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Disease-a-Month

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Entropion and ectropion

Farida Hakim, MD a, Paul O. Phelps, MD, FACS a,b,∗
a
Department of Ophthalmology and Visual Science, University of Chicago, Chicago, IL, United States
b
Division of Ophthalmology, Northshore University HealthSystem, 2050 Pfingsten Rd., Ste. 280, Glenview, IL 60026,
United States

Introduction

Disorders of eyelid malposition are highly prevalent, especially in an aging population. These
conditions can lead to significant ocular surface irritation and impair vision and quality of life if
left untreated. Entropion describes an inward rotation of the eyelid margin and is often associ-
ated with misdirection of the eyelashes and keratinization of the eyelid margin (Fig. 1). Ectro-
pion refers to an outward rotation of the lid margin (Fig. 2). Both conditions can affect upper
and lower lids, although the upper lids are rarely affected. The most common forms are invo-
lutional entropion and ectropion. The estimated prevalence of involutional entropion and ectro-
pion in people 60 years of age or older is 2.1% and 2.9%, respectively.1 The prevalence climbs as
high as 10.7% and 17.7% in people aged 80 years or older.1 Inflammatory, infectious or traumatic
processes affecting the facial skin or conjunctiva may result in scarring and lead to a cicatricial
entropion or ectropion. Abnormal spasms of the orbicularis oculi may lead to spastic entropion,
and paralysis of the facial nerve may lead to neurogenic ectropion (Fig. 3). Patients frequently
report non-specific symptoms such as blurry vision, epiphora, redness, pain, or foreign body
sensation. This review article aims to help primary care physicians understand how disorders
of eyelid malposition may be potential causes of ocular irritation and to recognize risk factors
for these disorders. This article will also discuss the medical and surgical treatment options that
may be available to patients with entropion or ectropion.

∗
Corresponding author at: Division of Ophthalmology, NorthShore University HealthSystem, 2050 Pfingsten Rd., Ste.
280, Glenview, IL 60026, United States.
E-mail address: pphelps@northshore.org (P.O. Phelps).

https://doi.org/10.1016/j.disamonth.2020.101039
0011-5029/© 2020 Elsevier Inc. All rights reserved.

Please cite this article as: F. Hakim and P.O. Phelps, Entropion and ectropion, Disease-a-Month, https://doi.org/10.1016/
j.disamonth.2020.101039
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Fig. 1. Patient with left lower eyelid laxity and inward turned lashes.

Fig. 2. Right lower eyelid spastic entropion. Note the prominence of orbicularis override.

Fig. 3. Right lower eyelid cicatricial ectropion. See lower lid and cheek scarring from previous Mohs surgery to remove
skin cancer.

Pathophysiology

Involutional eyelid changes occur primarily because of increased laxity in the periocular tis-
sues. Lateral canthal tendon laxity, lower eyelid retractor dehiscence, and orbicularis override
are considered the main causes of involutional entropion.2 Specifically, degeneration of colla-
gen fibers and elastic fibers that occurs with aging is associated with increased horizontal laxity
and can lead to both entropion and ectropion.3 These factors primarily manifest as entropion or
ectropion in the lower eyelids but may present as blepharoptosis in the upper eyelids.4 Atro-
phy of the tarsus in the setting of increased laxity also predisposes aging patients to entropion,
especially of the lower lid. Size of the tarsus matters; men tend to have larger tarsal plates
than women, and this may lead to the development of an involutional ectropion in men and
a predisposition to entropion in women.5 The relative position of periocular muscles and fat

Please cite this article as: F. Hakim and P.O. Phelps, Entropion and ectropion, Disease-a-Month, https://doi.org/10.1016/
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Fig. 4. Patient with left facial nerve paralysis. Lower lid ectropion is prominent. Upper eyelid retraction and left brow
ptosis can also be appreciated.

