Recalcitrant postoperative bleeding after ectropion repair in the setting of undiagnosed chronic disseminated intravascular coagulation.

Disseminated intravascular coagulation (DIC) is characterized by abnormal activation of the coagulation cascade, which leads to simultaneous hypercoagulation and excessive bleeding. While it typically occurs in systemic diseases, such as infection, inflammation, obstetric complications, and malignancy, it can rarely manifest postoperatively. This case report describes a patient who presented with prolonged, refractory bleeding after ectropion repair via a lateral tarsal strip procedure. Due to the inability to control the patient's bleeding with conservative measures followed by surgical exploration and electrocautery, the patient underwent a hematologic work-up. Laboratory studies were consistent with DIC, attributed to his large burden of endovascular stents. He was treated with anticoagulation using apixaban in addition to tranexamic acid to achieve lasting hemostasis. This case highlights the importance of thorough preoperative assessments, even for minor surgical procedures, and systemic workup for atypical postoperative bleeding.

Scleral Contact Lens to Preserve a Corneal Graft in Chronic Lagophthalmos.

Facial burns involving the periorbital region may lead to cicatricial ectropion and lagophthalmos, causing severe exposure keratopathy and eventually blindness if uncorrected. In these patients, it is critical to provide aesthetic and functional surgical correction to protect the ocular surface from chronic desiccation in addition to visual rehabilitation. Conventional methods may not be sufficient to provide visual rehabilitation in complex cases. Scleral lenses can be a multipurpose alternative for these patients. Herein, we present the challenging case of a patient who developed cicatricial lagophthalmos and exposure keratopathy after facial transplantation due to gasoline burns and received a scleral contact lens for visual rehabilitation.

Ectropión congénito en síndrome de Noonan / Congenital ectropion in Noonan syndrome

Caso clínico: Niña de 10 años con dismorfia facial, escoliosis, baja talla, hipotonía muscular, foramen oval permeable y retraso madurativo, acude a consulta para corrección de ectropión congénito bilateral. Al examen oftalmológico se constató ectropión palpebral inferior, euribléfaron y lagoftalmos bilaterales, con fenómeno de Bell positivo. Se realizaron injertos cutáneos autólogos de espesor completo en párpados inferiores con cantoplastia lateral bilateral, resolviendo el ectropión y mejorando la oclusión palpebral. Posteriormente, se hizo un estudio genético que reveló una mutación en el gen PTPN11 y permitió, junto a la clínica, hacer el diagnóstico de síndrome de Noonan (SN).DiscusiónEl SN es un trastorno genético multisistémico con una gran variedad de fenotipos, que suele cursar con alteraciones oculares y perioculares. El ectropión palpebral, característica distintiva de la paciente, es una manifestación oftalmológica infrecuente de este síndrome que puede corregirse con injerto cutáneo de espesor completo y cantoplastia lateral. (AU)

Case report: Ten-year-old female patient, with facial dysmorphia, scoliosis, short stature, muscular hypotonia, patent foramen ovale and maturational delay, presented for correction of bilateral congenital ectropion. Ophthalmological examination revealed bilateral lower eyelid ectropion, euryblepharon and lagophthalmos, with a positive Bell's phenomenon. She was treated with full-thickness autologous skin grafts on the lower eyelids with bilateral lateral canthoplasty, resolving the ectropion and improving eyelid occlusion. Subsequently, a genetic study was performed that revealed a mutation in the PTPN11 gene and allowed, together with the clinical picture, to make the diagnosis of Noonan syndrome.DiscussionNoonan syndrome is a multisystem genetic disorder with a wide variety of phenotypes, which usually presents with ocular and periocular disorders. Eyelid ectropion, a distinctive feature of this patient, is a rare ophthalmological manifestation of this syndrome that can be corrected with full-thickness skin graft and lateral canthoplasty. (AU)

Lateral Tarsoplasty Combined with a Full-Thickness Skin Graft for Managing Severe Lower Eyelid Ectropion Following the Subciliary Approach for Infra-Orbital Rim Fracture: A Retrospective Observational Study.

