[Challenges in the surgical correction of complicated ectropion cases]

Simple forms of involutional ectropion may be corrected by a horizontal shortening and a medial retractor-advancement procedure. In long-standing cases secondary changes of the skin and lid margin have to be corrected. This requires additional surgical steps. A complicated ectropion can develop to gross deformities of the lid margins so that resection and reconstruction of the margins become necessary. This study differentiates the indication of simple or complicated ectropion surgery and elucidates the surgical options for the complicated ectropion.

We reviewed our corrected ectropion cases operated between January 2000 and December 2008. The cases were categorised according to the indicated surgical technique into simple (grade 1), simple combined (grade 2), complicated (grade 3) forms and complicated forms with major lid margin deformities (grade 4).

Out of the 1101 corrected lids, we found 19 % to be simple ectropion cases (grade 1) that received a lateral tarsal strip procedure. An additional retractor advancement to correct the medial punctual eversion was necessary in 38 % of the cases of combined ectropion (grade 2). About the same number of the lids (41 %) was staged as complicated ectropion (grade 3) and required a subciliary skin graft and a lid margin reshaping. The remaining 2 % (grade 4) needed a lid margin reconstruction.

In ectropion cases we find progressive pathological changes due to the duration of the everted lid position. Such changes vary from simple forms of ectropion to more complicated forms. In order to achieve good postoperative results and avoid recurrences, the surgical correction should be based on the degree of lid alteration. In the initial stage of simple ectropion (grade 1) it is sufficient to correct the lid laxity. More advanced stages of simple combined ectropion require a medial, inverting retractor correction in addition to the lid shortening procedure (grade 2). These two surgical steps are insufficient to manage the complicated ectropion stage (grade 3), where additional skin grafting and lid margin reshaping are required. Sometimes the lid margin cannot be reshaped if a major deformity is found (grade 4). The solution in such cases is to excise and reconstruct the lid margin.