Involutional
- Mechanism
- Horizontal lid laxity (canthal tendon dehiscence)
- Key Clinical Clue
- Positive snap-back test, lid distraction >6 mm
- Surgical Treatment
- Lateral tarsal strip (gold standard)
Ectropion
Oculoplasty
Key Points
- •Involutional ectropion is the most common type — caused by age-related horizontal lid laxity from canthal tendon dehiscence
- •Lateral tarsal strip (LTS) is the gold standard surgery for involutional ectropion — >90% success rate
- •Snap-back test and lid distraction test (>6 mm = significant) are the key clinical assessments for horizontal laxity
- •Cicatricial ectropion requires anterior lamella replacement (skin graft) — never simply tighten the lid horizontally without addressing the skin shortage
- •Paralytic ectropion from CN VII palsy coexists with lagophthalmos — corneal protection is the priority (gold weight + lubrication + LTS)
Ectropion is outward turning (eversion) of the eyelid margin away from the globe, primarily affecting the lower lid. It results in exposure of the palpebral conjunctiva, disruption of the lacrimal pump mechanism, and secondary ocular surface disease.
Primarily affects the lower eyelid.
Involutional (age-related) ectropion is the most common type — prevalence increases with age, affecting up to 2–3% of adults over 60, rising sharply to 10–17% in those over 80.
Male predominance for involutional type (prevalence ~5% in men vs ~1.5% in women over 60).
Cicatricial ectropion common after burns, trauma, skin conditions.
Paralytic ectropion: associated with CN VII palsy.
Involutional (most common): age-related horizontal lid laxity from canthal tendon dehiscence + orbicularis weakness → lid sags away from globe.
Cicatricial: shortening of anterior lamella (skin) from burns (thermal/chemical), trauma, chronic dermatitis, actinic damage, post-surgical scarring, ichthyosis.
Paralytic: CN VII (facial nerve) palsy → loss of orbicularis tone → lower lid falls away from globe. Causes: Bell palsy, acoustic neuroma surgery, stroke, parotid tumour.
Mechanical: lid mass (tumour, chalazion) weighing lid down, or conjunctival chemosis pushing lid outward.
Congenital: rare, associated with Down syndrome, blepharophimosis syndrome.
Involutional: progressive stretching of lower lid retractors, canthal tendons, and orbicularis muscle with age → horizontal lid laxity → lid margin falls away from globe → punctum everts → loss of lacrimal pump function → epiphora → chronic wiping of tears further stretches lid → worsening cycle.
Cicatricial: contracture/shortage of anterior lamella (skin + orbicularis) pulls lid margin outward → conjunctival exposure.
Paralytic: loss of orbicularis oculi tone (CN VII) → lower lid support lost → gravitational ectropion + lagophthalmos (incomplete closure).
By aetiology:
- Involutional (senile) — most common; horizontal lid laxity
- Cicatricial — anterior lamella shortage (skin contracture)
- Paralytic — CN VII palsy
- Mechanical — lid mass or conjunctival oedema
- Congenital — rare
By degree:
- Punctal ectropion (medial) — punctum everted, epiphora
- Generalised ectropion — entire lower lid margin everted
By severity:
- Mild: punctal eversion only
- Moderate: lid margin eversion with conjunctival exposure
- Severe: complete eversion with corneal exposure and keratinisation of conjunctiva
- Advanced age (involutional).
- Previous lower lid surgery (blepharoplasty — over-resection of skin).
- Facial burns or trauma.
- Chronic sun exposure (actinic skin damage).
- Facial nerve palsy (Bell, surgical, stroke).
- Down syndrome (congenital).
- Chronic lid rubbing/wiping.
- Severe dermatological conditions (eczema, atopic dermatitis, ichthyosis).
Symptoms: epiphora (tearing — due to punctal eversion and loss of lacrimal pump), foreign body sensation, ocular surface irritation, cosmetic concern.
