Ectropion refers to a condition in which the palpebral conjunctiva, which normally contacts the ocular surface (cornea and bulbar conjunctiva), turns outward and becomes exposed. It occurs when the anterior lamella (skin and orbicularis oculi muscle) is relatively deficient compared to the posterior lamella (tarsus and conjunctiva), or when the supporting tissues of the tarsus become lax. Due to gravity, it most commonly occurs in the lower eyelid.
The everted eyelid margin separates from the ocular surface, and the punctum also turns outward. This impairs normal tear drainage, leading to epiphora, discharge, and damage from corneal exposure. It is a frequently encountered condition in elderly outpatient clinics, affecting patients’ quality of life both cosmetically and functionally.
Based on the cause, it is broadly classified into four types: involutional (age-related), paralytic, cicatricial, and mechanical. Since the pathophysiology differs for each type, the choice of treatment also varies accordingly.
Ectropion is a condition in which the eyelid margin is displaced outward (away from the eye). In contrast, entropion is a condition in which the eyelid margin is displaced inward (toward the eye), causing the eyelashes to rub against the cornea. Both conditions result from abnormalities in the supporting structures of the eyelids, but their symptoms and treatments differ.
The most common complaint in ectropion is epiphora (tearing). The outward displacement of the punctum disrupts the tear drainage pathway, causing continuous overflow of tears. Cosmetic concerns (the eyelid appearing turned outward) are often the most distressing issue for patients.
The main subjective symptoms are listed below.
The following findings are confirmed by slit-lamp examination and visual inspection.
Characteristic clinical findings by type are shown in the table below.
| Type | Characteristic Findings |
|---|---|
| Involutional | Laxity of the entire lower eyelid, conjunctival keratinization and thickening, punctal ectropion |
| Paralytic | Eyebrow drooping, mouth drooping, loss of nasolabial fold, scleral show, lagophthalmos |
| Cicatricial | Skin shortening at the scar contracture site, history of trauma or burns |
| Mechanical | Downward traction due to eyelid tumor/edema |
Epiphora (tearing) is the most frequent complaint, but cosmetic concerns can be the most serious in some cases. If inadequate corneal protection persists, it can progress to punctate keratopathy, keratitis, and corneal ulcer, ultimately posing risks of corneal perforation and visual impairment. Particularly in paralytic ectropion, lagophthalmos (incomplete eyelid closure) can accelerate corneal damage, requiring caution.
Ectropion is classified into 4 types based on cause. The pathophysiology, characteristics, and frequency of each type are summarized in the table below.
| Type | Pathophysiology | Age of Onset | Frequency |
|---|---|---|---|
| Involutional (degenerative) | Laxity of medial/lateral canthal tendons and orbicularis oculi muscle | Elderly | Most common |
| Paralytic | Orbicularis oculi muscle relaxation after facial nerve palsy | All ages | Less common |
| Cicatricial | Scar contracture after trauma, burns, or surgery | Depends on primary disease | Depends on primary disease |
| Mechanical | Physical traction due to eyelid tumor or edema | All ages | Relatively rare |
Age-related collagen degeneration and loss of elasticity of the medial and lateral canthal tendons lead to horizontal eyelid laxity. Weakening of the orbicularis oculi muscle also contributes to laxity. It commonly occurs in the lower eyelid and is the most frequently encountered type in geriatric ophthalmology clinics. It progresses gradually with age and does not resolve spontaneously.
Due to dysfunction of the facial nerve (cranial nerve VII), the tension of the orbicularis oculi muscle is lost, reducing support for the lower eyelid. Causes include Bell’s palsy, tumors, trauma, and after surgery. It is often accompanied by incomplete eyelid closure (lagophthalmos), increasing the risk of corneal damage. Since Bell’s palsy resolves spontaneously within 6 months in many cases, corneal protection should be maintained during this period while monitoring the condition.
This is a condition in which the anterior lamella (skin and orbicularis oculi muscle) is shortened due to scar contraction, pulling the eyelid margin outward. Causes include trauma, burns, chemical burns, Stevens-Johnson syndrome (SJS), after healing of a giant chalazion, and after eyelid surgery. If the underlying disease remains active, it is refractory, and surgery should be planned after the disease has subsided.
