Eyelid Malpositions: Entropion, Ectropion, Trichiasis and Chalazion
Last updated: November 2026
Lid malpositions are everyday oculoplastic problems: they cause a watering, irritated eye, and an inturned lid can scar the cornea. Classify by direction (in or out) and cause (involutional, cicatricial, paralytic, mechanical or congenital), and the right operation follows.
Entropion (lid turned in)
| Type | Cause | Treatment |
|---|---|---|
| Involutional (lower lid) | Horizontal laxity, disinserted lower lid retractors, overriding preseptal orbicularis | Temporary: everting (Quickert) sutures or taping. Definitive: lateral tarsal strip with retractor reinsertion (Jones procedure) |
| Cicatricial (upper lid more often) | Conjunctival scarring: trachoma, chemical injury, Stevens-Johnson syndrome, ocular cicatricial pemphigoid | Tarsal fracture or anterior lamellar reposition; treat the cause |
| Congenital or epiblepharon | A fold of skin pushes lashes against the cornea | Often resolves; surgery if corneal staining persists |
Ectropion (lid turned out)
| Type | Cause | Treatment |
|---|---|---|
| Involutional | Horizontal laxity, medial or lateral canthal tendon laxity | Lateral tarsal strip; medial spindle for punctal ectropion |
| Cicatricial | Skin shortage: burns, trauma, sun damage, previous surgery | Release scar and add skin (full-thickness graft or flap) |
| Paralytic | Facial (VII) nerve palsy | Lubrication, taping; lateral tarsorrhaphy, gold weight for the upper lid, lid tightening |
| Mechanical | A lid mass or swelling | Remove the cause |
Examination tests
- Snap-back test: pull the lower lid away and see how fast it returns.
- Lid distraction: more than 6–8 mm from the globe means significant laxity.
- Medial and lateral canthal tendon laxity; punctal position; Bell phenomenon and corneal sensation.
Trichiasis and distichiasis
- Trichiasis: normal lashes misdirected (often after trachoma or lid inflammation). Few lashes: epilation or electrolysis; many: radiofrequency ablation, cryotherapy, or surgery.
- Distichiasis: an extra row of lashes from the meibomian gland openings (congenital or acquired).
- Trachoma remains a leading cause of cicatricial entropion and trichiasis worldwide (SAFE strategy).
Chalazion and stye
- Stye (hordeolum): acute infection of a lash follicle (external) or meibomian gland (internal); warm compresses, lid hygiene.
- Chalazion: chronic lipogranuloma of a meibomian gland; warm compresses for 4–6 weeks, then incision and curettage or a steroid injection.
- Recurrent chalazion in the same place, especially in older adults: send for histology to exclude sebaceous gland carcinoma.
Where residents slip
- Doing everting sutures alone for involutional entropion with marked laxity: it recurs.
- Not sending a recurrent "chalazion" for histology.
- Forgetting corneal protection in facial palsy.
Test yourself: flip cards
Related: Tests for Blepharoptosis, Oculoplasty, Congenital NLD Obstruction: When to Wait, When to Act.
Key sources
- Collin JRO. A Manual of Systematic Eyelid Surgery. 3rd ed. Butterworth-Heinemann; 2006
- American Academy of Ophthalmology. BCSC Section 7: Oculofacial Plastic and Orbital Surgery (current edition)
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