Eyelid Retraction In Patients Research Articles

Nonsurgical treatment for upper eyelid retraction in patients with inactive Graves' orbitopathy.

To evaluate the effectiveness of incobotulinumtoxinA (Xeomin®) in treating upper eyelid retraction in patients with Graves orbitopathy (GO) initially scheduled for surgery via two different application sites. This is a comparative, prospective study, conducted at the Department of Ophthalmology, Medical School, University Hospital Centre Zagreb, EUGOGO site (EUropeanGroupOnGraves'Orbitopathy) in Croatia from January 2020 till January of 2021 in accordance with national health headquarter recommendations. All patients were classified as inactive with marked eyelid retraction and randomly divided into groups according to application sites. Group A underwent transconjunctival application (18 eyes) and group B transcutaneous application (20 eyes) of incobotulinumtoxinA. The primary end point of this study was lowering the eyelid, to alleviate anterior eye segment symptoms and achieve acceptable aesthetic appearance until surgery becomes available. There were no nonresponders and we found no statistically significant difference in the degree of lowering the eyelid between the two application sites. Following rules for avoiding spread of SARS-CoV-19, none of the patients included in this study were infected. Moreover, participants reported diminishing of anterior eye segment irritation and improved aesthetics. Treatment of inactive GO patients with incobotulinumtoxinA for upper eyelid retraction is efficient and safe and can be used as an adjuvant treatment while patients wait for surgery, by alleviating symptoms and improving the level of aesthetic satisfaction without causing a threat to anterior eye segment and visual function. The study showed that effect of treatment was the same, whether we applied the toxin transconjunctivaly or transcutaneously.

The Effect of Levator Recession for Upper Eyelid Retraction in Patients with Thyroid-associated Ophthalmopathy

Purpose: We analyzed factors that affect the outcome of levator recession surgery for upper eyelid retraction in patients with thyroid-associated ophthalmopathy.Methods: Retrospective analysis was performed based on the medical records of 24 patients with thyroid-associated ophthalmopathy who underwent upper eyelid levator recession surgery between February 10, 2010, and September 18, 2018. The margin to reflex distance (MRD), length and area of the upper and lower eyelids were measured and compared with the eyelid analysis software before and after 6 months of surgery on medical records. In addition, factors affecting the difference in MRD1 before and after surgery were examined by multivariate linear regression analysis.Results: Twenty-four patients were included in the study. The MRD1 decreased significantly from 5.12 ± 1.26 mm before surgery to 3.48 ± 1.08 mm at 6 months after surgery (p < 0.001). All upper eyelid measurements, i.e., UEL (p < 0.001), UMA (p < 0.001), UCA (p = 0.004), and ULA (p < 0.001), were significantly decreased after surgery, while none of the lower eyelid measurements showed significant changes. Multivariate logistic regression analysis indicated that lower preoperative MRD1 was associated with the success of the surgery (odds ratio, 0.31; 95% confidence interval, 0.09-1.01).Conclusions: Levator recession surgery is an efficient surgical method that can correct the upper eyelid retraction associated with thyroid-associated ophthalmopathy.

Surgical Outcomes of Correction of Upper Eyelid Retraction in Thyroid Eye Disease

Purpose: to evaluate the outcome of anterior blepharotomy in correcting eyelid retraction in patients with Thyroid Eye Disease (TED). Methods: Literature search was conducted from MEDLINE database through PubMed, Google scholar and ClinicalKey. Outcomes included margin-reflex distance, palpebral fissure height, and upper eyelid margin-superior limbus distance. Results: Sixteen articles were reviewed with a mean follow-up time in the studies varied, ranging from 6 to 61 months. The preoperative and postoperative mean MRDs varied. Although there were different success criteria, success rate for full thickness blepharotomy ranged from 59-93%, comparable with levator recession. The complication rates in 14 studies were less than 20%. Conclusion: Full thickness anterior blepharotomy and Müller muscle and levator recession, are safe and effective in correcting upper eyelid retraction in patients with TED. The anterior blepharotomy is a relatively quick and simple procedure.