Subciliary incision is a common approach for facial fracture surgery; however, it has a higher incidence of lower lid ectropion, which can be particularly challenging for beginning surgeons to manage. This study reports the usage of lateral tarsoplasty combined with a full-thickness skin graft (FTSG) to correct severe ectropion following the subciliary approach for infra-orbital rim fractures. We retrospectively reviewed all facial fracture cases involving infra-orbital rim fractures through a subciliary approach treated in our department between March 2021 and May 2023. Electronic medical records and clinical digital photographs of patients who met the inclusion criteria were reviewed. After reviewing 196 cases that used the subciliary approach, we found 6 patients (3.06%; 4 males and 2 females; mean age, 68.5 ± 4.89 years) with postoperative severe ectropion managed using lateral tarsoplasty and FTSG. The mean ectropion development and correction times after facial fracture surgery were 0.78 ± 0.24 and 0.91 ± 0.37 months, respectively. At the 12-month follow-up, all patients showed favorable outcomes, and the position of their lower eyelids was well maintained without ectropion recurrence. Based on these successful outcomes, lateral tarsoplasty combined with FTSG is proposed to be an effective and straightforward method for managing lower eyelid ectropion caused by facial fracture surgery.

Management of Ectropion Associated With a Malunited Zygomaticomaxillary Complex Fracture: A Case Report.

We report the case of a 35-year-old male patient who presented with a right zygomaticomaxillary complex fracture, which was five months old. It was associated with ectropion over the right eye. Diagnosis was made by clinical examination and confirmed by computed tomography, which included a three-dimensional reconstruction view. The patient was concerned about a projecting deformity over the right side of his face and blurring of vision. Surgical rationale of treatment was to easily access the surgical site for the correction of deformity and to achieve the desired facial contour and ectropion correction with uneventful postoperative healing. Deformity at the right zygomatic arch was exposed by a hemicoronal incision. Ectropion over the lower eyelid was addressed by performing Z-plasty. Outcomes were esthetically pleasing with no loss of motor and sensory functions loss. The patient was followed up for six months.

Congenital ectropion in Noonan syndrome.

Ten-year-old female patient, with facial dysmorphia, scoliosis, short stature, muscular hypotonia, patent foramen ovale and maturational delay, presented for correction of bilateral congenital ectropion. Ophthalmological examination revealed bilateral lower eyelid ectropion, euryblepharon and lagophthalmos, with a positive Bell's phenomenon. She was treated with full-thickness autologous skin grafts on the lower eyelids with bilateral lateral canthoplasty, resolving the ectropion and improving eyelid occlusion. Subsequently, a genetic study was performed that revealed a mutation in the PTPN11 gene and allowed, together with the clinical picture, to make the diagnosis of Noonan syndrome. Noonan syndrome is a multisystem genetic disorder with a wide variety of phenotypes, which usually presents with ocular and periocular disorders. Eyelid ectropion, a distinctive feature of this patient, is a rare ophthalmological manifestation of this syndrome that can be corrected with full-thickness skin graft and lateral canthoplasty.

Resolution of Pityriasis rubra pilaris induced ectropion with oral dexamethasone. A case report.

An 82-year-old male presented with generalised Pityriasis rubra pilaris (PRP) managed initially by dermatology team. The patient did not respond to first- and second-line treatment, including oral acitretin, steroid creams, and methotrexate, and developed bilateral cicatricial ectropion, for which he was referred to oculoplastic team for surgical management. A head injury resulting in subacute subdural haematoma, managed with a week course of low dose oral dexamethasone, resulted in the improvement of his skin condition and complete resolution of the cicatricial ectropion within a few weeks. Thus, systemic treatment of PRP with oral dexamethasone may be considered sooner in the treatment of cicatricial ectropion in similar cases.

Evaluation of dry eye disease and corneal epithelial mapping in patients with lower eyelid ectropion.

PURPOSE: To evaluate the corneal epithelial mapping, ocular surface parameters and their relationship with each other in lower eyelid ectropion patients according to severity. METHODS: This retrospective study included 48 lower eyelid ectropion patients and 63 healthy individuals as control group. Ocular surface and tear functions were evaluated with ocular surface staining score, tear film break-up time (BUT), non-invasive tear break-up time (NIBUT) and ocular surface disease index (OSDI). Meibography scores and corneal epithelial thickness (CET) mapping were evaluated. The lower eyelid ectropion was classified and divided into subgroups as follows: mild, moderate and severe. RESULTS: There was no significant differences between the groups for age and gender. Compared to controls, CET was significantly thinner at inferior (p = 0.047) and inferior nasal quadrants (p = 0.023) in the ectropion patients. Lower BUT and NIBUT, higher OSDI scores and higher ocular surface staining were observed in the ectropion patients. In the subgroups determined according to the severity of ectropion, ocular surface damage was found to be significantly higher as the severity of ectropion increased (p < 0.05). CONCLUSION: Patients with lower eyelid ectropion had worse ocular surface findings and more ocular complaints. Furthermore, the inferior and inferior nasal CETs were thinner in patients with lower ectropion.

