Medial ectropion / punctal eversion means the inner part of your lower eyelid tilts outward. Because the tear drain is no longer hugging the eyeball, tears don’t enter the drain properly—they run down your cheek. The exposed inner eyelid and lower cornea dry out and get irritated. In older adults, this usually happens because the lid tissues and tiny tendons get loose with age, or the lower-lid “retractor” muscle slips off where it should be attached. In scar-related cases, the skin tightens and pulls the lid outward. Facial-nerve problems or a mass weighing on the lid can also tilt it out. NCBI+1WebEye
These are eyelid malpositions at the inner corner (medial lower lid/punctum) that make the tear drain opening turn outwards and stop touching the tear lake. Tears can’t drain, so they run down your face (epiphora), the skin gets sore, and the eye feels dry/irritated even though it’s watery. The medial spindle procedure is a small operation that flips the punctum back in and supports the inner lid. Surgeons frequently combine it with lateral tarsal strip when the lid is globally loose. EyeWikiAAONature
Types
Involutional (age-related) medial ectropion.
The most common type. The lower lid stretches, its retractors loosen, and the inner corner (with the punctum) rolls out. NCBI+1Cicatricial (scar-pulling) medial ectropion.
Scarring of the skin/muscle in front of the lid (from burns, surgery, skin disease, chronic inflammation) shortens the front layer and tethers the lid outward. EyeWikiParalytic medial ectropion.
Weakness of the orbicularis muscle from facial-nerve (CN VII) palsy lets the lid sag and rotate out, especially medially. NCBIMechanical medial ectropion.
A lid mass, heavy redundant skin, or herniated fat weighs the lid down and everts the punctum. NCBICongenital medial ectropion / punctal malposition.
Rare. The punctum is placed or formed abnormally at birth; the medial lid may evert.Isolated punctal ectropion.
Only the punctum flips out, while the rest of the lid looks fairly normal; often needs a targeted fix such as a medial spindle. EyeWikiMixed patterns.
Many patients have a blend (e.g., age-related laxity + mild scarring), so doctors choose mixed solutions.
Causes
Aging (tissue laxity). Lid tendons and ligaments loosen over time; the inner corner drifts outward. Cleveland Clinic
Lower-lid retractor disinsertion. The “lower lid pulley” slips from its anchor, so the lid stops hugging the eye. WebEye
Medial canthal tendon laxity. The small inner-corner tendon stretches, letting the punctum roll out. PMC
General horizontal lid laxity. The whole lower lid is too loose and sags away from the globe. NCBI
Cicatricial skin changes (burns/trauma). Scar tissue shortens the front layer and pulls the lid outward. EyeWiki
Post-surgical scarring (e.g., after lower-lid blepharoplasty). Too much skin removal or scarring can evert the lid. EyeWiki
Chronic dermatitis or eyelid skin disease (e.g., ichthyosis). Repeated inflammation stiffens and shortens skin. EyeWiki
Topical medication irritation (e.g., some glaucoma drops). Long-term irritation may promote scarring/laxity. EyeWiki
Facial-nerve palsy (Bell’s palsy, stroke, tumor). Poor muscle tone lets the lid fall outward. NCBI
Eyelid tumors or cysts. Weight or mass effect tilts the lid down and out. NCBI
Redundant heavy skin or fat (dermatochalasis). Extra weight everts the lid mechanically. NCBI
Floppy eyelid syndrome. Abnormally lax lids evert easily, including medially.
Maxillary hypoplasia / midface descent. Midface support loss changes lid vectors and promotes ectropion. WebEye
Relative proptosis or globe position changes. Altered geometry pushes the lid away. WebEye
Chronic eye rubbing/allergy. Repeated pulling can worsen laxity over years.
Ocular cicatricial pemphigoid or Stevens-Johnson syndrome. Mucosal scarring tethers the lid outward.
Sun damage (actinic skin change). Thins and tightens skin, contributing to outward pull.
Prior lacrimal surgery (e.g., canalicular procedures). Can alter punctal alignment.
Infection-related scarring (e.g., trachoma history). Healed scarring can evert the lid. Saint Luke’s Health System Kansas City
Congenital punctal malposition. The tear opening is placed poorly from birth.
Symptoms
Tears running down the cheek (epiphora). The punctum isn’t touching the eyeball, so tears can’t drain.
Irritation or “gritty” feeling. The exposed inner lining dries and rubs on the eye surface.
Redness of the inner eye corner. Constant exposure inflames the conjunctiva.
Burning or stinging. Dry, exposed edges trigger a burning sensation.
