What is ectropion

Ectropion is where your eyelid turns outward and does not touch your eye. Patients may experience symptoms due to ocular exposure and inadequate lubrication. Ectropion is usually caused by ageing. Sometimes ectropion is caused by scar tissue pulling your eyelid out of position. Ectropion mainly affects the lower eyelid and can occur in one or both eyes.

The drooping eyelid can disrupt the drainage of tears, which can make the eyes:

• sore, red and irritated
• water excessively
• feel very dry and gritty
• more vulnerable to bacterial infections, such as conjunctivitis

In severe cases that aren’t treated, it’s possible to develop a corneal ulcer (a sore on the eye’s surface) that could affect your vision. But this is rare.

Definitive ectropion management is surgery. The operation is usually performed under a local anesthetic. Ectropion surgery usually takes 30 minutes to an hour, depending on whether the operation involves both eyes.

Your surgeon may need to remove a small section of your eyelid where the tissues have slackened most. If the problem is caused by tight skin or scar tissue, your surgeon may need to use a skin graft.

Your eyelid should be in a better position and your symptoms should improve.

Artificial tears and ointments can be used to protect the surface of your eye. Your surgeon may recommend a special soft contact lens for you to wear.

Figure 1. Ectropion

Ectropion types

There are four main types of ectropion: involutional, cicatricial, mechanical, and paralytic.

1. Involutional ectropion is caused by increased horizontal laxity of the lower eyelid.
2. Cicatricial ectropion is caused by shortening of the anterior lamella, which is comprised of the skin and orbicularis muscle.
3. Paralytic ectropion is caused by decreased orbicularis muscle tone supporting the lower eyelid.
4. Additionally, mechanical ectropion can occur when a mass, such as a tumor, displaces the lower eyelid margin.

Congenital ectropion can occur rarely, and may be seen in association with other congenital defects such as blepharophimosis syndrome or euryblepharon.

Ectropion causes

Most cases of ectropion are associated with ageing. As you age, the muscles under your eyes tend to weaken, and tendons stretch out. These muscles and tendons hold your eyelid taut against your eye. When they weaken, your eyelid can begin to droop.

Less common causes of ectropion include:

• Facial paralysis. Certain conditions, such as Bell’s palsy, and certain types of tumors can paralyze facial nerves and muscles. Facial paralysis that affects eyelid muscles can lead to ectropion.
• Eyelid growths. Benign lump, cyst or cancerous growths on your eyelid can cause the lid to turn outward.
• Damage to the skin around the eyelid as a result of an injury, a burn, a skin condition such as contact dermatitis, or previous surgery
• Scars or previous surgeries. Skin that has been damaged by burns or trauma, such as a dog bite, can affect the way that your eyelid rests against your eye. Previous eyelid surgery (blepharoplasty) can cause ectropion, particularly if a considerable amount of skin was removed from the eyelid at the time of surgery.
• Genetic disorders. Rarely is ectropion present at birth (congenital). When it is, it’s usually associated with genetic disorders, such as Down syndrome.

In rare cases, ectropion can be present from birth if the muscles under the eyelid don’t develop properly.

Risk factors for ectropion

• Age (gravity, loss of elasticity). The most common cause of ectropion is weakening muscle tissue associated with aging.
• Eyelid rubbing
• Repeated eyelid pulling (ex. contact-lens use)
• Floppy eyelid syndrome
• Long term use of eye drops
• Skin conditions which involve the eyelid
• Trauma
• Prior eyelid surgery. People who have had eyelid surgery are at higher risk of developing ectropion later.
• Previous cancer, burns or trauma. If you’ve had spots of skin cancer on your face, facial burns or trauma, you’re at higher risk of developing ectropion.

Ectropion symptoms

Normally when you blink, your eyelids distribute tears evenly across your eyes, keeping the surfaces of the eyes lubricated. These tears drain into small openings on the inner part of your eyelids (puncta).

If you have ectropion, your lower lid pulls away from your eye and tears don’t drain properly into the puncta. The resulting signs and symptoms can include:

• Watery eyes (excessive tearing). Without proper drainage, your tears may pool and constantly flow over your eyelids.
• Excessive dryness. Ectropion can cause your eyes to feel dry, gritty and sandy.
• Irritation. Stagnant tears or dryness can irritate your eyes, causing a burning sensation and redness in your eyelids and the whites of your eyes.
• Sensitivity to light. Stagnant tears or dry eyes can irritate the surface of the cornea, making you sensitive to light.

