Kerala Journal of Ophthalmology

: 2017  |  Volume : 29  |  Issue : 3  |  Page : 160--167

Eyelid malpositions: An overview

Marian Pauly1, TJ Maya2,  
1 Department of Orbit, Oculoplasty and Trauma, Giridhar Eye Institute, Kadavanthra, Kochi, India
2 Department of Ophthalmology, Giridhar Eye Institute, Kadavanthra, Kochi, India

Correspondence Address:
Dr. Marian Pauly
Senior Consultant and Head, Department of Orbit, Oculoplasty and Trauma, Giridhar Eye Institute, Kadavanthra, Kochi - 682 020


Eyelid malpositions are the result of forces acting upon the eyelid margin. A normal eyelid should have a quick return snap to the eyeball. Frequently, tendon laxity at the medial and lateral canthi will render the eyelid margin unstable making it susceptible to contractile forces. Based on the contractile forces either entropion, ectropion, retraction or lagophthalmos can occur. The goal in treating a given eyelid malposition is to reposition the eyelid so that the new healing forces will overcome the pathologic forces. The common approaches include eyelid and canthal tendon tightening, eyelid retractor advancement or recession and skin grafting or transposition flaps. This review article briefly describes the various aspects of lid malpositions in detail.

How to cite this article:
Pauly M, Maya T J. Eyelid malpositions: An overview.Kerala J Ophthalmol 2017;29:160-167

How to cite this URL:
Pauly M, Maya T J. Eyelid malpositions: An overview. Kerala J Ophthalmol [serial online] 2017 [cited 2022 Aug 15 ];29:160-167
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Malpostions of the eyelid can result from a host of causes, the consequences of which, can range from mild discomfort to the patient, to even causing potential threat to ocular surface. This article reviews the types, etiology, and management of the common eyelid malpositions except ptosis, encountered in clinical practice.

Eyelid malpositions in general are entropion, ectropion, eyelid retraction, and lagophthalmos.


It is useful to conceptualize the eyelid as comprising of two lamellae [Figure 1] and [Figure 2]:{Figure 1}{Figure 2}

Anterior – skin and orbicularis musclePosterior – tarsus and conjunctiva.


Causes of entropion may be congenital or acquired. There are three types of acquired entropion, namely involutional, cicatricial, and spastic.

The presenting symptoms can be varying from redness and pain around the eye, sensitivity to light and wind, sagging skin around the eye, excessive tears, and decreased vision, especially if the cornea is damaged.

Kemp and Collin grading of entropion[1]


Apparent posterior migration of meibomian glands

Conjunctivalization of eyelid margin + eyelash/globe contact on upgaze


Features of minimal entropion + eyelashes touching the globe in the primary position with or without thickening of the tarsal plate


Gross eyelid distortion + metaplastic eyelashes + presence of keratin plaques + eyelid retraction causing incomplete trichiasis.

 Congenital Entropion

Upper eyelid entropion occurs secondary to the mechanical effects of microphthalmos and enophthalmos [Figure 3].{Figure 3}

Lower eyelid entropion is caused by maldevelopment of the inferior retractor aponeurosis.

Differential diagnosis:

Epiblepharon – Epiblepharon comprises an extra horizontal fold of skin stretching across the anterior eyelid margin [2]Tarsal kink is a rare congenital eyelid anomaly manifesting with severe entropion, which may lead to corneal opacity and consequent [3] amblyopia. Modified temporary eyelid margin suture for tarsal kink correction provides better mechanical traction on the tarsal plate by drawing the upper eyelid down to the lower eyelid.

Treatment involves excision of a strip of skin and muscle and fixation of the skin crease to the tarsal plate (Hotz procedure).[4]

 Involutional Entropion

Predisposing factors:

Horizontal eyelid laxityVertical eyelid laxity due to weak lower eyelid retractor/disinsertion of lower eyelid retractors: Normally, they pull at the lower edge of tarsus inferiorly and posteriorly, thus preventing the inward turning of the eyelid margin. When laxed, it allows the eyelid margin to invertOverriding of preseptal over pretarsal orbicularis muscle: Rounded eyelid margin and occurrence of entropion on forceful eyelid closure and relative enophthalmos with deep superior sulcus point toward the overriding of preseptal over pretarsal orbicularisInvolution of the soft tissues of the orbit, particularly the orbital fat, may lead to involutional enophthalmos, which in turn can lead to unstable eyelid position with entropion.

