Eyelid Malpositions (Ptosis, entropion, ectropion and retraction)

Normally placed and well functioning eyelids are required for comfortable eyes which have good vision and aesthetics. Upper and lower eyelid malpositions are caused by a range of factors including ageing, trauma, tumour, swellings, infections, cysts and weakening of the facial nerves/muscles.

“Careful assessment of the eyelids and facial anatomy is the key to the correct diagnosis to provide an individualised tailored approach to the best treatment options” 

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Ptosis is when the upper eyelid is droopy. Mr Uddin has been treating patients with ptosis for over 25 years. From his extensive experience of treating patients with ptosis, Mr Uddin understands the impact that a change in a person’s appearance can have on their self-confidence, as well as their, such as affecting the ability to work and carry out day to day tasks.
For patients with ptosis, Mr Uddin undertakes a comprehensive assessment in conjunction with necessary investigations to find the underlying cause. He will then deliver a treatment plan specific to the individual.

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Upper eyelid retraction/lower eyelid traction/displacement

A high upper lid lid (retraction) or a low lower lid can make the eye look bigger, have more of the white of the eye showing and can result in poor eye closure

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Ectropion is a condition in which the eyelid becomes droopy, hanging loosely away from the eye and turned outwards.

Symptoms of ectropion

The eyes may water excessively and feel dry, gritty and irritated. Some people with the condition have red eyes, skin changes and increased sensitivity to light. Sometimes, it’s largely a cosmetic problem only

What causes ectropion?

The most common cause of ectropion is ageing; as the tissues and muscles of the eyelid become weaker over time and begin o sag. Other causes include:

  • Weakness of the facial/7th nerve which maintains tone and function of the facial muscles; Causing the lower lid to sag, but often affects the whole face
  • Cicatricial/contraction or shortening of the skin due to sun damage, surgery, injury or burns. Skin condition such as eczema or contact dermatitis can cause this and is often easily treated
  • Mechanical- lumps or tumour on the eyelid can pull the lid down
  • Congenital- Occasionally, ectropion may be present from birth due to a congenital disorder or if the eyelid tissues have not developed properly.
What treatments are available?

Treatment is dependent on the cause and underlying tissues.

  • skin conditions need to be identified and treated for example eczema, dry skin or sun exposure. These conditions cause skin changes which cause shrinking that can result in abnormalities of the lid position. This is reversed with appropriate treatment
  • Blepharitis and lid inflammation if adequately treated will reduce ectropion
What surgical options are there for treating ectropion?

The type of surgery required is determined by addressing the underlying anatomical and functional factors and also the wishes of the patient.

  • Age-related changes and lid laxity can be corrected with lid tightening surgery under local anaesthesia. If there is excessive skin or lower eyelid fat, this can also be improved cosmetically at the same time.
  • Tight skin or skin shortage can be treated with surgery that involves skin elevation and recruitment from the cheek area (eg mid-face lift), skin grafts or skin flaps.
  • Patients who have had previous cosmetic surgery, such as cosmetic lower eyelid blepharoplasty, facelift and trauma surgery, may require revisional ectropion surgery. There are many effective treatment options for these very distressing situations.
  • Tumours should be managed with a correct diagnosis, excision and reconstruction
  • Trauma causing ectropion can be challenging and more than just an eyelid problem, but with the correct assessment, the most effective treatments can be planned depending on the causes.
  • Treatment of facial weakness causing ectropion requires special consideration as it can affect the whole face. However, sometimes, straightforward eyelid surgery can be effective in improving the function, closure and looks 


Entropion is when the eyelid turns or rotates inward causing the eyelashes and skin to rub against the surface of the eye.

It is important to distinguish from other cases of misdirected eyelashes (see below)

Symptoms of entropion

This can cause the eyes to water excessively, there may be redness, irritation, pain. Sometimes there may be discharge or crusting around the eyelid, Entropian can result in acute or sight-threatening eyelid ulcers.

What are the causes of entropion?

Most cases of entropion are caused by the age-related sagging and weakening of the eyelid muscles and supporting tissues.

  • Entropion can also be caused by excessive muscle contraction, (sometimes called spastic entropion)
  • Conjunctival scarring inside the eyelid caused by autoimmune conditions
  • such as pemphigoid, Stevens-Johnson syndrome, chemical burns, previous surgery, trauma, infection (eg trachoma, conjunctivitis from MGD/adenoviral infection etc.)
  • It is very rare to be born with entropion (congenital entropion). The more common problem that is mistaken for childhood entropion is epiblepharon, where there is a roll of excess skin or muscle of the lower lid making the eyelashes turn in and rub the eye.
What treatments are available for entropion?
  • Lubricants and antibiotic drops and cream can help protect the eyes.
  • For temporary relief, the eyelid may be taped onto the skin in its normal position.
  • Botulinum toxin (Botox) injections may be if surgery is not an option.
  • Surgery is usually the most effective treatment. The procedure is usually completed as a daycase under local anaesthetic It consists of repositioning the lower eyelid tissues. It combines an everting procedure using stitches (sutures) only or repositioning the internal muscles (retractors). L lower eyelid tightening is necessary which is performed in the outer corner of the lid and heals very well. Surgery is often approached through a lower eyelid blepharoplasty approach which also allows improvement of excess skin and fat if desired.
What is Epiblepharon?

