We often see eyelid malpositions as a cause for tearing, burning and irritation. If an inflammatory condition is ruled out, such as blepharitis, dry eyes or meibomian gland disease, then start exploring the position of the lids.
The majority of patients above 55 years of age have some degree of lid laxity. A simple test is a snap back test with your finger. Observe how quickly the eyelid returns to appropriate apposition with the globe without the patient blinking. Also evaluate the position of the lateral canthal angle. If this complex is shifted medially, the tendon is likely stretched and the pump function of the eyelid is impaired.
Once it is determined that lid laxity is a contributing factor to tearing, consider the surgical options.
If the lower lid is the sole culprit, consider a lateral tarsal strip with or without reinserting the retractors. The lateral tarsal strip is a simple outpatient procedure that can be performed under local anesthesia. First, a lateral canthotomy is performed with or without an inferior cantholysis. The lateral lower lid is split into anterior and posterior lamellae by cutting with sharp Westcott scissors along the grey line. The anterior lamella from this region is removed. A double-armed suture (5-0 Merselene, Vicryl or 4-0 Vicryl) is passed through the tarsal tongue that was formed. The suture is then passed through the periosteum inside the lateral orbital rim. This creates a much tighter position of the lower lid.
If both the upper and lower lids are the problem and the entire lateral canthal tendon is dehisced, a lateral canthal tendon plication is more fitting. For this procedure an incision is made with a #15 blade horizontally from the lateral canthal angle extending approximately 15 mm. Dissection is carried down to expose the white tendon.
Over the lateral orbital rim, the periosteum is exposed. The inferior and superior arms of the tendon are then dissected. A double armed 5-0 suture (Merselene or Vicryl) is passed through the body of the tendon first. One arm is passed through the inferior crus and one arm through the superior crus, both locking. Each arm is then passed through the periosteum inside the lateral orbital rim. This suture pulls the entire lateral canthal tendon complex to a more anatomical position, restoring better pump function.