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Year : 2021  |  Volume : 59  |  Issue : 4  |  Page : 350-353

A study of the various etiologies and sequelae to ectropion and entropion

Department of Ophthalmology, Jothi Eye Care Centre, Puducherry, India

Date of Submission02-Jul-2021
Date of Decision05-Aug-2021
Date of Acceptance11-Aug-2021
Date of Web Publication21-Dec-2021

Correspondence Address:
Dr. Rajalakshmi Selvaraj
Department of Ophthalmology, Jothi Eye Care Centre, Puducherry - 605 001
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/tjosr.tjosr_97_21

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Purpose: This study aims to analyze the different etiologies of ectropion and entropion and helps in understanding the anatomical abnormalities responsible for the occurrence of entropion and ectropion, which is key to planning a successful surgical procedure. Methodology: It is a prospective study of 40 patients with ectropion and entropion studied for 17 months. Detailed slit lamp examination of lid abnormality, keratinization, trichiasis, corneal exposure was performed and axial length was measured. Results: The prevalence of ectropion and entropion put together was 0.064%. Paralytic ectropion ranks first among the different etiologies occupying 65.38%. The senile cause is the highest (78.57%) among the etiologies of entropion. The mean axial globe length of affected eyes in senile ectropion is 21.96 mm and in senile entropion is 20.73 mm. Conclusion: Eyelid malpositions have a low prevalence of 0.064%. The difference in the mean axial globe length between senile ectropion and entropion for this small sample size was found to be statistically significant. The overall percentage of conjunctival and corneal complications was found to be significantly higher in ectropion than in entropion.

Keywords: Axial globe length, ectropion, entropion, exposure keratitis, keratinization, tarsorrhaphy

How to cite this article:
Selvaraj R, Krishnamoorthy S, Vaithianathan V. A study of the various etiologies and sequelae to ectropion and entropion. TNOA J Ophthalmic Sci Res 2021;59:350-3

How to cite this URL:
Selvaraj R, Krishnamoorthy S, Vaithianathan V. A study of the various etiologies and sequelae to ectropion and entropion. TNOA J Ophthalmic Sci Res [serial online] 2021 [cited 2022 Sep 28];59:350-3. Available from: https://www.tnoajosr.com/text.asp?2021/59/4/350/333182

  Introduction Top

Eyelids act like a protective shield to our eyes, especially the cornea. Abnormal lid conditions such as ectropion and entropion, where eyelids are turned outward and inward, respectively, lead to discomfort to the patient in many forms such as cosmetic disfigurement, lacrimation, corneal ulceration, and opacity. The involutional or senile type of these malpositions share an interesting common pathology being the weakness of lid retractors, however the over-riding between pretarsal and preseptal plate of the eyelid determines whether the outcome is ectropion or entropion. The purpose of this study is to determine the etiology and prevalence of different types of ectropion and entropion of the eyelid, to examine how these disorders are related to gender, age and axial ocular globe projection; and to define the incidence of the associated ocular surface and pathologic eyelid findings. The secondary objective is to find the influence of axial globe length in involutional entropion and ectropion.

  Methodology Top

It is a prospective observational study done in the Department of Ophthalmology, for 17 months. The study was conducted after Institute Ethical Committee clearance. Screening of patients presented to the eye outpatient department (OPD) was done for eyelid malpositions, namely ectropion and entropion and 40 patients were enrolled.

Any history of trauma, surgery, chemical injury, seventh nerve palsy was elicited. They were subjected to clinical examination after obtaining informed consent from them in their vernacular language. Visual acuity was measured using Snellen's distant visual acuity chart. Initial examination was done by torch to understand the lid mal-position, then subjected to detailed Slit lamp examination. Parameters such as horizontal lid laxity, vertical lid laxity were assessed by the same person for all patients. Axial length was measured using USG-A scan, taking the average of ten readings in the affected eye.

The presence of chronic conjunctivitis, keratinization of exposed conjunctiva, thickening of lid margin associated with ectropion was noted. Any superficial punctate keratopathy (SPK) due to corneal exposure in ectropion and due to contact of misdirected eyelashes with cornea due to entropion were examined by slit-lamp examination. Any scar around the eyelid responsible for ectropion or entropion was noted.

