ACTA OPHTHALMOLOGICA SCANDINAVICA 2006

Correction of involutional lower

eyelid medial ectropion with
transconjunctival approach
retractor plication and lateral
tarsal strip
Kenneth C. S. Fong, Ioannis Mavrikakis, Suresh Sagili and
Raman Malhotra
Corneo-Plastic Unit, Queen Victoria Hospital, East Grinstead, UK

ABSTRACT. horizontal eyelid laxity. Previous meth-

Aim: We describe the technique and our results in managing lower eyelid ods described for this condition include
involutional medial ectropion using a combination of lateral tarsal strip to the diamond tarsoconjunctival excision
address horizontal eyelid laxity, and transconjunctival inferior retractor plica- combined with horizontal eyelid short-
tion to address inferior retractor dehiscence. ening (the ‘lazy-T’ procedure) (Smith
Methods: Patients with symptoms of epiphora or signs of medial ectropion were 1976) and the medial spindle procedure
(Nowinski & Anderson 1985), both of
offered this procedure. All had the following characteristics: medial lower eyelid
which require excision of posterior
eversion, punctal eversion >3 mm, medial canthal tendon laxity <4 mm, sig-
lamella tissue. These procedures can
nificant horizontal eyelid laxity and lacrimal systems that were patent to
be combined with horizontal eyelid
syringing. tightening such as the lateral tarsal
Results: A total of 24 eyelids of 17 patients underwent this procedure over a 12- strip (Anderson & Gordy 1979) or a
month period. The mean age of the patients was 79.7 years; 11 were male and six full-thickness pentagonal resection.
were female. The mean follow-up time was 18 months. Two eyes had undergone The transconjunctival approach to
previous surgery. All patients had restoration of the eyelid margin to the globe plicate the lower eyelid retractors to
and relief of symptoms. No complications were noted. the tarsus with horizontal eyelid short-
Discussion: These results suggest that excision of posterior lamellar tissue is not ening was first described by Tse et al.
necessary for correction of involutional medial ectropion. Transconjunctival (1991) and has since been reported by
plication or reattachment of retractors is easy to perform and allows for the O’Donnell (1994) and Shah-Desai &
repair of more than the medial portion of the retractors if required. Collin (2001). The advantage of this
approach is that excision of posterior
Key words: lower eyelid ectropion – lateral tarsal strip – retractor plication lamella tissue is not necessary and it
addresses the dehiscence of the retrac-
tors in a more purposeful approach. We
Acta Ophthalmol. Scand. 2006: 84: 246–249
present our results in addressing involu-
Copyright # Acta Ophthalmol Scand 2006.
tional medial ectropion with this
doi: 10.1111/j.1600-0420.2005.00603.x approach combined with a lateral tarsal
strip and describe the key steps in the
procedure with the aid of photographs.

Introduction disinsertion of fascial attachments

Lower eyelid involutional medial ectro- between the anterior and posterior
pion is a common cause of epiphora. lamella (Collin 1989). Its surgical man-
Materials and Methods
The aetiology of involutional medial agement usually involves an inverting A prospective interventional cohort
ectropion is related to horizontal eyelid procedure to the medial part of study was carried out on patients
laxity, inferior retractor dehiscence and the eyelid, with correction of any who presented to the Oculoplastic

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 ACTA OPHTHALMOLOGICA SCANDINAVICA 2006