Short-term qualitative and quantitative analyses of preseptal injection of hyaluronic acid on the treatment of acquired lower eyelid cicatricial ectropion / Análise preliminar qualitativa e quantitativa da injeção pré-septal de ácido hialurônico para tratamento do ectrópio cicatricial adquirido da pálpebra inferior

ABSTRACT 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.

RESUMO Objetivo: Recentemente, o ácido hialurônico foi proposto como promissor no tratamento do ectrópio cicatricial adquirido da pálpebra inferior. No entanto, não foram feitas avaliações quantitativas para confirmar este efeito, motivo que levou a realização do presente estudo que visou avaliar o efeito do ácido hialurônico no tratamento do ectrópio cicatricial adquirido da pálpebra inferior. Métodos: Oito portadores de ectrópio cicatricial adquirido da pálpebra inferior (13 pálpebras) foram tratados com uma única dose de 1 mL de ácido hialurônico, injetada na área pré-septal da pálpebra inferior. Os sintomas e o exame biomicroscópico foram realizados antes e 30 dias após a injeção do ácido hialurônico. A análise quantitativa da posição palpebral inferior (com e sem tração palpebral) foi determinada antes e 30 dias após a injeção do ácido hialurônico por meio de fotografias que foram analisadas usando o programa ImageJ. Resultados: Todos os pacientes apresentaram melhora parcial dos sintomas. A posição da pálpebra inferior foi elevada significativamente após a injeção do ácido hialurônico, com redução significativa dos ângulos medial e lateral, da distância entre o reflexo pupilar e a margem da pálpebra inferior, da área de fissura palpebral total e da área medial. No entanto, sinais de inflamação da margem palpebral e ceratite puntata da córnea persistiram. Conclusões: O ácido hialurônico injetado na área pré-septal da pálpebra inferior, melhorou os sintomas do ectrópio cicatricial adquirido da pálpebra inferior e elevou significativamente a posição da pálpebra inferior. Estudos com maior número de participantes e período de acompanhamento mais longo são necessários para melhor determinar os efeitos das injeções de ácido hialurônico a longo prazo no tratamento do ectrópio cicatricial adquirido da pálpebra inferior.

Prenatal ultrasound detection of collodion membrane in association with an autosomal recessive congenital ichthyosis due to transglutaminase 1 deficiency.

We describe a case of collodion baby diagnosed prenatally by ultrasound. Classic signs (ectropion, flattened nose, and eclabion) were detected on routine ultrasound at 21 weeks of gestation. At birth, the presence of collodion membrane was confirmed and subsequently, the diagnosis of an autosomal recessive congenital ichthyosis due to compound heterozygosity of the TGM1 gene was made.

Clinical features, evaluation, and management of ophthalmic complications of facial paralysis: A review.

The purpose of this review was to study the evaluation, diagnosis, and management of ophthalmic complications associated with facial nerve palsy and to discuss the current and future interventions. The ophthalmic complications of facial paralysis include lagophthalmos, ectropion, exposure keratopathy, ocular synkinesis, and crocodile tears. Evaluation by an ophthalmologist skilled in recognizing and managing complications of facial paralysis shortly after its initial diagnosis can help identify and prevent long-term complications. Several types of grading scales are used to evaluate, measure the severity, and track surgical and patient-reported treatment outcomes. Lagophthalmos or ectropion are managed using temporary measures aimed at lubricating and covering the eye, including scleral lenses; however, these measures can be expensive and challenging to acquire and maintain. Temporary surgical interventions include lateral tarsorrhaphy, weighted eyelid implants, lateral canthoplasty, and other procedures that tighten or lift the eyelid or surrounding tissues. Management of flaccid facial paralysis due to iatrogenic injury or neoplasm requires neurorrhaphy or graft repair. The most common techniques for dynamic reconstruction in chronic facial paralysis are regional and free muscle flap transfer. Future directions for the management of ophthalmic complications aim to induce blinking and eye closure by developing systems that can detect blinking in the normal eye and transmit the signal to the paralyzed eye using mechanisms that would stimulate the muscles to induce eyelid closure. Blink detection technology has been developed, and a study demonstrated that blinking can be stimulated using electrodes on the zygomatic branch of the facial nerve. Further studies are needed to develop a system that will automate blinking and synchronize it with that of the normal eye.

Ophthalmic findings in patients with autosomal recessive lamellar ichthyosis due to TGM1 mutations in an isolated population.