Lagophthalmos occurs as a component of seventh cranial nerve-lower motor neuron type palsy leading to paralytic ectropion. Any lagophthalmos with absent Bell's phenomenon was intervened with temporary or permanent tarsorrhaphy. Orbicularis oculi function was assessed subjectively by resistance to open eyes when the patient is asked to close eyes tightly.

Any herniated orbital fat or eyelid tumor causing mechanical ectropion was ruled out by clinical examination and also any cause of irritation or blepharospasm was looked for, to rule out spastic entropion. Congenital causes were evaluated as a part of facial dysmorphic syndromes or isolated abnormalities.

  Results Top

Of the 62,838 people who visited the OPD during the study period, 40 people presented with either eyelid ectropion or entropion which constitutes 0.064%. Forty persons were enrolled for this study of which 26 (65%) were diagnosed as ectropion and 14 (35%) were diagnosed as entropion. One patient had congenital etiology (3.85%) among 26 cases of eyelid ectropion. One patient among 14 cases of eyelid entropion had congenital etiology (7.14%).

Paralytic cause of ectropion ranks first among the different etiologies occupying 65.38%. The various causes of paralytic ectropion found in this study are shown in [Table 1], the most common being Bell's palsy. Cicatricial ectropion was 19.23% and senile etiology occupied only 11.54% of the causes of ectropion.
Table 1: Different causes for paralytic ectropion

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The senile cause is the highest (78.57%) among the etiologies of entropion. Other etiologies contribute 21.43% of the causes of entropion.

[Figure 1] depicts the etiological comparison wherein senile entropion occupies a higher percentage (78.57%) than senile ectropion (21.43%). Paralytic component causes only ectropion. Cicatricial cause for eyelid malposition is more common in ectropion (71.43%) than entropion (28.57%).
Figure 1: Etiological comparison of ectropion and entropion

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Senile ectropion and entropion begin to occur from 51 years of age, their percentage increases with age, predominant after 70 years and the mean age is 66 years. The paralytic cause of eyelid malposition occurs at the mean age of 52 years. Cicatricial etiology has a mean age of 48 years.

The total number of males and females taken for this study was equal and each 20 in number. However, in case of ectropion, the percentage of males (61.54%) was higher than females (38.46%) and the difference was found to be statistically significant. In case of entropion, the percentage of females (71.43%) was significantly higher than the percentage of males (28.57%).

On analyzing the lid preferences, it is seen that the occurrence of eyelid ectropion and entropion is more common in the lower eyelid (87.5%) than upper lid alone (5%) or involvement of both upper and lower lids (7.5%). The involvement of the upper lid is quite a rare entity, occurring with the cicatricial and congenital component. The pinch test and snap back test for eliciting the horizontal lid laxity were sensitive in 75% of the people studied. Lid laxity can be clinically assessed by pinch test and snap back test. Pinch test: The lower lid is pulled away from the globe. A displacement of more than 8 mm away from the globe indicates lid laxity. Snap back test: The lower lid is pulled downwards and forwards and then released. A normal eyelid returns to its normal position quickly without any blinking. If lid laxity is present, the distracted lid does not snap back quickly.

[Table 2] shows that the mean axial globe length of affected eyes in senile ectropion is 21.96 mm. The mean axial globe length of affected eyes in senile entropion is 20.73 mm.
Table 2: Mean axial length of eyes with senile ectropion and entropion in comparison to normal eyes

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The difference in the mean axial globe length between senile ectropion and entropion was found to be statistically significant. It is made out that 58.82% of cases of paralytic ectropion developed exposure keratopathy. Out of the 17 patients who had paralytic ectropion, 10 presented with exposure keratopathy and got tarsorraphy done; 2 had prophylactic tarsorrhaphy. [Flowchart 1] insists on the significance of performing prophylactic tarsorraphy in paralytic ectropion with corneal exposure to prevent Keratopathy.