Ectropion complications

Ectropion leaves your cornea irritated and exposed, making it more susceptible to drying. The result can be abrasions and ulcers on the cornea, which can threaten your vision.

Ectropion diagnosis

Ectropion can usually be diagnosed with a routine eye exam and physical. Your doctor may pull on your eyelids during the exam or ask you to close your eyes forcefully. This helps him or her assess each eyelid’s muscle tone and tightness.

If your ectropion is caused by a scar, tumor, previous surgery or radiation, your doctor will examine the surrounding tissue as well.

Understanding how other conditions cause ectropion is important in choosing the correct treatment or surgical technique.

Ectropion treatment

Treatment for ectropion depends on its severity and the underlying cause. Mild cases may not need any treatment.

If it’s only causing minor problems, your doctor or eye specialist can advise you about ways to relieve your symptoms and look after your eyes at home.

In more severe cases, an operation to correct the problem will probably be recommended.

Looking after your eyes

Your doctor may recommend using eye drops during the day and eye ointment at night to reduce irritation and keep your eye lubricated.

Try not to wipe your eyes excessively, as this can pull on the eyelid and make the problem worse.

If you need to wipe your eyes, it’s best to do this gently and wipe upwards and inwards (towards your nose).

If an operation is recommended, you may be advised to tape your eyelids closed at night with special skin tape as a temporary measure to help protect your eyes while you wait to have surgery.

Ectropion eyelid surgery

Surgery for ectropion is a relatively minor procedure that takes 30 minutes to an hour and is usually carried out under local anesthetic.

It’s normally performed on an outpatient basis, which means you won’t need to stay in hospital overnight.

The type of ectropion surgery you have depends on the condition of the tissue surrounding your eyelid and on the cause of your ectropion:

• Ectropion caused by muscle and ligament relaxation due to aging. Your surgeon will likely remove a small part of your lower eyelid at the outer edge. When the lid is stitched back together, the tendons and muscles of the lid will be tightened, causing the lid to rest properly on the eye. This procedure is generally relatively simple.
• Ectropion caused by scar tissue from injury or previous surgery. Your surgeon might need to use a skin graft, taken from your upper eyelid or behind your ear, to help support the lower lid. If you have facial paralysis or significant scarring, you might need a second procedure to completely correct your ectropion.

Before surgery, you’ll receive a local anesthetic to numb your eyelid and the area around it. You may be lightly sedated using oral or intravenous medication to make you more comfortable, depending on the type of procedure you’re having and whether it’s done in an outpatient surgical clinic.

Following surgery, a pad will be placed over your eye to protect it. This will need to remain in place for about a day.

After ectropion surgery you might need to:

• Wear an eye patch for 24 hours
• Use an antibiotic and steroid ointment on your eye several times a day for one week
• Use cold compresses periodically to decrease bruising and swelling

After ectropion surgery you will likely experience:

• Temporary swelling
• Bruising on and around your eye

Your eyelid might feel tight after surgery. But as you heal, it will become more comfortable. Stitches are usually removed about a week after surgery. You can expect the swelling and bruising to fade in about two weeks.

A course of antibiotic and steroid drops or ointment will usually be prescribed to help prevent infection and reduce inflammation.

You’ll have a follow-up appointment a week or two after your operation. This is to check on the position of your eyelid and sometimes to remove any stitches.

Ectropion repair recovery time

You should be able to go home after a few hours.

Do not get your eyelid wet, do strenuous exercise or bend down until the stitches are removed.

Do not wear eye make-up or drink alcohol for a few weeks, and keep your face out of the sun.

Regular exercise should help you to return to normal activities as soon as possible. Before you start exercising, ask the healthcare team or your GP for advice.

The results of an ectropion repair last for a long time. However, as you get older your skin and soft tissues of your eyelids will continue to slacken and the problem may come back.

Ectropion eyelid surgery complications

General complications

• pain
• bleeding
• infection of the surgical site (wound)

Specific complications

• cornea abrasion
• lid notch
• cosmetic problems