Natural history
Vertical shortening of skin due to inflammation can improve with elimination of acute inflammation.
Contraction of conjunctiva from inflammatory causes such as ocular cicatricial pemphigoid typically progresses without treatment and can result in severe corneal damage.
Contraction at level of septum can improve with observation and massage in the immediate postop period.
Retraction related to dysthyroid orbitopathy can improve with treatment, but has been demonstrated to persist in up to 40% patients (Radiology 1993; 188:115-118. QJ Med 1960; 29: 113-126).
Medical therapy
Remove inciting agents.
- Irrigate in case of burns.
- Remove allergens in case of atopy or contact dermatitis.
- Antibacterial/lid hygiene in presence of infection
- Withdraw offending agent in Stevens Johnson syndrome.
Treat underlying inflammation of skin.
- Atopy
- Topical steroids are a mainstay of therapy for atopic dermatitis.
- Recent data suggests even long durations of class III and IV steroids are well tolerated on the eyelids, although patients should still be monitored for glaucoma and cataracts. (J Am Acad Dermatol 2011; 64(2):275-281)
- Rosacea
- For subtype 2, papulopustular rosacea, topical metronidazole, azelaic acid, and anti-inflammatory dose doxycycline (40 mg) appear to be effective and safe for short-term use.
- Effectiveness of treatment for erythematotelangiectatic rosacea (subtype 1) is less well documented (The Cochrance Library 2011, Issue 3)
- Icthyosis: Tazarotene 0.1% cream
Treat signs of active conjunctival inflammation.
- Ocular cicatricial pemphigoid
- Address concomitant dry eye and blepharoconjunctivitis.
- After inflammation under control, treat
- Trichiasis
- Tistrichiasis
- Tntropion
- Retraction
- Systemic treatment with immunomodulatory agents, coordinated with rheumatologist or oncologist, after
- Baseline renal and liver function tests
- Complete blood count
- Test for glucose 6-phosphate dehydrogenase (GGPD) deficiency
- Slowly progressive mild to moderate OCP sometimes treated with Dapsone
- Mild to moderate cases or those unresponsive to Dapsone: mycophenolate mofetil (CellCept) or Methotrexate commonly used
- Rapidly progressive moderate to severe inflammation: role for Cytoxan
- Rituximab and immunoglobulin (Ophthal 1999; 106:2136-2143)
- Steroids used in selected cases usually early in treatment (Seminars in Ophthalmology 2011;2(4-5):270-277)
- Trachoma: azithromycin and tetracycline ointment
Acute middle lamellar deficiency (within 6 months of onset) can be improved with massage with or without intralesional corticosteroid injection.
Graves upper eyelid retraction
- In the early phase of the orbitopathy, triamcinolone injected subconjunctivally has been used.
- Botulinum toxin
- Hyaluronic acid fillers (Survey of Ophthalmology 2012; 58(1)) (Curr Opin Ophthal 2011; 22:391-393)
Surgery
Surgical options are determined in part by preoperative variables:
- Lower versus upper eyelid
- Degree of retraction
- Time elapsed since surgery or trauma
- Presumed lamella(s) involved
- Relative globe prominence and/or eyelid volume deficiency
- Horizontal eyelid laxity or orbicularis weakness
- Patient preference for multiple minimally invasive procedures versus more definitive invasive procedures.
Because so many variables are involved, and there is not complete agreement on surgical approaches to retraction repair, a comprehensive algorithmic approach incorporating all variables is not possible.
A basic algorithm is presented here (Figure 2).
Figure 2. Lower eyelid retraction.
Surgery for primarily anterior lamella deficiency
- Minimally invasive options
- Botulinum toxin relaxation of frontalis muscle can be temporarily helpful.
