Ectropion

Overview

Ectropion is a condition in which the eyelid, usually the lower lid, turns outward (everts), exposing the inner surface of the eyelid and the eyeball. This abnormal positioning disrupts the normal anatomy and function of the eyelid, leading to inadequate eye protection and improper tear drainage. The exposed inner eyelid (palpebral conjunctiva) and cornea become irritated, dry, and prone to infection. While ectropion can affect people of any age, it most commonly occurs in older adults due to age-related changes in the tissues supporting the eyelid.

The condition ranges from mild, where only a small portion of the eyelid sags away from the eye, to severe cases where the entire eyelid is turned outward. The severity often determines the degree of symptoms and the urgency of treatment. In mild cases, patients may experience minor irritation and excessive tearing, while severe ectropion can lead to significant corneal exposure, chronic conjunctivitis, and even vision-threatening complications such as corneal ulceration and scarring.

Ectropion affects approximately 2-3% of people over age 60, with prevalence increasing with advancing age. The condition is slightly more common in men than women, possibly due to differences in facial anatomy and skin elasticity. While most cases are acquired and develop gradually, congenital ectropion can occur, though it is rare. The impact on quality of life can be significant, as the constant eye irritation, tearing, and cosmetic concerns can affect daily activities, social interactions, and overall well-being. Fortunately, ectropion is highly treatable, with surgical correction offering excellent outcomes in most cases.

Symptoms

The symptoms of ectropion result from the abnormal eyelid position exposing the eye and disrupting normal tear flow. Symptoms typically worsen over time if left untreated.

Primary Symptoms

Associated Symptoms

Physical Signs

• Visible eyelid malposition: Lower lid sagging or turning outward
• Exposed conjunctiva: Pink inner eyelid tissue visible
• Punctal eversion: Tear drainage opening turned away from eye
• Lid laxity: Loose, stretched eyelid that can be pulled away easily
• Skin changes: Redness, thickening of exposed lid skin
• Tear staining: Discoloration of cheek from chronic tearing

Complications if Untreated

• Exposure keratopathy: Corneal drying and damage
• Corneal abrasion: Scratches from inadequate protection
• Corneal ulceration: Open sores on the cornea
• Chronic conjunctivitis: Persistent inflammation
• Vision loss: From corneal scarring in severe cases
• Psychological impact: Self-consciousness about appearance

Causes

Ectropion can result from various factors that weaken or alter the normal eyelid support structures. Understanding the underlying cause is crucial for appropriate treatment.

Involutional (Age-Related) Ectropion

• Most common type (90% of cases):
  • Weakening of eyelid muscles (orbicularis oculi)
  • Stretching of canthal tendons
  • Loss of skin elasticity
  • Horizontal lid laxity
  • Atrophy of orbital fat
• Progressive changes:
  • Gradual onset over years
  • Usually affects lower lids bilaterally
  • Worsens with gravity and time

Paralytic Ectropion

• Facial nerve palsy (Bell's palsy):
  • Loss of orbicularis muscle tone
  • Lower lid drops due to paralysis
  • Often accompanied by lagophthalmos
  • May be temporary or permanent
• Other neurological causes:
  • Stroke affecting facial nerve
  • Brain tumors
  • Möbius syndrome
  • Surgical nerve damage

Cicatricial (Scarring) Ectropion

• Skin conditions:
  • Chemical burns
  • Thermal injuries
  • Trauma with tissue loss
  • Previous surgery complications
• Inflammatory conditions:
  • Chronic dermatitis
  • Rosacea
  • Eczema
  • Drug reactions (Stevens-Johnson syndrome)
• Radiation therapy:
  • Treatment for facial cancers
  • Causes skin contracture
  • May develop years after treatment

Mechanical Ectropion

• Tumors or masses:
  • Eyelid tumors pulling lid down
  • Orbital masses
  • Herniated orbital fat
• Edema:
  • Allergic reactions
  • Thyroid eye disease
  • Chronic inflammation

Congenital Ectropion

• Down syndrome
• Blepharophimosis syndrome
• Ichthyosis
• Microphthalmos with cyst
• Rare isolated defect

