RELIEF OF EYELID RETRACTION: A SURGICAL PROCEDURE

A Comparative Study of Full-Thickness Blepharotomy Versus Transconjunctival Eyelid Lengthening in the Correction of Upper Eyelid Retraction in Graves' Orbitopathy

BACKGROUND

The study was designed to compare the outcome of full-thickness blepharotomy and transconjunctival eyelid lengthening in the correction of upper eyelid retraction (UER) in patients with Graves' orbitopathy (GO).

METHODS

This is a prospective randomized interventional study. Following ophthalmic examination, determination of the ocular surface disease index (OSDI) and photography, 27 patients with UER were randomly assigned to either graded full-thickness blepharotomy (G1) or transconjunctival Müller muscle recession and graded disinsertion of the levator palpebrae superioris muscle (G2). Six months later, patients were reevaluated. Digital images were analyzed with the assistance of customized software. A standardized "normal range" of upper eyelid height and contour was calculated based on healthy controls. The outcome of the two groups was compared.

RESULTS

Forty-seven eyelids of 27 patients (19 female) with UER were included. Twenty-seven eyelids (15 patients) were allocated to G1 and 20 eyelids (12 patients) to G2. On average, surgery lasted 37.46 ± 5.73 min in G1 and 32.70 ± 8.39 min in G2. Based on the margin reflex distance, 93% of the eyelids in G1 and 85% in G2 were within the normal range after surgery. The corresponding figures for lid contour were 63 and 55%. Both groups displayed significant improvement in OSDI scores. No significant difference was observed in the overall comparison.

CONCLUSIONS

The two surgical techniques were equally effective in the treatment of UER from GO. Postoperative contour outcomes were considerably worse in patients with severe UER than in patients with mild or moderate UER, regardless of group.

LEVEL OF EVIDENCE II

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to Table of Contents or the online Instructions to Authors www.springer.com/00266 . Study registered on ClinicalTrial.gov number: NCT01999790.

Lower Eyelid Retraction Surgery Without Internal Spacer Graft

BACKGROUND

Internal eyelid spacer graft is routinely placed during lower eyelid retraction surgery, which may be unnecessary.

OBJECTIVES

To evaluate the efficacy of lower eyelid retraction surgery without internal graft in select cases.

METHODS

Retrospective analysis of patients undergoing reconstructive lower eyelid retraction surgery without internal graft, by one surgeon from 2013 to 2015. Surgical technique included transconjunctival lower eyelid retractor lysis, canthoplasty, and temporary tarsorrhaphy, with or without subperiosteal midface-sub oribularis oculi fat (SOOF) lifting and scar lysis. Eyelids with true lower eyelid middle-lamella shortage were excluded. Analysis included 17 surgeries (11 patients). Eight of 11 patients had undergone at least one previous lower eyelid surgery with resultant lower eyelid retraction and sclera show. Preoperative and postoperative photographs at longest follow-up visit were analyzed with standardized measurements. Patient satisfaction was recorded using questionnaire.

RESULTS

Etiologies of lower eyelid retraction included prior lower blepharoplasty, thyroid eye disease, and chronic facial palsy. All 11 patients (17 procedures) demonstrated improvement of lower eyelid position. The mean improvement of marginal reflex distance was 2.2 mm (range, 1.6-2.8 mm). There was one case of mild overcorrection. The average follow-up was 7 months (range, 6 months-2 years). Midface lift was performed for 14 of 17 eyelids.

CONCLUSIONS

This study demonstrates improvement of lower lid position after lower eyelid retraction surgery without internal eyelid spacer graft in select patients. Most patients in our study had undergone previous lower eyelid blepharoplasty and required midface-SOOF lifting. The author proposes that "routine" placement of lower eyelid internal spacer/graft may not be necessary during lower eyelid retraction surgery.

Turn-over orbital septal flap and levator recession for upper-eyelid retraction secondary to thyroid eye disease

BACKGROUND

A turn-over septal flap has been reported as a spacer for levator lengthening in a single case report. This study reports the preliminary outcomes of this technique in a series of patients with upper-lid retraction (ULR) associated with thyroid eye disease (TED) causing symptomatic exposure keratopathy (EK).

METHODS

Retrospective, multicenter study of 12 eyelids of 10 patients with TED undergoing a transcutaneous levator-lengthening technique using the reflected orbital septum (OS) as a spacer. Change in palpebral aperture (PA) and contour, position of the skin crease (SC), symptoms of EK, and complications were recorded.

RESULTS

The average age was 47.5 years. Two patients were excluded, as their septa were found to be very thin at surgery. At an average of 13 months postoperatively, the PA was reduced by 2.5 mm on average (P<0.001) and was within 1 mm of the contralateral eyelid in 11 cases (92%); the position of the SC was within 1 mm of the desired position in all cases. EK resolved in all cases. Complications included one case of overcorrection and one case of recurrent lateral flare.