- Hyaluronic acid fillers have been used to address mild retraction. They do not lengthen the anterior lamella directly, but offer a cosmetically acceptable way to address mild retraction. (Ophthal Plast Reconstr Surg 2001; 23(5). Orbit 2013; 32(6):362-365)
- Invasive surgical options
- Horizontal eyelid tightening, often only temporary
- Skin grafting is a very direct way to address anterior lamella shortage, and can be in form of free graft or rotational flap. Most patients achieve good eyelid position and color match, and the majority of early postoperative sequellae can be reversed by massage, steroid ointment, and silicone gel application (Ophthal Plast Reconstr 2014; 30(6))
- Spacer grafting does not address anterior lamella deficiency directly, but mid and posterior lamella grafts can be used to address mild anterior lamella shortage in a cosmetically acceptable way (Figure 3).
- Spacer grafts, depending on the material, can be placed "en face" (Figure 4) or "en glove" (Figure 5). (Ophthal Plast Reconstr Surg 1992; 8: 183-195. OPRS 1992; 8(3). OPRS 2011; 27(2))
- Mid face lifting: A variety of techniques have been described for supporting the lower eyelid by addressing the mid face. (Ophthal Plast Reconstr Surg 1985; 1:229-235) (Ophthalmology 2006; 113(10)) (Ophthal Plast Reconstr Surg 2010; 26(3))
Figure 3. Top: Bilateral upper eyelid ptosis, lower rid retraction, and dry eye syndrome (rosacea). Bottom: Post-concomitant repair ptosis and retraction with human acellular dermis.
Figure 4. En face graft. (Arch Ophthal. 1990;10:1341.)
Figure 5. En glove graft. (Ophthal Plast Reconstr Surg. 1992;8(3):171.)
Surgery for posterior lamella deficiency
- Lengthening of posterior lamella with spacers, e.g., buccal mucosa, hard palate, nasal septum; see middle lamella for a more complete list.
- Horizontal tightening in presence of laxity
Surgery for middle lamella scarring
- Minimally invasive options, e.g., hyaluronic acid fillers (Ophthal Plastic Reconstr Surg 2007; 23(5))
- Division of middle lamellar scar tissue with traction suture (Ophthal Plast Reconstr Surg 1992; 8(3))
- Spacer grafting with some rigidity to provide vertical support to tarsus of lower eyelid
- Donor sclera
- Dermis or dermis fat graft
- Auricular cartilage
- Nasal cartilage
- Hard palate mucosal grafts
- Human acellular dermis
- Procine acellulcar dermis
- Polytetrafluoroethylene
- Porous polyethylene (Figures 6 and7)
- Spacer grafting in upper eyelid not commonly needed and probably of more limited use; ideal spacer would be more flexible, e.g., temporalis fascia (Survey of Ophthalmology 2013; 58(1). Arch Ophthal 1983; 101:262-264)
Figure 6. Top: Bilateral lower eyelid retraction secondary to esthetic surgery. Bottom: Post spacer graft, hard palate.
Figure 7. Top: Bilateral lower eyelid retraction secondary to esthetic surgery. Bottom: Post spacer graft porcine acellular dermal matrix.
Surgery for neuromyogenic retraction (e.g., Dysthyroid retraction, facial weakness)
- Minimally invasive
- Botulinum toxin directed to levator palpebrae superioris
- Subconjunctival triamcinalone, early in inflammatory process
- Hyaluronic acid (upper and lower) (Ophthal Plast Reconstr 2009; 25)
- Invasive surgical correction
- Upper eyelid dysthyroid retraction
- Eyelid retractors (levator palpebrae surgeries and Müller muscle) can be debilitated separately or in combination by an anterior or posterior approach.
- The muscles can be recessed, partially resected, or lengthened.
- Various spacers have been used, but improved results (in the upper eyelid) are not well documented compared to simple retractor weakening.
- Most surgeons do more aggressive surgery laterally. (Survey of Ophthalmology 2013; 58(1)).
- Upper eyelid retraction due to facial palsy: eyelid loads such as platinum or gold weights, or even hyaluronic acid (Ophthal Plast Reconstr Surg 2009; 25(1))
- Lower eyelid retraction: Retractors can be recessed (Br J Ophthalmol 2011; 95:1664-1669) or spacers can be used as previously described.