In cases of severe lower eyelid ectropion, the bulbar and palpebral conjunctivae become dry and thickened, undergoing histological changes that resemble the skin. This process is sometimes referred to as 'conjunctival metaplasia.' In this study, we present a case of severe lower eyelid ectropion and report on histological findings related to skin-like changes and the treatment.
 Surgery was performed to remove the hard, skin-like surface of the palpebral conjunctivae to prevent corneal damage. Tarsal plate shortening and orbicularis oculi muscle shortening surgeries were performed to improve the horizontal laxity of the lower eyelid. Moreover, fixation of the lower eyelid retractors to the tarsal plate was performed to improve vertical tension.
 The surgeries were effective in correcting ectropion, and corneal damage was prevented. Histologically, skin-like changes in the palpebral conjunctiva are different from those observed in conjunctival metaplasia.