Bilateral lid ectropion is a condition in which the eyelids are turned outward away from the eyeball and the conjunctiva is often exposed to varying degrees, often in combination with incomplete lid closure, more commonly in the lower lid than in the upper lid. In the milder cases, the posterior lip of the lid margin leaves the eye, and in the more severe cases, the lid conjunctiva is exposed and the eyelid is even incompletely closed. Ectropion can be classified as scarring, paralytic, senile, or spastic depending on the cause of the ectropion. Chronic conjunctivitis occurs when the lid conjunctiva is exposed for a long time after ectropion, resulting in increased secretions and a dry, hypertrophic and congested conjunctiva. What are the main causes of bilateral lid ectropion? 1. Spastic lid ectropion: This is caused by tension in the eyelid skin and spasmodic compression of the upper edge of the lid plate (the lower edge of the lower lid) by the orbital content of the orbicularis oculi muscle. It is seen in adolescents, especially in patients with vesicular conjunctivitis or highly protruding eyeballs. 2. Geriatric lid ectropion: seen only in the lower lid, due to the weakening of the orbicularis oculi muscle in the elderly and the laxity of the eyelid skin and canthal ligaments, which prevents the lid margin from pressing against the eyeball and eventually ectropion due to the weight of the lower lid itself falling down. This is compounded by tear spillage and chronic conjunctivitis caused by ectropion, which makes the patient frequently wipe tears downward, exacerbating the degree of ectropion. 3. Scarring lid ectropion: caused by scarring contraction of the eyelid skin surface. Eyelid skin scarring can be caused by trauma, burns, chemical injuries, eyelid ulcers, orbital osteomyelitis, or improper lid surgery. 4. Paralytic lid ectropion: seen only in the lower lid, where the contraction of the orbicularis oculi muscle is lost due to facial nerve palsy, and the lower lid sags under its own weight to form an ectropion.