Eyelid eversion, medically known as ectropion, is a condition where the lower eyelid turns outward, losing contact with the eye. This can lead to various symptoms and complications, as the eyelid's protective mechanisms are compromised. Ectropion is commonly associated with aging but can also result from other causes.
The lower lid does more than cover the eye: it also pumps tears towards the small opening in the inner corner that drains them away. Once the lid falls away from the globe this pump stops working and tears run down the cheek. That is why constant watering is the complaint patients notice most. At the same time the ocular surface is left exposed, so dryness and stinging appear as well. Patients often say the eye is watering and dry at once, and that apparent contradiction is exactly what one expects.
The diagnosis is made at the examination. Simple distraction tests measure how far the lid can be pulled away from the globe and how loose the tendons at the inner and outer corners have become; the speed with which the lid snaps back grades the laxity. I also check whether the tear opening in the inner corner has turned away from the eye, since this is often the source of the watering.
To find out whether the lid skin has shortened, I ask the patient to open the mouth and look up; if the skin is tight the lid is pulled down markedly, which tells me a graft may be needed. I stain the ocular surface to assess exposure damage and measure tear production. When facial palsy is involved I record the degree of lid closure failure and the upward rolling reflex of the eye. Where necessary the tear ducts are irrigated to separate lid-related watering from a blocked drainage system, a subject covered on the page about nasolacrimal duct obstruction in adults.
These measures ease symptoms and protect the cornea, but they do not correct lid position permanently.
I usually operate under local anaesthesia; the procedure takes between thirty and sixty minutes and the patient goes home the same day. When a graft is required the operation takes longer and recovery needs a few more weeks.
In the short video below I go through the symptoms of ectropion and why its definitive treatment is surgical.
Cold compresses in the first 48 hours reduce swelling and bruising. Sutures are removed during the first week depending on their position. Watering improves noticeably within days for most patients, though it may fluctuate until the lid oedema settles. In grafted patients the graft looks red and raised for the first few weeks, then fades and softens over months.
The lid may stay a little tight after surgery and the eye may look slightly narrow; this resolves as swelling subsides. Risks include undercorrection, excessive tightness, irregularity of the lid margin, a colour difference at the graft site and, rarely, recurrence. In ectropion caused by facial palsy, further procedures may be needed depending on nerve recovery. I see my patients several times during the first month.
Age-related tissue laxity is the leading cause of both, but the lid turns in opposite directions. In ectropion the lid falls away from the globe; tears cannot be pumped away, so constant watering dominates and the inner surface of the lid becomes visible. In entropion the lid rolls inward, the lashes rub the eye and grittiness and pain dominate. One can turn into the other over time in the same patient. The distinction is easy at the examination, and the treatment principle is the same in both: rebuilding the lid's lost support.
If your eye waters constantly, if the margin of the lower lid looks separated from the globe, if the surface of your eye hurts in the morning or if the lid no longer closes fully, you should be assessed. An eye that does not close leaves the cornea exposed and permanent damage can follow.
Ectropion is a condition that can significantly impact eye health and quality of life. Early diagnosis and appropriate treatment are essential to prevent complications such as corneal damage. If you suspect you have ectropion, consult an ophthalmologist promptly to explore your treatment options.
Ayşe Dolar Bilge MD, FEBOphth.
Ophthalmologist — Oculoplastic Surgery
As an Ophthalmologist, Dr. Ayşe Dolar Bilge, I provide diagnosis and treatment services with my experienced team.
Ectropion is an outward turning of the lower eyelid so that it loses contact with the eye. Once the lid falls away, the mechanism that pumps tears into the drainage channel in the inner corner stops working. Age-related tissue laxity is the commonest cause; trauma, facial palsy and previous surgery also account for cases.
The tendon anchoring the lid to the bone at the outer corner lengthens with age, and the lid falls outward under its own weight. Scar tissue after injury or surgery can shorten the lid skin and pull the lid down. Facial palsy, lid masses and sun-damaged, stiffened skin are other causes.
Yes, constant watering is the most typical complaint in ectropion. Once the lid separates from the globe, tears cannot be pumped towards the duct and run down the cheek. Watering has other causes too, so the tear ducts may be irrigated at the examination to rule out an obstruction.
Artificial tears and ointments protect the ocular surface and ease dryness and grittiness, and taping the lid at night shields the cornea. These are useful supportive measures, but they do not correct the position of the lid. Lasting correction comes from surgery.
Surgery is usually performed under local anaesthesia and takes thirty to sixty minutes. The essential step is shortening and reattaching the tendon that anchors the lid at the outer corner. Where watering dominates, an additional correction is made towards the inner corner. If the skin is short, thin skin from behind the ear or the opposite upper lid is used as a graft.
Cold compresses in the first 48 hours reduce swelling and bruising, and sutures come out during the first week. Watering improves within days for most patients, though it may fluctuate until the oedema settles. In grafted patients the graft looks red and raised for the first weeks, then fades and softens over months.
Yes. When the facial nerve is affected the muscle that closes the eye stops working, the lid sags and turns outward. Because lid closure is also impaired in this group, the cornea is left exposed and closer follow-up is needed. Depending on nerve recovery, either temporary protective measures or surgical correction is planned.
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