[Table 3] shows that the overall percentage of corneal complications (exposure keratitis, SPK, and opacity) was found to be significantly higher in ectropion than in entropion. [Table 4] portrays that the overall percentage of conjunctival complications (keratinization, symblepharon, congestion, chemosis) was found to be significantly higher in ectropion than in entropion.
Table 3: Statistical significance of corneal complications in ectropion and entropion

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Table 4: Statistical significance of conjunctival complications in ectropion and entropion

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  Discussion Top

In the present day scenario of increase in the Corporate sector in the field of Ophthalmology, also in institutional practice, we get to see very few cases of oculoplasty and even if diagnosed are mostly referred to Oculoplasty surgeons in a tertiary set up. Keeping in mind the uncommon occurrence of ectropion and entropion, this study was conducted for 17 months to identify its prevalence and also various etiologies. We were able to derive at interesting inferences with relation to axial globe length, apart from the age, gender and laterality preferences. Furthermore, the amount of corneal and conjunctival complications noted, simply explains that identifying these cases with their associated problems is the need of the hour. Any comprehensive ophthalmologist should at least be able to diagnose these lid pathologies at the earliest, lest the protective barriers, namely lids can themselves break the barrier and go on to damage the potential visual abilities of the patient.

A study at Brazil in 2011[1] reported that the prevalence of involutional ectropion was higher than involutional entropion in an elderly population which is in concurrence with the present study. Bedran et al. in 2010 discussed ectropion where they have quoted that congenital ectropion is rare and usually associated with other complications.[2] In our study too, only 5% was congenital eyelid malpositions. A retrospective study of ectropion among the Asian population comparing it with non-Asians found that the commonest etiology was “involutional” in both Asians and nonAsians.[3] It was followed by cicatricial, paralytic, congenital and mechanical. The commonest causes for cicatricial ectropion were postsurgical and traumatic which are similar to the present study.

Marked age-related increase in the prevalence of ectropion from age 60-years to 80-years and older has been noted.[3],[4] Our study shows a variable occurrence of eyelid malposition in different age groups. However, the mean age of senile ectropion and entropion was 66 years of age. Cicatricial conditions were common in the mean age of 48 years which explains the commonest etiology as trauma for cicatricial ectropion. The prevalence of involutional ectropion is higher in men and that of involutional entropion is higher in women.[1] The association of gender and involutional ectropion reported a statistically significant association between male gender and ectropion in a 10-year prospective study.[5] Also, presence of larger tarsal size in males predisposes to develop involutional ectropion and vice versa in females.[6] According to the present study, ectropion was common in males (62%) and entropion was common in females (71%). The lower lid is preferentially involved in all etiologies as per this study, which correlates well with the previous study by Chua et al.[3]

The axial globe length of senile ectropion is significantly longer than that of senile entropion.[1],[7] The influence of axial globe projection on lower eyelid malposition by Hertel's exophthalmometer was evaluated and concluded that axial globe projection in the ectropion group was significantly greater than entropion group.[8] This interesting derivation was confirmed in our study also. Hence, it could be arrived that axial globe length may be an influential factor in the onset of involutional eyelid malposition. Intriguingly, there is a study quoting that astigmatism measured via corneal topography could serve as an index of severity of eyelid laxity.[9]

Dry eye syndrome and SPK were seen significantly more often in involutional entropion. Whereas, chronic conjunctivitis was significantly more common in involutional ectropion.[1] In case of bilateral paralytic ectropion, one eye where tarsorrhaphy has been done shows clear cornea devoid of exposure keratitis. Whereas, in those patients, the other eye where tarsorrhaphy was not done, presents with exposure keratitis which heals on performing tarsorrhaphy.

There are few limitations in the study. In view of low prevalence of ectropion and entropion, the sample size was small. Hence the interesting association between axial length and lid malposition could not be extrapolated and may require further large studies. Next is that although the enrolled patients were surgically corrected as and when needed, the surgical management outcomes are not analyzed in this study.[3],[10],[11] Few etiologies like spastic and mechanical were not identified within the study period.

