Author: Claude (AI), from PubMed abstracts · Reviewed by: Dr Mina Abdelmseih · Reviewed: 2026-11-15 · Review due: 2027-11-15

Educational content only. Not personalised medical advice. Clinical decisions remain the responsibility of the treating clinician.

Entropion and Ectropion

Entropion is inward turning of the eyelid margin against the globe; ectropion is outward turning, usually of the lower lid [S10] [S9]. Both are common in older people and becoming more common with population ageing [S10] [S9]. Malpositions such as cicatricial entropion and paralytic lid deformity can cause exposure, inflammation and significant visual impairment [S12].

Key points - Entropion is involutional, cicatricial, spastic or congenital; involutional is the most common [S10]. - Acquired ectropion is involutional, paralytic, mechanical or cicatricial; involutional is the most common [S9]. - Lid instability usually comes from horizontal laxity or from disinsertion or attenuation of the lower lid retractors, so surgery should correct horizontal and vertical instability [S1]. - In the only RCT, everting sutures plus lateral tarsal strip was more effective for involutional entropion than everting sutures alone [S2].

Evidence last checked: 2026-10-17 (PubMed abstracts).

Red flags

• Corneal exposure in facial palsy: lagophthalmos, ectropion and exposure keratopathy are ophthalmic complications of facial paralysis [S8].
• Cicatricial entropion from inflammatory or iatrogenic posterior lamellar contraction is among the malpositions most harmful to the ocular surface [S12].
• Lashes rubbing the cornea with a corneal ulcer or reduced vision [G1].

Recognise it

Entropion - Involutional entropion is one of the commonest lower lid malpositions in the elderly [S2]. Asian eyelids develop it more often [S3]. - Proposed causes: vertical and horizontal lid laxity and preseptal orbicularis overriding the pretarsal orbicularis [S5]. Retractor attenuation appears to be the predominant factor in most patients; tarsal atrophy, enophthalmos and fat prolapse may contribute in some [S11]. - Cicatricial entropion arises from posterior lamellar contraction after inflammatory or iatrogenic injury [S12].

Ectropion - Involutional ectropion is caused by age-related degeneration of periocular tissues, with horizontal and vertical factors [S7]. - Cicatricial ectropion occurs when a scar below the eye pulls the lid down enough to evert it [S6]. - Paralytic: facial nerve palsy causes incomplete blinking, punctal malposition and lacrimal pump dysfunction, with tearing and ocular surface instability [S12].

Confirm it

• Assess horizontal laxity; the distraction test often shows margin laxity in involutional entropion, although the lids are typically not elongated [S11].
• Look for vertical laxity, orbicularis override and retractor dehiscence, since procedure choice depends on which are present [S5].
• In cicatricial ectropion, assess the medial or lateral extent, degree of scarring and lid laxity [S6].
• In facial palsy, grading scales are used to measure severity and track outcomes [S8].

Manage it

Before acting on this section, check the national and local guidelines, product information and regulatory approvals that apply where you practise. See the medical disclaimer.

Tier A (primary care / no specialist)

• Lubricate and protect the cornea; in lagophthalmos or ectropion, temporary measures aim to lubricate and cover the eye [S8].
• Refer for surgical assessment; the treatments described are surgical [S2].
• Refer facial palsy early: assessment by a skilled ophthalmologist shortly after diagnosis can help prevent long-term complications [S8].

Tier B (general eye clinic)

• Involutional entropion: a lateral tarsal strip is the typical treatment and may be combined with eversion techniques [S10]. Everting sutures plus lateral tarsal strip outperformed everting sutures alone in one RCT of 63 participants, supported by retrospective case series [S2]. Minimally invasive retractor procedures (everting sutures, transconjunctival approaches) work in patients without horizontal laxity, but recurrence is higher if a lax lid is not tightened horizontally [S3].
• Temporary option: in a case series of 11 patients, orbicularis botulinum toxin resolved involutional entropion within about 7 days, with 27% recurrence at 6 and 9 months [S4]. This is low-level evidence.
• Involutional ectropion: the lateral tarsal strip is the most used and effective surgery for horizontal laxity [S7].
• Facial palsy: temporary surgical options include lateral tarsorrhaphy, weighted lid implants and lateral canthoplasty [S8]. Scleral lenses can help but may be expensive and hard to obtain [S8].

Tier C (specialist centre)

• Combining procedures that correct several causative factors further lowers entropion recurrence [S5].
• Cicatricial entropion is best treated with lamellar repositioning or grafting [S12].
• Cicatricial ectropion: no single technique has been shown superior for most patients; choice depends on extent, scarring, donor tissue and laxity [S6].
• Chronic facial paralysis: dynamic reconstruction uses regional or free muscle flap transfer [S8].

Refer when

Pitfalls

• Using everting sutures alone in a horizontally lax lid: recurrence is higher [S3].
• Treating cicatricial entropion as involutional: it needs posterior lamellar surgery [S12].
• Missing corneal exposure in facial palsy [S8].
• One operation for every patient: repair should be individualised to each patient's anatomy [S11] [S5].

Evidence notes

• Thin evidence: a single small RCT [S2]; the Cochrane authors judged one RCT unlikely to change practice and called for more trials. Everything else is review or case-series level.
• Congenital and spastic forms are named but not described in these abstracts.
• Not covered by these sources: trachomatous entropion (see the trichiasis article), complication rates, anaesthesia, and outcomes in low-resource settings.

Related articles

• Trachomatous Trichiasis Surgery
• Blepharoptosis

References

See the numbered source list below. Each marker [S#] links to its PubMed and DOI record.