Mucous discharge or crusting. Irritation makes extra mucus; crust forms on lashes.
Blurry vision that clears with blinking. Tear film breaks up; a blink re-spreads tears.
Light sensitivity (photophobia). A drier cornea gets more sensitive to light.
Stringy, reflex tearing in wind or cold. The eye tries to “wash” itself, but tears can’t drain properly.
Soreness by the end of the day. Exposure worsens with fatigue.
Foreign-body sensation at the lower lid. The everted edge can rub on the cornea.
Skin irritation below the eye. Constant tear overflow irritates the skin.
Recurrent conjunctivitis or keratitis. Stagnant tears and exposure invite infection/inflammation.
Trouble wearing contacts. A poor tear film and exposure make lenses uncomfortable.
Cosmetic concern (turned-out lid). The lid looks rolled out at the inner corner.
Watering that doesn’t respond to drops. Because the drain is misaligned, lubricants don’t solve the plumbing problem.
Diagnostic tests
A) Physical exam
Slit-lamp inspection of the punctum and medial lid. The doctor looks up close: is the punctum facing the eye or away? Any redness, staining, or mucus? This is the core exam. EyeWiki
Tear meniscus height and dye staining. A higher “tear lake” with an everted punctum suggests outflow failure; fluorescein highlights dryness spots on the cornea.
Snap-back test. The doctor pulls the lid down and lets go; a slow return means laxity. NCBI
Distraction test (horizontal laxity). How far the lid can be pulled forward from the globe (often >6–8 mm suggests laxity). Eyes On Eyecare
Punctal apposition check. Does the punctum touch the tear meniscus in primary gaze? If not, it’s everted. Eyes On Eyecare
Look for retractor signs. A deep lower fornix, a white line, and poor down-gaze movement point to retractor slippage. WebEye
Eyelid skin and scar survey. Thin, tight, or scarred skin suggests a cicatricial component. EyeWiki
B) Manual tests (bedside maneuvers)
Lateral distraction test (medial canthal tendon stress). Gentle outward pull shows how much the inner tendon stretches; too much suggests medial laxity. Nature
Temporary re-apposition with a cotton-tip. Rolling the punctum inward briefly shows whether symptoms immediately improve (a quick “preview” of surgical benefit).
Lid-taping simulation. Taping the lid to improve apposition can demonstrate if better alignment relieves tearing.
Punctal dilation/probing. Ensures the opening isn’t scar-narrowed and the canaliculus is open; helpful when epiphora is disproportionate.
Eyelid traction and vertical pinch test. Checks for front-layer shortening (cicatricial pull) that would need a scar-lengthening approach. EyeWiki
C) Lab & pathological tests
Conjunctival biopsy with direct immunofluorescence if ocular cicatricial pemphigoid is suspected (to document mucous-membrane autoimmune scarring).
Thyroid function tests (TSH, free T4) if thyroid eye disease and lower-lid retraction are in the differential. EyeWiki
Diabetes screening (fasting glucose, HbA1c) when neuropathy or facial-nerve issues could be contributing to lid malposition.
D) Electrodiagnostic tests
Facial-nerve EMG / nerve-conduction studies for suspected CN VII palsy, to grade severity and recovery potential.
Blink reflex study (trigeminal-facial pathway) if broader cranial neuropathy is on the table.
E) Imaging tests
External and slit-lamp photography. Before/after photos document punctal position and exposure changes; useful for planning and follow-up.
Anterior-segment OCT (AS-OCT) to visualize lid–globe apposition and corneal surface changes in persistent exposure complaints.
CT/MRI (orbit, temporal bone, or brain) only when indicated—for example, a suspected eyelid/orbital mass (mechanical ectropion) or a central cause of facial-nerve palsy. NCBI
Non-pharmacological treatments
Lid taping at night (temporary) – a small hypoallergenic tape supports the inner lid against the globe so the punctum contacts the tear lake; purpose: short-term relief before surgery; mechanism: mechanical inversion.
Moisture chamber goggles – reduce evaporation and wind exposure; purpose: symptom relief; mechanism: creates a humid micro-environment.
Humidifier in rooms – keeps tears from evaporating quickly; mechanism: environmental humidity.
Warm compresses – liquefy meibum; improve tear film; mechanism: heat thins oils so they spread better.
Lid hygiene – gentle scrubs with approved cleansers; mechanism: lowers bacterial load/inflammation.
Blink training / screen breaks (20-20-20) – improves tear redistribution; mechanism: restores blink reflex.