 Spastic Entropion

Spastic closure of the eyelids allows the orbicularis oculi muscle to overwhelm the oppositional action of the lower eyelid retractors, resulting in an inturning of the eyelid margin and further irritation of the ocular surface from the inturned eyelashes. This occurs when there is spasm of muscle of Riolan (due to irritation) and lack of support of eyelid by the globe. It can be precipitated by intraocular surgeries.[5]

 Cicatricial Entropion

Cicatricial entropion occurs due to cicatrization of palpebral conjunctiva. Patients with cicatricial entropion usually display scar tissue of the conjunctiva, usually a result of trauma, chemical burns, Stevens–Johnson syndrome, ocular cicatricial pemphigoid, infections, or local response to topical medication.

Examination of the tarsus and palpebral conjunctiva usually points to the diagnosis in these cases.

system for acquired lower lid entropion - see [Figure 4].{Figure 4}


Sutures are passed to correct the lamellar dissociation as follows:(a) transverse sutures prevent upward movement of preseptal muscle and (b) everting sutures tighten the lower eyelid retractors and evert the eyelid.

Wies procedure

Transverse eyelid split + everting sutures – eyelid is split transversely to create fibrous tissue scar barrier which prevents the upward movement of preseptal muscle. Everting sutures shorten the lower eyelid retractors.[6]

Quickert procedure

Transverse eyelid split + everting sutures + horizontal eyelid shortening – lower eyelid retractors are mechanically tightened and double armed sutures are passed full thickness through the eyelid, entering the conjunctiva posteriorly low in the fornix and exiting on the anterior surface of the eyelid just inferior to the eyelashes. Sutures are tied tightly to give a slight overcorrection, which are left to dissolve over 10 days, and scar tissue holds the retractors in place. The scar forms a barrier for the overriding preseptal orbicularis.[7]

Jones procedure

Plication of lower eyelid retractors [Figure 5]a and [Figure 5]b creates a barrier to the upward movement of preseptal muscles:[8].{Figure 5}

Treatment of cicatricial entropion – lengthening of the posterior lamella

Mild – tarsal fracture operation is doneModerate to severe – lysis of the scar tissue and lengthening of the posterior lamella using mucous membrane grafts.[9],[10]

Treatment of spastic entropion – Quickert procedure.


Eyelid falls away or is pulled away from its normal apposition to the globe.


Inadequate corneal protectionTear drainage dysfunctionChronic inflammationSurface keratinization and metaplasia

Contributing factors are similar to entropion.

Clinical approach [11]

Horizontal eyelid laxity is tested as follows:

Eyelid distraction test: manually pulling the eyelid away from the eyeball. Normally, lower eyelid should not move more than 6 mm off the eyeballSnap backtest: pulling the lower eyelid inferiorly toward the inferior orbital rim. Normally, eyelid will spring back into position without a blink. If laxed, eyelid will remain away from the eye for a period of time

Medial canthal tendon (MCT) laxity: eyelid is pulled laterally and a lateral excursion of inferior punctum more than 2 mm denotes MCT laxityLateral canthal tendon (LCT) laxity: identified grossly by a rounded contour of the lateral canthus. Lateral part of the eyelid is moved medially and displacement of the lateral canthus is noted. Displacement more than 2 mm denotes LCT laxityPunctal eversion: examined under the slit lampLower eyelid retractor disinsertion/laxity: eyelid is completely evertedCicatricial changes: pull the eyelid upwardEyelid position during mouth openingPalpebral fissure heightSkin and conjunctiva: scars and tumorsOrbicularis tone: tested by forced closure of eyes, compared with other side also.


Causes of ectropion may be congenital or acquired. There are five types of acquired ectropion, namely involutional, cicatricial, paralytic, mechanical, and congenital.