also plays a role. Atrophy of orbital fat allows for the pre-septal orbicularis oculi to override
the pretarsal orbicularis muscle, promoting the inversion of the lid margin. Racial differences in
anatomy exemplify the way that aging-related changes to periocular tissues predispose to eyelid
malposition. A retrospective review performed in three different clinical practice settings found
the protrusion of orbital fat anterior to the orbital rim may be a reason that lower lid entropion
is more common than ectropion in Asian populations.6
Spastic entropion occurs when spasm of the orbicularis oculi muscle and sustained contrac-
tion leads to override of the pretarsal orbicularis muscle, and an inward deviation of the lid mar-
gin (Fig. 2). Ocular irritation from dry eye, infection, inflammation, or occurring post-operatively
can lead to muscle spasms. In fact, ocular surface irritation from involutional entropion can also
perpetuate a cycle of muscle spasm and entropion. Consequently, spastic entropion is often as-
sociated with involutional entropion. In contrast, orbicularis dysfunction from facial nerve palsy
can result in a paralytic ectropion (Fig. 4). Poor eyelid closure and blinking leads to corneal ex-
posure, inadequate tear film distribution, and chronic ocular surface irritation. These patients
may also complain of epiphora as dysfunction of the orbicularis muscle leads to failure of the
lacrimal pump system.7
Cicatricial entropion is caused by processes that lead to contracture of the tarsus or conjunc-
tiva and subsequent inward rolling of the eyelid margin. A variety of conditions can lead to ci-
catricial entropion. Autoimmune inflammatory conditions such as ocular cicatricial pemphigoid
and hypersensitivity reactions such as Stevens–Johnson Syndrome are known etiologies. Any in-
fection causing chronic irritation and scarring poses a risk for entropion. Trachoma is a com-
mon infection appearing globally that causes cicatricial entropion, but this infection is not com-
mon in the United States. Chemical or thermal burns with ocular involvement are additional
causes of scarring and entropion. Use of some topical medications (e.g. pilocarpine) can also
lead to chronic irritation, conjunctival scarring and shortening, and subsequent cicatricial entro-
pion. Conditions that cause scarring of skin anterior to the eyelids can pull the lid away from
its primary position and cause a cicatricial ectropion (Fig. 3). Such conditions include chronic
inflammatory conditions affecting the eyelid like rosacea or atopic dermatitis, skin cancer or ac-
tinic skin changes from excessive sun exposure, chemical and thermal burn injuries, radiation,
and surgery or trauma to the face. Given the variety of causes for cicatrizing disorders of the
eyelid, a thorough history to identify risk factors, exposures, and predisposing conditions is crit-
ical. Similar to cicatricial ectropion or entropion, a mechanical ectropion or entropion can be
caused by masses that secondarily evert or invert the lid margin.

Clinical examination

Clinical examination begins with observation of the periocular skin and eyelids, noting lesions
that may be altering lid position through mass effect or gravity, scar formation, rashes, or asym-
metry between the two eyes. If the lid margin is rotating inward, as in entropion, one should

Please cite this article as: F. Hakim and P.O. Phelps, Entropion and ectropion, Disease-a-Month, https://doi.org/10.1016/
j.disamonth.2020.101039
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Fig. 5. Involutional left lower eyelid ectropion with prominent tarsal erythema.

look for the presence of misdirected eyelashes that may be touching the cornea. In these pa-
tients, it is important to establish whether the lashes are misdirected without entropion (trichi-
asis) or if lashes originate from a location posterior to the normal lash line (distichiasis). Epi-
blepharon is a hereditary condition in which pretarsal orbicularis oculi muscle and skin ride
above the eyelid margin to form a horizontal fold of tissue that causes the cilia to project ver-
tically. This condition is most common in patients of east Asian descent and can appear similar
to entropion, but the eyelid margin should be in a normal position. Physicians must also as-
sess the patient for conjunctival injection, discharge, periorbital or eyelid swelling, erythema, or
other signs signaling an infection. In addition to the increased eyelid laxity, patients with invo-
lutional ectropion and entropion commonly present with dry eyes, chronic conjunctivitis, and
chronic blepharitis (inflammation of the eyelids) (Fig. 5).1 Involutional entropion can be distin-
guished from a cicatricial entropion by external observation as well as by “digital eversion.” In
this maneuver, an examiner should be able to correct an involutional entropion by placing gen-
tle traction with fingers to evert both lids and return to normal position. This is not the case
with cicatricial entropion, as the scarring causes irreversible shortening of tissues.7
The “pinch test” and “snap-back test” are commonly used to assess eyelid laxity. In the pinch
test, the examiner gently pulls the lid away from the globe; a distance greater than 8 mm is sug-
gestive of increased laxity. In the snap-back test, the examiner places gentle downward traction
on the lower lid or upward traction on the upper lid.8 If the lid does not briskly return to its
primary position, the result is considered abnormal. Observation of the position of the puncta is
also key. In normal eyes, the puncta should be inverted and opposed to the globe. If the puncta
are everted, this may be suggestive of eversion of the entire lid margin and the presence of ec-
tropion.9 Patients with such presentations will likely complain of tearing. Additionally, during
the pinch test, if the punctum can be displaced laterally, this is suggestive of medial tendon
laxity. Assessment of the shape of the lateral canthus can also be helpful. In a normal eye, the
shape should be an acute angle. A rounded shape may suggest lateral tendon laxity.9 Patients
with upper and lower eyelid laxity may have “floppy eyelid syndrome” which is a separate entity
diagnosed by easily everting the eyelid and associated tarsal conjunctival erythema. This can be
another source of chronic ocular surface irritation. Patients with this condition may have comor-
bid conditions related to increased tissue laxity such as obstructive sleep apnea. If obstructive
sleep apnea is suspected, patients should be asked about pat patiengs patients should be asked
associated signs and symptoms (e.g. increased daytime somnolence, snoring, CPAP use) during
the examination and patients may benefit from additional work-up.