Avoid eye rubbing – prevents further laxity and dermatitis; mechanism: reduces mechanical strain.
Sleep position changes – avoid face-down or pressure on lids; mechanism: reduces nocturnal lid strain.
Optimize CPAP mask fit (if applicable) – prevents air leak drying and lid traction; mechanism: reduces mechanical/air trauma.
Cold compresses in inflammatory flares – reduces swelling that weighs down the lid; mechanism: vasoconstriction.
UV-blocking eyewear outdoors – protects periocular skin; mechanism: reduces actinic damage/cicatricial pull.
Allergen avoidance & home dust control – less eyelid itching and rubbing; mechanism: reduces histamine-driven irritation.
Punctal plugs (temporary test) – counterintuitive but can help surface dryness while waiting for surgery; mechanism: conserves tears when drainage is dysfunctional downstream (use selectively).
Soft bandage contact lens (short-term) – protects the ocular surface from exposure; mechanism: reduces friction and evaporation.
Lubricating ointment at bedtime – technically a medical product but non-systemic; mechanism: coats ocular surface for night protection.
Skin barrier cream on lower inner cheek – protects macerated skin from constant tearing; mechanism: moisture barrier.
Treat underlying dermatitis with non-drug measures – avoid offending cosmetics/soaps; patch-test guided changes.
Eyelid exercises after surgery (as directed) – supports healing position; mechanism: retrains orbicularis.
Counsel on gentle makeup removal – reduces traction on already lax lids; mechanism: mechanical protection.
Plan for surgery when conservative care fails – timely referral avoids chronic skin breakdown and exposure keratopathy; mechanism: definitive mechanical correction with medial spindle ± adjuncts. (Surgery details below.) EyeWikiNature
Drug treatments
Medications don’t “tighten” a loose lid; they reduce symptoms, inflammation, infection, and allergy while you use conservative care or prepare for surgery. Doses are typical—your clinician may adjust for you.
Preservative-free artificial tears (ocular lubricant; 1 drop 4–6×/day or as needed). Purpose: comfort; Mechanism: replaces tear volume; Side effects: brief blur.
Lubricating ointment (bedtime). Purpose: overnight protection; Mechanism: oily barrier; Side effects: morning blur.
Topical antihistamine/mast-cell stabilizer (e.g., olopatadine 0.1% bid). Purpose: itch control; Mechanism: blocks histamine & stabilizes mast cells; Side effects: stinging.
Topical macrolide antibiotic (e.g., erythromycin 0.5% ointment qHS 1–2 weeks) for anterior blepharitis. Purpose: reduce bacterial load; Side effects: blur, allergy.
Oral doxycycline 50–100 mg daily or bid (limited course) for meibomian gland dysfunction/rosacea. Purpose: anti-inflammatory, meibum quality; Side effects: photosensitivity, GI upset (avoid in pregnancy/children).
Short course mild topical steroid (e.g., loteprednol 0.2–0.5% qid, taper). Purpose: calm significant inflammation; Side effects: pressure rise, cataract risk if overused—needs supervision.
Topical cyclosporine 0.05–0.1% bid (immunomodulator). Purpose: reduce chronic dry-eye inflammation; Mechanism: T-cell modulation; Side effects: burning on instillation.
Lifitegrast 5% bid (LFA-1 antagonist). Purpose: inflammatory dry eye; Side effects: dysgeusia, irritation.
Topical azithromycin 1% (short course). Purpose: meibomian antimicrobial/anti-inflammatory; Side effects: stinging.
Topical calcineurin inhibitor for periocular dermatitis (very cautious use of tacrolimus 0.03% to skin, not into eye). Purpose: dermatitis control to reduce scarring traction; Side effects: burning; avoid ocular contact.
Dietary & supportive supplements
These do not correct lid laxity, but can support the ocular surface/eyelid health. Always check interactions and medical conditions.
Omega-3 (EPA+DHA) 1–2 g/day – may support meibum quality; large trials show mixed results for dry eye. Mechanism: anti-inflammatory lipid mediators.
Flaxseed oil 1–2 g/day – plant omega-3 (ALA) supporting tear film lipids.
GLA (evening primrose/borage) 240–320 mg/day – may reduce ocular surface inflammation via DGLA pathways.
Vitamin D 1000–2000 IU/day – general immune support; deficiency links to dry eye in some studies.
Vitamin A within RDA (avoid excess) – epithelial health; deficiency causes severe dry eye.
Vitamin C 500–1000 mg/day – collagen support/antioxidant for skin healing.