PURPOSE: To describe the ocular clinical characteristics of a group of Mexican patients with lamellar ichthyosis (LI) arising from TGM1 pathogenic variants. METHODS: Ophthalmological exploration, pedigree analysis and genetic screening were performed in patients with an established clinical diagnosis of lamellar ichthyosis from families located in a small community in the Southeast of Mexico. RESULTS: Nine patients with LI in five families were identified. There were six affected females. All patients (9/9) demonstrated eye lid abnormalities with eight patients showing lid margin abnormalities. Madarosis was present in only three individuals and corneal scarring was documented in two. All nine individuals carried biallelic TGM1 variants, either homozygously or as compound heterozygous. CONCLUSION: Ocular anomalies are common in individuals with TGM1-related LI. The occurrence of a variety of private or rare mutations hampers the identification of a genotype-phenotype correlation for ocular anomalies in this disorder.

Reconstruction of Bilateral Upper and Lower Eyelid Ectropion Caused by a Liquid Unblocker Chemical Burn.

Liquid drain unblockers, although meant to be used by professionals with protective equipment, are sometimes used in the household without any precautions. This could lead to severe chemical burns, as in the case we present with severe eyelid ectropion. This study aims to stress the need for preventive measures regarding the use of chemicals and for close observation and timely surgical intervention in chemical burn patients to prevent and limit disfigurement. A 45-year-old woman was injured while using an unblocker (90% sulfuric acid) at home. Accidentally, a quantity of the liquid was spilled on her face. She was initially examined in ophthalmology emergencies because of the obvious ocular involvement, and the cutaneous component was underestimated. On the third post-burn day, she was referred as an outpatient to our clinic, and because of the soft consistency and patchy pattern of the burn, she was asked to revisit in a week. Unfortunately, she reappeared two months post-burn with severe ectropion of all four eyelids and a high risk of corneal abrasion, desiccation, and further damage to the already injured left eye as well as the right eye. She underwent three operations in six months and a fourth 15 months after the accident, with the release of the scarred eyelids with full-thickness skin grafts, Z-plasties, and V-Y plasties. After four operations and sessions of triamcinolone acetonide intralesional injection, the patient has a satisfactory eyelid position and function with adequate closure and scar maturation. Domestic use of strong industrial chemicals is dangerous, and public education for prevention is urgently needed. On the other hand, it is mandatory to follow up very closely with chemical burn patients to prevent severe sequelae, especially in the delicate and contraction-prone periocular and perioral areas. Reconstruction, in these cases, is a complex task. Often, several surgeries are needed to restore acceptable function and appearance. Burn disfigurement and self-stigma will follow the patients to some extent throughout their lives.

[Modern opportunities of lagophthalmos correction]. / Sovremennye vozmozhnosti korrektsii lagoftal'ma.

The main goal in the treatment of lagophthalmos is prevention of serious corneal complications. Based on the results of 2453 surgeries performed in patients with lagophthalmos, a detailed analysis of modern surgical techniques was carried out highlighting their advantages and disadvantages. The article describes in detail the most effective methods of static correction of lagophthalmos, their features and indications, and presents the results of using an original palpebral weight implant.

Collodion baby with ectropion in a Syrian newborn: a case report study.

Collodion baby is a rare congenital disorder and a very intense disorder in which the baby suffers from several complications, such as trans-epidermal water loss. Only ∼270 cases of collodion babies have been reported in the literature since 1892. This disease may later develop one of a spectrum of diseases including lamellar ichthyosis, which the patient may had Congenital lamellar ichthyosis with ectropion, which was clinically distinguished by the collodion baby phenotype at birth. Case presentation: The authors are reporting the first case in Syria, a 20-day-old white Syrian male newborn, vaginally delivered at 38 weeks of pregnancy, with normal conditions, and congenital lamellar ichthyosis was shown by physical examination, as parchment-like scales were covering the newborn's skin, which was starting to detach and showing the "collodion baby" appearance. Ophthalmologic examination revealed a bilateral ectropion of the upper eyelids with tarsal eversion. A treatment of Tobramycin 0.3% eye ointment was prescribed four times a day, with a viscotears liquid gel eye drops 4 times a day, and vaseline petroleum jelly to be applied three times daily. At 2-month follow-up, a significant improvement was noted. Conclusion: Ichthyosis have a wide range of disorders that involve the skin and have inherited and acquired forms. As a result, keratolytic and systemic retinoids can have significant benefits in restoring skin function.

Unilateral chronic angle-closure glaucoma in a pediatric patient with neurofibromatosis: a case report.

