Ectropion is an outward turning of the eyelid margin. Patients may experience symptoms due to ocular exposure and inadequate lubrication. Definitive management is surgical. Medical management is temporizing but can improve symptoms while waiting for surgery.


  • Involutional ectropion is caused by increased horizontal laxity of the lower eyelid and disinsertion of the lower eyelid retractors.
  • Cicatricial ectropion is caused by shortening of the anterior lamella, which is comprised of the skin and orbicularis muscle.
  • Paralytic ectropion is caused by decreased orbicularis muscle tone supporting the lower eyelid.
  • Additionally, mechanical ectropion can occur when a mass, such as a tumor, displaces the lower eyelid margin.

Congenital ectropion can occur rarely, and may be seen in association with other congenital defects such as blepharophimosis syndrome or euryblepharon.


  • Age (gravity, loss of elasticity)
  • Eyelid rubbing
  • Repeated eyelid pulling (ex. contact-lens use)
  • Floppy eyelid syndrome
  • Long term use of eye drops
  • Skin conditions which involve the eyelid
  • Trauma
  • Prior Eyelid Surgery

Physical examination

  • Facial architecture: Examine the bony architecture of the lower orbital rim and midface position. Patients with hypoplastic midface, also known as hemiproptosis, will have an inferior orbital rim located posteriorly relative to the globe.
  • Facial nerve palsy: Inspect the face and test facial muscle strength to assess for paralysis.
  • Eyelid laxity: To test for horizontal laxity, place a thumb beneath the lateral canthus and push the eyelid laterally and superiorly. If the lid margin does not roll back into position, suspect a cicatricial component. In involutional cases, the ectropion typically disappears with this maneuver. The eyelid distraction test is done by pulling the lid away from the globe. Normal lid distraction is between 2-3 mm. If it is more than 5mm, there is substantial laxity. In cases of cicatricial ectropion, the eyelid malposition will often become accentuated by asking the patient to look upwards and to open his or her mouth at the same time; the maneuver places the anterior lamella on maximum stretch.
  • Eyelid pathology: Examine the eyelid margin under magnification to look for signs of chronic blepharitis, palpebral conjunctival hypertrophy and keratinization, conjunctival scarring, and to rule out suspicious changes such as loss of lashes (madarosis), ulceration, or infiltration.
  • Punctal ectropion: Assess the position of the lower punctum which may rotate away with medial laxity and no longer make contact with the ocular surface and tear lake.
  • Ocular surface: Examine the cornea for epithelial changes secondary to exposure.


  • Lower eyelid laxity: the lower eyelid is horizontally tightening by a lateral tarsal strip or similar procedure.
  • Lower eyelid retractor disinsertion: the Jones procedure of reattaches retractors to the tarsus.
  • Punctal ectropion: the medial spindle procedure reapposes the everted punctum.
  • Cicatricial ectropion often requires lengthening of the anterior lamella by a skin graft.
  • Paralytic ectropion requires horizontal tightening and correction of punctal ectropion. With facial nerve paralysis, corneal exposure and brow ptosis may also need to be addressed.
  • Mechanical ectropion from facial ptosis may often require surgical elevation of the mid face (such as a suborbicularis oculi fat lift), or a face lift in conjunction with lower lid tightening.
  • In some cases of heavy facial tissues or recurrence, periosteal fixation may not be successful and therefore require additional fixation using bone plates or bone tunnels to which the lower lid can be suspended.