Triamcinolone acetonide deep fornix injection for the treatment of upper eyelid retraction in patients with thyroid-associated ophthalmopathy

Objective: To evaluate the efficacy of triamcinolone acetonide deep fornix injection for the treatment of upper eyelid retraction caused by thyroid-associated ophthalmopathy (TAO). Methods: Case-control study. A retrospective analysis was conducted on 64 eyes in 53 patients with upper eyelid retraction caused by TAO from October 2015 to December 2018. Thirty-nine eyes in 33 patients diagnosed with TAO with upper eyelid retraction were treated with triamcinolone acetonide deep fornix injection (20 mg), once per month until the therapeutic effect was stable, as the treatment group. Twenty-five eyes in 20 patients were not treated (the observation group). The ocular examination indexes of the two groups were compared. Paired t-test and independent sample t-test were used for statistical analysis. Results: There were 6 males and 27 females in the treatment group, aged (43±12) years, and 5 males and 15 females in the observation group, aged (40±13) years. There was no significant difference in gender, age, history and baseline ocular examination indexes between the two groups (all P>0.05). In the treatment group, the number of injections was (2.18±0.94) times (range, 1 to 5 times). After (6.74±3.89) months of follow-up, the marginal reflex distance (MRD1) was reduced from (6.85±0.88) mm to (4.38±1.04) mm, the score of quality of life in thyroid eye disease (TED-QOL) was reduced from 22.03±4.33 to 7.91±3.25, and the clinical activity score (CAS) was reduced from 2.82±0.39 to 0.97±0.39 (t=14.68, 21.36, 20.92; all P<0.01). There was no statistically significant difference in the degree of exophthalmos, intraocular pressure, the diameter of the rectus muscle measured by B-ultrasound before and after treatment (all P>0.05). After (8.65±5.15) months of follow-up, the eyelid retraction also improved in the observation group, but the improvement was more obvious in the treatment group. The differences of MRD1, TED-QOL and CAS before and after treatment in the treatment group were (2.46±1.05) mm, 14.06±3.80 and 1.85±0.51 respectively, which were significantly higher than those before and after the follow-up in the observation group [(0.32±0.75) mm, 3.24±2.86 and 0.56±0.58, respectively; t=8.86, 11.90, 8.98; all P<0.01]. There was no recurrence in the two groups. In the treatment group, 5 patients (6 eyes) showed a transient intraocular pressure rise, which was controlled after medication; 3 women had menstrual changes. Conclusions: Deep fornix injection of triamcinolone acetonide for treating upper eyelid retraction is convenient and effective. It can significantly reduce symptoms and improve patients' quality of life. (Chin J Ophthalmol, 2020, 56:524-529).

Relationships between eyelid position and levator-superior rectus complex and inferior rectus muscle in patients with Graves' orbitopathy with unilateral upper eyelid retraction.