Zinc (up to ~11 mg/day men, 8 mg/day women unless otherwise advised) – epithelial repair co-factor.
Curcumin 500–1000 mg/day – anti-inflammatory; variable absorption.
Green tea extract (EGCG 200–400 mg/day) – antioxidant/anti-inflammatory potential.
Hyaluronic acid oral 120–240 mg/day – skin hydration support.
Lactoferrin 250–350 mg/day – tear protein support (limited data).
Astaxanthin 4–12 mg/day – antioxidant; small studies suggest eye-strain benefits.
N-acetylcysteine 600–1200 mg/day – mucolytic/antioxidant; occasionally used for filamentary keratitis (medical supervision).
Bilberry/anthocyanins 80–160 mg/day – vascular antioxidant; limited ocular surface data.
Probiotics (per label) – potential immune modulation/skin barrier support in dermatitis-prone patients.
Advanced / regenerative / biologic” options
There are no approved stem-cell drugs to tighten a lax medial eyelid. Some biologic/advanced therapies can help the ocular surface when exposure/tearing causes damage. Use only with specialist oversight.
Autologous serum eye drops (ASEDs) 20–50% typically 4–8×/day – patient’s own serum used as biologic tear substitute; can improve severe dry eye/epithelial healing while lid issues are addressed. Evidence from systematic reviews supports benefit in ocular surface disease; concentration and dosing vary by clinic. FrontiersPMCPubMedEyes On EyecareReview of Optometry
Platelet-rich plasma (PRP) eye drops – similar concept with growth factors; dosing protocols vary (investigational/regional practice). Goal: promote epithelial healing.
Sutureless amniotic membrane device (e.g., PROKERA®) – a tissue ring applied to the cornea to reduce inflammation and speed healing in keratitis/epithelial defects worsened by exposure; stays a few days. Not a drug and not for lid tightening; helps the surface heal. PubMedBioTissue+1Verywell Health
Cenegermin (recombinant human nerve growth factor) 0.002% – 1 drop 6×/day for 8 weeks; FDA-approved for neurotrophic keratitis (not for ectropion), but relevant if exposure causes or coexists with corneal anesthesia. U.S. Food and Drug AdministrationNCBI+1FDA Access Data
Biologic bandage contact lenses (collagen/biopolymer; investigational in some regions) – protect surface in exposure; not corrective for lid position.
MSC-derived exosome / stem-cell eyedrops – experimental only; no established dosing or regulatory approval for this indication; discuss risk/benefit in clinical trials.
Surgeries
Medial spindle (tarsoconjunctival diamond excision with re-insertion)
Procedure: a diamond of conjunctiva and lower-lid retractors at the inner lid is excised; tissues are reinserted and sutured to invert the punctum toward the tear lake.
Why: directly corrects punctal eversion in involutional medial ectropion; often combined with other tightening steps. EyeWikiAAOLateral tarsal strip (LTS)
Procedure: shortens and anchors the outer lid to the lateral orbital rim to correct global horizontal laxity.
Why: when the entire lower lid is loose, LTS + medial spindle provides both global and medial support. NatureMedial canthopexy/canthoplasty
Procedure: tightens or reconstructs the medial canthal tendon and inner corner structures.
Why: corrects significant medial tendon laxity so the punctum stays inverted.Punctoplasty (e.g., three-snip) with punctal eversion repair
Procedure: enlarges a stenotic punctum and aligns it correctly (often combined with eversion repair).
Why: improves inflow when the opening is narrow and maloriented.Anterior lamellar reposition or skin graft for cicatricial ectropion
Procedure: releases scar bands and adds tissue if skin is short.
Why: scar-related outward pull needs release and replacement skin to allow the lid to sit flush.
(Older literature and surgical videos describe these techniques and their combinations; medial spindle is predictable and pairs well with LTS when needed. JAMA NetworkPubMedWebEyeAAO)
Prevention tips
Don’t rub your eyes; use cold compresses instead.
Treat blepharitis/MGD early with hygiene and warm compresses.
Protect from sun/wind with wraparound sunglasses.
Avoid irritating cosmetics/cleansers near the punctum; patch-test if you react.
Manage allergies (environmental control, appropriate drops).
Keep humidity up at home and work.
Sleep on your back or side without face pressure; optimize CPAP mask fit.
Address dermatitis promptly with clinician guidance to prevent scarring.
Stop smoking; smoke worsens surface inflammation and skin aging.
Seek timely surgical evaluation if tearing persists—earlier repair prevents skin damage.
When to see a doctor
Persistent tearing for weeks despite good lubrication and hygiene.