CONCLUSIONS

The turn-over orbital septal flap technique may be a viable option as an autogenous spacer for the treatment of ULR in TED. This technique may be possible in cases where the OS has been opened by previous surgery but may not be feasible in patients in whom the septum is very thin.

Current concepts of ocular adnexal surgery

Ophthalmic Plastic and Reconstructive Surgery is a specialized area of ophthalmology that deals with the management of deformities and abnormalities of the eyelids, lacrimal system and the orbit. An ophthalmoplastic surgeon is able to identify and correct abnormalities of the ocular adnexae such as ectropion, lid retraction, conjunctival scarring with severe entropion, that can cause secondary ocular surface disorders; manage patients with watering eye, and when needed intervene with a dacryocystorhinostomy by external or endonasal approach and moreover minimize disfigurement following enucleation or evisceration and prevent further corneal damage, alleviate complains of tearing and grittiness, but also cosmetic complaints in patients with Graves' orbitopathy. Aim of this manuscript was to review current established and recently evolving surgical procedures.

Preaponeurotic fat advancement for prevention of unexpected higher eyelid crease in upper eyelid-lengthening surgery

PURPOSE

To present a modified technique based on preaponeurotic fat advancement for preventing higher eyelid crease in upper eyelid-lengthening surgery.

METHODS

Outcomes of Japanese patients with Graves' orbitopathy-related upper eyelid retraction who underwent transcutaneous upper eyelid-lengthening surgery were reviewed. The minimum follow-up period was 6 months. A total of 17 upper eyelids in 11 patients (average age, 38.4 years) were included. After confirming appropriate upper eyelid lowering with good contour, preaponeurotic fat was fully exposed and fixed on the upper tarsal plate 1 mm superior to the planned eyelid crease with 5 sutures. Skin-tarsus-skin sutures were placed to create an eyelid crease and close the skin. Simple suture tarsorrhaphy was performed with 2 sutures.

RESULTS

No upper eyelids demonstrated higher eyelid crease postsurgically. Upper eyelid fullness caused by the advanced preaponeurotic fat was not conspicuous.

CONCLUSIONS

Our technique is a countermeasure against higher eyelid crease in upper eyelid-lengthening surgery.

Adnexal Surgery for Severe Ocular Surface Disease

Secondary causes of ocular surface disease are-to a large extent-due to disorders of the ocular adnexae. The main pathomechanisms involved include exposure, abrasion and malnutrition, resulting from a multitude of disorders such as ec- or entropion (e.g. in cicatrizing conjunctivitis), lid retraction and severe aqueous deficiency. In the presence of these problems, surgical attempts of ocular surface reconstruction frequently fail. Here we review established and evolving new techniques in the field of adnexal surgery to specifically address these problems.

Graded Full-Thickness Anterior Blepharotomy for Correction of Upper Eyelid Retraction Not Associated With Thyroid Eye Disease

PURPOSE

To evaluate the efficacy of graded full-thickness anterior blepharotomy for upper eyelid retraction of various causes not associated with Graves eye disease.

METHODS

Twenty-one eyelids of 18 patients with upper eyelid retraction not caused by Graves eye disease were treated with graded full-thickness anterior blepharotomy. Preoperative and postoperative symptoms, midpupil to upper eyelid distance, lagophthalmos, and superficial punctuate keratopathy were evaluated.

RESULTS

Upper eyelid retraction was due to facial nerve palsy in 4 patients (22%), overcorrected ptosis in 5 patients (28%), and cicatrix after trauma in 6 patients (33%). One patient each (6% each) had retraction from graft-versus-host disease, after blepharoplasty, and after orbicularis oculi myectomy for blepharospasm. At a mean of 10 months follow-up, presenting symptoms resolved or improved in 17 patients (94%) and remained unchanged in 1 patient (6%). Midpupil to upper eyelid distance, lagophthalmos, and superficial punctuate keratopathy all improved significantly (all p < 0.001). No surgical complications occurred.

CONCLUSIONS

Graded full-thickness anterior blepharotomy is a safe, effective, and rapid technique for patients with symptomatic upper eyelid retraction due to etiologies other than Graves eye disease. This technique improves symptoms and signs of ocular exposure while addressing relative upper eyelid height symmetry and contour.

A Modified Posterior Approach for Upper Eyelid Retraction

PURPOSE

To describe and review a graded technique for lowering the upper eyelid from a posterior approach, recessing or resecting Müller muscle and levator aponeurosis but leaving a central pillar of Müller muscle intact, occasionally including a temporal tarsorrhaphy or superior tarsal strip where needed, and performing tissue dissection with a hot-wire cautery instrument.