Neurofibromatosis type 1 (NF1) is an autosomal dominant genetic disease that causes multi-system damage. It is rarely associated with angle-closure glaucoma, especially in pediatric patients. We herein report a case of unilateral chronic angle-closure glaucoma in a patient with NF1. A 5-year-old girl with a large subcutaneous soft mass and multiple scattered coffee-milk spots presented with low vision, increased intraocular pressure, and angle closure in her right eye. Lisch nodules were seen in both eyes. In her right eye, ectropion uveae was observed at the top and bottom margins of the pupil. Magnetic resonance imaging of the skull and orbit revealed no abnormalities. Finally, trabeculectomy was performed on the right eye, after which the right eye showed a stable intraocular pressure. NF1 combined with angle-closure glaucoma is rare and easily missed in the clinical setting. Early diagnosis and treatment may achieve good results.

[Painful anisocoria in a five-year-old child: A rare diagnosis which must not be missed]. / Anisocorie douloureuse chez un enfant de cinq ans : un diagnostic rare à ne pas méconnaître.

Congenital ectropion uveae (CEU) is a rare anomaly of the embryonic development of the anterior segment of the eye. We report the case of a 5-year-old child with an undiagnosed CEU who was treated urgently for an acute angle closure attack. CASE DESCRIPTION: A 5-year-old child was referred urgently for evaluation of anisocoria with mydriasis of the right eye and severe headache. Brain imaging with contrast injection was initially performed in the pediatric emergency department and ruled out central nervous system pathology. The initial examination of the right eye revealed an intraocular pressure (IOP) of 37mmHg, corneal edema, congenital ectropion uveae, mydriasis with pupillary block, a closed angle on gonioscopy, and a clear lens. The examination of the left eye was unremarkable, with no visible CEU. The initial management consisted of medical treatment with topical glaucoma drops and miotics and acetazolamide at 10mg/kg/d. Re-evaluation under general anesthesia showed persistent mydriasis and no resolution of the pupillary block. Filtering surgery was performed in the absence of a complete response to medical treatment, allowing control of IOP without drops and complete regression of the corneal edema. DISCUSSION: CEU is a rare malformation, and pressure complications represent an insignificant proportion of pediatric glaucoma cases. The acute presentation of acute angle closure in this potentially blinding short-term setting, however, makes detection and management difficult in very young children in a great deal of pain. Only one similar case has been reported in the pediatric literature. CONCLUSION: Acute angle closure complicating CEU is exceptional and difficult to diagnose in a pediatric context. Parents of children with this predisposing condition should be informed of the need to consult urgently when clinical signs of elevated intraocular pressure appear.

Acquired ectropion uveae: A case series.

Acquired ectropion uveae (AEU) is a common sequela to various inflammatory and ischemic conditions, though it is not well recognized. There is a paucity of literature describing AEU. So here, we present five cases where we documented ectropion uveae following chronic inflammation. Patients with ectropion uveae following chronic inflammation and ischemia were retrospectively reviewed. Their medical records and clinical findings were analyzed. Five patients of various ages were found to have AEU, of which 1 was post trabeculectomy with phacoemulsification and posterior chamber intraocular lens, 1 following neovascular glaucoma (NVG), 1 following uveitic glaucoma, and 2 following iridocorneal endothelial syndrome. Patients with NVG and uveitic glaucoma also had undergone glaucoma filtration surgeries. AEU may be seen secondary to inflammatory and ischemic processes and should be looked for carefully as they may cause progressive glaucoma.

First unilateral glaucoma in an Omani boy with neurofibromatosis type 1 initially presented as proptosis with ectropion uvea.

A 4½-year-old boy presented to the ophthalmology clinic with intermittent left eye (LE) redness, protrusion, and reduced LE vision. He was noticed to have multiple skin hyperpigmented lesions increasing in size and number since birth. Clinically diagnosed as neurofibromatosis (NF)-type I associated with LE glaucoma, axial myopia, and amblyopia. He was started on topical timolol eye drops, then switched his timolol to latanoprost due to parasomnia (sleep disturbances and sleepwalking), and his symptoms improved significantly within 6 weeks with controlled intraocular pressure. NF-1 is a congenital multisystemic disease which needs special attention and continuous monitoring. Unilateral glaucoma is not a common association but can be the presenting ophthalmic manifestation. Multidisciplinary management is crucial for these patients.

Ectropion following topical 5-fluorouracil treatment.

Topical 5-fluorouracil is a common treatment for actinic keratoses. Its side effects may include intense erythema, erosions, contact dermatitis, systemic intolerance in susceptible individuals, and ulcerations. We present a case of a 78-year-old woman who developed unilateral ectropion after topical 5-fluorouracil application. This case highlights the importance of clear patient instruction while prescribing topical 5-fluorouracil. Patients should be advised to wash their hands thoroughly after application. We also stress the importance of counseling patients to keep the medication away from the orbital rim, eye, and eyelid.