Signs:
- Lower lid margin turned outward (away from globe)
- Exposed palpebral conjunctiva (may become keratinised and thickened)
- Punctum everted and visible (not in tear lake)
- Horizontal lid laxity (snap-back test positive: lid does not spontaneously return to globe — >6 mm distraction = significant)
- Inferior corneal SPK (exposure keratopathy)
- Conjunctival injection and chemosis
- Secondary eczematisation of lid skin (from chronic tearing)
Specific to type:
- Cicatricial: visible skin scar/contracture pulling lid down
- Paralytic: incomplete eye closure (lagophthalmos), reduced blink, loss of forehead wrinkles (ipsilateral), mouth droop
- Mechanical: visible mass weighing lid down
Clinical examination usually sufficient.
- Snap-back test: pull lower lid down and release — delayed return indicates horizontal laxity.
- Lid distraction test: pull lid away from globe; >6 mm = significant laxity.
- Assess medial and lateral canthal tendon laxity.
- Assess CN VII function (forehead wrinkling, eye closure, smile).
- Corneal examination: SPK (fluorescein staining), exposure keratopathy.
- Schirmer test: if associated dry eye.
- MRI/CT: if CN VII palsy of unknown aetiology.
Entropion — lid turns INWARD (opposite direction); lashes abrade cornea.
Floppy eyelid syndrome — upper lid easily everts with gentle upward traction during sleep; associated with obstructive sleep apnoea.
Lagophthalmos without ectropion — incomplete closure from proptosis (TED), post-blepharoplasty, CN VII palsy.
Lower lid retraction — lid margin lower than normal but not everted; common in TED.
Conjunctivochalasis — redundant conjunctiva over lower lid; may mimic epiphora of ectropion.
Chronic epiphora → eczematisation of periocular skin.
Exposure keratopathy → corneal ulceration → perforation (in severe paralytic cases).
Keratinisation of exposed palpebral conjunctiva.
Recurrent conjunctivitis.
Corneal scarring.
Amblyopia (rare — only in congenital cases).
Psychological impact (cosmetic).
Conservative (temporary/adjunctive):
- Lubricating drops and ointment (prevent corneal drying).
- Taping lid closed at night (paralytic ectropion).
- Moisture chamber spectacles.
- Treat underlying cause (e.g., dermatitis, tumour).
Surgical (definitive):
Involutional:
- Lateral tarsal strip (LTS) — GOLD STANDARD. Tighten horizontal lid laxity by shortening lid at lateral canthus. >90% success.
- Medial conjunctivoplasty (lazy-T procedure): for medial/punctal ectropion — combines conjunctival resection with horizontal tightening.
Cicatricial:
- Release skin contracture + full-thickness skin graft (FTSG) from upper lid, post-auricular, or supraclavicular donor site.
- Z-plasty for linear scars.
Paralytic:
- Temporary: gold/platinum weight implant in upper lid (improves closure) + lateral tarsal strip for lower lid.
- Tarsorrhaphy (temporary or permanent) for corneal protection.
- Definitive: facial nerve repair/reanimation if indicated.
Mechanical:
- Remove causative mass + horizontal lid tightening if needed.
Involutional: excellent surgical outcome with lateral tarsal strip (>90% success).
Cicatricial: good with adequate skin grafting, but may require revision.
Paralytic: depends on CN VII recovery. Gold weight + LTS provides good corneal protection.
Recurrence possible if underlying cause not addressed.
Corneal complications preventable with timely surgery.
Clinical Pearls
1
Lateral tarsal strip is the GOLD STANDARD for involutional ectropion — tightens the lid horizontally by reattaching the lateral canthal tendon.
2
The snap-back test and lid distraction test are the key clinical assessments — >6 mm lid distraction or failure to snap back indicates significant horizontal laxity requiring surgical correction.
3
Paralytic ectropion from CN VII palsy often coexists with lagophthalmos — corneal protection is the priority (gold weight + lubrication + lower lid tightening).