This is a condition in which the eyelid is pulled downward by the weight of an eyelid tumor or eyelid edema. Removal of the causative tumor or management of edema is the priority, and ectropion often improves after the cause is eliminated.
Involutional ectropion is the most common type, occurring frequently in the elderly (especially those aged 60 and older). Paralytic ectropion occurs at all ages, often due to Bell’s palsy (approximately 20–30 per 100,000 population per year 1)). Prevalence data for ectropion overall in Japan are insufficient (source_gaps recorded), and no consistent trend regarding sex differences has been shown 2).
Diagnosis of ectropion is easy by visual inspection to confirm exposure of the palpebral conjunctiva. In cases of facial nerve palsy, diagnosis is generally easy based on history and findings such as eyebrow droop, drooping of the mouth corner, and disappearance of the nasolabial fold.
The pinch test (snap-back test) is most widely used to evaluate horizontal eyelid laxity. The eyelid is pinched with fingers and pulled forward, and the return after release is assessed. If the eyelid separates more than 6–8 mm from the globe, horizontal laxity is considered present. If it does not return quickly to its original position without blinking after release, this is also evidence of laxity.
Other tests are shown below.
The clinical severity criteria are shown in the table below.
| Severity | Findings |
|---|---|
| Mild | Only punctal ectropion, no corneal epithelial disorder |
| Moderate | Wide exposure of palpebral conjunctiva, punctate keratopathy present |
| Severe | Risk of corneal ulcer/perforation (e.g., paralytic, thyroid eye disease complications) |
In age-related ectropion, prolonged exposure of the conjunctiva can lead to keratinization and thickening, sometimes appearing as a tumor-like mass. Differentiation from malignant tumors (e.g., squamous cell carcinoma) is necessary. If ectropion treatment alone does not improve the condition or if rapid changes are observed, a biopsy should be performed.
Conservative treatment is indicated for mild cases or for paralytic cases soon after onset. Since Bell’s palsy often resolves spontaneously within 6 months, it is recommended to observe the patient while ensuring thorough corneal protection during this period.
Surgery is indicated for cases that do not improve with conservative treatment, or for age-related, cicatricial, or other types where spontaneous resolution is not expected. Representative surgical procedures are shown in the table below.
| Surgical procedure | Indication | Overview |
|---|---|---|
| Wedge resection | Mild to moderate horizontal laxity | Horizontal shortening of the full eyelid width |
| Kuhnt-Szymanowski procedure | Moderate to severe laxity | Wedge resection + orbicularis oculi muscle shortening + excess skin excision |
| Lateral tarsal strip procedure | Severe laxity, widely used | Cut the lateralmost tarsal plate and suture it to the periosteum of the lateral orbital rim |
| Auricular cartilage graft | Posterior lamella reinforcement in severe cases | Conchal cartilage grafted as a spacer |
| Flap and skin graft | Cicatricial ectropion (skin deficiency) | Cover the skin defect with a flap or free skin graft |
Most cases of eyelid ectropion can be managed with one of the following procedures: wedge resection, Kuhnt-Szymanowski method, or lateral tarsal strip method.
Involutional ectropion
Lateral tarsal strip method is the first choice. It restores the fixation strength of the lateral canthal tendon and reliably corrects horizontal laxity.
Wedge resection: Selected when laxity is relatively mild.
Kuhnt-Szymanowski method: Suitable for cases with excess skin. Adds orbicularis oculi muscle shortening and skin excision to wedge resection.
Paralytic ectropion
Lower eyelid: Lateral tarsal strip method, wedge resection, and conchal cartilage graft are used.
Upper eyelid (lagophthalmos): Levator palpebrae superioris lengthening (lid loading with gold plate or fascia graft) is indicated.
Timing of surgery: Plan after a 6-month period of spontaneous recovery from onset.
Cicatricial ectropion
Principle: After releasing the scar tissue, perform a flap or skin graft according to the skin deficiency.
Timing of surgery: Plan after the underlying disease activity has subsided. Be especially cautious after SJS and chemical burns.
Full-thickness skin graft: For extensive skin defects of the lower eyelid, grafts from the postauricular area or supraclavicular fossa are performed.
Mechanical ectropion
Treat the cause first: Prioritize resection of the causative tumor or management of edema.
Eyelid reconstruction: Plan eyelid repair if ectropion persists after removal of the cause.
