Residency · Residency · Ophthalmology
Eyelid Malpositions: Ptosis, Entropion, and Ectropion
Introduction
Eyelid malpositions are among the most common conditions encountered in oculoplastic practice. Ptosis, entropion, and ectropion each result from distinct anatomic and pathophysiologic mechanisms, and accurate diagnosis is essential for selecting the appropriate surgical correction. This lecture reviews the classification, evaluation, and surgical management of these three entities.
Ptosis
Definition and Classification
Ptosis (blepharoptosis) is an abnormally low upper eyelid position. Normal margin-reflex distance 1 (MRD1) is 4-5 mm. Classification by etiology:
Aponeurotic -- most common; involutional dehiscence or disinsertion of the levator aponeurosis. Myogenic -- myasthenia gravis, chronic progressive external ophthalmoplegia, myotonic dystrophy. Neurogenic -- cranial nerve III palsy, Horner syndrome. Mechanical -- lid mass, dermatochalasis, cicatricial changes. Traumatic -- post-surgical or post-injury levator damage.
Clinical Evaluation
Measure MRD1, MRD2, palpebral fissure height, and levator function (normal >= 12 mm) Assess phenylephrine test for Muller muscle-conjunctival resection (MMCR) candidacy. Rule out pseudoptosis: dermatochalasis, contralateral lid retraction, hypotropia, enophthalmos. Check for Hering dependence by elevating the ptotic lid and observing the contralateral lid.
Surgical Options
| Procedure | Indication | Levator Function | Key Notes |
|---|---|---|---|
| Levator advancement/resection | Moderate-severe ptosis | >= 5 mm | Most common surgical repair |
| Muller muscle-conjunctival resection (MMCR) | Mild ptosis | Good | Positive phenylephrine test required |
| Frontalis sling | Severe ptosis | < 4 mm | Congenital ptosis, CN III palsy |
Levator advancement/resection -- levator function >= 5 mm. Muller muscle-conjunctival resection (MMCR) -- mild ptosis with positive phenylephrine test. Frontalis sling -- levator function < 4 mm (e.g., congenital ptosis, CN III palsy)
Entropion
Definition and Classification
Entropion is inward turning of the eyelid margin, causing lash-cornea contact and irritation.
Involutional -- most common; horizontal lid laxity, lower retractor disinsertion, overriding preseptal orbicularis. Cicatricial -- tarsal conjunctival scarring (trachoma, Stevens-Johnson syndrome, ocular cicatricial pemphigoid, chemical burns) Congenital -- rare; epiblepharon is more common in Asian children. Spastic -- acute orbicularis spasm secondary to ocular irritation.
Surgical Management
Involutional: quickert sutures (temporary), lateral tarsal strip + lower retractor reinsertion + orbicularis repositioning. Cicatricial: posterior lamellar graft (mucous membrane, hard palate, amniotic membrane)
Ectropion
Definition and Classification
Ectropion is outward turning of the eyelid margin, leading to exposure, tearing, and conjunctival keratinization.
Involutional -- horizontal lid laxity, canthal tendon laxity. Cicatricial -- skin shortage from trauma, burns, prior surgery, actinic damage. Paralytic -- facial nerve (CN VII) palsy. Mechanical -- lid tumor, edema, orbital fat prolapse.
Surgical Management
Involutional: lateral tarsal strip procedure, medial canthal tendon plication if medial ectropion present. Cicatricial: skin graft (full-thickness from upper lid or postauricular) or flap reconstruction. Paralytic: gold weight implant, lateral tarsorrhaphy, canthoplasty.
Complications of Untreated Eyelid Malpositions
Corneal abrasion, ulceration, and scarring (entropion) Chronic epiphora and conjunctival keratinization (ectropion) Exposure keratopathy and secondary infection. Amblyopia in pediatric congenital ptosis with visual axis occlusion.
Key Clinical Pearls
Always check for Hering dependence before ptosis surgery to avoid unmasking contralateral ptosis. A positive phenylephrine test (>= 2 mm lid elevation) predicts good MMCR outcomes. Involutional entropion has three pathogenic components; address all three for durable repair. Cicatricial ectropion requires tissue replacement, not simply horizontal tightening. In paralytic ectropion, prioritize corneal protection while awaiting potential nerve recovery.
References
- Finsterer J. Ptosis: causes, presentation, and management. Aesthetic Plast Surg. 2003;27(3):193-204.
- Vallabhanath P, Carter SR. Ectropion and entropion. Curr Opin Ophthalmol. 2000;11(5):345-351.
- Nerad JA. Oculoplastic Surgery: The Requisites in Ophthalmology. Mosby; 2001.
- American Academy of Ophthalmology. Orbit, Eyelids, and Lacrimal System. BCSC Section 7. 2023-2024.