Ectropion (Turning out of the lower eyelid)

What is Ectropion?

Ectropion is a condition where the lower eyelid turns away from the eyeball. As the condition becomes more severe, the lining of the eyelid (the conjunctiva) is exposed to the air and can become red and swollen and sometimes crusty.

What causes ectropion?

The commonest reasons for an ectropion developing are:

  • Increasing age. The eyelid loses its elasticity and tone and with gravity tends to fall away from the eye.
  • Sun exposure. Over a lifetime, exposure to the sun can in some people lead to the skin under the eyelid and on the cheek becoming tight and this can pull the eyelid downwards.
  • Facial muscle weakness. If the muscles of the face, and particularly the muscles that close the eye, are weak, the eyelid can develop an ectropion. Conditions such as a Bell’s palsy can cause facial muscle weakness and ectropion.
  • Scars of the lower eyelid or upper cheek, or previous operations for example to remove skin cancers.

What symptoms can occur with ectropion?

Apart from the abnormal appearance of the eyelid with the lining visible as a reddish pink area, symptoms of ectropion can include the following:

  • Watering of the eye. The opening of the lower tear duct sits on the edge of the eyelid and as the eyelid turns away from the eye, the tears can no longer reach the opening of the tear duct, and build up in the eye before running onto the cheek.
  • Soreness of the eyelid and eye. The eyelid may become sore as the lining is exposed to the air, becoming swollen, red and inflamed, and sometimes crusty. The eye itself can also become sore because the surface of the eye can dry out. This occurs because the lower eyelid is no longer helping to perform its function of helping to spread tears over the front surface of the eye
  • Redness and crusting of the eyelid edge and lining
  • Discharge from the eye. The eye will often produce more mucous when there is ectropion present, and additionally, normal mucous cannot drain away properly because the tear duct is not working. Overnight, the mucous can dry and form a crust on the eyelid or at the inner corner of the eye.
  • Rarely, the front surface of the eye (the cornea) can develop an ulcer which can be very serious for the health of the eye. Corneal ulcers are commoner when ectropion is present.

How is ectropion treated?

Ectropion is usually treated by surgery. It is not major surgery. If the ectropion is mild and not causing much in the way of symptoms, then no treatment at all may be required. Sometimes the redness, inflammation and crusting of the lower eyelid can be treated with topical ointments to partially relieve these symptoms, but this sort of treatment will very rarely correct the ectropion completely.

What sort of anaesthetic will be used?

Nearly all ectropion operations are performed with a local anaesthetic.  Before any local anaesthetic is injected into the skin of the eyelid, your anaesthetist will give you some medicine in the form of a sedative and pain killer so that the eyelid injection will not be painful and is often not even noticed or remembered. During the operation, you will however be aware that the eyelid is being operated on but it will not be painful. It is important for you to say if there is any pain during the operation.

What is done during an ectropion operation?

What is done during an ectropion operation will depend on the causes of the ectropion. In most cases the eyelid will be “tightened”, usually by making a very small incision at the outer corner of the eye and pulling the eyelid across to reattach it just inside the rim of the bony eye socket at the outer corner (this is sometimes called a “tarsal strip” operation). In combination with this, there may be other procedures performed. These can include the following:

  • Some stitching on the inside of the lower eyelid
  • Re-opening the lower tear duct opening which can sometimes be narrowed or closed if the ectropion has been present for a long time
  • Skin graft to the lower eyelid. This is commonly used where there has been sun damage to the skin or there is some scarring of the lower eyelid. The skin may be taken from places such as behind or in front of the ear, from over the collar bone below the base of the neck, or from the inside of the upper arm. If a skin graft is used, the eye will usually remain covered with a dressing for 5 – 7 days, rather than the usual dressing which stays on only overnight, or in many cases there may be no dressing at all if a skin graft is not used.

How long will I stay in hospital?

Most patients having ectropion surgery can go home on the day of surgery, but a few are kept in overnight after the operation. You will be told at the time the surgery is booked how long you will stay in hospital.

What problems can occur with ectropion surgery?

Most ectropion operations are successful, but occasionally problems may occur. These include the following:

  • Failure to correct the ectropion. If this occurs, the eyelid is still usually in a better position than it was prior to the operation, but if the ectropion is not fully corrected, the eye may continue to water.
  • Scarring. There is always a small scar at the outer corner of the eye where the eyelid is tightened, but this fades over 2 – 3 months and is very rarely noticeable after that time. Most of the rest of the scar will be inside the lower eyelid and not visible
  • Skin graft problems. Skin grafts are usually noticeable but become less noticeable over several months. The skin may be a slightly different colour and texture and the graft is often “lumpy” or hard in the first 2 -3 months. The graft also tends to shrink a little over time.
  • Recurrence of the ectropion. This may occur some years later as the conditions that led to the ectropion persist and the tissues continue to gradually lose their elasticity with time. Usually, surgery for ectropion should be helpful for many years.
  • Infection. This is very rare with eyelid surgery and can be treated with antibiotics.
  • Bleeding. A little bleeding in the first 24 hours is common. Occasionally, there may be more significant bleeding about 5 – 10 days after surgery, usually from the outer corner of the eye. If this happens, clean the eye, fold several tissues up, close the eye and hold the tissues firmly over the area that is bleeding (or the whole eye if you are not sure) for 10 minutes. Repeat a second time if this does not help.
  • Eyelashes of the lower eyelid turning in. With ectropion the eyelashes are also turned away from the eye. When the ectropion is corrected, sometimes the eyelashes may have changed their normal direction so that when the eyelid sits against the eye again, the eyelashes point upwards and can contact the surface of the eye. If this occurs, the eye can be scratchy and sore. This problem usually corrects itself, but occasionally these abnormally directed eyelashes may have to be treated.