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

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Clinic at Queen Victoria Hospital, East
Grinstead, UK, between November
2003 and December 2004, with symp-
toms of epiphora or findings of involu-
tional medial ectropion.
All patients had the following fea-
tures: medial lower eyelid eversion
with good lateral eyelid to globe appo-
sition, punctal eversion >3 mm (as
measured by the distance from the
punctum to the globe), minimal medial
canthal tendon laxity (as measured by
lateral distraction of the punctum of
4 mm), punctum not apposed to the
globe with simple lateral traction of the
lower eyelid, lacrimal systems patent to
syringing and significant lateral hori-
zontal eyelid laxity (as assessed by the
distraction test).
All the patients consented to
undergo transconjunctival approach
retractor plication and lateral tarsal
strip lower eyelid tightening under
local anaesthetic in day case surgery.
Patient confidentiality was maintained
and the study was carried out accord-
ing to the principles adopted by the
Declaration of Helsinki. All cases
were performed by a single surgeon
(RM). Postoperative assessment con-
sisted of follow-up visits to the clinic
at 1 week, 1 month and every
6 months post-surgery. Success was
defined as lack of epiphora and correc-
tion of the medial ectropion at
18 months post-surgery.
Fig. 1. Using scissors, an incision is made in the conjunctiva just below the tarsal plate to expose
the inferior retractors. A lateral tarsal strip has already been performed but the tarsal strip has not
yet been attached to the orbital periosteum.
ACTA OPHTHALMOLOGICA SCANDINAVICA 2006
Technique
Local anaesthetic (lignocaine 2% with
adrenaline 1 : 80 000) was injected into
the subconjunctival space of the lower
eyelid just below the tarsal plate and
into the lateral canthus transcuta-
neously. The lower eyelid was retracted
inferiorly by an assistant and a hori-
zontal posterior incision was made
along the lower border of the tarsal
plate through the conjunctival surface
and underlying layer (that represents
the fusion of the lower eyelid retractors
and orbital septum). This incision was
made with spring scissors and extended
2 mm medial to the punctum and med-
ial to the midpoint of the eyelid later-
ally (Fig. 1). The orbital septum was
entered by sharp dissection and the
retractors, which lie immediately pos-
terior to the orbital fat pad, were
exposed. A cotton tip was used to
sweep away loose tissue and fat. The
retractors were identified by gripping
them and asking the patient to look
up and then down while placing slight
traction on the retractors so that a pull
was felt during the downgaze. Two 6.0
vicryl sutures on a quarter-circle needle
were then used to reattach the retrac-
tors to the lower edge of the tarsus
(Fig. 2). No attempt was made to
include the cut edge of the conjunctiva
or to close the conjunctival incision.
The sutures were placed and initially
tied with a single throw to assess the
eyelid position. The amount of retrac-
tor plication was altered as required by
taking a larger or smaller bite of the
inferior retractors. The sutures were
tied so that the knots were buried and
left to absorb.
The lower eyelid was then shortened
with a lateral tarsal strip (Anderson &
Gordy 1979). The tarsal strip was
attached to the periosteum with a
double-armed 5.0 vicryl suture. The
lateral canthus was then reformed
with 6.0 vicryl. The cut orbicularis
fibres were reattached with 6.0 vicryl
and the skin was then closed with 6.0
vicryl.
Results
A total of 24 eyelids of 17 patients
underwent this procedure over a 12-
month period. The mean age was
79.7 years (range 60–89 years).
Eleven patients were men and six
were women. The mean follow-up
time was 18 months (range 15–24
months). Two eyes had undergone
previous surgery (punctoplasty with a
three-snip procedure). Nine patients
(53%) presented with complaints of
epiphora. One of the 24 eyes had
almost complete tarsal ectropion (as
defined by complete eversion of the
lower eyelid with the tarsal plate
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
perform and very effective in correcting
involutional medial ectropion. Its main
advantage lies in avoiding any excision
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ACTA OPHTHALMOLOGICA SCANDINAVICA 2006
Fig. 2. The inferior retractors (held by forceps in the picture here) are identified as a white sheet of
tissue lying just behind the orbital fat pad; 6.0 vicryl sutures are used to attach the cut edge of the
retractors to the lower border of the tarsal plate.
Fig. 3. Preoperative appearance of a right lower lid ectropion.
Fig. 4. Postoperative appearance of the eyelid in Fig. 3, 3 months after transconjunctival
approach retractor plication and lateral tarsal strip to the right lower eyelid.
of posterior lamella tissue. This is
important as repeated excision of pos-
terior lamellar tissue will have an effect
on the depth of the inferior fornix.
248
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,
following horizontal eyelid shortening.
Wesley (1982) then described a poster-
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
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
retractors that may cause eyelid
inversion.
The disinsertion of the lower eyelid
retractors from the inferior tarsal bor-
Many techniques have been der as a cause of medial ectropion was
described for correction of medial first described by Putterman (1978).
ectropion. In the lazy-T procedure This may result in deepening of the
(Smith 1976), a triangle of posterior lower fornix as the disinserted

Fig. 5. The dehisced inferior retractors can be seen as a grey band through the conjunctiva
(arrow).
retractors pull the fornix down. It is
our observation that, in fact, the fornix
can also be shallower than expected
and we believe this occurs if the fibres
between the conjunctiva and retractors
have also dehisced. The edge of the
retractors may be seen through the
conjunctiva as a grey band (Fig. 5),
but this may be difficult to assess
clinically with chronic conjunctival
changes, such as hyperaemia and kera-
tinization. Other clinical clues to
retractor disinsertion include medial
tarsal ectropion (in the absence of hor-
izontal eyelid laxity) (O’Donnell 1994),
loss of lower eyelid excursion in down-
gaze (Shah-Desai & Collin 2001) and
loss of the lower eyelid skin crease
(Frueh & Schoengarth 1982).
ACTA OPHTHALMOLOGICA SCANDINAVICA 2006
In conclusion, the procedure
described appears to offer a simple solu-
tion to involutional medial ectropion. It
is recommended for lower eyelid medial
ectropion without excessive medial
canthal tendon laxity. It has the advan-
tage of reattaching or plicating the entire
medial half of the lower eyelid retractors
and avoids the excision of posterior
lamella tissue.
References
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tarsal strip procedure. Arch Ophthalmol
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Collin JRO (1989): Ectropion. In: Manual of
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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
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repair. Orbit 20: 81–86.
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ectropion of the lower punctum. Arch
Ophthalmol 94: 1149–1150.
Tse DT, Kronish JW & Buus D (1991):
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Arch Ophthalmol 109: 427–431.
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Received on July 12th, 2005.
Accepted on September 11th, 2005.
Correspondence:
Raman Malhotra FRCOphth
Consultant Ophthalmologist and Oculoplastic
Surgeon
Corneo-Plastic Unit
Queen Victoria Hospital
East Grinstead RH19 3DZ
UK
Tel: þ 44 1342 414560
Fax: þ 44 1342 414106
Email: malhotraraman@hotmail.com
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