Most cases can be managed with wedge resection, Kuhnt-Szymanowski procedure, or lateral tarsal strip procedure. The technique is selected according to the degree of laxity and the type of cause. For age-related ectropion, the lateral tarsal strip procedure shows particularly stable results. Severe cases or cicatricial ectropion with skin deficiency may require additional procedures such as auricular cartilage grafting, flaps, or skin grafts.
The prognosis for age-related and paralytic ectropion is generally good. However, with advancing age, eyelid laxity may progress again, sometimes requiring reoperation. Cicatricial ectropion tends to recur if the underlying disease remains active. Regular postoperative follow-up is important.
The eyelid is broadly divided into the anterior lamella (skin and orbicularis oculi muscle) and the posterior lamella (tarsus and conjunctiva). The tarsus maintains the shape as the eyelid skeleton and houses the meibomian glands. The medial canthal tendon (medial palpebral ligament) and lateral canthal tendon (lateral palpebral ligament) fix the medial and lateral ends of the tarsus to the orbital bone, maintaining the horizontal position of the eyelid. The orbicularis oculi muscle (innervated by the facial nerve) is responsible for eyelid closure and the lacrimal pump function. Disruption of these supporting structures is the essence of ectropion.
Persistent ectropion leads to the following sequence of changes.
Punctal eversion → impaired tear drainage → epiphora: Normally, the punctum contacts the ocular surface, but when eversion causes the punctum to separate from the eye, tears overflow without being directed into the lacrimal sac.
Exposure of palpebral conjunctiva → dryness → keratinization and thickening: The conjunctiva that normally contacts the inner surface of the eye is exposed to air, leading to keratinization and thickening due to chronic irritation. It may appear as a mass.
Corneal exposure → increased evaporation → corneal epithelial damage → corneal ulcer → perforation: Especially in paralytic ectropion with incomplete eyelid closure, the cornea may be exposed even during sleep, leading to rapid progression of epithelial damage.
The prognosis for surgery for age-related and post-facial nerve palsy ectropion is generally good. The lateral tarsal strip procedure has been shown to be effective in various reports 3), and long-term correction of ectropion can be expected.
Cicatricial ectropion may be refractory when the underlying disease is active (e.g., after Stevens-Johnson syndrome or chemical burns), and multiple surgeries may be required. Inadequate corneal protection poses risks of corneal ulcer, perforation, and visual impairment.
Age-related and cicatricial ectropion do not resolve spontaneously and often require surgery. Paralytic ectropion may resolve spontaneously with recovery of the underlying cause such as Bell’s palsy, but surgery may be expedited if there is a risk of corneal damage. In mechanical ectropion, removing the cause may improve the ectropion.
Long-term outcomes of the lateral tarsal strip procedure: Long-term follow-up studies report high success rates over 5 years postoperatively 3,4). However, some relaxation may recur with aging, and reoperation rates vary by report.
Medial spindle procedure (medial triangular resection): This method involves triangular resection of the conjunctiva and tarsal plate near the medial canthus for ectropion with medial punctal ectropion. Its usefulness as a procedure specialized for correcting punctal ectropion has been reported 5).
Hyaluronic acid filler injection: As a non-surgical treatment for patients who do not wish for invasive surgery, filler injection around the orbit is being considered. Temporary improvement has been reported, but evidence for long-term outcomes is limited 6).
Botulinum toxin: Botulinum toxin injection into the orbicularis oculi muscle of the unaffected side may be performed to improve asymmetry due to facial nerve palsy. Some reports indicate effectiveness for aesthetic symmetrization 7).
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Rougraff PM, Tse DT, Johnson TE, Feuer W. Involutional entropion repair with fornix sutures and lateral tarsal strip procedure. Ophthal Plast Reconstr Surg. 2001;17(4):281-7.
Goldberg RA, Lee S, Jayasundera T, Tsirbas A, Douglas RS, McCann JD. Treatment of lower eyelid retraction by expansion of the lower eyelid with hyaluronic acid gel. Ophthal Plast Reconstr Surg. 2007;23(5):343-8.
Salinas NL, Jackson O, Walker NJ. Treating facial paralysis: the plastic surgeon’s role. Clin Plast Surg. 2016;43(2):367-80.