Clinic at Queen Victoria Hospital, East Technique eyelid position. The amount of retrac-
Grinstead, UK, between November Local anaesthetic (lignocaine 2% with tor plication was altered as required by
2003 and December 2004, with symp- adrenaline 1 : 80 000) was injected into taking a larger or smaller bite of the
toms of epiphora or findings of involu- the subconjunctival space of the lower inferior retractors. The sutures were
tional medial ectropion. eyelid just below the tarsal plate and tied so that the knots were buried and
All patients had the following fea- into the lateral canthus transcuta- left to absorb.
tures: medial lower eyelid eversion neously. The lower eyelid was retracted The lower eyelid was then shortened
with good lateral eyelid to globe appo- inferiorly by an assistant and a hori- with a lateral tarsal strip (Anderson &
sition, punctal eversion >3 mm (as zontal posterior incision was made Gordy 1979). The tarsal strip was
measured by the distance from the along the lower border of the tarsal attached to the periosteum with a
punctum to the globe), minimal medial plate through the conjunctival surface double-armed 5.0 vicryl suture. The
canthal tendon laxity (as measured by and underlying layer (that represents lateral canthus was then reformed
lateral distraction of the punctum of the fusion of the lower eyelid retractors with 6.0 vicryl. The cut orbicularis
4 mm), punctum not apposed to the and orbital septum). This incision was fibres were reattached with 6.0 vicryl
globe with simple lateral traction of the made with spring scissors and extended and the skin was then closed with 6.0
lower eyelid, lacrimal systems patent to 2 mm medial to the punctum and med- vicryl.
syringing and significant lateral hori- ial to the midpoint of the eyelid later-
zontal eyelid laxity (as assessed by the ally (Fig. 1). The orbital septum was
distraction test).
All the patients consented to
entered by sharp dissection and the Results
retractors, which lie immediately pos-
undergo transconjunctival approach terior to the orbital fat pad, were A total of 24 eyelids of 17 patients
retractor plication and lateral tarsal exposed. A cotton tip was used to underwent this procedure over a 12-
strip lower eyelid tightening under sweep away loose tissue and fat. The month period. The mean age was
local anaesthetic in day case surgery. retractors were identified by gripping 79.7 years (range 60–89 years).
Patient confidentiality was maintained them and asking the patient to look Eleven patients were men and six
and the study was carried out accord- up and then down while placing slight were women. The mean follow-up
ing to the principles adopted by the traction on the retractors so that a pull time was 18 months (range 15–24
Declaration of Helsinki. All cases was felt during the downgaze. Two 6.0 months). Two eyes had undergone
were performed by a single surgeon vicryl sutures on a quarter-circle needle previous surgery (punctoplasty with a
(RM). Postoperative assessment con- were then used to reattach the retrac- three-snip procedure). Nine patients
sisted of follow-up visits to the clinic tors to the lower edge of the tarsus (53%) presented with complaints of
at 1 week, 1 month and every (Fig. 2). No attempt was made to epiphora. One of the 24 eyes had
6 months post-surgery. Success was include the cut edge of the conjunctiva almost complete tarsal ectropion (as
defined as lack of epiphora and correc- or to close the conjunctival incision. defined by complete eversion of the
tion of the medial ectropion at The sutures were placed and initially lower eyelid with the tarsal plate
18 months post-surgery. tied with a single throw to assess the turned upside down).
At the time of surgery, the retractors
were found to be disinserted from the
inferior border of the tarsus in all 24
eyelids. All patients achieved restora-
tion of the eyelid margin to the globe
and relief of symptoms. No complica-
tions were noted. Figure 3 shows the
preoperative appearance and Fig. 4
the 3-month postoperative appearance
in the same patient.

Discussion
This study aimed to assess the efficacy
of our technique for addressing involu-
tional lower eyelid ectropion using the
transconjunctival approach to plicate
the retractors (with no excision of the
posterior lamella) and the lateral tarsal
strip to address horizontal eyelid laxity.
We found this procedure to be easy to
Fig. 1. Using scissors, an incision is made in the conjunctiva just below the tarsal plate to expose perform and very effective in correcting
the inferior retractors. A lateral tarsal strip has already been performed but the tarsal strip has not involutional medial ectropion. Its main
yet been attached to the orbital periosteum. advantage lies in avoiding any excision

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ACTA OPHTHALMOLOGICA SCANDINAVICA 2006