4
In cicatricial ectropion, never simply tighten the lid horizontally — the anterior lamella shortage MUST be addressed with a skin graft or flap.
5
Chronic epiphora from ectropion causes skin eczematisation, which leads to more wiping, which worsens the laxity — a vicious cycle that only surgery breaks.
6
Post-blepharoplasty ectropion is the most common complication of lower lid blepharoplasty — caused by over-resection of skin (anterior lamella shortage).
7
The medial spindle/conjunctivoplasty (lazy-T procedure) is specifically designed for medial/punctal ectropion — it shortens the conjunctiva and repositions the punctum.
8
Exam Trap: Involutional ectropion is the most common type — caused by horizontal lid laxity from canthal tendon dehiscence. The snap-back test (lid fails to return to globe) is positive. Do not confuse with cicatricial ectropion, which requires skin grafting.
9
Exam Trap: Cicatricial ectropion has visible skin scarring or shortage (anterior lamella deficit) pulling the lid down. Treatment requires release of contracture + full-thickness skin graft — a lateral tarsal strip alone will fail because it does not address the skin deficit.
10
Exam Trap: Medial ectropion causes epiphora (excessive tearing) because punctal eversion prevents the punctum from sitting in the tear lake, disrupting the lacrimal pump mechanism. Patients often chronically wipe tears, which further stretches the lid — a vicious cycle.
Oral-exam questions
- What is the gold standard surgery for involutional ectropion? — Lateral tarsal strip (LTS) — it tightens horizontal lid laxity by shortening the lateral aspect of the lid and reattaching it to the lateral orbital tubercle (Whitnall tubercle).
- What clinical tests assess horizontal lid laxity? — Snap-back test (pull lid down, release — should snap back immediately) and lid distraction test (pull lid away from globe — >6 mm is significant). Both indicate canthal tendon laxity.
- Why should you never simply tighten the lid in cicatricial ectropion? — Because the anterior lamella shortage (skin deficit) is the primary pathology. Tightening alone will recur or worsen. Must release the contracture and replace skin with a full-thickness skin graft.
- What is the best donor site for full-thickness skin graft in cicatricial ectropion? — Upper lid skin (best colour/thickness match), post-auricular skin (good match, hidden donor site), or supraclavicular skin.
- What is the lazy-T procedure? — Medial conjunctivoplasty combined with a full-thickness wedge excision and diamond conjunctival resection — specifically for medial/punctal ectropion where the punctum is everted causing epiphora.
- How does a gold weight help in paralytic ectropion? — A gold or platinum weight (0.6–1.6 g) is implanted in the upper lid to improve eyelid closure by gravity, compensating for orbicularis weakness from CN VII palsy. Combined with LTS for the lower lid.
Mnemonics
ECTROPION types
E — Elderly (involutional — most common)
C — Cicatricial (skin contracture, burns)
T — Trauma / paralytic (CN VII)
R — Retraction (lower lid, TED — differential)
O — Out-turning of lid margin
P — Punctal eversion (earliest sign)
I — Involutional = lateral tarsal strip
O — Orbicularis weakness
N — Nerve VII palsy (paralytic type)
Comparison Tables
Types of Ectropion — Aetiology, Mechanism, and Surgical Correction
| Type | Mechanism | Key Clinical Clue | Surgical Treatment |
|---|---|---|---|
| Involutional | Horizontal lid laxity (canthal tendon dehiscence) | Positive snap-back test, lid distraction >6 mm | Lateral tarsal strip (gold standard) |
| Cicatricial | Anterior lamella shortage (skin contracture) | Visible scar/contracture pulling lid down | Release contracture + FTSG (upper lid/post-auricular) |