METHODS

A 10-year retrospective chart review was performed. Where follow-up was less than 6 months, telephone interviews were conducted to assess patient satisfaction with the procedure. Statistical analysis was performed using an unpaired t test.

RESULTS

Ninety-nine patients (161 eyelids, 62 bilateral and 37 unilateral) with a mean age of 47 years (range, 21-82 years) were studied. The mean follow-up period was 61 months. The mean preoperative and postoperative margin reflex distances (MRD1) were 7.3 mm (range, 4.5-10 mm) and 4.3 mm (range, 2-7 mm), respectively. Eighty-nine percent (144/161 eyelids) achieved the target result of an MRD1 of 4 +/- 1 mm after one procedure. Fifteen eyelids (9% of operated eyelids) required a second procedure, and in this group, 2 (13% of the reoperated eyelids) underwent a third procedure. Although bilateral cases were more likely to achieve symmetry (p = 0.0071), 90% of either unilateral or bilateral cases achieved a postoperative MRD1 of 4 +/- 1 mm. Both mild (MRD1 of 5-7 mm) and severe (MRD1 > 7 mm) cases of eyelid retraction achieved similar operative outcomes. In the first 6 months after surgery, complications included undercorrection (8 eyelids), overcorrection (2 eyelids), and pyogenic granuloma (2 eyelids). None had a flattened upper eyelid contour. Late recurrence of retraction was seen in 9 eyelids. Mean operative time was 16 minutes per eyelid.

CONCLUSIONS

This technique of lowering the retracted upper eyelid is effective even in severe cases of eyelid retraction. Minimal complications were encountered, and upper eyelid contours were well preserved. The use of hot-wire cautery dissection proved useful in shortening operative time.

Efficacy of "thick" acellular human dermis (AlloDerm) for lower eyelid reconstruction: comparison with hard palate and thin AlloDerm grafts

OBJECTIVES

To evaluate the efficacy of thick acellular human dermis (thick AlloDerm [LifeCell Corporation, The Woodlands, Tex]) grafts for posterior and middle lamellae reconstruction to correct lower eyelid retraction and to compare the long-term efficacy of thick AlloDerm with thin AlloDerm and hard palate grafts.

METHODS

Retrospective analysis of patients undergoing lower eyelid reconstruction, which encompassed subperiosteal midface lifting, middle lamellae scar lysis, and placement of lower eyelid thick AlloDerm graft. Analysis included 21 surgical procedures in 11 patients. All patients had undergone at least 1 previous lower eyelid surgery with resultant lower eyelid retraction and scleral show. Preoperative and postoperative photographs were used for analysis. Measurements of the corneal diameter and distance from pupil center to lower eyelid margin were obtained, standardized, and compared.

RESULTS

Of 21 procedures, 16 (8 of 11 patients) demonstrated improvement of lower eyelid position. The mean improvement of the median marginal reflex distance was 1.6 mm (range, 0.4-2.2 mm). The average follow-up after surgery was 215 days (range, 3-12 months). Of 21 procedures (3 patients), 5 failed to demonstrate improvement of lower eyelid position, with the mean final eyelid position lower postoperatively by 0.8 mm (range, 0.4-1.4 mm).

CONCLUSIONS

We demonstrated long-lasting improvement of lower eyelid position with placement of thick AlloDerm grafts during lower eyelid reconstruction. The patients in our study had undergone previous lower eyelid blepharoplasty with resultant middle lamellae tethering. Surgical correction included subperiosteal midface-lift and middle lamellae scar lysis, in addition to thick AlloDerm graft placement to the lower eyelid. The results are comparable to hard palate grafts but perhaps superior to thin AlloDerm grafts.

Pre-Whitnall Levator Recession With Hang-Back Sutures in Graves Orbitopathy

PURPOSE

To describe a technique for lengthening the levator palpebrae muscle at the level of the transverse orbital ligament (Whitnall ligament) by using hang-back sutures in cases of upper eyelid retraction in Graves orbitopathy, and to report its results.

METHODS

A cohort of consecutive patients undergoing this procedure by a single surgeon was analyzed. The surgical technique involved division of the levator muscle high up, at the level of the transverse orbital ligament, with lengthening of the muscle by a graded amount with the use of nonabsorbable hang-back sutures. The length of the sutures was twice the amount of desired lowering of the eyelid.

RESULTS

Surgery was performed on 38 eyelids of 21 patients. The mean preoperative eyelid retraction was 4.7 mm (range, 3 mm to 8 mm). Thirty-two eyelids (84%) were within 1 mm of the desired postoperative position. One patient required reoperation for significant undercorrection (2 eyelids), another 4 had ptosis repairs for overcorrection (5 eyelids, one of which was only 1-mm overcorrected). One eyelid required medial contour repair, but none needed lateral contour correction.