Treatment

Numerous non-surgical treatment options for ectropion and entropion exist. Patients can use
tape to keep their eyelids in a normal position.10 This method has proven effective for involu-
tional entropion and ectropion, as well as paralytic ectropion.10 , 11 Taping is safe, non-invasive
and patients can be instructed in the technique. For all types of entropion and ectropion, non-

Please cite this article as: F. Hakim and P.O. Phelps, Entropion and ectropion, Disease-a-Month, https://doi.org/10.1016/
j.disamonth.2020.101039
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prescription artificial tears and lubricating ointments help maintain the health of the ocular
surface. Lubrication helps reduce irritation from lashes and keratinized skin in entropion and
mitigates the dryness from increased exposure in ectropion. Lubricating drops or artificial tears
can be used 3–4 times per day. Ointments are recommended at night as the consistency of the
formula can cause blurry vision, but patients may use during the day as well. Misdirected eye-
lashes should be epilated in clinic to reduce corneal injury and irritation. In cases of spastic en-
tropion, it is essential to address the underlying conditions causing irritation and muscle spasm.
Similarly, in cases of cicatricial entropion or ectropion, it is imperative to treat an underlying
infection or inflammatory condition prior to consideration of surgical correction. Botulinum in-
jection has also proven to be an effective treatment for involutional and spastic entropion.12 , 13
Adverse effects from injection include ptosis, diplopia, and localized bruising.
As involutional eyelid malposition are related to aging, the risks for developing this condition
may be mitigated by reducing sun exposure, maintaining good nutrition and reducing or elim-
inating tobacco and alcohol use. While no clear evidence shows that involutional entropion or
ectropion can be prevented, these exposures are all associated with accelerated aging.14
There are a variety of surgical techniques for correction of entropion and ectropion. Quickert–
Rathbun sutures evert the eyelid and can be used as a temporizing measure for involutional
entropion. This procedure can be performed by an ophthalmologist in an office setting and is
therefore suitable for patients who are poor surgical candidates due to other medical comor-
bidities.15 However there is a higher rate of recurrence compared to other techniques.16 More
definitive surgical techniques for involutional ectropion and entropion aim to correct the rotation
of the lid margin and reduce laxity by tightening the lid in the horizontal direction. In patients
without excess horizontal laxity, surgical techniques can focus on reinsertion or advancement
of lower lid retractor muscles.9 , 15 Suture tarsorrhaphy can be performed to partially close the
eyelids in paralytic ectropion. The goal is to reduce corneal exposure and protect the ocular sur-
face. This procedure can also be performed by an ophthalmologist in the clinic. For cicatricial
entropion and ectropion, surgical approaches aim to reduce the scarring and vertical shortening.
Skin grafts and mucous membrane grafts may be necessary.

Summary

Entropion and ectropion are highly prevalent disorders of eyelid position, most commonly
caused by involutional changes from by aging-related degeneration of the periocular tissues. In-
flammatory, infectious, or traumatic processes that cause scarring of the facial skin or ocular
surface can lead to a cicatricial entropion or ectropion. Dysfunction of the periocular muscles
can cause a spastic entropion or a paralytic ectropion. These conditions can cause significant
ocular irritation and discomfort. It is important for primary care physicians to recognize the
risk factors that predispose patients to these conditions. Clinical examination relies on observa-
tion and many findings can be appreciated without the use of a slit-lamp or special equipment.
While surgical correction offers definitive treatment, symptoms can be managed medically with
lubrication and less invasive solutions such as taping or botulinum toxin injections.

Sources of support and disclosures

None.

Acknowledgments

We thank Mira Shiloach, MS, CCRP for her edits.

Please cite this article as: F. Hakim and P.O. Phelps, Entropion and ectropion, Disease-a-Month, https://doi.org/10.1016/
j.disamonth.2020.101039
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Please cite this article as: F. Hakim and P.O. Phelps, Entropion and ectropion, Disease-a-Month, https://doi.org/10.1016/
j.disamonth.2020.101039