Ectropion

Ectropion is what happens when the lower eyelid falls away from the eyeball and turns outwards. The rim stops resting against the eye, the pink inner surface ends up on show, and the eye loses the narrow strip that has held its tear film in place all its life. In itself the condition is not dangerous and it almost always involves the lower lid only, but living with it is wearing: the eye waters and dries out at the same time, reddens by evening and is stuck shut by morning. Most often it comes with age and settles in over months, which is why it gets put down to tiredness for so long. Yet how early it is spotted is exactly what decides whether drops will be enough.

Why the lid needs to sit against the eye

The lower lid does two jobs at once, and both become obvious only when it stops doing them.

The first is windscreen wiper. With every blink the rim sweeps across the cornea and spreads the tear film over it again. That film is very thin, lasts a few seconds and breaks up if it is not renewed; wherever it breaks, the surface of the eye dries instantly. A lid that stands off wipes thin air, and part of the cornea is left uncovered — particularly the lower part, the very strip that is exposed during sleep.

The second job is drainage. At the inner corner of the eye there is a tiny opening, the tear punctum, through which tears drain into the nose. That opening has to sit dipped in the pool of tears and pressed against the eye, and the muscle of the lid acts as a pump with each blink. As soon as the lid turns away, the punctum faces the air, the pump works on nothing and tears spill over the edge.

Hence the central paradox of the condition: the eye runs not because there are too many tears but because they cannot get away, while the cornea gets none of them and dries. That is why treatments for dryness help here and so-called drops for watering do not.

The opposite situation also exists: the lid margin rolls inwards and the lashes rub on the eye. That is entropion, a different problem with different treatment, even though the early complaints look alike.

What it feels like

The set of complaints is fairly recognisable and they usually build up together.

• An eye that runs constantly. Tears spill down the cheek in the wind, in the cold, while reading, sometimes for no reason at all. From endless dabbing, the skin under the eye becomes sore and flaky.
• Grittiness and burning. This is the cornea drying. It is worse by the end of the day and after screen work, and worse first thing too if the eye has not closed fully overnight.
• Redness. Both the white of the eye and the exposed inner lining of the lid go red, and that lining gradually thickens and coarsens in the air. On brown or black skin the redness of the lid itself is harder to see, so swelling and symptoms are the better guide.
• Vision that drifts. Letters blur, then clear for a second after a few blinks. What behaves that way is not the eye but the tear film breaking up.
• Crusting in the morning, stuck lashes, repeated conjunctivitis and styes: an unprotected surface picks up infection more easily.
• An eye that does not shut fully. Hardly anyone notices this themselves; it is usually the family who see the person asleep with the eyes half open.

Why the lid turns out

There are several causes, and what happens next depends directly on which one it is.

• Age. The commonest picture by far: the ligaments anchoring the lid to the bony rim of the socket stretch, the muscle weakens and the lid sags under its own weight. It develops over years, usually in both eyes, though one is more obvious.
• Facial nerve palsy. The muscle that closes the lids stops receiving instructions and the lid drops away at once, over hours or days. This happens with Bell's palsy, after surgery on the parotid gland, after shingles with a rash in the ear, and after a stroke. Ectropion rarely comes alone here: on the same side the eyebrow will not lift and the corner of the mouth droops.
• Scarring. The skin below the eye has shortened and is pulling the lid down: burns, injury, years of sun damage and, very often, the mark left by surgery, including eyelid reduction or the removal of a lid tumour.
• Chronic inflammation of the lid skin: eczema, seborrhoeic dermatitis, allergy. A category of its own, and one that is frequently missed, is years of eye drops, most often those for glaucoma: the skin answers the preservatives with a low-grade dermatitis, then puckers and tugs at the lid.
• A lump on the lid. A cyst or a tumour drags the margin down by its weight or distorts it as it scars.
• A congenital form. Rare, and usually alongside other differences in the structure of the face.

What should not be put down to age

A lid that has been sagging slowly can be raised calmly at a routine appointment. But there are situations where waiting is the wrong move.