CONCLUSIONS

This procedure gives a relatively predictable result in patients with moderate to severe upper eyelid retraction and avoids the postoperative complication of contour deformities, especially lateral flare.

Quantitative comparison between upper eyelid retraction induced voluntarily and by Graves orbitopathy

PURPOSE

To compare 2-dimensional palpebral fissure measurements of normal subjects with voluntary upper eyelid retraction and patients with Graves upper eyelid retraction.

METHODS

Three groups of monocular palpebral fissure images were measured. Group 1 consisted of 32 images of healthy subjects with the upper eyelid in a normal position of rest. Group 2 included the same subjects with voluntary upper eyelid retraction. Group 3 included 45 images of patients with Graves upper eyelid retraction. Fissure images were acquired with a digital camera and transferred to a Macintosh computer. For all images, three variables were quantified with NIH Image software: the midpupil-to-upper eyelid margin distance and the nasal and temporal upper areas of the palpebral fissure.

RESULTS

Voluntary upper eyelid retraction significantly increases the absolute difference between the temporal and nasal areas of normal subjects. The disproportion between the lateral and medial areas of the palpebral fissure was greater for the patients with Graves than for the control group with voluntary eyelid retraction, even though there was no difference between the midpupil-to-upper eyelid margin distance of these two groups. Overall, there was a positive correlation between the midpupil-to-upper eyelid margin distance and absolute difference between the temporal and nasal areas (r = 0.75, P < 0.0001).

CONCLUSIONS

In normal subjects, voluntary upper eyelid retraction increases the disproportion between the lateral and medial aspects of the fissure. However, even for the same amount of eyelid elevation, the mean disproportion of the control group with voluntary eyelid retraction is smaller than the disproportion displayed by patients with Graves. These findings suggest that an enhanced lateral retraction is a normal finding associated with levator muscle contraction.

Autogenous hard palate mucosa: the ideal lower eyelid spacer?

BACKGROUND/AIMS

Raising a displaced lower eyelid frequently involves recession of the lower eyelid retractors with interposition of a "spacer," and several materials for this purpose have been described. This study reviewed the results of autogenous palatal mucosa in the treatment of lower eyelid displacement, including assessment of any donor site morbidity.

METHODS

A retrospective case note review of consecutive patients treated at Moorfields Eye Hospital between 1993 and 1998. All patients underwent insertion of hard palate mucosa between the inferior border of the tarsus and the recessed conjunctiva and lower eyelid retractors. Parameters studied included the underlying diagnosis, measurements of lower lid displacement or retraction, related previous surgery, the experience of the operating surgeon, intraoperative and postoperative complications, surgical outcome, and length of follow up. The main outcome measure was the position of the lower eyelid relative to the globe in primary position of gaze.

RESULTS

102 lower eyelids of 68 patients were included and a satisfactory lid position was achieved in 87/102 (85%), with inadequate lengthening or significant recurrence of displacement occurring in 15 cases. Donor site haemorrhage requiring treatment in the early postoperative period occurred in seven patients (10%).

CONCLUSION

Autogenous hard palate mucosa is an effective eyelid spacer and provides good long term support for the lower eyelid. Donor site complications are the main disadvantage, but may be minimised by attention to meticulous surgical technique and appropriate postoperative management.

The effect of Müllerectomy on Kocher sign

PURPOSE

To measure the magnitude of the effect of attention on upper eyelid retraction in patients with thyroid orbitopathy (Kocher sign) and to determine if Müllerectomy can abolish this effect.

METHODS

The study design was prospective with two phases: The first one was observational and the second interventional. Two groups of eyes were studied. The control group consisted of 30 eyes of 30 healthy subjects. The second group included 34 eyes of 17 patients with thyroid orbitopathy and hyperthyroidism. The mid-pupil to eyelid margin distance of both groups was measured when the subjects were relaxed and during attentive gaze. The same measurements were performed for the patients with thyroid orbitopathy after Müllerectomy. All measurements were performed on digitalized images of the palpebral fissure with software on a Macintosh computer.

RESULTS

Attention induced a mean increment of 1.33 mm in the mid-pupil eyelid margin distance of patients with thyroid orbitopathy. For the control subjects, attention did not modify the position of the upper eyelid. After Müllerectomy, the effect of attention was abolished.

CONCLUSIONS

Müllerectomy abolishes the variability of upper eyelid retraction induced by attentive gaze in patients with thyroid orbitopathy.

