A Lazy-T Modification in the Treatment of Medial Ectropion

Involutional ectropion, caused by horizontal and vertical eyelid laxity and variable stretching or disinsertion of the capsulopalpebral fascia, can be surgically corrected by a number of methods.¹ The lazy-T technique, described by Byron Smith in 1976,² is a good option for ectropion repair predominantly in the medial portion of the lower lid. Horizontal and vertical eyelid shortening is achieved by full thickness excision of a portion of the lower lid as well as the posterior lamella in a sideways “T” configuration.²

Chronic exposure of the medial palpebral conjunctiva can lead to stenosis of the punctum. Also, a vertical full-thickness incision of the lower lid placed too close to the punctum can lead to poor apposition of the punctum to the globe during suture closure of the lid margin, even if horizontal and vertical laxity are addressed appropriately by the lazy-T technique. Although the lateral tarsal strip technique can effectively treat horizontal laxity from involutional ectropion, this technique can progressively pull the punctum laterally, especially with repeat procedures.

We present a modification of the lazy-T procedure that successfully treated moderate medial ectropion with good lateral anchoring.

METHODS

After obtaining approval by the University of Illinois at Chicago institutional review board, patients who underwent the modified lazy-T procedure performed by the senior author (A.P.) were included in this retrospective consecutive case series between June 2010 and June 2018. Presenting symptoms, past surgeries, and preoperative and last postoperative lower eyelid positions were recorded, including evaluation of laxity (snapback and distraction tests), lagophthalmos, and apposition of the eyelid and punctum to the eye. This case report adhered to the ethical principles outlined in the Declaration of Helsinki. Collection and evaluation of the protected patient health information was HIPAA compliant. Consent was obtained for use of photographs.

The schematic of the surgical technique is in Figure 1. To address horizontal laxity, a #11 blade was employed to make a full-thickness incision through the tarsus approximately 4 mm lateral to the lower punctum. Both sides of the wound were grasped with toothed forceps, and the lateral portion was crossed over the medial portion. A small marking incision was made on the skin where the lateral portion just meets the medial edge. A #11 blade was then utilized to make a full-thickness incision at this marked location. Resection of the lower lid segment was conducted. High-heat electrocautery was employed for hemostasis. The margin was then closed utilizing three 6-0 double-armed silk sutures to close the tarsus, gray line, and lash line. Then 6-0 vicryl sutures were utilized to close the remainder of the tarsus employing partial thickness bites, and 6-0 silk was employed to close the skin.

Figure 1.

A schematic of the modified lazy-T surgical technique. (A-G) A full-thickness wedge was incised through the tarsum lateral to the lower punctum. (H-L) A Bowman probe was utilized to evert the lower lid through the inferior canaliculus, and an ellipse of tissue in the conjunctiva was incised.

A punctal dilator was employed to dilate the lower and upper puncta of the affected eyes. A Kelly punch was utilized to enlarge the stenotic portions of the puncta. A Bowman probe was then inserted into the inferior canaliculus, and the lower lid was everted. An ellipse of tissue of about 3 to 4 mm in vertical height was made with a #15 blade in the conjunctiva and a retractor band below the inferior punctum and canaliculus. A small skin incision was made immediately anterior and inferior to the segment. A double-armed 6-0 vicryl suture was utilized to close the conjunctival wound in a double vertical mattress stitch that was externalized through the skin incision and tied. A 6-0 silk suture was then employed to close the superficial skin wound.

At the end of the case, a combination antibiotic-steroid ointment was placed on the stitches and on the eye. Patients were discharged on a course of oral antibiotics and topical prednisolone eye drop QID × 10 days, then BID × 10 days. Sutures were removed at 10 to 12 days of follow-up. Patients were seen postoperatively at 10 to 12 days, 1 month, 3 months, and 6 months after surgery.

RESULTS

Nine eyelids from 6 men and 1 woman ranging in age from 35 to 86 years (mean, 70.8 years) were included in this case series. Presenting symptoms were tearing and irritation of eyes in all cases. Six of 9 eyelids had previous lower lid ectropion repair conducted elsewhere that had failed, leading to recurrence of ectropion. The range of previous surgery was 4 to 15 years before presentation. Of the 9 eyelids, 5 had involutional ectropion, 1 had paralytic ectropion from chronic progressive external ophthalmoplegia (CPEO), and 3 had a combination of mild cicatricial ectropion (from either previous basal cell carcinoma excisions or other eyelid surgeries) in addition to significant horizontal laxity. All 9 eyelids had moderate ectropion predominantly medially and centrally on the lower lid and well-anchored lateral canthal tendons (the lower eyelids could not be pulled nasally). There was punctal ectropion in all cases. All cases had poor snapback and positive distraction tests. Lagophthalmos was present in 3 eyelids of 3 patients, ranging from 1 to 3.5 mm (mean, 2.7 mm). Medial scleral show was recorded in 3 eyelids, between 0.5 and 2 mm (mean, 1 mm). Besides conjunctival injection and punctate keratopathy (present in 3 eyes), patients had otherwise unremarkable eye exams. Patients had between 4 and 8 mm of full-thickness horizontal resection.

