Requires urgent ocular surface protection |
Senile ectropion is primarily a clinical diagnosis. Evaluation documents severity, identifies the dominant anatomical defect, excludes mimics, and plans surgery.
- Slit-lamp examination: assess punctal position, conjunctival changes, corneal staining with fluorescein or rose bengal, and exposure keratopathy.
- Distraction test: quantifies horizontal lower lid laxity.
- Snap-back test: assesses lid tone; normal lid returns immediately, while a lax lid returns slowly or only after blinking.
- Medial distraction test: assesses medial canthal tendon laxity; punctal displacement > 2 mm is significant.
- Lacrimal syringing: excludes concurrent nasolacrimal duct obstruction in a patient with epiphora.
- Schirmer test / TBUT: performed when dry eye or reflex tearing is suspected.
- MRD1 / MRD2 documentation: useful baseline record before periocular surgery.
A. Conservative Temporising Measures
- Lubricating drops and ointment to protect the ocular surface.
- Moisture chamber spectacles in severe exposure.
- Temporary taping of the lower lid to the cheek, especially when surgery must be delayed.
- Treat reversible associated causes such as facial palsy where relevant.
- Conservative treatment protects the cornea but definitive treatment of senile ectropion is usually surgical.
B. Surgical Procedure Selection
| Predominant Defect | Procedure of Choice | Principle |
|---|---|---|
| Horizontal laxity, especially lateral canthal tendon laxity | Lateral tarsal strip (LTS) | Shortens the lower lid horizontally and reattaches the tarsal strip to periosteum on the inner aspect of the lateral orbital rim |
| Medial ectropion / punctal ectropion | Medial conjunctivoplasty / Lazy-T / Lester Jones tarsoconjunctival diamond excision | Diamond or elliptical excision of redundant posterior lamella below the punctum, with tightening of the medial posterior lamella |
| Isolated medial canthal tendon laxity | Medial canthal tendon plication or shortening | Plicates the medial canthal tendon to the posterior lacrimal crest periosteum |
| Diffuse horizontal laxity with medial punctal ectropion | LTS combined with medial conjunctivoplasty | Addresses both lateral/horizontal and medial/punctal components |
| Lower lid retractor dehiscence with anterior rotation of tarsus | Lower lid retractor reinsertion | Reattaches capsulopalpebral fascia to the inferior tarsal border |
Use the qualified term Lester Jones tarsoconjunctival diamond excision for the punctal ectropion procedure. Do not call it simply the Lester Jones procedure, because that usually refers to Jones tube conjunctivodacryocystorhinostomy (CDCR) in lacrimal surgery.
C. Lateral Tarsal Strip: Key Operative Steps
- Perform lateral canthotomy and cantholysis of the inferior crus of the lateral canthal tendon.
- Create a lateral tarsal strip by separating anterior lamella and removing conjunctival epithelium from the tarsal edge.
- Pull the strip laterally to judge the amount of horizontal shortening required.
- Excise excess tarsal strip.
- Fix the de-epithelialised tarsal strip to periosteum on the inner aspect of the lateral orbital rim using 4-0 or 5-0 Vicryl/Prolene.
- Reform the lateral canthal angle and close skin.
D. Management of Specific Problems
| Problem | Management |
|---|---|
| Exposure keratopathy | Urgent lubrication, ocular surface protection, and definitive surgical correction; temporary tarsorrhaphy if cornea is threatened |
| Conjunctival keratinisation | Usually improves after lid repositioning; long-term lubricants may be needed |
| Recurrence after LTS | Reassess for under-corrected medial canthal tendon laxity or punctal ectropion; add medial conjunctivoplasty and/or MCT plication as indicated |
- Overcorrection causing entropion.
- Undercorrection or residual ectropion, often due to unaddressed medial canthal tendon laxity.
- Wound dehiscence, haematoma, or infection.
- Rounding or webbing of the lateral canthus causing poor cosmesis.
- Lacrimal canalicular injury if medial conjunctivoplasty is too aggressive.
- Persistent epiphora due to concurrent nasolacrimal duct obstruction.
| Condition | How to Differentiate | Management Implication |
|---|---|---|
| Cicatricial ectropion | Vertical skin shortage, scarring, taut anterior lamella, history of burn/surgery/radiotherapy/skin disease | Needs skin graft, Z-plasty, or local flap; LTS alone will fail |
| Paralytic ectropion | Facial nerve palsy, weak orbicularis, lagophthalmos, poor Bell's phenomenon or reduced corneal sensation | Corneal protection, facial palsy management, tarsorrhaphy or lid loading when required |
| Mechanical ectropion | Unilateral ectropion with lid tumour, oedema, or heavy lesion | Treat or excise the causative lesion |
| Floppy eyelid syndrome | Rubbery upper lid that everts easily, classically in obese males; associated with obstructive sleep apnoea | Screen for OSA and manage lid laxity appropriately |
Trap 1 — TRUE
“The most common type of ectropion in clinical practice is involutional ectropion.”
