The CMGs are guidelines on the diagnosis and management of a range of common and rare, but important, eye conditions that present with varying frequency in primary and first contact care.

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Outward rotation of the eyelid margin (usually lower).  Occurs in approx. 4% of the population over 50 (bilateral in 70%).  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


Sore, red, watery eye
Symptoms variable depending on severity


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

Mucus discharge
Distraction test

  • if lower lid can be pulled >6mm 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)


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

Possible management by ophthalmologist


  • 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 (

Sources of evidence

Hintschich C. Correction of entropion and ectropion. Dev Ophthalmol. 2008;41:85-102

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.

Version 7

Date of search 19.04.19
Date of revision 24.10.19
Date of publication 22.03.21
Date for review 18.04.21

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