To assess the relationships between eyelid position and levator palpebrae superioris (LPS)-superior rectus (SR) complex and inferior rectus (IR) muscle volume in patients with Graves' orbitopathy (GO) with unilateral upper eyelid retraction. This was a cross-sectional observational study of 48 patients with GO with unilateral upper eyelid retraction. To measure muscle volume, computerized tomography scans were performed, and 3D images were analyzed. Digital photographs were taken, and vertical eyelid height was measured using computed eyelid analysis software. The measured muscle volumes and eyelid heights were assessed, and correlation analysis was performed. To verify the parameters that are predictive for the presence of upper eyelid retraction, receiver operating characteristic curves were analyzed, and logistic regression was performed. The volume of the LPS/SR muscle complex in the eyes with upper eyelid retraction was increased in 41 eyes (85.4%). The mean volume of the LPS/SR complex was 0.92±0.40cm3 in the eyes with upper eyelid retraction and 0.72 ± 0.27cm3 in the contralateral eyes (p < 0.0001). While there was no correlation between LPS/SR complex volume and margin reflex distance1 (MRD1, the vertical distance between the center of the pupil to the center of the upper eyelid margin) (R = 0.024, p = 0.869), MRD1 and MRD2 (the vertical distance between the center of the pupil and the center of the lower eyelid margin) in the retracted eyes were negatively correlated (R = - 0.441, p = 0.002). In patients with upper eyelid retraction without increased LPS/SR complex volume, IR volume and MRD2 of the contralateral eye were 0.48 ± 0.10cm3 and 5.92 ± 0.45mm, respectively. In the retracted eye, they were 0.37 ± 0.17cm3 and 5.32 ± 0.59mm, respectively (p = 0.018, and 0.028). Regression models incorporating LPS/SR complex volume, MRD1, and lid lag could predict the presence of upper eyelid retraction with an accuracy of 92.5%. In patients with GO, increased LPS/SR complex volume in the retracted eye and increased IR volume of the contralateral eye were both associated with unilateral upper eyelid retraction. The combination of LPS/SR complex volume, MRD1, and lid lag can be used as a reliable index of upper eyelid retraction in patients with GO.

Simultaneous ipsilateral transconjunctival repair of upper and lower eyelid retraction in thyroid-associated ophthalmopathy

ABSTRACTPurpose: To report a simple, highly effective technique of simultaneous transconjunctival repair of upper and lower eyelid retraction in patients with thyroid eye disease (TED).Methods: A retrospective interventional case review was conducted on 22 eyes of 19 TED patients. The lower eyelid was recessed with placement of a tarsoconjunctival spacer graft harvested from the upper eyelid. The upper eyelid was then recessed through the conjunctival incision used to harvest the tarsal graft. A temporary tarsorrhaphy was placed for 5–7 days. The postoperative outcome was assessed by measuring the margin reflex distance of the upper eyelid (MRD1), inferior scleral show (ISS), and lagophthalmos.Results: The absolute change in MRD1 ranged from 0 to 5 mm with an average of 1.86 ± 1.34 mm. The absolute change in ISS ranged from 0 to 2 mm with an average of 1.3 ± 0.49 mm. One patient had postoperative lagophthalmos and 17 of 19 had improvement in their ocular surface exposure symptoms. None of the patients’ grafts were observed to undergo absorption during the postoperative course.Conclusions: This technique of harvesting a free tarsoconjunctival graft from the upper eyelid as a posterior spacer for the lower while simultaneously recessing the upper eyelid through the same incision is an effective and durable method of correcting eyelid retraction in TED.

Correction of eyelid retraction using a half-thickness tarsal flap for lengthening of the eyelid following ptosis surgery

Various surgical procedures for correction of upper eyelid retraction have been reported, many of which have had favorable results. However, most of these reports are concerned with the correction of upper eyelid retraction in patients with thyroid ophthalmopathy, and few have focused on upper eyelid retraction caused by overcorrection during ptosis surgery. Corrective surgery for upper eyelid retraction resulting from ptosis surgery is often difficult because of the extensive irregular contracture caused by scar tissue. However, as this is a repeat surgery following ptosis surgery, it is important to ensure good postoperative evaluation indices, particularly favorable symmetry, appropriate palpebral fissure width, appropriate crease height, and natural-looking parabolic eyelid margins. Here, we report the lengthening of the upper eyelids using a half-thickness tarsal flap to address upper eyelid retraction secondary to ptosis surgery. By using a half-thickness tarsal flap, the anatomy of the levator insertion onto the tarsal plate is retained, so that good eyelid contour can be obtained, and the results are quantitatively reproducible. Therefore, this technique can be considered for the treatment of upper eyelid retraction and has a potentially wide range of applications. Level of Evidence: Level V, therapeutic study.

