Caribbean Small Island Developing States (SIDS) are vulnerable to climate change impacts including sea level rise, invasive species, ocean acidification, changes in rainfall patterns, increased temperatures, and changing hazard regimes including hurricanes, floods and drought. Given high dependencies in Caribbean SIDS on natural resources for livelihoods, a focus on ecosystems and their interaction with people is essential for climate change adaptation. Increasingly, ecosystem-based adaptation (ecosystem-based adaptation) approaches are being highlighted as an approach to address climate change impacts. Specifically, ecosystem-based adaptation encourages the use of local and external knowledge about ecosystems to identify climate change adaptation approaches. This paper critically reviews ecosystem-based adaptation in Caribbean SIDS, focusing on the need to integrate local and external knowledge. An analysis of current ecosystem-based adaptation in the Caribbean is undertaken alongside a review of methodologies used to integrate local and external expertise for ecosystem-based adaptation. Finally key gaps, lessons learnt and suggested ways forward for ecosystem-based adaptation in Caribbean SIDS and potentially further afield are identified.