Efficacy of a Triticum vulgare Extract as a Treatment of Cervical Ectropion: A Prospective Observational Cohort Study.

OBJECTIVES: To assess the effectiveness of a topical treatment for cervical ectropion with vaginal ovules containing aqueous extract of Triticum vulgare . METHODS: Prospective observational cohort study conducted between November 2020 and November 2022 at the colposcopy clinics of 2 different hospitals. Sexually active patients with a colposcopic diagnosis of cervical ectropion, awaiting ablative procedure, were included in the study and prescribed medical therapy with vaginal T. vulgare ovules (group 1) or wait-and-see therapy (group 2). At both enrollment and 2-month follow-up, a symptomatologic evaluation recording the intensity of postcoital bleeding, leucorrhea, and dyspareunia was performed with a Visual Analog Scale (VAS) questionnaire, and a colposcopic examination was performed, calculating the size of the ectropion area. RESULTS: A total of 116 patients (58 in group 1 and 58 in group 2) were included. Topical treatment with vaginal ovules containing aqueous extract of T. vulgare for 2 months resulted in significant decrease of symptoms related to cervical ectropion and significant reduction of the size of the ectropion area. CONCLUSIONS: Our results support the efficacy of topical treatment with vaginal ovules containing aqueous extract of T. vulgare for symptomatic cervical ectropion; our study also suggests that expectant management, despite being widely practiced, seems to lead to a worsening of the natural history of ectropion.

Case Report: Corneal Ulceration from Bilateral Ectropion Due to Congenital Ichthyosis.

SIGNIFICANCE: Ichthyosis is a group of heterogenous inherited skin disorders characterized by abnormal cornification and keratinization of the skin. Autosomal recessive congenital ichthyosis presents with severe lagophthalmos and cicatricial ectropion of both upper and lower lids. Chronic corneal exposure from lid abnormalities may lead to ulcerative keratitis or corneal perforation. PURPOSE: The case highlights a rarely seen condition that presents with potentially serious ocular complications and vision loss. Corneal complications may be avoided or managed with moisture goggles, corneal vaulting with scleral lenses, topical therapeutics, amniotic membrane, and surgical lid repair. CASE REPORT: A 25-year-old woman presented with a painful right eye for 1 week. She had a medical history of autosomal recessive congenital ichthyosis. Her ocular adnexa revealed bilateral lagophthalmos and cicatricial ectropion of both upper and lower lids. The slit lamp of examination revealed an injected eye with corneal ulcer with hypopyon in the right eye and quiet eye with corneal scarring in the left eye. The patient was treated with topical moxifloxacin and polymyxin B sulfate/trimethoprim as well as in-office homatropine 5% in the right eye. The keratitis was treated to resolution, and the patient referred for consultation on lid repair. CONCLUSIONS: Chronic corneal exposure from autosomal recessive congenital ichthyosis may lead to severe dry eye, ulcerative keratitis, or perforation. Patients should be monitored carefully for corneal disease, educated on methods and devices to protect the corneal surface, and referred for surgical repair if indicated. Although rare, this condition presents unique findings that may be visually devastating. Awareness of the condition, as well as the various clinical presentations and appropriate management necessary, will prove beneficial to the patient.

Severe ectropion in lamellar ichthyosis managed medically with oral acitretin.

Congenital ectropion is commonly associated with lamellar ichthyosis. Severe eyelid ectropion may cause corneal exposure, keratopathy, and permanent corneal scarring. We report a neonate with severe, bilateral, congenital ectropion and eclabium managed using oral retinoids. Both corneas were protected with topical antibiotics and lubricating eyedrops and eye ointments. At 12-month follow-up, the child was doing well, with no ectropion or corneal opacity.

Apremilast Use in a Case of Cicatricial Ectropion Secondary to Severe Lamellar Ichthyosis.

Ichthyosis is a cutaneous disorder characterized by excessive amounts of dry thickened skin surface scales. Ocular manifestations of ichthyosis include cicatricial ectropion, which may cause exposure keratoconjunctivitis and rarely corneal perforation. Topical emollients, anti-inflammatory ointments, and systemic retinoids have been used to control the disease process, while surgical correction with donor graft has been reserved for severe cases involving corneal exposure. The authors report a case of a Caucasian male with lamellar ichthyosis with severe bilateral upper and lower eyelid cicatricial ectropion and corneal ulceration requiring surgical correction. Treatment with apremilast, a novel phosphodiesterase-4 inhibitor, for the treatment of a concomitant plaque psoriasis achieved good control of his skin diseases and minimized the recurrence of eyelid ectropion.

Reversible cicatricial ectropion associated with EGFR inhibitors.