At last follow-up (mean, 4 months; range, 3-6 months), tearing and eye irritation resolved in all cases. In all cases, the lower lid was well apposed to the globe and snapback and distraction tests improved. One of 3 patients had complete resolution of lagophthalmos. Two had improvement of 1 mm at last follow-up (including the CPEO patient whose poor upper lid closure likely contributed to lagophthalmos as well). Two patients had resolution of medial scleral show. Notably, the punctum was well positioned against the globe and was not significantly displaced laterally even with the larger resections. An example patient preoperatively and postoperatively is shown in Figures 2 and 3.

Figure 2.

(A) A preoperative image of this 86-year-old male patient with involutional ectropion and punctal eversion. (B) The same patient 3 months postoperative showing improvement in lid apposition to the globe.

Figure 3.

A preoperative image of this 73-year-old male patient with involutional and punctal ectropion on (A) primary gaze and (C) upgaze. The same patient 3 months postoperative on (B) primary gaze and (D) upgaze.

DISCUSSION

We report on a modified lazy-T plus punctoplasty procedure that successfully treated moderate medial ectropion. Involutional ectropion can present with good lateral anchoring. In mild to moderate cases that are predominantly centered medially and centrally, the lazy-T procedure, first described by Byron Smith,² is an option that can both vertically and horizontally shorten the eyelid. A full-thickness vertical incision is made just lateral to the lower eyelid punctum, and a horizontal incision in the palpebral conjunctiva and retractor band is made starting from the vertical incision and continuing medially. An appropriate amount of shortening is determined by sliding the tissues over each other.

In our modification, a full-thickness incision was made at least 4 mm lateral to the punctum (as opposed to just next to the punctum) to prevent instability of the punctum during closure. An ellipse of capsulopalpebral fascia and conjunctiva was excised starting at least 2 mm inferior to the punctum and canaliculus to provide additional inward rotation. Vertical shortening in the tissue bridging these 2 incisions, as described in the original procedure, was not felt to be necessary to the ectropion repair and so no incision was made in this intervening area.

Exposure of the puncta and palpebral conjunctiva can cause inflammatory changes leading to stenosis of the punctal opening. We thus additionally performed a punctoplasty to improve tear drainage. Although a lateral tarsal strip can effectively tighten horizontal laxity, it can pull the puncta progressively more laterally, away from its normal anatomic position. Six of 9 eyelids in our series had previous ectropion repair. To prevent progressive displacement of the puncta, especially when the lateral canthal tendon was well-anchored from previous repair, we performed the procedure described above, which successfully maintained the punctal position. The procedure described here can be conducted as a standalone without additional lateral canthal tightening in most cases. Good candidates for the modification described here are those with involutional ectropion but not with significant cicatricial ectropion, because scar tissue lysis or correcting anterior lamellar deficiencies may more appropriately address the root of the problem.

Other modifications to the lazy-T procedure have been described. Instead of resecting an ellipse of tissue, capsulopalpebral fascia from the exposed full-thickness resection is pulled superomedially and advanced into a subconjunctival pocket inferior to the punctum.³ For medial ectropions with a component of vertical cicatricial traction of the skin, a medially based skin transposition flap can add vertical skin lengthening in additional to repair of the ectropion.⁴

Limitations to our study include small patient sample, heterogenous population, and no direct comparison with other surgical techniques for ectropion repair. Future randomized studies that compare various techniques are important to address success and complications. In addition, direct measurement of the puncta position would provide quantitative support to our findings though may be difficult due to the anterior projection of the puncta preoperatively due to ectropion.

CONCLUSIONS

A patient’s presentation and prior surgical history is important when considering an approach to ectropion repair. The modifications to the lazy-T procedure discussed here can be considered in treating medial ectropion with good lateral anchoring.

We have presented a modification of the classic lazy-T procedure for medial ectropion repair. Our case series of patients who underwent the modified lazy-T technique were evaluated for eyelid position and improvement in symptoms. Our technique involves a titrated full-thickness excision starting at least 4 mm lateral to the punctum, vertical shortening of the conjunctiva and capsulopalpebral fascia centered inferior to the punctum, and a lower lid punctoplasty. Our outcomes are as follows: 6 of 9 eyelids had previous ectropion repair elsewhere that failed, all patients had improvement in tearing and eye irritation at 3-6 months postoperative, and all eyelids and puncta had good apposition to the eye. We conclude that the modification proposal may be an effective treatment option for the correction of medial ectropion with good lateral anchoring.

Disclosures

The authors declared no potential conflicts of interest with respect to the research, authorship, and publication of this article.

Funding

This study was funded by an unrestricted RPB departmental grant for vision research (NEI P30 EY001792).