Risk Factors

Several factors increase the likelihood of developing ectropion:

Age-Related Factors

• Advanced age: Primary risk factor
  • Risk increases after age 60
  • Highest prevalence in 80+ age group
  • Progressive tissue changes
• Gender: Slightly higher risk in males
• Genetic factors: Family history of lid laxity

Medical Conditions

• Previous eye conditions:
  • Chronic conjunctivitis
  • Blepharitis
  • Previous eye surgery
  • Thyroid eye disease
• Skin conditions:
  • Dermatitis
  • Psoriasis
  • Rosacea
  • Seborrheic dermatitis
• Systemic conditions:
  • Connective tissue disorders
  • Down syndrome
  • Facial nerve disorders

Environmental and Lifestyle Factors

• Sun exposure: Chronic UV damage to skin
• Smoking: Accelerates skin aging
• Eye rubbing: Chronic mechanical stress
• Sleep position: Sleeping face-down
• Occupational hazards: Chemical exposure

Iatrogenic Factors

• Previous blepharoplasty (overcorrection)
• Facial cosmetic procedures
• Radiation therapy to face
• Certain medications causing skin changes

Diagnosis

Diagnosis of ectropion is primarily clinical, based on observation and examination. Additional tests help determine the underlying cause and plan treatment.

Clinical Examination

• Visual inspection:
  • Eyelid position at rest
  • Degree of lid eversion
  • Punctal position
  • Symmetry between eyes
• Dynamic assessment:
  • Lid movement with blinking
  • Forced eye closure
  • Looking up and down
  • Smiling (checks facial nerve)

Specific Tests

• Snap-back test:
  • Pull lower lid down
  • Release and observe return
  • Normal: immediate snap back
  • Abnormal: slow or no return
• Distraction test:
  • Pull lid away from globe
  • Measure distance (>6mm abnormal)
  • Indicates horizontal laxity
• Pinch test:
  • Assess medial canthal tendon
  • Lateral canthal tendon integrity

Ocular Surface Evaluation

• Slit lamp examination:
  • Corneal staining with fluorescein
  • Conjunctival inflammation
  • Tear film assessment
  • Lid margin evaluation
• Schirmer test: Tear production measurement
• Tear breakup time: Tear film stability

Additional Assessments

• Photography:
  • Document severity
  • Track progression
  • Surgical planning
  • Compare pre/post treatment
• Neurological evaluation:
  • If paralytic cause suspected
  • Facial nerve function
  • Bell's phenomenon
• Imaging (if indicated):
  • CT/MRI for masses
  • Assess orbital pathology

Classification

• By severity:
  • Mild: Punctum everted only
  • Moderate: Partial lid eversion
  • Severe: Complete lid eversion
• By location:
  • Medial ectropion
  • Lateral ectropion
  • Total ectropion

Treatment Options

Treatment depends on the severity, underlying cause, and impact on the patient's quality of life. Options range from conservative management to surgical correction.

Conservative Management

• Lubricating eye drops:
  • Artificial tears during day (preservative-free)
  • Use frequently (every 1-2 hours)
  • Gel drops for longer lasting effect
• Lubricating ointments:
  • Applied at bedtime
  • Protects cornea overnight
  • May blur vision temporarily
• Moisture chambers:
  • Protective eyewear
  • Reduces evaporation
  • Side shields on glasses
• Taping:
  • Temporary measure
  • Tape lower lid up at night
  • Skin-friendly tape only

Medical Management

• Anti-inflammatory drops:
  • For associated inflammation
  • Short-term corticosteroids
  • Cyclosporine for chronic cases
• Antibiotics:
  • For secondary infection
  • Topical erythromycin or bacitracin
  • Oral antibiotics if severe
• Botulinum toxin:
  • For paralytic ectropion
  • Induces protective ptosis
  • Temporary measure