The management of cicatricial ectropion resulting from epidermal growth factor receptor (EGFR) inhibitors is unclear. We describe two cases of bilateral cicatricial ectropion following the use of an EGFR inhibitor who were treated with oral doxycycline, topical ophthalmic steroid and antibiotic ointment to the eyelids, and topical facial steroid cream with lubrication. The first case resolved with discontinuation of panitumumab infusions along with institution of the aforementioned regimen. However, it is unclear whether the resolution was from discontinuation of the infusions or from the instituted regimen. The second case resolved without a dose adjustment of cituximab. This case may provide support for the use of this regimen prior to discontinuation of the offending agent, as there was a successful outcome without alteration of the infusions. Additional cases are necessary to determine if this is a successful means of treating bilateral lower-lid cicatricial ectropion from EGFR inhibitors.

Ectropion Improvement with Topical Tazarotene in Children with Lamellar Ichthyosis.

BACKGROUND/OBJECTIVES: Lamellar ichthyosis (LI) is a well-described phenotypic subtype of autosomal recessive congenital ichthyosis (ARCI). The condition typically presents at birth with collodion membrane and leads to thick, plate-like scaling of the skin throughout the body, alopecia, and prominent ocular manifestations. Ocular complications include bilateral cicatricial ectropion and lagophthalmos. These ocular complications can lead to chronic exposure keratitis and in some cases corneal ulceration and blindness. No cure for ichthyosis exists. Treatment of ocular complications in LI includes surgical correction, systemic retinoids, and a variety of topical therapies such as emollients, keratolytics, and retinoids. METHODS: Five children with LI cared for at our institution were identified and included. Patient age at the start of therapy ranged from 2 weeks to 9 years. Electronic medical records were reviewed and data from pediatric dermatologist and pediatric ophthalmologist visits were obtained. Data were collected before and after treatment of daily or twice-daily 0.05% to 0.1% tazarotene cream applied to the face and eyelids. RESULTS: All patients had improvement in the degree of ectropion, with complete resolution in two of the five patients. The two patients with lagophthalmos at the time of tazarotene initiation experienced complete resolution. No adverse effects were reported. CONCLUSIONS: Tazarotene cream appears to be effective in the management of ectropion and lagophthalmos in the setting of LI in children, even in the neonatal period.

The management of congenital superior conjunctival fornix prolapse.

AIM: To present the management of bilateral congenital superior fornicial prolapse and provide its up-to-date review of literature. METHODS: We present the management of congenital bilateral superior fornicial prolapse treated conservatively with topical antibiotics, lubricants and hypertonic saline. One-week, 2-weeks and 1-month follow-up is presented. Results were assessed in terms of reduction of chemosis and eyelid opening. Updated current English peer-reviewed literature was researched. RESULTS: The superior fornicial prolapse resolved with conservative management within 10 days, resulting in normal eyelid motility at the end of 1 month. At present 61 cases have been reported in English peer-reviewed journals. The proposed etiology is varied. Conservative management with topical medication provides relief. CONCLUSIONS: Congenital fornicial prolapse is a rare condition. Topical medication provides complete resolution of prolapse. Authors emphasise the need for awareness of condition among ophthalmologists and neonatologists, because of its gruesome appearance.

Use of hyaluronic acid gel in the management of cicatricial ectropion: results and complications.

AIMS: To report our experience using hyaluronic acid gel injection in the lower eyelid to treat cicatricial ectropion. METHODS: Clinical records and literature review. RESULTS: Between November 2009 and June 2011, 12 lower eyelids of 11 patients with cicatricial ectropion were treated with hyaluronic acid gel. All 11 patients demonstrated improvement in the eyelid position after treatment but only 3 patients (27.3%) experimented total correction after injection. Although the correction was partial in the majority of the patients, the signs and symptoms associated with conjunctival and corneal exposure improved in all patients. Seven patients (63.7%) developed irregular fullness which resolved over time, but in 4 patients (36.3%) fullness persisted for one year. CONCLUSIONS: In our experience, hyaluronic acid gel is a nonsurgical, minimally invasive and safe technique that improves cicatricial ectropion, but with a poor cosmetic result that limits its use. This treatment could be considered only in patients who decline surgery or are poor surgical candidates, as the aesthetic result would not be acceptable to many.

Glaucoma management in congenital ectropion uveae: Surgical outcomes from a large tertiary referral center in South India.