A new technique of modified levator muscle prolongation treatment of iatrogenic upper eyelid retraction

Objective To evaluate the effect of correcting upper eyelid retraction in patients with iatrogenic ophthalmopathy by a new technique of modified transsection and longitudinal suture levator muscle prolongation treatment. Methods The traditional levator muscle flap trapezoidal incision was changed into horizontal incision, According to the amount of upper eyelid retraction we designed a transverse incision with 1∶2 in the central part of levator aponeurosis. Along the line of incision was designed transverse incision of Mulller's muscle combined with levator aponeurosis complex was designed, with longitudinal suture of incision. Results Five patients (6 eyes) with iatrogenic upper eyelid retraction were treated by this method. The follow-up was performed for 3 to 12 months. All were satisfied with good cosmetic results, the degree of bilateral corneal exposure was symmetrical, with no recurrence and complications, except for 1 cases of unilateral upper eyelid retraction width slightly asymmetry. Conclusions The application of modified levator muscle prolongation treatment is not only quite simple, easy to adjust in operation, but also with reliable effect and less complication. It is effective for iatrogenic upper eyelid retraction range from mild to moderate degrees of correction. Key words: Levator muscle; Iatrogenic upper eyelid retraction; Modified transsection and longitudinal suture

Correction of Lower Eyelid Retraction Using Acellular Human Dermis During Orbital Decompression.

To investigate the surgical outcome of grafting acellular human dermis compared with concurrent lower eyelid retractor recession during swinging eyelid orbital decompression for correction of lower eyelid retraction in patients with Graves' orbitopathy. Institutional Review Board-approved retrospective nonrandomized study of 54 Graves' orbitopathy patients (95 eyes) from 2008 to 2012. Patients who received decompression were divided into 3 groups: Group 1 with conjunctival lengthening using 0.3-mm thickness AlloDerm (36 eyes), Group 2 with inferior retractor recession (33 eyes), and Group 3 with decompression only (26 eyes). Outcome measures included lower eyelid height, inferior sclera show, cosmetic appearance, and complications. Baseline clinical characteristics and the degree of improvement of exophthalmos were not different between groups. Preoperative MRD2 was higher in group 1 (8.0 mm) than in groups 2 (6.9 mm, p < 0.001) and 3 (6.6 mm, p < 0.001). Mean improvement of MRD2 as well as postoperative improvement of inferior scleral show at postoperative 4 to 6 months were significantly higher in group 1 (2.7 mm) than in groups 2 (1.8 mm, p < 0.001) and 3 (1.2 mm, p < 0.001). Simultaneous correction of lower eyelid retraction using thin AlloDerm during swinging eyelid orbital decompression maximizes improvement of lower eyelid retraction compared with concurrent inferior retractor recession.

Hyaluronic acid gel injection for upper eyelid retraction in thyroid eye disease: functional and dynamic high-resolution ultrasound evaluation.

The goal of this study is to determine the functional and dynamic effects of hyaluronic acid (HA) gel injection into the levator plane for improving upper eyelid retraction in patients with thyroid eye disease (TED). This is a prospective, non-randomized study of consecutive patients with symptomatic unilateral upper eyelid retraction in the setting of active and inactive TED. Study participants underwent HA gel injection subconjunctivally into the levator plane and were examined before injection, 1 to 3 months after injection, and at the clinician's discretion thereafter. At each of the time points, high-resolution ultrasound imaging and clinical photographs were taken, and the marginal reflex distance 1 (MRD1) was measured. Eight patients (4 in the active stage of TED, 4 in the inactive stage of TED) were injected on average with 0.45 ml of HA gel. The average baseline MRD1 was 5.6 mm prior to HA injection, 4.6 mm at the first follow up after injection, and 5 mm at the final follow up after injection. HA was localized ultrasonographically to multiple anatomical locations and changed in morphology over time but not in anatomical location. All patients demonstrated increased fluidity of eyelid excursion on dynamic ultrasound after HA injection. There were no vision-threatening complications in this study. Despite variability in the HA gel distribution and long-term conformational changes on ultrasound examination, HA injection may be an effective and minimally invasive method to improve upper eyelid position for patients with mild eyelid retraction in both the active and inactive stages of TED.