Surgical Correction

• Lateral tarsal strip procedure:
  • Most common surgery
  • Tightens horizontal lid laxity
  • High success rate
  • Outpatient procedure
• Medial spindle procedure:
  • For medial ectropion
  • Removes diamond of conjunctiva
  • Tightens medial lid
• Retractor reinsertion:
  • Reattaches lower lid retractors
  • Combined with other procedures
  • Improves lid position
• Full-thickness skin graft:
  • For cicatricial ectropion
  • Replaces scarred skin
  • Usually from upper lid or behind ear

Specialized Procedures

• For paralytic ectropion:
  • Gold weight implantation
  • Palpebral spring
  • Temporalis muscle transfer
  • Facial reanimation surgery
• For complex cases:
  • Midface lifting
  • Canthopexy or canthoplasty
  • Combined procedures

Post-Operative Care

• Cold compresses first 48 hours
• Antibiotic ointment to incisions
• Head elevation when sleeping
• Avoid straining or heavy lifting
• Follow-up at 1 week, 1 month
• Suture removal at 5-7 days

Expected Outcomes

• Success rate >90% for involutional ectropion
• Immediate symptom improvement
• Cosmetic improvement
• Low recurrence rate
• Complications rare

Prevention

While age-related ectropion cannot be entirely prevented, certain measures may help reduce risk or slow progression:

Eye Protection

• Sun protection:
  • Wear UV-blocking sunglasses
  • Wide-brimmed hats
  • Avoid excessive sun exposure
  • Use sunscreen around eyes
• Avoid eye trauma:
  • Protective eyewear for sports
  • Safety glasses for work
  • Careful with chemicals

Healthy Habits

• Gentle eye care:
  • Avoid aggressive rubbing
  • Remove makeup gently
  • Use hypoallergenic products
  • Keep eyelids clean
• General health:
  • Don't smoke
  • Stay hydrated
  • Healthy diet rich in antioxidants
  • Regular exercise

Medical Management

• Treat allergies and skin conditions promptly
• Manage chronic eye conditions
• Regular eye examinations
• Early intervention for lid problems
• Careful selection of cosmetic procedures

For High-Risk Individuals

• Monitor for early signs
• Prophylactic lubrication
• Avoid sleeping face-down
• Consider preventive taping if recommended
• Regular follow-up with eye care provider

When to See a Doctor

Early evaluation and treatment of ectropion can prevent complications and improve outcomes. Seek medical attention for:

See an Eye Doctor Promptly For:

• Eyelid turning outward, even slightly
• Excessive tearing that doesn't improve
• Chronic eye redness or irritation
• Feeling of something in the eye
• Mucous discharge from eyes
• Light sensitivity increasing over time
• Blurred vision with eye symptoms

Seek Urgent Care If:

• Severe eye pain develops
• Sudden vision loss or changes
• Signs of corneal ulcer (white spot on eye)
• Inability to close eye completely
• Facial weakness or drooping (possible stroke)
• Eye injury with lid involvement

During Your Appointment:

• Be prepared to discuss:
  • When symptoms started
  • Previous eye problems
  • Medications you're taking
  • Any facial trauma or surgery
  • Family history of eye problems
• Questions to ask:
  • What type of ectropion do I have?
  • Will it get worse without treatment?
  • What are my treatment options?
  • When should I consider surgery?
  • What are the risks if left untreated?

Follow-up Care:

• Regular monitoring if mild
• Track symptom progression
• Post-surgical check-ups
• Annual eye exams
• Report any new symptoms

Related Conditions

References

1. Bedran EG, et al. Ectropion. StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023.
2. Mitchell P, et al. Prevalence of eyelid disorders in the Blue Mountains Eye Study. Australian and New Zealand Journal of Ophthalmology. 2021;49(3):242-248.
3. Damasceno RW, et al. Involutional ectropion and entropion: pathogenesis and treatment. Current Opinion in Ophthalmology. 2019;30(5):388-393.
4. Pereira MG, Rodrigues MA, Rodrigues SA. Eyelid entropion and ectropion. Seminars in Ophthalmology. 2020;35(4):219-226.
5. American Academy of Ophthalmology. Ectropion and Entropion. EyeWiki. 2023.
6. Vallabhanath P, Carter SR. Ectropion and entropion. Current Opinion in Ophthalmology. 2020;31(5):394-398.