PURPOSE: To evaluate the long-term outcomes of glaucoma management in patients with congenital ectropion uveae (CEU) over a period of three decades at a single large referral tertiary eye care center. METHODS: Retrospective chart review of all patients with CEU treated surgically from 1990 to 2019 was performed. Primary combined trabeculotomy-trabeculectomy (CTT), trabeculectomy with and without mitomycin-C (MMC) (0.2 mg/mL for 1 min) and transscleral cyclophotocoagulation (TSCPC) were performed. Intraocular pressure (IOP) ≥6 and ≤16 mmHg without medications was considered as complete success and IOP≤ 16 mmHg with the use of upto 2 medications as qualified success. RESULTS: A total of 26 eyes of 21 patients were identified with a median age of 7 years (range, 6 days to 19 years) at the time of glaucoma surgery. Median follow-up was 51.1 months (range, 7-244.6 months). Primary CTT was performed in 17 eyes (65%), trabeculectomy in 5 eyes (19%) with application of MMC in 2 eyes, and 3 eyes (12%) underwent TSCPC. One painful blind eye (4%) underwent evisceration. Mean IOP reduced from 30.8 ± 7.6 mmHg on a mean of 1.3 ± 0.8 glaucoma medications preoperatively to a mean IOP of 15.2 ± 5.9 mmHg (P < 0.0001) on a mean of 0.2 ± 0.5 medications postoperatively at final follow-up (P = 0.0009). Complete success was achieved in 20 eyes, and qualified success in 2 eyes. CONCLUSIONS: CTT is a safe and efficacious primary procedure for management of early-onset glaucoma in CEU. Trabeculectomy with or without adjuvant MMC is a viable second line of treatment in late-onset glaucoma with CEU for IOP control.

Short-term qualitative and quantitative analyses of preseptal injection of hyaluronic acid on the treatment of acquired lower eyelid cicatricial ectropion.

PURPOSE: Recently, hyaluronic acid (HA) was proposed as a promising option for the treatment of acquired lower eyelid cicatricial ectropion. However, this effect was not confirmed by quantitative assessments. This study aimed to assess the effect of hyaluronic acid on the treatment of acquired lower eyelid cicatricial ectropion. METHODS: Eight patients with acquired lower eyelid cicatricial ectropion (13 eyelids) were treated with a single 1 mL injection of hyaluronic acid in the preseptal area of the lower eyelid. Evaluation of symptoms and biomicroscopic exam was performed before and 30 days after hyaluronic acid injection. Quantitative analysis of the lower eyelid position (with and without lid traction) was determined before and 30 days after hyaluronic acid injection through standard photographs analyzed using the ImageJ. RESULTS: All patients experienced partial improvement of symptoms. The lower eyelid position was significantly lifted after hyaluronic acid injection with a significant reduction of medial and lateral angles, reduction of the margin reflex distance, and total and medial ocular fissure area. However, signs of lid margin inflammation and corneal punctate keratitis persisted. CONCLUSIONS: Hyaluronic acid injected in the pre-septal area of the lower eyelid improved acquired lower eyelid cicatricial ectropion symptoms and significantly lifted the position of the lower eyelid. Further studies, with a large number of participants and a long-term follow-up period, are needed to better determine the permanency of the effects of hyaluronic acid injections on the treatment of acquired lower eyelid cicatricial ectropion.

Dupilumab-associated ectropion and punctal stenosis treated with tacrolimus ointment (0.03%) in a 15-year-old girl.

A 15-year-old Asian girl with severe atopic dermatitis was referred for dupilumab-associated blepharoconjunctivitis. Medical history was significant for severe atopic dermatitis. She was started on prednisolone acetate 1% ophthalmic suspension three times daily, and dupilumab injections were withheld after the initial visit. The patient was noted to have right lower eyelid ectropion, cicatricial occlusion, and severe punctal stenosis 6 weeks later. She was started on 0.03% tacrolimus ointment to the eyelid margin. Resolution of ectropion and restoration of punctal patency with residual stenosis were observed 4 weeks later. This is the first reported adolescent case of dupilumab-associated ectropion and punctal stenosis successfully treated with topical tacrolimus ointment.

Evaluation of 5-aminolevulinic acid-mediated photodynamic therapy on cervical low-grade squamous intraepithelial lesions with high-risk HPV infection.

