Eyelid dislocation: causes, symptoms, diagnosis, treatment

Eversion of the eyelid (syn. ectropion) is a condition in which the eyelid moves away from the eye, resulting in the exposure of the palpebral and bulbar conjunctiva. The lower eyelid almost always everts. Even with a slight degree of eversion of the lower eyelid, the lower lacrimal point shifts, which leads to lacrimation. The epithelium of the palpebral part of the lower eyelid conjunctiva begins to keratinize. The eyelid sags, eversion of the lower lacrimal point leads to lacrimation and constant lacrimation that is painful for patients, the development of chronic blepharitis and conjunctivitis. Severe lagophthalmos can contribute to the formation of a corneal ulcer.

The following forms of eversion of the eyelid margin are distinguished: congenital, age-related, paralytic, cicatricial.

Congenital eversion of the eyelid

Congenital eversion of the eyelid, especially isolated, is the most rarely observed form; it is caused by shortening of the outer - skin-muscle - plate of the eyelid. With a low degree of eyelid maladaptation, as a rule, there is no need for surgical correction.

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Age-related eversion of the eyelid

Age-related eversion of the eyelid is the most common form; it is caused by excessive stretching of the eyelid ligaments, which leads to drooping of the eyelid. Treatment is surgical - horizontal shortening of the lower eyelid. In case of isolated eversion of the lower lacrimal punctum, vertical shortening of the conjunctiva and application of sutures that reposition the lower lacrimal punctum are performed on an outpatient basis.

This eversion of the lower eyelid is observed in elderly patients. It manifests itself as lacrimation, and if it persists for a long time, it leads to inflammation, thickening and keratinization of the tarsal conjunctiva.

Pathogenesis of age-related eversion of the eyelid

1. Horizontal eyelid laxity is identified when the central portion of the eyelid is pulled 8 mm or more away from the eyeball and does not return to its normal position without blinking.
2. Tendon weakness of the medial canthus is detected by pulling the lower eyelid outward, noting the position of the lowest point. If the eyelid is healthy, the lowest point does not move more than 1-2 mm. If the weakness is moderate, the lowest point reaches the limbus, and in severe cases - the pupil.
3. Tendon weakness of the lateral canthus is characterized by its rounded appearance and the ability to pull the lower eyelid medially by more than 2 mm.

Treatment of age-related eversion of the eyelid

When choosing the surgical technique, the following are taken into account: the degree of eversion (predominance of medial or general ectropion), the degree of horizontal weakness of the eyelid, the severity of horizontal insufficiency of the tendons of the angle of the eye slit, the volume of “excess” skin.

1. In case of medial ectropion, the Lazy-T technique is used: cutting out a tarsoconjunctival rectangular flap 4 mm high and 8 mm long parallel to and below the canal and its orifice in combination with through excision of a pentagonal flap lateral to the orifice.
2. In case of generalized ectropion, horizontal shortening of the eyelid is performed by excision of a through pentagonal flap of the eyelid in the area of greatest eversion. The pronounced tendon insufficiency of the medial angle of the palpebral fissure is leveled.
3. 3. Generalized ectropion with "excess" skin is eliminated using the Kuhnl-Szymanowski technique, the essence of which is the excision of a lateral penetrating pentagonal flap of the eyelid in combination with cutting out a triangular flap in the area of "excess" skin. Severe tendon insufficiency of the medial angle of the eye slit is leveled.

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Paralytic eversion of the eyelid

Paralytic eversion of the eyelid is observed with facial nerve paralysis, and may occur after denervation of the fibers of the orbicularis oculi muscle (botulinum toxin). Treatment consists of constant eye moistening; the eyelids are taped during treatment. In case of long-term pathology (more than 6 months), horizontal shortening of the external ligament of the eyelid is performed, and blepharorrhea is performed if necessary.

Paralytic ectropion is caused by paralysis of the ipsilateral facial nerve and is associated with retraction of the upper and lower eyelids and drooping of the eyebrow. The latter may cause narrowing of the palpebral fissure.

Possible complications

• Exposure keratopathy is caused by a combination of lagophthalmos and insufficient distribution of tears on the cornea by the eyelids.
• Lacrimation is induced by poor apposition of the inferior lacrimal punctum, dysfunction of the lacrimal pump, and increased tear production, which causes corneal dryness.

Temporary treatment

Aimed at protecting the cornea until the function of the facial nerve is restored.

1. Use of artificial tears or ointment during the day. A bandage on the eyelid during sleep is usually applied in mild cases.
2. The use of temporary tarsorrhaphy (latching the lower and upper eyelids together laterally), especially in patients with Bell's phenomenon deficiency, when the cornea is not covered by the eyelids when blinking, which leads to its drying out.

Ongoing treatment

It is used in the presence of Hell phenomenon deficiency for 3 months or in case of long-term damage to the facial nerve, for example after removal of an auditory nerve neuroma. The goal of treatment is to reduce the horizontal and vertical dimensions of the palpebral fissure using the following procedures.

1. Performing a medial canthoplasty if the tendon of the medial canthus is not damaged. The eyelids are sutured medial to the lacrimal punctum so that the lacrimal punctum is inverted and the gap between the inner canthus and the lacrimal punctum is reduced.
2. Medial wedge resection with tarsal tendon suturing to the posterior lacrimal crest is used to correct medial ectropion in combination with medial canthal insufficiency.
3. The lateral canthal suspension is used to correct residual ectropion and to elevate the lateral canthus.

Cicatricial eversion of the eyelid

Cicatricial eversion of the eyelid develops as a result of a burn, after injuries and operations, and during skin infections. At the time of a thermal burn, squeezing tightly can prevent damage to the edges of the eyelids.

Cicatricial ectropion is caused by scarring or contracture of the skin and underlying tissues, causing the eyelid to move away from the eyeball. If the skin is pulled toward the orbital rim with a finger, the eversion decreases and the eyelids close. When opening the mouth, the eversion becomes more pronounced. Depending on the etiology, both eyelids may be affected: local damage (trauma) or generalized (burns, dermatitis, ichthyosis).

Treatment of cicatricial ectropion is complex and usually lengthy.

1. In cases of limited damage, a combination of scar excision and Z-plasty (skin elongation in the vertical direction) is used.
2. In severe common cases, the tactics of skin flap displacement or transplantation are used. Autotransplants are cut from the upper eyelid, posterior and anterior parotid surfaces and supraclavicular region.

In the earliest possible time after the appearance of eversion, it is advisable to perform blepharorrhea, and in the delayed period, free skin grafting may be required. Local application of proteolytic enzymes and physiotherapy are often necessary. The prognosis for performing the appropriate intervention is good, the effect is usually stable, but in severe cases, relapses are possible.

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Mechanical eversion of the eyelid (ectropion)

Mechanical ectropion is caused by tumors located at or near the edge of the eyelid that mechanically evert it. Treatment consists of eliminating the cause if possible and correcting significant horizontal insufficiency of the eyelid.