History of ocular irritation, conjunctival irritation (eye redness), keratopathy, epiphora (excessive tearing), ocular trauma, eye or eyelid surgery, or facial paralysis

History of chronic eye irritation

Evidence of sagging or eversion of the lower eyelid margin

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  Search findings to classify etiology of ectropion

  
  
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  Involutional, cicatricial, paralytic, mechanical

Evaluate lateral canthal tendon

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  Can be lax or detached

  
  
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  Occasionally associated with medial canthal tendon laxity and/or dehiscence or detachment of the lower eyelid retractors

Snap back test

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  Pull lower eyelid down and away from globe and observe length of time to return to original position

  
  
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  Ectropion is significant if the eyelid does not immediately snap back or does not return to original position

Eyelid distraction test

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  Laxity: Lower eyelid can be pulled away from the eye by more than 6 mm

Medial canthal laxity test

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  Pull lower eyelid laterally

  
  
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  Punctum should not move laterally by more than 1 mm

Lateral canthal laxity test

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  Pull lower eyelid medially

  
  
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  Lateral canthal angle should not move medially by more than 2 mm

Assess orbicularis oculi strength

Bell’s phenomenon (palpebral oculogyric reflex)

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  Ask patient to close eyes while holding eyelids open

  
  
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  Observe for upward and outward movement of eye upon eye closing

  
  
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  This protects the cornea when the eyes are closed

Slit lamp examination with fluorescein to evaluate for corneal epithelial disease