Ectropion

As we age, most of us experience the facial wrinkles and sagging skin associated with having celebrated more birthdays. Unfortunately, sometimes that relaxation of the tissues of the eyelids causes a condition called ectropion that results in the bottom lid sagging downwards and outwards so its edge is no longer right next to the globe.

Our tears are constantly being replenished by glands in both lids and the lacrimal gland, located above each eye. The excess tears normally escape the eye through two tiny ducts that drain into the nasal cavity. Each eyelid, the upper and the lower, has its own duct. The tears drain into them by capillary action, but in order for this to work properly, both lids must be in contact with the globe. The lower lid in particular is important because most of the drainage work is handled there; even if the upper lid is in its proper position next to the globe, gravity causes most of the fluid to drain into the lower duct opening.

Entropion, a different disorder where the lower eyelid rolls inward, has similar causes. The two types of improper lid alignment are sometimes confused, but are quite different.

Because the eyelid is no longer up next to the globe, the lower areas of the eye can become dried out and damaged because they are exposed to the air. . (See photo at right; edge of lower lid is sagging away from the globe, allowing the tears to form a pool. Normal tear drainage is also ineffective, because the duct opening is also sagging away from the globe.)

Ectropion is usually seen in older adults, although sometimes it is seen in infants if there is insufficient skin in the lids at birth. In other cases, trauma to the eye after burns or surgery on the lids can cause scarring in what is known as cicatricial ectropion. There is also an increased incidence of ectropion in people who suffer from chronic ocular allergies, thought to be caused by the constant rubbing of the eyelid tissues, stretching them so they sag outwards.

Symptoms

The tears are made mostly of saline; if there is impaired drainage, the fluids pool into the pouch formed by the sagging lid and will eventually overflow, causing skin irritation. The overflow irritates the skin below the eyes; this is usually perceived by the person experiencing it as excess eye watering. Rubbing the eye only makes the lid sag more and makes the problem worse.

Ectropion usually includes some or all of these signs and symptoms:

• Sagging eyelid skin around the eyes, particularly noticeable in the lower lid
• Redness
• Burning
• Itching
• Dryness of the eye
• Eye irritation
• Excess tearing
• Thinning eyelid tissues
• Inflammation of the lining of the eye, called conjunctivitis

It seems like a contradictory finding, but the pooling of the tears in the lower lid can cause other areas to be dry and irritated, which causes more tearing in turn, and the cycle continues.

These signs do not always indicate ectropion, but if you experience one or more of them, see your eyecare practitioner.

Left untreated, the salinity of the overflow will cause skin irritation and even erosion; also, because the lids aren’t draining properly, the lower part of the eye can become chronically dry, causing damage to the ocular tissues, especially the lower cornea and conjunctivia.

Treatment

In mild forms, ectropion can be treated with artificial tears which will reduce the irritation and calm the production of excess tears in response to the dryness.

In addition, patients should try to decrease the rubbing of the lids and instead use a blotting action to soak up the fluid. Try to avoid rubbing the lower lid, especially towards the temples as this will only cause more stretching and will not improve comfort.

In most cases, surgical intervention is usually required to tighten the tendons in the eyelids and bring them back into contact with the eye.

Surgery for ectropion is usually uncomplicated and will result in a noticeable improvement in comfort and appearance; the surgery acts to restore the normal position of the lid next to the eye. The lids themselves take over once they are back in position.

If you experience burning, tears overflowing your lower lids or any other symptoms, see your eyecare practitioner for advice as ectropion does not reverse itself or get better with time.