• The face has dropped within hours. The eye will not close, the brow will not lift, the corner of the mouth has slipped. Even if it turns out to be Bell's palsy, it needs assessing the same day. And if an arm or a leg has weakened along with the face, speech has become muddled or vision has gone, call an ambulance straight away (across Europe the single number is 112): a stroke can begin exactly like this.
• A lump or a sore on the lid that will not heal. What should worry you is a thickening that grows over months, a small wound that bleeds now and again, a patch where the lashes have fallen out and not returned, or a lid distorted at one single point. This is the most important line on the page: skin cancer of the eyelid looks unremarkable and is removed completely at an early stage, while a neglected one works its way back into the socket.
• The eye has become suddenly painful, light-sensitive, cloudy or blurred. This is how damage to a dried-out cornea shows itself, up to and including an ulcer. It needs looking at within hours, not whenever an appointment comes up.
• A lid that has turned out suddenly in a young person, with no history behind it. The cause needs finding — it does not appear on its own.

Day-to-day care

While you wait for an appointment or prepare for surgery, there is a single aim: keep the cornea from drying out. These are not cosmetic measures, they genuinely prevent complications.

• Lubricate the eye on a schedule, not when it starts to sting. Artificial tears during the day, preferably preservative-free if you use them often; a thicker gel or ointment at night, which lasts until morning although it blurs vision for a while.
• Wipe tears the right way. Dab rather than rub, and move the tissue upwards and towards the nose, which pushes the lid back against the eye. The instinctive movement, down and outwards, stretches the lid further and makes the problem worse month by month.
• Do not rub your eyes at all, neither when they itch nor on waking. If there is itching, something cool held against the closed lid is better.
• Cover the eye at night if it does not close: your doctor will show you how to tape the lid with a suitable dressing or use a moisture chamber. Improvising with ordinary sticky tape is not a good idea.
• Remove whatever dries the air: air conditioning or a fan blowing at your face, a heater beside the bed, wind, smoke. Outdoors, any pair of glasses works as a windbreak.
• Look after the skin and the lid margin. A warm compress and gentle cleaning along the lash line in the morning clear the crusting. Use an emollient on the skin under the eye, and if it is inflamed, treat it: a dry, puckered patch pulls the lid down.
• Review your drops. If you have been using something for glaucoma for years, say so: sometimes switching to a preservative-free preparation is enough to settle the skin.

What the doctor decides

The diagnosis is made by looking, with no equipment involved: the lid is examined and its tone tested by pulling the margin away and watching how fast it springs back. A healthy lid snaps into place instantly; a stretched one stays off. At the same time the doctor checks whether the eye closes fully, what state the cornea is in, whether the facial nerve is working and whether there is anything suspicious on the lid.

If there is hardly any trouble, treatment is not compulsory: monitoring and lubrication are enough. Once the cornea is drying and the watering interferes with daily life, the answer is a small operation under local anaesthetic.

• In age-related ectropion the lid is shortened and tightened, and re-anchored to the bony rim of the socket at the outer corner. This is the commonest and the most predictable of these operations.
• If only the inner part of the lid with the tear punctum has turned out, it is rotated back with a small stitch placed on the inner surface.
• In the scarring form, tightening alone is not enough: the skin has to be given back its length with a flap or a graft, most often taken from the upper lid or from behind the ear.
• With a facial nerve palsy the eye is protected first and time is allowed: the nerve often recovers on its own over weeks or months. If it does not, the lid is tightened, and sometimes a thin weight is added to the upper lid so that it closes more readily.
• Lumps on the lid are removed with the tissue sent for examination, and the lid is rebuilt either at the same operation or as a second stage.

Recovery takes a couple of weeks: swelling and bruising last a few days and an ointment is prescribed for a while. The result usually holds, but tissues carry on stretching with age, so after some years the lid occasionally needs tightening again.

Online consultation

A remote appointment is a convenient way to work out what is happening to the lid and how urgent it is. The doctor will ask how long it has been going on and how quickly it has progressed, whether the eye waters, whether there is grittiness, whether the eye closes during sleep, which drops you use regularly, and whether there has been surgery, injury or a burn in the area, then ask you to show the lid to the camera with it pulled gently down. That conversation usually makes clear whether this is age-related laxity, a scar or a facial nerve palsy, whether an eye specialist is needed within days, and what to do about the dryness today. Choosing lubricants, the technique for protecting the eye overnight, and questions before and after surgery are all straightforward to cover online. What cannot be handled on a screen is a face that has dropped suddenly, a sore on the lid that will not heal, or severe eye pain with sensitivity to light: those need to be seen in person, and quickly.

This material is for information only and does not replace medical advice.