Ectropion

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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 50. 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
  • paralytic
  • 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

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:

  • if punctum is spontaneously visible at slit lamp, ectropion is present

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 recognise their limitations and where necessary seek further advice or refer the patient elsewhere

Non pharmacological

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)
 

Pharmacological

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 by ophthalmologist

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

Plain language summary

Ectropion is a condition in which the eyelid (usually the lower eyelid) becomes slack and is no longer in contact with the eyeball. The commonest cause is loss of elasticity and muscle tone of the eyelids which happens as part of the ageing process. The affected eye becomes sore, red and watery. Patients may be helped by artificial tears and unmedicated ointments. If the eye does not close fully at night, it may need to be taped shut. Sometimes a bandage contact lens is fitted to protect the eye surface from drying. If these measures do not help, one of a number of possible surgical operations, usually carried out under local anaesthetic, may solve the problem.

Ectropion
Version 8
Date of search 20.05.21
Date of revision 30.07.21
Date of publication 05.04.22
Date for review 19.05.22
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