Documente Academic
Documente Profesional
Documente Cultură
Snap-back test
o Perform this test by pulling the lower lid away and down from the
globe for several seconds. If the lid resumes position, note the time
required for the lid to return to its original position without the patient
blinking.
o The snap-back test provides a good idea of relative lower lid laxity.
Lids with normal laxity immediately spring back to original position;
the longer this takes, the more laxity is present.
o Assign grades on a scale from 0-4 (0 = normal laxity, 4 = severe
laxity).
Medial canthal laxity test
o Perform this test by pulling the lower lid laterally from the medial
canthus. Measure displacement of the medial punctum. Greater
distance equates to more laxity. Normal displacement ranges from only
0-1 mm.
o Assign grades on a scale from 0-4 (0 = normal laxity, 4 = severe
laxity).
Lateral canthal laxity test
o Perform this test by pulling the lower lid medially from the lateral
canthus. Measure displacement of the lateral canthal corner. Greater
distance equates to more laxity. Normal displacement ranges from only
0-2 mm.
o Assign grades on a scale from 0-4 (0 = normal laxity, 4 = severe
laxity).
Schirmer test
o Because entropion is only one of several differential diagnoses of
epiphora, having a measure of the degree of eye dryness is important.
The Schirmer test is used to assess tear production and provides such a
measure
o Tiny filter paper tabs are inserted in the lower lids and removed after a
few minutes. The dampened area is measured in millimeters.
Fluorescein cornea test
o This test is essential when looking for signs of corneal damage.
o It can detect damage from lashes or lid skin rubbing on the cornea.
Lacrimal system irrigation
o Check for lacrimal system blockage.
o If the system is blocked, a dacryocystorhinostomy (alone or in
combination with an entropion procedure) would possibly be better
than treating the entropion alone.
Slit-lamp examination
o This examination is especially good for checking corneal status.
o The test also checks for evidence of dryness.
Presence or absence of Bell phenomenon test
o Instruct patient to attempt eye closure while the examiner holds lids
open.
o If eyes move up, the test indicates a positive result for Bell
phenomenon.
Orbicularis muscular tone check
o
o
If surgical therapy is unwarranted or impossible, patients with lower lid entropion should
be treated medically. Symptomatic therapy can be achieved using artificial tear ointment
or drops. Moisture shields are also helpful. Additionally, the lower lid can be taped down
slightly, everting the lid and lashes from the eye using specially designed or normal skin
tape.
For temporary spastic entropion (eg, from postoperative ocular surgery), botulinum toxin
(BOTOX) injections to the lower lid can be considered. The author usually administers
3 injections of 5 units BOTOX laterally, centrally, and medially. Effects usually start in
2 days and last 3-6 months. If the inciting event disappears, BOTOX injections can be a
permanent cure.
The same BOTOX therapy can also be a useful adjunct in reoperations or surgical
treatments, especially in patients in whom orbicularis tone is 3-4 or higher.
Ectropion usually involves the lower lid and often has a component of horizontal lid
laxity.
Patients may have a lid deformity for months or even years before they seek
medical attention.
Patients often complain of irritated or red eyes with tearing. They may
constantly wipe their eyes, thereby exacerbating lid laxity and the ectropion.
Advanced age may suggest the patient has involutional ectropion.
Eye drop instillation with chronic eversion of the lower lid can lead to
involutional ectropion.
A history of facial burns, lid surgery, or lid trauma is usually easily confirmed
on cursory examination and may suggest cicatricial ectropion.
In patients with cicatricial ectropion and periocular skin rash, a history of facial
skin cancer and topical and systemic medication use should be ascertained (see
Causes).
For patients with facial nerve palsy, the caregiver should be asked if nocturnal
lagophthalmos occurs. These patients should also be examined for corneal
problems.
Physical
Gestalt examination of the visage may reveal a connective tissue disorder, prior
surgical scars or burns, cancerous skin conditions, or the physiognomy for
floppy eyelid syndrome. All of these findings may be important in ectropion
evaluation.
Documentation of visual acuity and examination of the cornea and the
conjunctiva are part of any complete oculoplastic examination. Corneal
exposure, corneal ulceration, and conjunctival keratinization may accompany
ectropion.
Because of gravity, ectropion usually involves the lower lid and is described as
punctal, medial, lateral, or tarsal (complete). Laxity-related ectropion typically
begins medially; with time, the central lid margin and the lateral lid may evert.
