Treatment of eyelid retraction is based on the severity and underlying etiologic factors. In patients with mild eyelid retraction, artificial tears, lubricants, and ointments may be sufficient to protect the cornea and minimize symptoms. Mild eyelid retraction resulting from lower blepharoplasty or TED may resolve spontaneously over time. A variety of surgical techniques have been developed to correct eyelid retraction that persists or that poses an immediate threat to the eye. Except in cases of severe exposure keratopathy, surgical intervention is undertaken only after serial measurements have established stability of the eyelid position. Upper eyelid retraction can be corrected by excision or recession of the Müller muscle (anterior or posterior approach), recession of the levator aponeurosis with or without hang-back sutures or other spacer (Fig 12-22), measured myotomy of the levator muscle, or full-thickness transverse blepharotomy.
Figure 12-22 Bilateral upper eyelid retraction in thyroid eye disease. A, Preoperative appearance. B, Same patient after upper eyelid retractor recession.
(Courtesy of Bobby S. Korn, MD, PhD.)
If the patient has lateral flare, a small eyelid-splitting lateral tarsorrhaphy combined with recession of the upper and lower eyelid retractors can improve the upper eyelid contour; however, this technique may limit the patient’s lateral visual field.
As with correction of the upper eyelids, treatment of lower eyelid retraction is directed by the underlying etiologic factors. Anterior lamellar deficiency (eg, excess skin resection from blepharoplasty) requires recruitment of vertical skin by means of a midface-lift or addition of skin with a full-thickness skin graft. Middle lamellar deficiency (eg, posttraumatic septal scarring) requires scar release and possible placement of a spacer graft. Posterior lamellar deficiency from congenital scarring or conjunctival shortage (eg, mucous membrane pemphigoid) may require a full-thickness mucous membrane graft.
Severe retraction of the lower eyelids, common in patients with TED, may require a spacer graft between the lower eyelid retractors and the inferior tarsal border. Autogenous auricular cartilage, hard-palate mucosa, free tarsal grafts, acellular dermal matrix, and dermis fat are common spacer materials. It is often necessary to perform some type of horizontal eyelid or lateral canthal tightening or elevation as well. However, because horizontal tightening of the lower eyelid in a patient with proptosis may exacerbate the eyelid retraction, use of this technique requires caution.
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.