This can be congenital, childhood or familial. Sufferers have an excess roll of skin or muscle of the lower lid making the eyelashes turn in and rub the eye.

It is more common in East Asian individuals. Often the child “grows out of it” as the face grows. If more irritating, a straightforward surgical procedure to remove and reposition the skin and muscle can be performed.

Eyelash disorders

Eyelash disorders (Trichiasis, distichiasis, metaplastic lashes, madarosis)

Problems with eyelashes may be due to abnormally directed lashes or abnormally growing lashes (Trichiasis, distichiasis, metaplastic lashes, madarosis). They can occasionally signify more serious underlying conditions.
Sometimes the whole eyelid turns in (epiblepharon/entropion).
It's important to distinguish the underlying cause.

What is trichiasis?

Trichiasis is a common condition in which the eyelashes grow towards the eye causing irritation. It is caused by chronic blepharitis (eyelid inflammation), scarring from previous surgery or occasionally an eyelid tumour may be present lik this. Sometimes certain eyedrops may be to blame.

Symptoms of trichiasis are similar to entropion. Those with the condition may experience watery eyes, redness and the feeling of a foreign body within the eye.

What is distichiasis?

An extra row of lashes grows further back on the eyelid. It may affect both upper and lower eyelids. It is often congenital and may have other associated problems, including occasionally swelling elsewhere (lymphedema)

What are metaplastic eyelashes?

These are lashes that grow from the “wrong” part of the eyelid margin. They are associated with chronic inflammation including blepharitis, chronic conjunctivitis, ocular cicatricial pemphigoid and Steven-Johnson syndrome.

What treatments are available for abnormal eyelashes?

  • Identify and treat the undying cause.
  • Lubricants and antibiotics can be used to treat the irritation.

Depending on the severity of the condition the following can be used:

  • Epilation involves periodical removal of eyelashes with fine forceps
  • Electrolysis- a special electrical current is applied to remove hair by destroying the hair root or follicle
  • Cryotherapy -freezing the eyelash follicles
  • Surgical excision of lash follicles
  • Surgery to eyelid in more complex cases
What is Madarosis?

This is when some eyelashes (or eyebrow hairs) are missing. It can affect all four eyelids.

It should be remembered that there is normally some general loss of eyelashes and reduced volume of lashes with advancing age.

However when it is localised to a smaller area and if there is scarring, the cause can be inflammation (Blepharitis/MGD/rosacea), trauma or occasionally an eyelid skin cancer.

The more generalised eyelash loss there is, the more difficult it is to manage. It is important to treat the underlying cause if this is known.

Causes include autoimmune conditions for example alopecia areata or discoid lupus erythematosus, abnormalities of the thyroid gland (both overactive and underactive thyroid disease), dermatitis, medical treatments such as chemotherapy or radiotherapy and trichotillomania when hair is lost due to repeated trauma often by pulling

Floppy Eyelid Syndrome

Symptoms of floppy eyelid syndrome

This is often misdiagnosed as persistent red sticky eyes, chronic conjunctivitis, and ptosis. Usually stickiness is a feature and often worse in the morning.

What is floppy eyelid syndrome?

Floppy eyelid syndrome (FES) is characterised by loose skin and stretchy eyelids, which easily flip over. It is caused by a weakness in the underlying tissues of the eyelids or persistent rubbing, perhaps at night. It is commonly associated with sleep apnoea, being overweight and keratoconus.

What treatments are available?

An antibiotic and anti-inflammatory drops and ointment can be used to treat irritation and inflammation.

Eyelids may need to be taped shut at night to stop them rubbing against the pillow. Eyelid tightening surgery is often the most effective treatment.

Weight reduction and review by a sleep apnoeas specialist is helpful

What is Blepharochalasis Syndrome?

Blepharochalasis is a rare condition characterised by repeated upper eyelid swelling and inflammation. It usually starts in the teens or early 20’s.

It often affects both eyes. There is shiny swelling of the lids, causing the eye to close, lasting a few days. The swelling then recovers spontaneously. It is usually painless and not itchy.

The repeated swelling leaves a thin, crepe-like skin with stretching of the outer part of the eyelid and droopy eyelid
Medical treatment can be difficult.

There is effective surgical treatment, once the swelling episodes have subsided. This includes removal and realignment of skin and upper eyelid position (modified blepharoplasty and ptosis surgery). Lateral canthal fixation (fixing the loosely attached outer lid) can be done with sutures, local periosteum (strong lining of the bone) or fascia lata (strong material similar to the tendon which can be taken from the led or temple)

What is Euryblepharon?

It is a condition you are born with. It results in abnormal looking lower eyelid, especially towards the outer aspect, resulting in ectropion or pulling down of the eyelid.
Treatment is careful surgery.

Trauma and lid malpositions

Contact us

Moorfields Private Outpatient Centre

9-11 Bath St EC1V 9LF
London (Central London)

Moorfields Private Practice

8 Upper Wimpole St W1G 6LH
London (Central London)

Parkside Hospital

53 Parkside SW19 5NX
London (Wimbledon)

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