Both the distraction test and the snap-back test are usually performed for
abnormal horizontal lid laxity.
o Anterior lid distraction of more than 6-8 mm from the globe suggests
horizontal lid laxity.
o If the lower lid is pulled inferiorly, the lid should quickly return to its
previous position. If not, this may be interpreted as an abnormal snapback test result. The patient should not be allowed to blink the eyelid
back into position.
If cicatricial ectropion is suspected, superiorly displace the lower lid margin. If
the lower lid margin does not extend 2 mm above the inferior limbus, then
cicatricial ectropion should be considered. In patients with skin erythema and
cicatricial ectropion, skin cancer or a medication-induced skin rash should be
excluded.
The puncta should not be visible, unless the lid is everted. If this is not the case,
punctal ectropion is present.
Chronic punctal ectropion may result in punctal phimosis.
Chronic ectropion may cause keratinization of the lid margin and the palpebral
conjunctiva.
In patients with complete tarsal ectropion, a white line in the inferior fornix is
often present, indicating a disinserted capsulopalpebral fascia.
Causes
Medical Care
Surgical Care
The orbicularis layer can be closed with 6-0 Vicryl. The skin can be
closed with 6-0 plain gut. A stitch through the lateral-most gray line of
the upper and lower lateral lid will help to keep the lateral canthus
"sharp."
o If the patient requires topical drops (eg, glaucoma therapy)
postoperatively, do not retract the lower lid for the first month during
drop instillation.
o It is not uncommon for patients to complain of discomfort at the lateral
canthus several weeks following this procedure.
Transconjunctival ectropion repair has been described.
Kuhnt-Szymanowski (Smith modification): When marked inferior
dermatochalasis accompanies ectropion and the lateral canthal tendon is not
dehisced, an inferior subciliary blepharoplasty skin incision can be combined
with pentagonal wedge excision of the orbicularis and posterior lamellae.
Precise closure is required to prevent a lid notch.
Tarsal ectropion
o This complete eversion of the lower lid occurs when disinsertion of the
capsulopalpebral fascia from the inferior tarsal border is present.
o In addition to horizontal lid tightening, reinsert the retractors (ideally
from a conjunctival approach).
o A spindle of redundant conjunctiva, no more than 3 mm in vertical
height, can be excised, if necessary.
o A double-armed 5-0 chromic suture can be used to reattach the
capsulopalpebral fascia to the inferior tarsus in a running fashion.
Medial ectropion: If tearing is the primary problem in patients with punctal
ectropion, a 1-snip or 2-snip inferior punctoplasty may be beneficial. Easily
performed with Vannas scissors and topical anesthetic, punctoplasty restores
continuity between the lacus lacrimali and the medial canthal angle. For mild-tomoderate medial ectropion, a medial conjunctival spindle procedure (excision of
the medial conjunctiva and retractors) can be performed.
o Following anesthetic injection in the medial inferior fornix, the inferior
canaliculus can be guarded with a lacrimal probe.
o A horizontal ellipse or diamond of conjunctiva and underlying lid
retractors is excised inferior to the punctum, approximately 3-4 mm
high and 6-8 mm wide. The base of the wound is cauterized.
o Then, the defect is closed with double-armed 5-0 chromic inverting
suture. This can be accomplished by engaging the inferior lip of the
wound, then the superior lip of the wound; the needle is then redirected
from the inferior lid to the cutaneous surface. Alternatively, buried
interrupted 6-0 polyglactin stitches can be used to close the medial
conjunctival spindle.
The Byron Smith lazy-T procedure is a well-described procedure for repairing
prominent medial ectropion. It combines a lower lid, full-thickness pentagonal
wedge resection, 3-4 mm temporal to the punctum with resection of a medial
triangle of conjunctiva and lower lid retractors (similar to medial conjunctival
spindle).
o Usually, 5-8 mm of lower lid is excised in the pentagonal wedge. When
closed, the incisions resemble a "T" lying on its side, hence the name
lazy T.
o If marked medial canthal laxity is present, medial canthal tendon
plication generally is performed with a lid shortening procedure.
o A lacrimal probe is placed to guard the lower canaliculus. A skin
incision, extending from just medial to the medial canthus to just
temporal to the punctum, is made inferior to the canaliculus.
o A double-armed 5-0 nylon suture is placed from the medial inferior
tarsus to the medial canthal ligament near the anterior lacrimal crest.
o