University of Iowa Health Care

Ophthalmology and Visual Sciences

Lateral Canthal Tendon Disinsertion

Authors: Ryan J. Diel, MD; Erin A. Shriver, MD, FACS

Posted December 30, 2019


Here we present a 67-year-old woman with Graves' disease, diagnosed over 15 years ago, who developed ophthalmopathy. Over the course of her disease, she has undergone radioactive iodine ablation, a right inferior rectus recession with concurrent left superior rectus recession, right eyelid retraction repair with a hard palate graft, and a left lower lid retraction repair by release of retractors with concurrent inferior rectus recession. Despite these corrective surgeries, she continued to describe discharge, inflammation, and irritation of the right eye. On exam she was noted to have right conjunctival injection, corneal epitheliopathy, and significant lateral canthal tendon disinsertion (LCTD) which is likely the underlying etiology for her symptoms.

The 3 most common clinical features of lateral canthal disinsertion are[1]:

  1. Medial and inferior movement of the lateral commissure with attempted eyelid closure
  2. Incomplete apposition of the eyelid margins with corneal exposure
  3. A blunted or vertically displaced lateral canthal angle

Three additional clinical features of lateral canthal tendon disinsertion include:

  1. Narrowing of the horizontal palpebral fissure
  2. Temporal imbrication of the eyelids on attempted closure
  3. Pseudo upper or lower eyelid retraction

This patient's eyelid configuration demonstrates 5 of the 6 classic features of LCTD including: medial and inferior movement of the lateral commissure with attempted lid closure, a superiorly displaced lateral canthal angle, narrowing of the horizontal palpebral fissure, temporal eyelid imbrication, and pseudo upper eyelid retraction. This case also highlights the use of the cotton tip applicator to physically reposition the lateral canthal angle confirming the diagnosis of LCTD.


  1. Shriver EM, Erickson BP, Kossler AL, Tse DT. Lateral Canthal Tendon Disinsertion: Clinical Characteristics and Anatomical Correlates. Ophthalmic Plast Reconstr Surg 2016;32(5):378-385. DOI: 10.1097/iop.0000000000000552
last updated: 12/31/2019
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