Aetiology

Outward rotation of the eyelid margin (usually lower).  Occurs in approx. 0.3% of the population under 60, rising to 16.7% of the population aged 80 or over. Various causes:

• involutional (age-related  degeneration)
  • most common
  • horizontal lid laxity
  • weakness of pretarsal part of orbicularis oculi muscle
  • weakness of medial and lateral canthal tendons
• cicatricial: scarring +/- contracture of skin and underlying tissues
  • trauma
  • burns
  • skin tumours
  • actinic skin changes due to prolonged sun exposure
  • chronic blepharitis
• paralytic
  • (refer to Clinical Management Guideline on Facial Palsy)
• mechanical
  • tumour at or near the lid margin
  • lid swelling due to inflammation from infection or allergy
• congenital
  • rare bilateral condition

Predisposing factors

Lid laxity increases with age
Trauma or previous surgery

Symptoms of ectropion

Sore, red, watery eye
Symptoms variable depending on severity

Signs of ectropion

Inferior lid margin not in contact with globe:

• region involved may be punctal, medial, lateral, or tarsal (complete)
• involutional ectropion typically begins medially; central lid margin and lateral lid may become involved later
  Keratinisation of exposed tarsal conjunctiva

Lower punctum not in contact with tear meniscus:

• A visible punctum at slit lamp without lid eversion usually indicates ectropion

Conjunctival hyperaemia
Exposure keratopathy
Epiphora

Mucus discharge
Distraction test

• if lower lid can be pulled >8mm from globe, it is lax
• positive test indicates canthal tendon laxity

Snap-back test

• with finger, pull lower lid down towards inferior orbital margin
• release: lid should snap back
• lid slow to return to normal position: indicates poor orbicularis tone

Differential diagnosis

Ectropion is a physical sign, rather than a disease entity

Management by optometrist

Practitioners should work within their scope of practice, and where necessary seek further advice or refer the patient elsewhere

Mild cases require no treatment:

• advise that lid rubbing may increase lid laxity

Taping the lids closed at night when there is a risk of corneal exposure
(GRADE*: Level of evidence=low, Strength of recommendation=strong)

Therapeutic contact lens where constant protection from corneal exposure is indicated
(GRADE*: Level of evidence=low, Strength of recommendation=weak)
 

Ocular lubricants for tear deficiency/instability related symptoms (drops for use during the day, unmedicated ointment for use at bedtime)
NB Patients on long-term medication may develop sensitivity reactions which may be to active ingredients or to preservative systems (see Clinical Management Guideline on Conjunctivitis Medicamentosa). They should be switched to unpreserved preparations
(GRADE*: Level of evidence=low, Strength of recommendation=strong)
 

Management category

Mild asymptomatic involutional cases
B2: alleviation/palliation: normally no referral. Monitor for deterioration
More severe cases possibly requiring surgery
B1: initial management followed by routine referral

Possible management in secondary care or local primary/community pathways where available

Additional guidance may be available

Surgery:

• a variety of surgical procedures (choice determined by nature, position and degree of ectropion) e.g. lateral tarsal strip, with or without transconjunctival retractor plication, or wedge resection
• tarsorrhaphy sometimes necessary

Surgery is indicated for:

• ocular surface exposure (increased risk of microbial keratitis)
• chronic epiphora or ocular irritation
• recurrent bacterial conjunctivitis
• poor cosmesis

There are no available data from randomised trials to provide evidence for the most effective intervention for the correction of involutional ectropion

Evidence base

*GRADE: Grading of Recommendations Assessment, Development and Evaluation (www.gradingworkinggroup.org)
 

Sources of evidence

Hakim F, Phelps PO. Entropion and ectropion. Dis Mon. 2020;66(10):101039

Milbratz-Moré GH, Pauli MP, Lohn CLB, Pereira FJ, Grumann AJ. Lower Eyelid Distraction Test: New Insights on the Reference Value. Ophthalmic Plast Reconstr Surg. 2019;35(6):574-577

Mitchell P, Hinchcliffe P, Wang JJ, Rochtchina E, Foran S. Prevalence and associations with ectropion in an older population: the Blue Mountains Eye Study. Clin Experiment Ophthalmol. 2001;29(3):108-10

Vallabhanath P, Carter SR. Ectropion and entropion. Curr Opin Ophthalmol. 2000;11(5):345-51

Last updated

Ectropion
Version 9
Date of search 14.07.23
Date of revision 18.07.23
Date of publication 17.10.23
Date for review 13.07.25
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