Visible outward punctum or a gap between lid and eye.
Skin breakdown at the inner lower lid/cheek.
Eye pain, light sensitivity, or vision decline—rule out corneal damage from exposure.
History of facial nerve palsy, trauma, burns, or prior eyelid surgery.
Any acute change after an injury or procedure around the inner corner.
What to eat and what to avoid
Helpful choices
Water—aim for steady hydration; tears start with water.
Omega-3–rich fish (salmon, sardines) 2–3×/week—supports tear oils.
Colorful vegetables & berries—antioxidants support skin/ocular surface.
Nuts/seeds (walnut, flax, chia)—healthy fats for meibum.
Lean proteins & collagen-supporting nutrients (vitamin C foods) for skin repair.
Avoid or limit
6) Very salty foods if you notice eyelid puffiness/edema.
7) Alcohol excess—dehydrates and worsens inflammation.
8) Smoking and secondhand smoke—drying and inflammatory.
9) High-sugar ultra-processed snacks—pro-inflammatory.
10) Personal trigger foods that flare dermatitis (keep a diary if needed).
FAQs
1) Does medicine cure medial ectropion or a flipped punctum?
No. Drops and ointments soothe the eye and protect the surface, but a mechanical problem usually needs a mechanical fix (surgery such as a medial spindle ± LTS). EyeWikiNature
2) What exactly happens during a medial spindle? Will it show?
The surgeon removes a small diamond of inner-lid tissue and sutures it to flip the punctum inward. The stitches are tucked inside; externally visible changes are minimal. EyeWiki
3) Why do doctors add a lateral tarsal strip?
If the whole lid is loose, fixing only the punctum won’t last. LTS tightens the outer lid so the medial repair holds. Nature
4) Is this the same as a Krukenberg spindle?
No—Krukenberg spindle is pigment on the cornea from pigment dispersion/pigmentary glaucoma; it has nothing to do with eyelid eversion. PMCCleveland Clinic
5) How long is recovery?
Most people resume light activity within days; final settling may take weeks. Your surgeon will set specifics based on the exact combination of procedures.
6) Will tearing stop completely?
If the main issue was punctal eversion, many patients have major improvement. If there’s also downstream blockage (nasolacrimal duct issues), tearing may persist and need lacrimal procedures.
7) What risks should I know?
Bruising, temporary irritation, over/undercorrection, need for additional tightening, infection (rare). Your surgeon will review your personal risk.
8) Can I try plugs or special drops instead of surgery?
You can reduce symptoms with plugs and lubricants, but a turned-out punctum typically needs surgical repositioning for a durable fix. EyeWiki
9) I have eczema around my eyes—does that matter?
Yes. Periocular dermatitis can pull the lid outward; treating the skin (and avoiding irritants) helps, and surgery may include scar release/skin graft if cicatricial.
10) What if I also have facial nerve weakness?
Paralysis-related ectropion may need additional canthal tightening and surface protection (e.g., moisture chambers, lubricants) while nerve recovers or as permanent care.
11) Are “stem-cell drops” available for this?
No approved stem-cell medicines correct lid laxity. Biologics like autologous serum drops and amniotic membrane devices can help the corneal surface if it’s damaged by exposure, but they don’t tighten the lid. FrontiersPubMed
12) Do I need imaging?
Usually no for straightforward involutional cases. Imaging is used when trauma, tumors, or complex scarring are suspected.
13) Can exercises fix it?
Exercises may improve blink quality but won’t reverse laxity once it’s established.
14) Could allergies cause this?
Allergies don’t cause eversion directly but itching → rubbing → laxity; controlling allergies helps.
15) How do I pick a surgeon?
Look for an oculoplastic surgeon experienced with medial spindle and LTS; ask how often they combine procedures and their outcomes in cases like yours.
Disclaimer: Each person’s journey is unique, treatment plan, life style, food habit, hormonal condition, immune system, chronic disease condition, geological location, weather and previous medical history is also unique. So always seek the best advice from a qualified medical professional or health care provider before trying any treatments to ensure to find out the best plan for you. This guide is for general information and educational purposes only. Regular check-ups and awareness can help to manage and prevent complications associated with these diseases conditions. If you or someone are suffering from this disease condition bookmark this website or share with someone who might find it useful! Boost your knowledge and stay ahead in your health journey. We always try to ensure that the content is regularly updated to reflect the latest medical research and treatment options. Thank you for giving your valuable time to read the article.
The article is written by Team RxHarun and reviewed by the Rx Editorial Board Members
Last Updated: August 12, 2025.