Ectropion and entropion are mostly untouched by comprehensive ophthalmologists. This observational study on such uncommon entities, stresses on the anatomical differences in the tarsal plate, pathogenesis of involutional etiology, and useful tests like the pinch test and snap back test to diagnose even mild grades of ectropion and entropion, especially the senile type. Literature speaks on drug induced ectropion or entropion caused by Apraclonidine and Tamsulosin respectively, which needs to be borne in mind during history taking.[12],[13] Most patients with paralytic ectropion in Bell's palsy seek treatment only after they develop exposure to keratitis. Timely intervention with temporary or permanent tarsorrhaphy along with lubricants do wonders in curing the same. However, the clinical application of the study is largely for trainees and postgraduates insisting on the prompt diagnosis and early treatment of these conditions to evade sight-threatening consequences.

  Conclusion Top

Eyelids are the protective elements of the eyeball and in specific, the cornea. Eyelid malpositions, apart from causing vision-threatening problems, do affect individuals cosmetically and psychologically. Thus, Oculoplasty holds a huge responsibility in satisfying the patients with eyelid malposition both in terms of vision and cosmesis. So, it is recommended that the sub-specialty of Oculoplasty should be an essential part of every Department of Ophthalmology. The most curious part of the study is the unexpected significant difference in axial globe length between the two groups of ectropion and entropion. It can definitely be a further research question in search of pathogenesis.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Damasceno RW, Osaki MH, Dantas PE, Belfort Jr R. Involutional entropion and ectropion of the lower eyelid: Prevalence and associated risk factors in the elderly population. Ophthalmic Plastic & Reconstructive Surgery 2011;27:317-20.  Back to cited text no. 1
Bedran EG, Pereira MV, Bernardes TF. Ectropion. Semin Ophthalmol 2010;25:59-65.  Back to cited text no. 2
Chua J, Choo CT, Seah LL, Fong KS, Chee SP, Chuah CT, et al. A 5-year retrospective review of Asian ectropion: How does it compare to ectropion amongst non-Asians?. Annals of the Academy of Medicine-Singapore 2011;40:84.  Back to cited text no. 3
Mitchell P, Hinchcliffe P, Wang JJ, Rochtchina E, Foran S. Prevalence and associations with ectropion in an older population: The Blue Mountains Eye Study. Clinical & Experimental Ophthalmology 2001;29:108-10.  Back to cited text no. 4
Deitz LW, Garibaldi DC, Merbs SL, Grant MP, Iliff NT. Association of gender and involutional ectropion of the lower eyelid; A 10–year perspective. Investigative Ophthalmology & Visual Science 2004:1;45:5606.  Back to cited text no. 5
Bashour M, Harvey J. Causes of involutional ectropion and entropion-age-related tarsal changes are the key. Ophthalmic Plastic & Reconstructive Surgery 2000;16:131-41.  Back to cited text no. 6
Jyothi SB, Seddon J, Vize CJ. Entropion-ectropion: the influence of axial globe length on lower eyelid malposition. Ophthalmic Plastic & Reconstructive Surgery 2012;28:199-203.  Back to cited text no. 7
Heimmel MR, Enzer YR, Hofmann RJ. Entropion-ectropion: the influence of axial globe projection on lower eyelid malposition. Ophthalmic Plastic & Reconstructive Surgery 2009;25:7-9.  Back to cited text no. 8
Detorakis ET, Ioannakis K, Kozobolis VP. Corneal topography in involutional ectropion of the lower eyelid: Preoperative and postoperative evaluation. Cornea. 2005;24:431-4.  Back to cited text no. 9
Miletić D, Kuzmanović Elabjer B, Bosnar D, Bušić M. Our approach to operative treatment of lower lid ectropion. Acta clinica Croatica 2010;49:283-7.  Back to cited text no. 10
Barnes JA, Bunce C, Olver JM. Simple effective surgery for involutional entropion suitable for the general ophthalmologist. Ophthalmology 2006;113:92-6.  Back to cited text no. 11
Waqar S, Simcock P. Lower lid entropion secondary to treatment with alpha-1a receptor antagonist: A case report. Journal of medical case reports 2010;4:1-2.  Back to cited text no. 12
T Britt MI, Burnstine MA. Iopidine allergy causing lower eyelid ectropion progressing to cicatricial entropion. British journal of ophthalmology 1999;83:987.  Back to cited text no. 13


  [Figure 1]

  [Table 1], [Table 2], [Table 3], [Table 4]


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