Eyelid Disorders: Understanding Ptosis, Entropion, and Surgical Repair

The most common cause? Aging. Over time, the muscle that lifts your eyelid - the levator - stretches and weakens. It’s like a rubber band that’s been pulled too many times. About 5% of adults over 70 deal with this. But it’s not just age. Some people are born with it. Others develop it after eye surgery, trauma, or nerve damage. Even long-term contact lens wear can contribute - studies show it increases risk by around 30%.

Doctors measure ptosis using something called the margin reflex distance (MRD). Normal is 4 to 5 millimeters. If it drops below 2 mm, it’s considered moderate. Below 1 mm? That’s severe. You might not notice it at first, but you’ll start feeling it: eye strain, headaches from constantly lifting your brows, or even neck pain from tilting your head back to see better.

What Is Entropion? When Your Eyelid Turns Inward

Entropion is the opposite problem - the eyelid rolls inward. It mostly happens in the lower lid, and in about 97% of cases, that’s where you’ll find it. When this happens, your eyelashes start rubbing against your eyeball. Imagine sandpaper gently scraping your cornea every time you blink. That’s what it feels like.

The result? Constant irritation, redness, watery eyes, mucus buildup, and a gritty feeling like you’ve got dirt in your eye. Left unchecked, this can lead to corneal scratches, ulcers, and even permanent vision loss. It’s not just uncomfortable - it’s dangerous.

The biggest cause? Aging. Around 80% of entropion cases in Western countries are involutional - meaning they come from the natural loosening of eyelid tissues over time. Other types include cicatricial (caused by scarring from burns, surgery, or infections like trachoma), spastic (temporary, from eye inflammation), and congenital (rare, present at birth).

Trichiasis is a related issue. It’s when eyelashes grow inward because the follicles are damaged - often from long-term blepharitis. It’s not full entropion, but it causes the same problem: lashes scratching your eye. Treatment? Epilation, electrolysis, or laser removal.

What’s the Connection to Blepharitis?

You can’t talk about eyelid disorders without mentioning blepharitis. It’s one of the most common eyelid problems out there - and it often shows up alongside ptosis and entropion. Blepharitis is inflammation of the eyelid margins. There are two types: anterior (crusty buildup at the base of lashes) and posterior (clogged oil glands - called meibomianitis).

When those glands get blocked, they don’t release the oily layer your tears need to stay stable. That leads to dry eyes, which makes irritation worse. And if you’re rubbing your eyes to feel better? That can actually make entropion or ptosis worse over time.

It’s chronic. That means no quick fix. You need daily hygiene: warm compresses, gentle lid scrubs with baby shampoo, and sometimes antibiotic ointments. Skip this, and you’re just feeding the cycle.

Surgical Repair: How Doctors Fix These Problems

Eye drops and ointments can help with symptoms, but they don’t fix the underlying problem. If your eyelid is drooping or rolling inward, surgery is usually the only real solution.

For ptosis, the approach depends on how strong your eyelid muscle still is:

• Levator resection: Used when the muscle still has decent strength (more than 4mm of movement). The surgeon shortens the muscle to lift the lid. Success rate? 85-95%.
• Frontalis sling: For severe cases where the muscle is too weak. The eyelid is connected to the forehead muscle (frontalis) using a synthetic or harvested tissue sling. It’s effective but can look a little unnatural.
• Müller’s muscle-conjunctival resection: Best for mild ptosis, especially if your eyelid lifts well after a phenylephrine eye drop test. Less invasive, faster recovery.

Since 2018, many surgeons have started using adjustable sutures. After surgery, you’re awake for a few minutes while the doctor fine-tunes the lid height. This cuts down on the need for revision surgery by about 25%.

For entropion, the surgery depends on the type:

• Tarsal fracture procedure: The gold standard for involutional entropion. The surgeon tightens the eyelid by repositioning the tarsal plate. Success rate? 90-95%.
• Tarsal wedge resection: Used for cicatricial entropion caused by scarring. A small wedge of tissue is removed to pull the lid back into place.
• Quickert sutures: A temporary fix. Thin sutures are placed to flip the lid outward. Works for 60-70% of cases - but often doesn’t last.

Newer techniques use absorbable sutures and minimally invasive tools. Recovery used to take 4-6 weeks. Now, many people are back to normal in just 1-2 weeks.

What About Ectropion? The Other Side of the Coin

While not the focus here, ectropion - when the eyelid turns outward - often shows up in the same patients. It’s the opposite of entropion. The lid pulls away from the eye, leaving it dry and exposed. It can be caused by aging, facial paralysis, or scarring from skin cancer or lymphoma.

Doctors sometimes treat it first with lubricating drops and steroid ointments. But if it’s severe - especially if it’s cicatricial - surgery is almost always needed. The same techniques used for entropion can be adapted, but the approach is reversed.

When to See a Doctor

Not every droopy eyelid needs surgery. But some signs mean you shouldn’t wait:

• Your eyelid suddenly droops - especially if it happened fast
• You can’t see clearly without lifting your brow
• Your eye feels scratched, painful, or unusually red
• You have constant tearing or thick mucus
• Your vision is blocked by skin or lashes

If you’re over 60 and notice changes - don’t brush it off as just aging. Early intervention stops complications. A simple eye exam can confirm whether it’s ptosis, entropion, or something else.

Who’s at Risk?

Age is the biggest factor. But other things raise your chances:

• History of eyelid surgery (increases risk by 40-60%)
• Chronic dry eye or blepharitis
• Previous eye trauma or burns
• Long-term contact lens wear
• Family history of eyelid problems

And yes - trachoma, a bacterial infection from poor sanitation, is still a leading cause of entropion in parts of Africa, Asia, and the Middle East. It’s rare in Australia, but global travel means it’s something doctors keep on their radar.

What to Expect After Surgery

Surgery is usually done as a day procedure under local anesthesia. You’ll go home the same day. Swelling and bruising are normal - they peak around day 2 and fade in 1-2 weeks. You’ll need to avoid heavy lifting, bending, and rubbing your eyes for at least a week.

Complications aren’t common, but they happen:

• Overcorrection (lid too high) - 5-10% of ptosis cases
• Undercorrection (lid still drooping) - 3-8%
• Lid asymmetry - 5-15%
• Dry eye - 10-20%
• Recurrence of entropion - 5-15%
• Infection or scarring - 1-5%

Most people report major improvements in vision and comfort. Many say they feel less tired, sleep better, and even look more alert.

The Bigger Picture

The global market for eyelid surgery is growing fast - up from $1.8 billion in 2022 to an expected $2.7 billion by 2028. Why? Because people are living longer. More of us are reaching ages where eyelid tissues weaken. And we’re more aware now - thanks to better information and less stigma around cosmetic eye procedures.

What’s next? Researchers are looking into genetic markers that might predict who’s likely to develop these conditions. Imagine a simple test at age 50 that tells you your risk. That could lead to earlier, simpler interventions - maybe even non-surgical options down the line.

For now, though, the best advice is simple: pay attention to your eyelids. If something feels off - don’t ignore it. See an eye specialist. It’s not just about looking better. It’s about protecting your sight.