| Paralytic | Loss of orbicularis tone (CN VII palsy) | Lagophthalmos, forehead asymmetry, mouth droop | Gold weight (upper lid) + LTS (lower lid) ± tarsorrhaphy |
| Mechanical | Mass effect weighing lid down | Visible lid tumour/chalazion | Remove mass ± lid tightening |
| Congenital | Developmental | Associated with Down syndrome | Horizontal lid tightening |
Cicatricial
- Mechanism
- Anterior lamella shortage (skin contracture)
- Key Clinical Clue
- Visible scar/contracture pulling lid down
- Surgical Treatment
- Release contracture + FTSG (upper lid/post-auricular)
Paralytic
- Mechanism
- Loss of orbicularis tone (CN VII palsy)
- Key Clinical Clue
- Lagophthalmos, forehead asymmetry, mouth droop
- Surgical Treatment
- Gold weight (upper lid) + LTS (lower lid) ± tarsorrhaphy
Mechanical
- Mechanism
- Mass effect weighing lid down
- Key Clinical Clue
- Visible lid tumour/chalazion
- Surgical Treatment
- Remove mass ± lid tightening
Congenital
- Mechanism
- Developmental
- Key Clinical Clue
- Associated with Down syndrome
- Surgical Treatment
- Horizontal lid tightening
Ectropion vs Entropion — Comparison
| Feature | Ectropion | Entropion |
|---|---|---|
| Direction | Lid turns OUTWARD | Lid turns INWARD |
| Lid most affected | Lower lid (involutional) | Lower (involutional), Upper (cicatricial) |
| Key symptom | Epiphora (tearing) | Foreign body sensation, pain |
| Corneal damage mechanism | Exposure (lagophthalmos) | Lash abrasion (trichiasis) |
| Involutional mechanism | Horizontal lid laxity only | Horizontal laxity + retractor dehiscence + orbicularis override |
| Cicatricial mechanism | Anterior lamella shortage | Posterior lamella shortage |
| Gold standard surgery (involutional) | Lateral tarsal strip | Jones procedure / Wies procedure |
Direction
- Ectropion
- Lid turns OUTWARD
- Entropion
- Lid turns INWARD
Lid most affected
- Ectropion
- Lower lid (involutional)
- Entropion
- Lower (involutional), Upper (cicatricial)
Key symptom
- Ectropion
- Epiphora (tearing)
- Entropion
- Foreign body sensation, pain
Corneal damage mechanism
- Ectropion
- Exposure (lagophthalmos)
- Entropion
- Lash abrasion (trichiasis)
Involutional mechanism
- Ectropion
- Horizontal lid laxity only
- Entropion
- Horizontal laxity + retractor dehiscence + orbicularis override
Cicatricial mechanism
- Ectropion
- Anterior lamella shortage
- Entropion
- Posterior lamella shortage
Gold standard surgery (involutional)
- Ectropion
- Lateral tarsal strip
- Entropion
- Jones procedure / Wies procedure
Self-Assessment (5)
MCQ
A 72-year-old man presents with chronic tearing from the left eye. Examination reveals eversion of the lower lid margin with the punctum visible above the tear lake. The snap-back test is positive and lid distraction is 8 mm. What is the most appropriate surgical treatment?
MCQ
A patient develops lower lid ectropion after a facial burn. The lid is pulled down by contracted scar tissue. What is the key surgical step?
MCQ
A patient with Bell palsy develops lower lid ectropion with lagophthalmos and exposure keratopathy. What combination of procedures provides the best corneal protection?
MCQ
What is the significance of a lid distraction test exceeding 6 mm?
MCQ
What is the most common complication of lower lid blepharoplasty that can cause ectropion?
References
- AAO Preferred Practice Pattern: Eyelid Malposition (2019)
- Salmon JF. Kanski's Clinical Ophthalmology: A Systematic Approach, 9th Edition (2019)
- Rootman J. Diseases of the Orbit: A Multidisciplinary Approach, 3rd Edition
- Dutton JJ. Atlas of Clinical and Surgical Orbital Anatomy, 2nd Edition
- Ehlers JP, Shah CP. The Wills Eye Manual: Office and Emergency Room Diagnosis and Treatment of Eye Disease, 8th Edition
- Collin JRO. A Manual of Systematic Eyelid Surgery, 3rd Edition
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