BACKGROUND: The treatment options for low-grade squamous intraepithelial neoplasia (LSIL) of the cervix with high-risk HPV infection have not been standardized. Studies show that photodynamic therapy (PDT) mediated by 5-aminolevulinic acid (ALA-PDT) might be effective. In this retrospective study, the clinical efficacy and safety of ALA-PDT in the treatment of LSIL were evaluated. METHODS: ALA-PDT was performed in 55 LSIL patients aged 21-45 years who also showed high-risk HPV infection and cervical ectropion. HPV test, cytology, colposcopy and pathology were examined before and after treatment. Meanwhile, PDT-related symptoms and adverse reactions were also reviewed. RESULTS: At 6-month follow-up after PDT, except for 5 patients who showed the persistence of LSIL lesions, the pathological regression ratio of 90.1% (50/55) was achieved. No HPV-DNA was detected in exfoliated cervical cells in 81.8% (45/55) patients. Among them, the HPV clearance ratio of I Degree cervical ectropion was 96.2%, significantly higher than that of II Degree (70.8%) and III Degree (60%). Significant shrunk of cervical ectropion and reduction of vaginal secretions after PDT were seen in 78.0% patients. CONCLUSION: ALA-PDT is a safe and effective therapeutic option for patients of reproductive age who suffer from LSIL with high-risk HPV infection and cervical ectropion.

Dramatic Improvement of Severe Cicatricial Ectropion after Discontinuing Long-Term Erlotinib Therapy in a Patient with Lung Cancer

There is no consensus on the choice of systemic and ophthalmic treatment for patients who develop ocular toxicity with erlotinib in the few cases reported previously. Various ocular complications related to erlotinib have been reported, with one of the most serious being corneal perforation. Our patient was at risk of potential corneal perforation because of severe cicatricial ectropion and diffuse punctate corneal epitheliopathy. Therefore, erlotinib treatment was temporarily discontinued with the approval of the oncology department and the patient was closely followed. She was prescribed steroid eye ointment, single-use preservative-free artificial tears, and eye lubricant gel to protect the ocular surface. On day 4 of treatment, the patient's findings were significantly improved. After 1 week, the cicatricial ectropion had dramatically improved and the patient's complaints were completely resolved. To our knowledge, there is no case report of a patient with both ocular toxicity after long-term use that shows dramatic improvement with drug cessation, and severe cicatricial ectropion affecting the entire lower eyelid. Here, we described a patient who used erlotinib for 3 years due to non-small cell lung cancer and developed severe cicatricial ectropion which improved dramatically within one week of temporarily discontinuing erlotinib and discussed the possible reasons. Although ocular complications with erlotinib are usually encountered early in treatment, it should be kept in mind that erlotinib-related ocular complications may also arise with long-term use.

Non-surgical management of congenital ichthyosis using hyaluronic acid gel injection.

AIM: To test if hyaluronic acid gel injection in the upper eyelid achieves correction of congenital cicatricial ectropion and reduction in lagophthalmos, in preparation for intraocular surgery. METHODS: This case reports the long-term outcome of hyaluronic acid gel injection in the upper eyelid for the correction of ectropion prior to cataract surgery. One millilitre of hyaluronic acid gel was injected in both the upper eyelids of a child with congenital ichthyosis in the suborbicularis plane, prior to cataract surgery. RESULTS: Lagophthalmos reduced by 15 mm in the right eye and 13 mm in the left eye. Subsequently, the child underwent cataract surgery without any complications. CONCLUSION: We demonstrate the long-term outcome of using hyaluronic acid gel injection for successful, non-surgical correction of cicatricial ectropion in ichthyosis.

Drug-induced ectropion: what is best practice?

PURPOSE: To review cases of possible drug-induced ectropion and recommend what we consider to be best practice. DESIGN: Retrospective observational case series. PARTICIPANTS: Thirteen consecutive outpatients. METHODS: Records of 13 outpatients on topical medication presenting with topical drug-induced ectropion were retrospectively analyzed. MAIN OUTCOME MEASURES: Eyelid position, topical agent causing the allergy, and medical and surgical management options. RESULTS: In all 13 patients, the ectropion resolved partially or completely after discontinuing the offending topical agent. Dorzolamide (53%) was the most common offending agent, followed by brimonidine (23%). One of the 13 patients underwent failed ectropion surgery correction before referral, but improved once the topical agent was discontinued. Two of the patients successfully underwent surgical correction for ectropion after discontinuing their topical therapy. Those patients who discontinued the topical therapy and had a short course of steroid therapy did not require surgical correction. CONCLUSIONS: This study demonstrates that sensitivity to topical agents can induce ectropion in more than 1 manner. Chronic exposure to the causative agent leads to cicatricial changes in the anterior lamella of the eyelid in susceptible individuals, and can manifest as contact dermatitis leading to tissue edema and mechanical ectropion. Early recognition of this condition and discontinuation of therapy is of paramount importance; it may lead to complete resolution. Topical steroids are a necessary adjunct in the management of drug-induced ectropion. Based on our experience, we propose a management algorithm for drug-induced ectropion.

Resolution of pityriasis rubra pilaris-induced cicatricial ectropion with systemic low-dose methotrexate.

