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Repair of the lax medial canthal tendon
  1. B A O’Donnell1,
  2. R L Anderson2,
  3. J R O Collin3,
  4. R G Fante4,
  5. D R Jordan5,
  6. P Ritleng6
  1. 1Department of Ophthalmology, Royal North Shore Hospital, Sydney 2065, Australia
  2. 2Department of Orbital and Ophthalmic Plastic Surgery, John A Moran Eye Centre, University of Utah, 1002 East South Temple, Salt Lake City, UT 84102, USA
  3. 3Moorfields Eye Hospital, City Road, London EC1V 2 PD, UK
  4. 4Advanced Oculoplastic Surgeons, 2005 Franklin Street, Suite 2–610, Denver, CO 80205, USA
  5. 5The Doctors’ Building, Suite 104, 340 McLeod Street, Ottawa, Ontario K21A4, Canada
  6. 610 rue du Congrés, 06000 Nice, France
  1. Correspondence to: Dr Brett O’Donnell, Level 2, Suite 3, 66 Pacific Highway, St Leonards 2065, NSW, Australia; brett.odonnell{at}

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Medial canthal tendon (MCT) laxity is a common condition, usually age related and often causing symptoms of epiphora, discharge, irritation, and redness. MCT repair is more complicated than that of its lateral counterpart because of the intimate relation with the canaliculus (Fig 1). The position and patency of the canaliculus can be affected by any surgery to the canaliculus. Because of the problems with surgical repair, surgery is often delayed until the MCT laxity is advanced (Fig 2)

Figure 1

Anatomy of medial canthal tendon.

Figure 2

Severe MCT laxity.

For this clinical controversy, a panel of five eyelid surgeons was invited from Canada, England, France, and the United States to give their management for the symptomatic patient with MCT laxity and their surgical techniques according to the degree of laxity (Table 1).

View this table:
Table 1

Questions regarding the lax MCT

Opinion: Richard Anderson

The lateral canthal tendon (LCT) is much weaker than the MCT and most cases of lid laxity involve the LCT more than the MCT. Therefore, most cases of lid laxity are best corrected with the lateral tarsal strip (LTS) procedure (Fig 3).1,2 I grade MCT laxity with the amount of lateral displacement of the punctum—that is, as mild with minimal displacement, moderate with several millimetres, or severe with displacement to the medial limbus. With mild to moderate medial ectropion or punctal eversion, I combine the LTS with a medial spindle procedure3 behind the punctum which tightens the conjunctiva and lower lid retractor to roll in the eyelid margin. I only repair the MCT if severe medial ectropion is present or lateral tendon tightening would displace the punctum too far laterally creating cosmetic or functional deformity.

Figure 3

Lateral tarsal strip.

For moderate to severe amounts of MCT laxity I prefer a posterior limb plication. I make a small incision behind the caruncle and an incision …

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