Glabellar rhytids in thyroid-associated orbitopathy

PURPOSE

To correlate the presence and severity of glabellar rhytids with disease severity in patients with thyroid-associated orbitopathy (TAO).

METHODS

Retrospective, noncomparative medical record review of 113 consecutive new patient visits with the clinical diagnosis of TAO. Ocular examination features studied included assessment of visual acuity, optic nerve appearance and function, proptosis, strabismus, eyelid position, and exposure keratopathy. These features were correlated with graded clinical photographs evaluating rhytid severity using the Fisher exact text.

RESULTS

Eighty of 97 patients included in the study (82.5%) had glabellar rhytids. Eyelid retraction was present in 95 of the 97 patients (98%). Patients with diplopia had more severe rhytids (p < 0.05). Patients with at least three abnormal clinical findings tended to have more severe rhytids.

CONCLUSIONS

Glabellar rhytids are a common finding in patients with TAO, and tend to be present in patients with diplopia and multiple stigmata of the disease.

Porous polyethylene as a spacer graft in the treatment of lower eyelid retraction

PURPOSE

An experimental study was performed to: 1) assess the tolerance and incorporation of porous polyethylene (Medpor) in the posterior lamella of the rabbit lower eyelid; 2) analyze the effect of implant thickness on incorporation; 3) investigate the ability of conjunctiva to grow over vascularized Medpor and; 4) determine the effects of Medpor surface modification on biocompatibility and fibrovascularization.

METHODS

In phase I, 10 rabbit eyelids were operated on to analyze the effects of implant thickness and to develop the surgical technique used in phase II of the study. In phase II, 20 lower eyelids of 10 rabbits received 0.85-mm-thick Medpor grafts, each rabbit receiving both an uncoated implant and one coated with an immobilized collagen.

RESULTS

There were no extrusions in phase II. with a postoperative follow-up from 14 to 17 weeks. Fourteen of 20 eyelids had full-thickness conjunctival incisions or excisions placed over the Medpor implant to determine the growth potential of conjunctiva over a vascularized implant. All but one eyelid showed complete defect coverage, occurring in as little as 3 days. Histopathology indicated complete Medpor fibrovascularization as early as 4 weeks after implantation. Because neither coated nor uncoated implants extruded in phase II, no conclusions can be drawn regarding the efficacy of Medpor surface modification.

CONCLUSION

Medpor was well tolerated in this soft tissue application, and it offers advantages over other graft materials.

A single technique to correct various degrees of upper lid retraction in patients with Graves' orbitopathy

BACKGROUND

Several lengthening techniques have been proposed for upper eyelid retraction in patients with Graves' orbitopathy and variable rates of success have been reported. Most authors recommend different procedures for different degrees of retraction, but cannot prevent residual temporal retraction in a significant number of cases. The modified levator aponeurosis recession described by Harvey and colleagues, in which the lateral horn is cut completely, seems to be an exception to this rule, but was evaluated in a limited number of cases only.

METHOD

The authors further modified Harvey's technique by dissecting the aponeurosis together with Müller's muscle of the tarsus and the conjunctiva medially only to the extent necessary to achieve an acceptable position and contour of the eyelid in upright position. They also used an Ethilon 6.0 suture, instead of Vicryl, on a loop. It is placed between the tarsal plate and the detached aponeurosis to prevent spontaneous disinsertion. This modification was used in 50 Graves' patients (78 eyelids) with a upper lid margin-limbus distance ranging from 1 to 7 mm and evaluated using strict criteria.

RESULTS

A perfect or acceptable result was obtained in 23 of 28 patients (82%) with bilateral retraction and in 18 of 22 patients (82%) with unilateral retraction. Seven eyelids were overcorrected (too low) and three undercorrected, necessitating reoperation. All other eyelids had an almond-like contour and a lid crease of 10 mm or less. No complications except subcutaneous haematomas were seen. Two patients showed a recurrence of lid retraction 9 months after the operation.

CONCLUSION

This technique is safe and efficacious and can be used for all degrees of eyelid retraction.

Surgical treatment of thyroid eye disease

Thyroid eye disease may result in exophthalmos, diplopia, and eyelid malpositions, which can be corrected with different surgical procedures. Several techniques for decompressing the orbit have been described, and the advantages and disadvantages of the techniques are discussed. Our own results of the transantral approach are briefly summarized. Eye muscle surgery should be performed after an orbital decompression, and it is not unlikely that more than one muscle operation will be needed in order to achieve single vision. A number of operative procedures for eyelid surgery have been described, and the results of the various methods are generally good.

