Ectropion is a condition where the eyelid margin turns outward, leaving an exposed inner eyelid surface that can quickly get irritated. It generally affects the lower eyelid and occurs in older individuals. Ectropion is divided into five main classes according to the causes namely, involutional, cicatricial, paralytic, mechanical, and congenital. The severity of ectropion may vary from mild (only one part of the eyelid is affected) and severe (the entire margin length is turned out).

Preparation & Expectation Before Surgery

The patient will be educated about the various interventions, the benefits, associated risks and complications. A proper examination will be conducted to determine the best procedure to adopt. The doctor will likely want to know specific details from the patient concerning the symptoms, previous surgery, previous radiation treatment, other eye injuries, any medications in use, etc.

Types, Purpose & Procedure

Before surgery, the surgeon uses local anesthesia to numb the eyelids and surrounding areas. S/he then sedates the patient with oral or intravenous medications depending on the type of surgery.

The main treatment plan for ectropion is surgical, although lubricants and artificial tears can help to relieve associated symptoms while awaiting surgery. Surgery restores the punctum (opening of tear duct) and eyelid margin to their proper anatomical positions. The treatment also protects the eye from exposure and improves the symptoms caused by ectropion. 

However, surgery should only be performed on individuals who can tolerate the procedure. An underlying medical cause should be addressed before surgery can be considered. Complications can arise if there is an untreated infection or inflammation. Surgery also should be deferred if ectropion is caused by long term use of eye drops like brimonidine and dorzolamide. Congenital, mechanical, involutional, and paralytic ectropion usually require a different line of treatment; hence, it's essential to establish the cause before surgical intervention can be considered.

The following procedures based on the cause of ectropion can be performed:

The doctor administers topical as well as local anesthesia.
The surgeon places a shield over the cornea and traction sutures in the eyelid’s lash line. S/he then makes a subciliary incision into the eyelid, followed by dissection to release scarring until the posterior lamella (movable folds) returns to its anatomical location. The lid is then tightened. The surgeon transfers tissue from the donor site to the area requiring a graft. S/he will close the donor site, remove the corneal shield, and use frost sutures.

The doctor administers topical as well as local anesthesia.
The surgeon places a shield over the cornea and makes a lateral canthal incision with the surgical division of either corner of the eye where both the upper and lower eyelids meet. S/he will then split the lateral lower eyelid’s anterior and posterior lamella. The surgeon goes ahead to form a tarsal strip from the muscle, conjunctiva, and skin. The lid is pulled laterally to the eyelid rim to get the estimated tarsal required and remove redundancies. The surgeon ties up the strip to the lateral rim’s periosteum (a dense layer of connective tissue) and removes any excess skin and muscle. S/he then closes the incision on the skin and removes the corneal shield. 

Medial Ectropion Repair
The doctor administers topical as well as local anesthesia.
The surgeon places a shield over the cornea and uses a traction suture and Bowman probe to turn the eyelid margin out. S/he removes an ellipse (egg or oval shape) of the conjunctiva and lower lid retractors (muscles that open the eyelid). If the surgeon performs a caruncular (red prominence at the inner corner of the eye) recruitment, s/he may remove a part of the lateral caruncle.

A double-armed suture is passed through the lower lid retractors, the apex close to the punctum, and the apex downwards, and out through the eyelid. In the case of caruncular recruitment, the surgeon passes a double-armed suture through the medial tendon instead of the apex downwards. If need be, the surgeon can perform a lateral strip and tie the sutures to pull the punctum upside down before removing the corneal shield.

Lateral Tarsal Strip with Medial Spindle
The surgeon administers topical as well as local anesthesia. 
The surgeon removes an area of the conjunctiva shaped like a diamond. Lower eyelid retractors beneath the punctum are removed. The surgeon closes the lower eyelid retractors and conjunctiva. S/he strips the epithelium of its covering and splits the anterior and posterior lamellae before tearing the conjunctiva and the lower eyelid retractors from the strip. S/he removes the eyelash follicles and attaches the strip to the periosteum of the inner lateral orbital rim. The lateral canthus’ sharp angle is then reformed before the skin is closed.

Risks, Side Effects & Complications

Ectropion surgery is relatively safe and effective even though there can be a recurrence that necessitates a repeat of the procedure.

After surgery, the patient will experience temporary swelling and bruising around the eye.

Bleeding, pain, infection, corneal injury, erosion or bursting of the suture are possible complications. Others include corneal abrasion (scratch), poor cosmesis, lower eyelid retraction among others.

After Care, Recovery & Outcome

The patient can use cold compresses to relieve any swelling and bruising. The eyelid may also feel tight, but that should ease with time as healing takes place. The surgeon might prescribe an antibiotic and steroid ointment several times a day for a week. 

The stitches may be removed after one week, and the swelling and bruising should subside in about two weeks. The patient will wear a patch on the eye for 24 hours.

The patient can use artificial tears and eye ointments to help keep the cornea lubricated. Care should be taken when wiping the eyes. Constantly wiping the eyes is discouraged since it causes further stretching of the under-eye muscles and tendons, worsening the ectropion. The patient should avoid wetting the eyelid, undertaking strenuous activity, and bending down until the stitches are removed.  Alcohol, the sun, and make-up should also be avoided.