Involutional ectropion usually occurs in the lower eyelid because of the effects of gravity on a horizontally lax lower eyelidCicatricial ectropion of the upper or lower eyelid occurs following loss of skin secondary to thermal or chemical burns, mechanical trauma, surgical trauma, or chronic actinic skin damage leading to shortening of anterior lamella, chronic inflammation of the eyelid from dermatologic conditions such as rosacea, atopic dermatitis, eczematoid dermatitis, or herpes zoster infections [Figure 6]a and [Figure 6]bParalytic ectropion occurs due to loss of orbicularis tone occurring as a result of paralysis of facial nerve, commonly seen following trauma, Bell's palsy, or following surgery to remove intracranial neoplasms such as acoustic neuromaMechanical ectropion usually caused by the effect of gravity or mass effect induced by bulky tumors of the eyelid. Fluid accumulation, herniated orbital fat, or poorly fitted spectacles may also be mechanical factors in lower eyelid ectropionCongenital ectropion is rare and occurs usually in the lower eyelid. It occurs due to vertical deficiency of anterior lamella. Congenital ectropion may be isolated or associated with Down syndrome.{Figure 6}


Treatment option depends on the predominant component of laxity, whether medial, lateral, or both; accordingly, single procedure or a combination of procedures can be used.

 Horizontal Laxity

Lateral tarsal strip [Figure 7]: Lateral canthotomy is followed by lysis of inferior crus of lateral canthal tendon. A thin strip is fashioned from the lateral end of tarsus by removing the overlying skin, orbicularis, and conjunctiva. Depending on the amount of eyelid laxity, excessive redundant tarsus is excised. Lateral edge of the tarsus is then anchored to the periorbita lining the inner part of lateral orbital wall with a nonabsorbable suture-like 6-0 prolene [12]Bick's procedure: Full-thickness excision of the eyelid is done just medial to the lateral canthal angle. Resection of the eyelid in this location may cause rounding and medial displacement of the lateral canthal angle [13]Kuhnt–Szymanowski procedure [Figure 8]: This procedure is useful when there is excess of lower eyelid skin in addition to the horizontal laxity. Horizontal eyelid shortening + blepharoplasty: full-thickness pentagon excision is combined with excision of redundant skin [15]Lateral canthal tendon plication [Figure 9].{Figure 7}{Figure 8}{Figure 9}

 Medial Canthal Tendon Laxity

Medial canthal tendon plication

The canalicular part of medial canthal tendon is shortened by suturing the medial end of lower tarsal plate to the main part of medial canthal tendon with a buried nonabsorbable suture.

Punctal ectropion

See [Figure 10] for punctal ectropion.{Figure 10}

 Paralytic Ectropion – management

Medial canthoplasty

See [Figure 11] and [Figure 12]a, [Figure 12]b, [Figure 12]c, [Figure 12]d for medial canthoplasty.{Figure 11}{Figure 12}

Fascial sling

See [Figure 13] for fascial sling.{Figure 13}


To tackle exposure keratopathyDecreases the visual fieldDisfiguring.

 Cicatricial Ectropion-Management

Conservative management

Antiscar creamsOcclusive dressings: silicone gel sheet

Cicatricial ectropion of the lower eyelid is usually treated in a three-step procedure:

Vertical cicatricial traction is surgically releasedThe eyelid is horizontally tightened with a lateral tarsal strip operationThe anterior lamella is vertically lengthened via a midface lift or full-thickness skin graft.

Z-plasty: Done in localized scar. Either single/multiple Z-plasty can be done. Each Z increases the length of wound by 30% and redirects it by relaxing the area under tension [Figure 14].{Figure 14}

 Eyelid Retraction

Normally, upper eyelid lies 1–2 mm below the superior limbus and lower eyelid margin just touches the inferior limbus.

Certain measurements are made to make a diagnosis:

Position of the upper and lower eyelids in relation to the limbusVertical palpebral fissure heightLagophthalmosLevator muscle functionExophthalmometryAssess ocular movementsR/o Marcus Gunn Jaw-Winking phenomenon and Duane's retraction syndromeR/o pseudoretraction.

Pseudoretraction may be seen in cases of contralateral eyelid ptosis with a Hering effect. In the presence of unilateral ptosis, equal central nuclear outputs to both levator muscles may result in elevation and retraction of the previously normal opposite eyelid. Pseudoretraction of the elevated eyelid is suggested when on gently lifting the ptotic eyelid, the retracted eyelid returns to its normal resting position. Similarly, digital closure of the retracted eyelid results in elevation of the opposite ptotic eyelid.


Congenital acquired


Primary congenital – either upper/lower eyelid or both

Diagnosis of exclusionRetraction stable over timeLevator muscle fibers tend to extend more anteriorlyManagement: only observation, surgery is deferred till 4 years of age unless retraction is severe and causing exposure of cornea.