The role of Müller's muscle reconsidered

It is a traditional teaching that the levator aponeurosis is the main transmitter of the levator palpebrae muscle. However, there are several points that raise doubts in this fundamental concept of the levator aponeurosis as being the primary interconnecting mechanism in upper lid elevation. Despite the structural integrity of the levator complex, drooping of the upper eyelids is seen to develop in situations such as Horner's syndrome and in times of excessive fatigue and sleepiness. Amid the controversy in the literature regarding the specific role of the levator aponeurosis in the lid-elevating mechanism, we have observed that the levator aponeurosis fails to make constant attachment to the tarsal plate. This has led us to speculate on the possible role of the posterior lamella - Müller's muscle - as the primary transmitter of the levator muscle action to the tarsal plate.

Ophthalmic eponyms from the Mayo Clinic

Numerous ophthalmic eponyms are associated with the Mayo Clinic. Some of the terms, such as Hollenhorst plaque and Kearns-Sayre syndrome, are well known, whereas others are relatively cryptic or parochial. Although eponyms have their detractors, the designations will likely appear in the medical lexicon for many years to come.

Correction of lower eyelid retraction in thyroid eye disease: a randomised controlled trial of retractor tenotomy with adjuvant antimetabolite versus scleral graft

BACKGROUND/AIMS

Lower eyelid retraction in thyroid eye disease contributes to ocular discomfort and an unsightly appearance, especially if asymmetrical. The use of donor scleral grafts is effective in lengthening the lower eyelids but carries a risk of virus transmission. Other techniques, including those which do not use grafts, need to be compared with scleral grafts. Recurrent retraction is a recognised complication of thyroid eyelid surgery; therefore, the authors investigated the use of antimetabolites to reduce postoperative fibrosis.

METHODS

In this prospective randomised controlled trial of 25 patients (35 eyelids), the use of donor sclera in 20 lower eyelids (13 patients) was compared with partial tenotomy of the anterior part of the lower eyelid retractors (ALER) with adjuvant peroperative antimetabolite in 15 lower eyelids (12 patients). A 5 minute peroperative application of either 5-fluorouracil (25 mg/ml) in nine lower eyelids (eight patients) or mitomycin C (0.2 mg/ml) in six lower eyelids (four patients) was used to focally inhibit fibroblasts. Follow up ranged from 3 to 18 months (mean 7.8).

RESULTS

One month after surgery the results of both groups were similar. However, at 3 months after surgery the results of scleral grafting were better than tenotomy with antimetabolites: 3/12 patients (25%) treated with tenotomy and adjuvant antimetabolite required subsequent surgery using grafts for correction of recurrent retraction. There were no significant complications associated with the use of antimetabolites in the eyelid in the doses used in this study.

CONCLUSIONS

This randomised prospective trial shows that donor scleral grafts were more effective in the long term than partial tenotomy with adjuvant antimetabolite in the correction of lower eyelid retraction associated with thyroid eye disease. The use of peroperative antimetabolites in the lower eyelid was safe.

Ophthalmic eponyms from the Mayo Clinic

Numerous ophthalmic eponyms are associated with the Mayo Clinic. Some of the terms, such as "Hollenhorst plaque" and "Kearns-Sayre syndrome," are well known, whereas others are relatively obscure. Although eponyms have their detractors, the designations likely will appear in the medical lexicon for many more years.

Modern and Physiological Concepts of Eyelid Rejuvenation

Detailed consideration is given to rejuvenation of the upper and lower eyelids and periorbital area using modern and physiological concepts that are based on reversing the effects of ageing. A new idea is proposed for the pathophysiology of herniated fat pads of the lower eyelids. This concept must be kept in mind when considering the management and prevention of enophthalmia. Techniques to improve the infraorbital sulcus, crow's feet and eyebrow ptosis during aesthetic surgery are also presented.

Primary infratarsal lower eyelid retractor lysis to prevent eyelid retraction after inferior rectus muscle recession

PURPOSE

To evaluate a procedure to prevent lower eyelid retraction, which may occur after inferior rectus muscle recession surgery as a direct consequence of the intimate anatomic connections between the inferior rectus muscle and lower eyelid retractors.

METHODS

We evaluated the technique of primary infratarsal lower eyelid retractor lysis on 12 eyelids of ten patients undergoing inferior rectus muscle recession of 3 mm or more. Indications for surgery included restrictive strabismus related to Graves' ophthalmopathy, orbital blowout fracture, and orbital fibrosis syndrome.

RESULTS

For the 12 eyes, inferior rectus muscle recession ranged from 3 to 10 mm (mean, 5.3 mm). Postoperatively there was no significant change in mean lower eyelid position (P > .82), and no patient developed inferior scleral show.

CONCLUSION

Primary infratarsal eyelid retractor lysis is an effective technique for preventing lower eyelid retraction after inferior rectus muscle recession strabismus surgery.