Involutional or senile ectropion is the commonest type, not paralytic or cicatricial ectropion.
Trap 2 — FALSE
“Epiphora in ectropion is caused only by punctal malposition.”
Epiphora is due to both punctal eversion out of the lacrimal lake and lacrimal pump failure from orbicularis/lid laxity.
Trap 3 — TRUE
“A lower lid distraction test of more than 6-8 mm indicates significant horizontal lid laxity.”
Distraction >6-8 mm from the globe is significant; a delayed snap-back test also indicates poor lid tone.
Trap 4 — FALSE
“The bare term 'Lester Jones procedure' should be used for medial conjunctivoplasty in punctal ectropion.”
Use the full term 'Lester Jones tarsoconjunctival diamond excision' if using the eponym. The bare term 'Lester Jones procedure' usually means Jones tube CDCR.
Trap 5 — TRUE
“Medial conjunctivoplasty / Lazy-T is useful for medial ectropion with punctal eversion.”
It involves diamond or elliptical posterior lamellar excision below the punctum and may be combined with horizontal shortening if lid laxity coexists.
Trap 6 — FALSE
“Lateral tarsal strip corrects all cases of cicatricial ectropion when horizontal laxity is present.”
In cicatricial ectropion, the vertical anterior lamellar deficiency must be corrected first with skin grafting, Z-plasty, or a local flap; LTS alone will fail.
Trap 7 — TRUE
“Floppy eyelid syndrome primarily affects the upper lid and is associated with obstructive sleep apnoea.”
It causes a rubbery upper lid that everts on gentle traction and should prompt screening for OSA.
Trap 8 — TRUE
“Retractor reinsertion is indicated when retractor dehiscence causes anterior rotation of the tarsus and outward lid margin rotation.”
The capsulopalpebral fascia is reattached to the inferior tarsal border when retractor dehiscence is the dominant component.
Q: How do you clinically differentiate involutional from cicatricial ectropion?
A: Involutional ectropion shows horizontal lid laxity on distraction/snap-back testing, usually bilateral lower lid involvement, and no anterior lamellar scarring. Cicatricial ectropion shows vertical skin shortage, taut/scarred anterior lamella, often unilateral disease, and the lid cannot be manually repositioned without skin tension.
Q: A patient has medial ectropion with epiphora and patent syringing. What is the management?
A: Confirm punctal ectropion and assess horizontal laxity. Treat isolated medial punctal ectropion with medial conjunctivoplasty / Lazy-T / Lester Jones tarsoconjunctival diamond excision. Add LTS if significant horizontal laxity coexists.
Q: What is the significance of the capsulopalpebral fascia in senile ectropion?
A: It is the lower lid retractor, analogous to the levator aponeurosis. Age-related attenuation or dehiscence causes anterior/outward rotation of the tarsus; retractor reinsertion corrects this component.
A 70-year-old man has recurrent ectropion 3 months after lateral tarsal strip. Horizontal correction appears adequate, but medial distraction test shows 4 mm lateral displacement of the punctum from the lacrimal crest. What is the likely reason for failure and how would you revise?
Answer
The likely cause is unaddressed medial canthal tendon laxity. LTS corrects the lateral/horizontal component, but significant MCT laxity allows persistent medial lid eversion and punctal malposition. Revision should address the medial component with medial conjunctivoplasty / Lazy-T / Lester Jones tarsoconjunctival diamond excision for punctal ectropion and MCT plication or shortening to the posterior lacrimal crest periosteum using a non-absorbable suture. Reassess residual horizontal laxity and repeat LTS if needed.
References
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- Kanski JJ, Bowling B. Clinical Ophthalmology: A Systematic Approach. 8th ed. Elsevier; 2016.
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- Nerad JA. Techniques in Ophthalmic Plastic Surgery. Elsevier Saunders; 2010.
- Tyers AG, Collin JRO. Colour Atlas of Ophthalmic Plastic Surgery. 3rd ed. Butterworth-Heinemann; 2008.
- Anderson RL, Gordy DD. The tarsal strip procedure. Arch Ophthalmol. 1979;97(11):2192-2196.
- Jordan DR, Anderson RL. The lateral tarsal strip revisited. Arch Ophthalmol. 1989;107:604-606.