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Ectropion
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Pathophysiology: Why does the eyelid turn out?

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Congenital Ectropion
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Congenital ectropion is very rare. When present, it is due to

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a vertical shortage of skin. This may be seen in congenital

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skin diseases such as icthyosis. In this condition the lower lid
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skin keratinization process is faulty which subsequently leads

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to tight scaly skin that gradually pulls the lower lid over.
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by ○
Blepharophimosis syndrome is a congenital disorder with
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David R. Jordan ptosis, phimosis, telecanthus and lateral lower lid ectropion
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(secondary to tight lower lid skin). Both conditions are very
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M.D., F.R.C.S.(C), F.A.C.S.

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rare.
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Professor of Ophthalmology
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University of Ottawa
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Ottawa, ON, Canada
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Acquired Ectropion
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Involutional Ectropion – is by far the commonest form of

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Introduction
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ectropion. [Figure 1] The etiology is similar to involutional

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entropion with laxity of the medial and lateral canthal tendons

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Ectropion refers to an outward turning of the eyelid and may
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and thinning of the lower lid retractors (help stabilize the lower
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be unilateral or bilateral [Figure 1]. It primarily involves the

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lower lid and only very rarely the upper lid. As the eyelid lid in the vertical position). The orbicularis muscle however
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does not ride upward as it does in entropion. In ectropion the
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turns out, the eye often begins to tear since the punctal
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openings move out of position and are unable to collect orbicularis has a normal or decreased tone. In addition ectropic
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lids have tarsal plate heights that are greater in vertical height
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tears properly. With further outward turning the conjunctiva

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becomes red, dry and irritated. If untreated it may cause than normal lids. Thus, in the aging lax lid there is loosening
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or thinning of the medial and lateral canthal tendon tissue as

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persistent eye irritation, recurrent tearing and discharge.
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well as the lower lid retractors. Whether the eyelid turns in or

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Etiology
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Ectropion may be classified as congenital or acquired.

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Congenital ectropion is uncommon. Acquired ectropion

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may be divided into involutional, paralytic, cicatricial,

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inf lammatory or mechanical types [Table 1].
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Table 1 – Ectropion Classification

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• very rare
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Congenital
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Acquired • involutional
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•
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paralytic
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• cicatricial
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•
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inflammatory
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• mechanical
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Figure 1 – Involutional ectropion of the lower lid.

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1
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out often depends upon the tone of the orbicularis muscle as

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well as the height of the tarsus. A weak orbicularis (e.g. seen

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as a result of aging or in 7th nerve palsy) will allow the aging

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lid to fall over. A higher tarsal plate in the face of a weak
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orbicularis will also have a tendency to fall outward whereas

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shorter tarsal plates will have a tendency to turn inward
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(providing the orbicularis tone is active – as is the case with

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entropion).

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Paralytic ectropion – follows temporar y or permanent
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seventh nerve palsy. When the orbicularis muscle loses its tone

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the lid loses an important support structure and as a result

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the lid falls outward. Poor blinking ability and incomplete lid
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closure, lead to corneal exposure, tearing, chronic eye

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irritation and corneal ulceration.
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Cicatricial ectropion – involves a scarring process of the skin
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Figure 2 –
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with resultant shortening of the skin. It may be seen secondary

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Cicatricial

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to thermal/chemical burns or trauma [Figure 2].
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ectropion –

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Inf lammatory ectropion – is associated with inf lammation
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secondary to
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of the skin as seen in acute allergic reactions to topical drops
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or ointment, atopic dermatitis, eczema or occasionally rosacea ○ a scar, pulling
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the lid over.

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[Figure 3]. Each of these conditions may cause tightening of
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the lid skin which may then pull the lid outward. If the process
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becomes chronic the eyelid will remain permanently turned

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out due to tight lower lid skin. In the early phase however it
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may be reversible with anti-inf lammatory steriod creams.

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Mechanical ectropion – bulky tumors of the eyelid may pull

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the lid over. Similarly, poorly fitting eye glasses sitting on a lax
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lid may pull the eyelid outward.

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How is Ectropion treated?
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Ectropion treatment for the most part is surgical. The only
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types that may be amenable to temporizing measures are the

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inf lammatory variety and the paralytic form (secondary to
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7th ner ve palsy). If there is active inf lammation of the skin

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(ex atopic dermatitis, allergy) a steroid cream may settle the
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inf lammation and allow the ectropic lid to return to a normal

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position. In the 7th nerve palsy patients, the use of lubricating
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drops and ointment combined with taping the involved lids
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closed at night may be successful in keeping the eye
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comfortable for a short time period while working on recovery
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of function. If the 7th nerve function recovers the lid should

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Figure 3 – Inflammatory ectropion – secondary to severe
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return to normal.
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atopic dermatitis of the lower lid.

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Most ectropions, however, will require surgery. Surgery is

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generally done as an outpatient under local anesthesia. The

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surgery involves tightening the lower lid and turning the lid
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margin back to its normal position. If one eyelid is operated

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Complications
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on, patients are usually patched overnight. If both eyelids are

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Ectropion surgery is successful in over 95% of patients.

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involved, cool compresses over each eye rather than eye

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patches are used. Antibiotic drops and ointment are required Recurrence occasionally occurs over 2-10 years but is
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uncommon. If the ectropion does recur, surgery can always

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for about 7-10 days post surgery. Pain is not a major factor.
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be done again. Occasionally an infection occurs at the site

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Most people will have some mild discomfort in the first one
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to two days. Patients can return to their usual daily activities where sutures are placed, oral antibiotics and war m
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within 2-3 days. compresses are required if this occurs.

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If you have any questions regarding the topics of this newsletter, or requests for future topics of “InSight”, please contact Dr. David R. Jordan
by telephone (613) 563-3800, fax (613) 563-1576 or e-mail at drjordan@magma.ca • Check our Web Site for previous issues of InSight – www.drjordan.on.ca