'Henderson's' relief of eyelid retraction revisited

The purpose of the study was to identify those patients with thyroid eye disease and upper eyelid retraction who would benefit from Henderson's procedure (myotomy of Muller's superior tarsal muscle with graded division of levator aponeurotic fibres on the anterior tarsal plate). The clinical records of patients attending the Thyroid Clinic of Moorfields Hospital who had undergone Henderson's procedures were reviewed. Twenty-two patients (19 women, 3 men) had Henderson's procedures at age 35-69 years (mean 49.9), with a mean follow-up of 4.55 years. Eleven patients had bilateral upper eyelid surgery, 11 unilateral (33 eyelids). The pre-operative vertical palpebral apertures ranged from 11 to 19 mm (mean 13.95); the post-operative vertical palpebral apertures ranged from 8 to 15 mm (mean 11.45), a mean reduction of 2.5 mm (p < 0.001). Eight of twenty-two patients (36%) had further eyelid surgery and 3 of 22 (14%) had further surgery recommended because of persistent upper eyelid retraction, abnormal eyelid contour (lateral flare) and asymmetry. It is concluded that Henderson's procedure should be reserved for those patients with minor degrees of almost symmetrical upper eyelid retraction who do not have abnormalities of their eyelid contour.

Repair of upper eyelid retraction: a comparison between adjustable and non-adjustable sutures

BACKGROUND

The challenge with the surgical repair of upper eyelid retraction is to obtain a more predictable and satisfactory postoperative eyelid contour and height, and to minimise the need for further surgery.

METHODS

A retrospective analysis was performed on all patients treated surgically for eyelid retraction at Moorfields Eye Hospital over a 13 year period.

RESULTS

In this study good postoperative results were obtained in 10 of 13 (77%) eyelids using adjustable sutures, compared with 56 of 148 (38%) eyelids using non-adjustable sutures (p < 0.01). With non-adjustable sutures, good results were achieved more often for non-thyroid compared with thyroid related eyelid retraction (26/55 versus 31/93 eyelids respectively, p < 0.05). Previous eyelid surgery did not affect outcome.

CONCLUSION

We recommend the use of adjustable sutures for the repair of upper eyelid retraction, particularly in patients with thyroid disease.

New technique of levator lengthening for the retracted upper eyelid

Retraction of the upper eyelid associated with shortening of the levator mechanism occurs most commonly in association with Graves' disease but occasionally arises as a complication of blepharoplasty or other surgical procedures. A new technique of a castellated type aponeurotomy of the levator aponeurosis is carried out to lengthen the levator. This procedure appears to give a predictable, stable and symmetrical result.

Results of Müllerotomy and levator aponeurosis transposition for the correction of upper eyelid retraction in Graves disease

BACKGROUND

Upper eyelid retraction in Graves disease may cause functional morbidity and aesthetic deformity. Surgery to correct thyroid-related upper eyelid retraction may result in temporal undercorrection with failure to eliminate lateral eyelid retraction, leading in turn to a poor eyelid contour postoperatively.

METHODS

In 1984, one of the authors developed a new procedure for correcting moderate to severe upper eyelid retraction associated with Graves disease. The surgical technique consists of a Müllerotomy and recession of the levator aponeurosis combined with medial transposition of the lateral horn of the levator aponeurosis. The procedure was performed on 37 patients (72 eyelids). Müller's muscle was used as the spacer to set the eyelid height. Transposition of the levator aponeurosis allowed adjustment of eyelid contour.

RESULTS

Thirty patients (58 eyelids) had excellent results, six (13 eyelids) had good results, and one (1 eyelid) had a poor result. No patient required re-operation for asymmetry, unacceptable contour, or malposition. Only one eyelid had significant overcorrection, and only one eyelid had significant undercorrection, requiring further surgery. The most frequent unwanted effects were high eyelid crease (24 eyelids) and residual temporal flare (6 eyelids); however, most of these were seen early in the series before the lateral levator transposition modification was added.

CONCLUSION

This procedure allows successful and simultaneous correction of both eyelid position and contour in patients with moderate to severe thyroid-related upper eyelid retraction.

Epiphora in facial paralysis

Current management concepts of epiphora in established facial palsy are reviewed and compared with those advocated by McLaughlin and criticized by Stallard in 1949.

Eyelid surgery in dysthyroid ophthalmopathy

Dysthyroid ophthalmopathy often gives rise to functional and cosmetic problems due to eyelid retraction. There are several causes of this state which are usually most obvious in the upper lid. Surgery should be delayed until the condition is stable and other operations have been done. A number of operative procedures have been used. In the upper eyelid, the traction of the Müller muscle and, most often, the levator is released; in the lower eyelid, the retractors are recessed or excised. Spacers have been used especially in the lower lid. The retractors can be reached either through the skin or the conjunctiva. Both methods give good results. In the upper lid, the risk of damaging other structures is lower with a skin incision; in the lower lid the conjunctival incision gives easier access to the tissues. The complications most frequently seen are over- or undercorrection both of which may necessitate a reoperation.