Benign transient conjugate downward gaze in preterm infantsPretectal or dorsal midbrain syndrome – collier signFacial nerve paralysis [14] – unopposed action of levator, following the loss of tone of orbicularisPinealomaHydrocephalusMarcus Gunn syndromeAberrant regeneration of third nerve.Orbital floor fracture/basilar artery disease.


ProptosisCraniosynostosisMyopiaBuphthalmosIrritation from contact lensFollowing orbital floor fracture/orbitotomy.


Thyroid eye disease [17]

Proposed mechanisms: orbital proptosis secondary to enlargement of the rectus muscles, levator and Müller's muscle infiltration with fibrosis, excessive sympathetic innervation, abnormal adhesions between the levator and adjacent tissues

Other important myogenic causes are postsurgical complications of vertical rectus muscle recessions, ptosis overcorrection.


Alternatives to surgery

Eyelid retraction associated with Graves' disease may show some improvement following the treatment of dysthyroidism.


Surgical correction of eyelid retraction is indicated when it causes exposure keratopathy and for cosmetic indications.

Cosmetic reasons are as follows:

Upper eyelid retraction correction

Muller muscle recession with/without levator recession:After adequate anesthesia is achieved, the eyelid crease is incised and dissection continues through the orbicularis oculi muscle to the septum. The septum is identified and incised 1–2 mm above its insertion into the aponeurosis. Orbital fat can be gently pushed superiorly with cotton-tipped applicators. The inferior attachments of the aponeurosis are freed from the superior border of the tarsus. Dissection under the aponeurosis and above Müller's muscle is continued up to Whitnall's ligament. Müller's muscle is excised from the superior border of the tarsus up to the level of Whitnall's ligament. The position of the eyelid relative to the superior limbus is evaluated. The eyelid should be ptotic, and the procedure now becomes a ptosis repair. The aponeurosis may be advanced to tarsus or sutured directly to conjunctiva so that the eyelid margin lies at the appropriate height. Can be done transconjunctivally alsoPlacement of spacers to lengthen the upper eyelid: Tarsus, autologous fascia, processed collagen, sclera were used for this purpose. Sclera was the most commonly used initially, but it caused eyelid thickening, cyst formation and had a potential risk of prion disease transmission. Later, Mersilene mesh was used. The primary problem associated with spacers in the upper eyelid is the obvious increased risk of corneal irritation and abrasionFull-thickness anterior blepharotomy – Koornneef procedure [Figure 15]a and [Figure 15]b:Surgical procedures in cases with thyroid eye disease are not performed until the ophthalmopathy is fully stabilized, which takes about 6–12 months. Until this time, botulinum toxin can be used as a reliable adjunct to the treatment of eyelid retraction. An average drop in the upper eyelid of 2–3 mm can be achieved with a transconjunctival injection of 2.5–5 units for about 3 months.{Figure 15}

Lower eyelid retraction

Involutional lower eyelid retraction-eyelid tightening procedures such as lateral tarsal stripCicatricial retraction may need anterior lamellar augmentation with a skin graftLower eyelid retraction associated with thyroid-related orbitopathy can be managed by transconjunctival recession of lower eyelid retractors with/without the use of spacer materials.

Mild lower eyelid retraction can also be treated with fillers such as stabilized hyaluronic acid.


Causes of lagophthalmos

Common cause – facial nerve paralysisOther causes – related to cicatricial changes of the eyelids due to chemical/thermal injury or disorders such as Stevens–Johnson syndromeNeurogenic eyelid retractionExophthalmos in thyroid eye diseaseProptosis of any etiology.


Main aim – to prevent exposure keratitis and reestablish eyelid functionMainstay of treatment – intensive lubricationMedical treatment:

Botulinum toxin chemodenervation to induce a protective ptosis – 7.5 units of botulinum neurotoxin type A is injected into the levator muscle.[18]

Surgical procedures;

Tarsorrhaphy and upper eyelid reanimation techniques including eyelid loading with gold weights and palpebral springs and thinner platinum loadings [19]Prosthetic replacement of the ocular surface ecosystem device provides a liquid bandage to protect the cornea from eyelid interaction and desiccation, in addition to improving vision.[20]

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


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