lamella including retractors is excised,

with medial horizontal eyelid shorten-
ing. The medial spindle (Nowinski &
Anderson 1985) technique involves the
excision of a diamond of conjunctiva
and retractors with sutures tied ante-
riorly on the skin. Both these proce-
dures, however, involve the excision of
posterior lamella tissue in order to
achieve inversion of the eyelid.
However, the procedure reported in
our study simply requires reattachment
or placation of the retractor complex
only, but achieves the same effect.
The repair of disinserted retractors
to correct lower eyelid ectropion has
been used for several years. Putterman
(1978) first reported an anterior
approach via the skin to the retractors,
Fig. 2. The inferior retractors (held by forceps in the picture here) are identified as a white sheet of
following horizontal eyelid shortening.
tissue lying just behind the orbital fat pad; 6.0 vicryl sutures are used to attach the cut edge of the Wesley (1982) then described a poster-
retractors to the lower border of the tarsal plate. ior transconjunctival approach, with
excision of a large ellipse of conjunc-
tiva in tarsal ectropion. The approach
described by Tse et al. (1991) to the
retractors was also transconjunctival
but included the use of inverting
sutures. Our approach to repairing
the retractors was broadly similar to
that described by O’Donnell (1994)
and Shah-Desai & Collin (2001).
However, we made no effort to
close or suture the conjunctival inci-
sion as we believe that this is not
necessary. The conjunctiva appears to
migrate and any excess appears to
spread out so as not to accumulate in
one spot. Additionally, the fornix is
not shortened if the conjunctiva is
Fig. 3. Preoperative appearance of a right lower lid ectropion.
left alone.
Our series appears to be the largest
reported using this technique for cor-
recting involutional medial ectropion
and once again confirms its effective-
ness. It is certainly our procedure of
choice for this particular condition
and we firmly believe that excision of
posterior lamella tissue is not required
in the vast majority of involutional
medial ectropion. Intraoperatively,
the amount of retractor plication can
be titrated against eyelid height and
eyelid margin position. This can
avoid excessive advancement of the
Fig. 4. Postoperative appearance of the eyelid in Fig. 3, 3 months after transconjunctival retractors that may cause eyelid
approach retractor plication and lateral tarsal strip to the right lower eyelid. inversion.
The disinsertion of the lower eyelid
retractors from the inferior tarsal bor-
of posterior lamella tissue. This is Many techniques have been der as a cause of medial ectropion was
important as repeated excision of pos- described for correction of medial first described by Putterman (1978).
terior lamellar tissue will have an effect ectropion. In the lazy-T procedure This may result in deepening of the
on the depth of the inferior fornix. (Smith 1976), a triangle of posterior lower fornix as the disinserted

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Frueh BR & Schoengarth LD (1982):

Evaluation and treatment of the patient
with ectropion. Ophthalmology 89:
1049–1054.
Nowinski TS & Anderson RL (1985): The
medial spindle procedure for involutional
medial ectropion. Arch Ophthalmol 103:
1750–1753.
O’Donnell B (1994): Age-related medial ectro-
pion of the lower eyelid. Aust N Z J
Ophthalmol 22: 183–186.
Putterman AM (1978): Ectropion of the lower
eyelid secondary to Muller’s muscle-
capsulopalpebral fascia detachment. Am J
Ophthalmol 85: 814–817.
Shah-Desai S & Collin R (2001): Role of the
lower lid retractors in involutional ectropion
repair. Orbit 20: 81–86.
Smith B (1976): The ‘lazy-T’ correction of
Fig. 5. The dehisced inferior retractors can be seen as a grey band through the conjunctiva
ectropion of the lower punctum. Arch
(arrow).
Ophthalmol 94: 1149–1150.
Tse DT, Kronish JW & Buus D (1991):
Surgical correction of lower-eyelid tarsal
retractors pull the fornix down. It is In conclusion, the procedure ectropion by reinsertion of the retractors.
our observation that, in fact, the fornix described appears to offer a simple solu- Arch Ophthalmol 109: 427–431.
can also be shallower than expected tion to involutional medial ectropion. It Wesley RE (1982): Tarsal ectropion from the
and we believe this occurs if the fibres is recommended for lower eyelid medial detachment of the lower eyelid retractors.
Am J Ophthalmol 93: 491–495.
between the conjunctiva and retractors ectropion without excessive medial
have also dehisced. The edge of the canthal tendon laxity. It has the advan-
retractors may be seen through the tage of reattaching or plicating the entire
Received on July 12th, 2005.
conjunctiva as a grey band (Fig. 5), medial half of the lower eyelid retractors Accepted on September 11th, 2005.
but this may be difficult to assess and avoids the excision of posterior
clinically with chronic conjunctival lamella tissue. Correspondence:
changes, such as hyperaemia and kera- Raman Malhotra FRCOphth
tinization. Other clinical clues to Consultant Ophthalmologist and Oculoplastic
retractor disinsertion include medial References Surgeon
Corneo-Plastic Unit
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gaze (Shah-Desai & Collin 2001) and Collin JRO (1989): Ectropion. In: Manual of Tel: þ 44 1342 414560
loss of the lower eyelid skin crease Systematic Eyelid Surgery. 2nd edn. Fax: þ 44 1342 414106
(Frueh & Schoengarth 1982). Edinburgh: Churchill Livingstone 27–40. Email: malhotraraman@hotmail.com

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