Thyroid lid surgery

A retrospective study of 58 thyroid patients undergoing eyelid surgery for thyroid related lid malposition is reported. A treatment strategy is suggested, based on the results of this experience. The following points are stressed: (1) The importance of recognising and relieving the inferior rectus tethering component of upper lid retraction when present. (2) The usefulness of a scleral graft in lower lid retractor recession. (3) The inadequacy of lateral tarsorrhaphy in relieving lid retraction but its value in camouflage.

Upper eyelid retraction treated by cross-face free muscle graft: case report

Upper eyelid retraction can be an early sign of Graves' disease. In a patient with no obvious endocrinological disturbance first the left and later the right upper eyelid became retracted. Since there was no exophthalmos it was decided to counteract the levator over-activity with free muscle grafts as used in the correction of paralytic lagophthalmos.

The surgical management of thyroid-related upper eyelid retraction

Excision of Müller's muscle can usually correct thyroid-related upper eyelid retraction. A transcutaneous approach to Müller's muscle was used in 22 eyelids. The findings at surgery included diffuse eyelid scarring, disinsertion of the levator aponeurosis, fat herniation, and changes resembling dermatochalasis. Identification and correction of these factors, complemented anterior resection of Müller's muscle and influenced final eyelid position and cosmesis.

The use and fate of fascia lata and sclera in ophthalmic plastic and reconstructive surgery

The introduction and use of newer surgical materials, better surgical instruments, finer suture materials, and improved optical equipment have allowed us to advance certain techniques in ophthalmic surgery and ophthalmic plastic surgery. In oculoplastic surgery, fascia lata and sclera are but a few of these materials used with greater frequency. In this paper, a number of techniques are described depicting the use of fascia lata and sclera. A histologic study of these materials after variable periods of implantation is presented.

The use of sclera in the treatment of dysthyroid eyelid retraction

The use of sclera for correcting dysthyroid lid retraction is described. Forty-three procedures on 14 patients are reviewed. Of these 43 procedures, 18 were for upper eyelid retraction, and 25 were for lower eyelid retraction. A tapered graft, larger temporally, was used for the upper eyelid. An eliptical graft of uniform vertical height was used for lower eyelid. Moderately predictable results were obtained; 66% of patients were corrected to within 1 mm of desired positions after the first operative procedure. Only 13% of patients required additional surgery. When secondary procedures were required, the eyelids were corrected to the desired location. Complications were minimal. Sclera proved to be an excellent graft material for dysthyroid eyelid retraction.

Graves' ophthalmopathy. A clinical and immunologic review

Graves' thyroid disease and the orbitopathy which often accompanies it have puzzled physicians and scientists for more than 150 years. Although certain histopathological features have been documented, it is not known what mechanisms are responsible for the systemic and/or ocular disorders. The ocular condition characteristic of Graves' disease may exist in the absence of clinical or biochemical evidence of thyroid dysfunction, and when the systemic and ocular condition exist together, they may follow completely different clinical courses. Because the relationship between the thyroid disorder and the orbitopathy is not established, the authors refer not to "thyroid ophthalmopathy," but to "Graves' ophthalmopathy." In this review, histopathological features of Graves' ophthalmopathy are reviewed. The differential diagnosis of the ophthalmopathy and approaches to its evaluation are discussed, notably the T-4 radioimmunoassay, T-3 resin uptake and TSH tests, as well as CT scanning and ultrasonography. The characteristics of Classes 0-6 ophthalmopathy are outlined and the management of cases in each class is considered. The possible immunological basis for Graves' ophthalmopathy is also reviewed.

The aponeurotic approach to eyelid retraction

A technique for the upper lid retraction that involves an anterior approach similar to aponeurotic ptosis surgery is presented. Instead of advancing the aponeurosis, it is recessed and Müller's muscle is completely extirpated. The lateral horn of the levator must be cut to relieve the marked temporal elevation of the eyelid. Lid height and contour are adjusted intraoperatively with patient cooperation. In the lower lid, the retractors are recessed via a conjunctival approach unless simultaneously performed with orbital decompression. Any amount of lid retraction may be corrected by this technique in the upper lid and up to 3 mm of lower lid retraction can be corrected. Lid height in both the upper and lower lid is lasting and predictable. Thirty-one patients (63 eyelids) have been operated on using this technique with good results. Results in 17 patients (35 eyelids) with follow-up ranging from 8 to 42 months are presented.