Eyelid retraction is the superior displacement of the upper eyelid or the inferior displacement of the lower eyelid (or both), exposing sclera between the limbus and the eyelid margin (Fig 12-21). It can be unilateral or bilateral. Lower eyelid retraction may also be a normal anatomic variant in patients who have shallow orbits or certain genetic orbital or eyelid characteristics. Retraction of the eyelids often leads to lagophthalmos and exposure keratopathy, with consequences ranging from ocular irritation and discomfort to vision-threatening corneal decompensation.
Eyelid retraction can have local, systemic, or central nervous system causes. The most common are thyroid eye disease (TED), recession of the vertical rectus muscles, aggressive tissue removal during blepharoplasty, and overcompensation for a contralateral ptosis (Hering’s law of equal innervation).
Thyroid eye disease is the most common cause of both upper and lower eyelid retraction, as well as unilateral or bilateral proptosis. Because proptosis commonly coexists with and may mimic eyelid retraction in patients with TED, these conditions are evaluated through eyelid measurements and exophthalmometry. A common finding in TED-related eyelid retraction is temporal flare. In this condition, the eyelid retraction is more severe laterally than medially, resulting in an abnormal upper eyelid contour that appears to flare upward along the lateral half of the eyelid margin. See Chapter 4 for a more extensive discussion of TED.
Iatrogenic eyelid retraction may be induced by recession of the vertical rectus muscles, owing to anatomic connections between the superior rectus and the levator palpebrae superioris muscle in the upper eyelid and between the inferior rectus muscle and capsulopalpebral fascia in the lower eyelid. Another iatrogenic cause of eyelid retraction, especially of the lower eyelids, is excessive resection of skin, middle lamellar scarring, and untreated lower eyelid laxity during cosmetic lower blepharoplasty. Correction may require any combination of lower eyelid tightening, midface-lifting, full-thickness skin grafting, or spacer grafting. Conservative excision of skin in lower blepharoplasty, along with concomitant correction of any lower eyelid laxity, minimizes the risk of this problem.
Other etiologies include Parinaud syndrome, an example of eyelid retraction caused by a central nervous system lesion. Congenital eyelid retraction occurs as a rare, isolated entity.
Excerpted from BCSC 2020-2021 series: Section 10 - Glaucoma. For more information and to purchase the entire series, please visit https://www.aao.org/bcsc.