PURPOSE: To report a case of pityriasis rubra pilaris (PRP)-induced bilateral lower eyelid cicatricial ectropion that resolved with systemic low-dose methotrexate. DESIGN: Observational case report. METHODS: A retrospective case review of a patient with cicatricial ectropion caused by PRP. RESULTS: A 82-year-old female presented with bilateral lower eyelid cicatricial ectropion secondary to PRP. The patient did not systemically respond to conventional oral retinoid therapy. She was treated with low-dose methotrexate and experienced dramatic resolution of her signs and symptoms, including complete resolution of her bilateral cicatricial ectropion. CONCLUSION: Systemic treatment of PRP with low-dose methotrexate may result in successful treatment of cicatricial ectropion without surgery.

The role of botulinum toxin in correcting frontalis-induced eyelid pseudo-retraction post ptosis surgery.

We report a case of a 52-year-old female patient who developed overcorrection, due to brow overuse, post surgery for bilateral aponeurotic ptosis. The patient had undergone levator palpebrae superioris plication bilaterally. Due to brow overuse habituated by long standing ptosis, the patient presented with superior scleral show, post ptosis surgery. The lid contour was normal in both eyes and when brow overaction was blocked mechanically, the palpebral fissure heights were normal, comparable, with no scleral show bilaterally. Despite repeated instructions, when the patient continued brow overuse subconsciously, an injection of botulinum toxin was given just above both brows. This led to elimination of brow overuse within a month, with elimination of superior scleral show. The patient maintained lid and brow symmetry with no overaction, eight months post injection.

Congenital eversion of upper eyelids: case report and management.

Congenital eversion of the upper eyelids is a rare condition, the exact cause of which remains unknown. It is more frequently associated with Down's syndrome and black babies. If diagnosed early and treated properly, the condition can be managed without surgery. We report a case of congenital bilateral severe upper eyelid eversion in a normal infant, born by vaginal delivery. The case was conservatively managed by lubricants, antibiotics and eyelid patching.

[Botulinum toxin injection-treatment of upper lid retraction in thyroid eye disease]. / Transkonjunktivale Botulinumtoxininjektion zur Behandlung der Oberlidretraktion bei endokriner Orbitopathie.

OBJECTIVE: Upper lid retraction associated with thyroid eye disease may result in conjunctival and corneal exposure as well as in an esthetic problem. We evaluated the effect of botulinum toxin injections in order to lower the upper lid. METHODS: This prospective study included 19 eyes of 13 female patients presenting with scleral exposure aged 28-50 years. We injected 5-15 IE botulinum toxin A (Botox) transconjunctivally into the levator muscle. Lid position, negative side effects, and patient satisfaction were evaluated. RESULTS: Lid retraction improved from 2.4 mm (+/-1.4 mm) prior to injection to 0.5 mm (+/-2.3 mm) 4 weeks after injection. In 11 of 19 eyes 4 weeks after injection and in 8 of 14 eyes 12 weeks after injection scleral exposure had resolved. Diplopia did not occur and tear production was not influenced. Two eyes had transient ptosis. Lid lag increased from 0.34 (+/-0.6 mm) to 0.84 mm (+/-0.9 mm). Of 13 patients, 8 were satisfied with the result. CONCLUSION: Botulinum toxin A injection provides effective treatment especially in mild lid retraction and as a temporary solution for patients with unstable thyroid disease.

[Use of topical cutaneous N-acetylcysteine in the treatment of major bilateral ectropion in an infant with lamellar ichthyosis]. / Utilisation de la N-acétylcystéine en application topique cutanée dans le traitement d'un ectropion bilatéral chez un enfant atteint d'ichthyose lamellaire.

PURPOSE: To report for the first time bilateral ectropion treatment in an infant with severe lamellar ichthyosis associating N-acetylcysteine applied directly to the skin and oral acitretin. METHODS: An 8-week-old male child with major bilateral ectropion due to lamellar ichthyosis was given treatment associating oral acitretin (Soriatane) and topical N-acetylcysteine. Though the precorneal tear film quality could be maintained, after 1 month of initial treatment with acitretin only, bilateral upper eyelid ectropion remained threatening for the child's cornea. The adjunction of topical N-acetylcysteine enabled a complete regression of ectropion. No complementary surgery was needed and the eyelids remained well positioned. CONCLUSION: Topical N-acetylcysteine has been proved to have an antiproliferative effect on keratinocytes in vitro and in vivo. It may be useful in the treatment of major forms of ectropion in children with lamellar ichthyosis. Its association with conventional acitretin treatment may prevent unnecessary surgery.