Inversion of the century: causes, symptoms, diagnosis, treatment

The turn of the century (synctropion ectropion) is a disease in which the eyelid moves away from the eye, as a result of which the palpebral and bulbar conjunctiva are exposed. Almost always there is a reversal of the lower eyelid. Even with an insignificant degree of eversion of the lower eyelid, the lower lacrimal point shifts, which leads to lacrimation. The epithelium of the palpebral part of the conjunctiva of the lower eyelid begins to cornify. The eyelid is sagging, the turning of the lower lacrimal point leads to a spasmodic and painful for the patients constant lacrimation, the development of chronic blepharitis and conjunctivitis. A pronounced lagophthalmus can promote the formation of a corneal ulcer.

Distinguish the following forms of the turn of the edge of the century: congenital, age, paralytic, scarring.

Congenital eversion of the century

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

[1], [2], [3]

Age reversal of the century

Age reversal of the century is the most common form; is caused by excessive stretching of the ligament of the eyelids, which leads to the sagging of the eyelid. Surgical treatment - horizontal shortening of the lower eyelid. With an isolated reversal of the lower lacrimal point, the vertical shortening of the conjunctiva and the suturing of the lower lacrimal point are performed on an outpatient basis.

This reversal of the eyelid of the lower eyelid is observed in elderly patients. It is manifested by lacrimation, and long-existing - leads to inflammation, thickening and coronation of the tarsal conjunctiva.

Pathogenesis of the age-related eyelid reversal

1. The horizontal weakness of the eyelid is revealed by pulling the central part of the eyelid 8 mm or more from the eyeball and not returning it to its normal position without flashing.
2. The tendon weakness of the medial angle of the eye gap is revealed by pulling the lower eyelid outward, noting the positions 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 limb, and in pronounced cases - the pupil.
3. The tendon weakness of the lateral angle of the eye gap is characterized by its rounded appearance and the ability to pull the lower eyelid medially more than 2 mm.

Treatment of age eyelid reversal

When choosing a technique, the operations take into account: the degree of eversion (the predominance of the medial or general ectropiope), the degree of horizontal weakness of the eyelid, the severity of the horizontal insufficiency of the tendons of the eye-slit angle, the volume of the "excess" skin.

1. With medial ectropion, the Lazy-T technique is used: cutting out a tarsoconjunctival rectangular flap 4 mm in height and 8 mm long parallel and below the tubule and its mouth in combination with a through excision of the pentagonal flap on the side of the mouth.
2. With the generalized ectropion, a horizontal shortening of the eyelid is produced by excising the through pentagonal flap of the eyelid in the region of greatest inversion. The pronounced tendon deficiency of the medial angle of the eye gap is leveled.
3. 3. The generalized ectropion with the "excess" skin is eliminated with the help of the Kuhnl-Szymanowski technique, the essence of which consists in excision of the lateral through pentagonal flap of the eyelid in combination with the triangular flap in the area of the "excess" skin. The pronounced tendon deficiency of the medial angle of the eye gap is leveled.

[4], [5], [6],

Paralytic Eversion of the Century

The paralytic reversal of the eyelid is observed with paralysis of the facial nerve, it can occur after denervation of the fibers of the circular eye muscle (botulinum toxin). Treatment consists in constant moistening of the eye; for the treatment period, the eyelids are sealed. With long-lasting pathology (more than 6 months), the horizontal ligament of the outer ligament of the eyelid is horizontally shortened, if necessary, blepharoraphy is performed.

Paralytic ectropion is caused by paralysis of the ipsilateral facial nerve, is associated with retraction of the upper and lower eyelids and the lowering of the eyebrows. The latter can cause narrowing of the eye gap.

Possible complications

• Exposure keratopathy is due to the combination of a lagophthalmus and an insufficient distribution of eyelids tears on the cornea.
• Lachrymation is induced by non-adherence to the lower lacrimal point, impaired tear pump performance and increased tear production, which causes dryness of the cornea.

Temporary treatment

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

1. Apply artificial tears or ointments throughout the day. Adhesive tape on the eyelid during sleep is usually imposed in mild cases.
2. The use of the temporary tarzoraphy technique (cross stitching of the lower and upper eyelids from the lateral side), especially in patients with Bell's deficiency, when the cornea does not cover with blinking for centuries, which leads to its drying.

Continuous treatment

Applied in the presence of deficiency of the Hell phenomenon during 3 months or with prolonged lesion of the facial nerve, for example after removal of the neuroma of the auditory nerve. The goal of the treatment is to reduce the horizontal and vertical dimensions of the ocular gap by the following procedures.

1. Performing medial cantoplasty, if the tendon of the medial angle of the optic gap is not damaged. The eyelids stitch medial to the lacrimal point so that the lacrimal point is inverted and the gap between the inner corner and the lacrimal point decreases.
2. Medial wedge resection with filing of the tarsal tendon to the posterior tear ridge is used to correct the medial ectropion in combination with the medial canthalic insufficiency.
3. The lateral canthalic suspension is used to correct the residual ectropiope and to lift the lateral angle of the eye gap.

Cicatricial inversion of the eyelid

Cicatricial eversion of the eyelid develops as a result of burns, after injuries and surgeries, and skin infections. At the time of a thermal burn, a tight squeeze can prevent damage to the edges of the eyelids.

Scar ectropion is caused by scarring or contracture of the skin and underlying tissues, as a result of which the eyelid departs from the eyeball. If you move the skin with your finger to the edge of the orbit, the turn will decrease and the eyelids will close. When opening the mouth, the turning of the eyelid becomes more pronounced. Depending on the etiology, both centuries can be affected: local injury (trauma) or generalized (burns, dermatitis, ichthyosis).

Treatment of scar ectropion is complex, as a rule, a long one.

1. In cases of limited lesion, a combination of rumen excision with Z-shaped plasty (skin elongation in the vertical direction) is used.
2. In severe cases, the tactics of moving the skin flap or its transplantation are used. Autotransplants are cut from the upper eyelid, posterior and anterior parotid surfaces and the supraclavicular area.

At the earliest possible time after the appearance of the reversal, it is advisable to perform blepharophrenia, and in the delayed period, free skin plasty may be required. Often there is a need for local application of proteolytic enzymes, physical therapy. The prognosis for performing the appropriate intervention is good, the effect is usually stable, but in severe cases, relapses are possible.

[7], [8]

Mechanical reversal of the eyelid (ectropion)

Mechanical ectropion is caused by tumors located along the edge or near the edge of the eyelid, which mechanically turn it out. Treatment consists in eliminating, if possible, the cause and correction of a significant horizontal insufficiency of the eyelid.