Benzalkonium Chloride–Induced Denervation of Orbicularis Oculi Muscle in Rabbits

To examine the potential for benzalkonium chloride (BAK) to cause denervation of the orbicularis oculi muscle (OOM) in a rabbit model. Pigmented rabbits were separated into five groups consisting of five rabbits each. Group 1 was injected with 1 mL of BAK 0.25% in the OOM of the upper eyelid. Group 2 was injected with 1 mL of BAK 0.5%. Group 3 included untreated controls. Groups 4 and 5 underwent surgical severing of the facial nerve (to cause complete paralysis of the OOM). Strength-duration curves for electrical stimulation of muscle twitches were measured for each group and chronaxie values were calculated to determine innervation status. Groups 1 and 4 were stimulated at 1 week postintervention while groups 2 and 5 were stimulated at 4 weeks postintervention. The rabbits were then sacrificed and the eyelids sent for histological analysis. In group 1, all five rabbits demonstrated denervation of the OOM in the injected area. In group 2, one rabbit developed an abscess at the injection site and was sacrificed at 1 week. Of the remaining four rabbits, two showed complete denervation and two showed denervation with evidence of partial reinnervation. The histology demonstrated marked atrophy of the OOM for BAK-treated rabbits when compared with controls. In group 3, all five rabbits showed normal OOM function. In groups 4 and 5, all rabbits showed denervation of the OOM and histological evidence of muscle atrophy similar to groups 1 and 2. BAK causes denervation when injected into the OOM in rabbits. The clinical relevance of this finding may be the onset of lagophthalmos and eyelid retraction in patients with chronic BAK exposure.

Eye Signs and Serum Eye Muscle and Collagen XIII Antibodies in Patients with Transient and Progressive Thyroiditis

There have been reports of the development of ophthalmopathy in patients with subacute thyroiditis (SAT) in the absence of Graves' disease and thyroid-stimulating hormone receptor (TSH-r) antibodies. The aim of the study was to determine the prevalences of eye and eyelid signs and positive eye muscle and collagen XIII antibody tests in patients with SAT and silent thyroiditis (ST) and in patients with Hashimoto's thyroiditis (HT) as chronic thyroiditis controls. Ophthalmopathy was classified as Nunery type 1 (orbital inflammation, proptosis, without restrictive myopathy) or Nunery type 2 (with restrictive myopathy). We tested for antibodies against calsequestrin, flavoprotein (Fp), G2s, and collagen XIII in 5 patients with SAT, 6 with ST, and 11 with HT, and in 12 age- and sex-matched healthy subjects, using an optimized and standardized enzyme-linked immunosorbent assay (ELISA). At the first visit, eye signs were found in two patients with SAT, one with type 1 ophthalmopathy and one with type 2 ophthalmopathy, and in three patients with ST, two with type 1 ophthalmopathy and one with dominant upper eyelid retraction only. Later in the course of their illness, one other patient with ST developed mild type 1 disease, giving an overall prevalence of any eye signs of 50% in patients with TT. Five patients with HT had mild type 1 ophthalmopathy and dominant upper eyelid retraction. One or more eye muscle antibodies were detected in three patients with SAT, four with ST, and seven with HT, of which calsequestrin and Fp antibodies were the most commonly found. TSH-r antibodies were detected in only one patient with ST, at the time when she developed Graves' hyperthyroidism following an episode of ST. The development of mild, but definite, ophthalmopathy or dominant upper eyelid retraction in patients with TT and chronic (Hashimoto's) thyroiditis in the absence of TSH-r antibodies or Graves' hyperthyroidism is an interesting observation that should be further addressed in larger groups of patients, including those with postpartum thyroiditis. These preliminary findings also raise questions about the mechanism for the link between ophthalmopathy and thyroid autoimmunity.

Transconjunctival Müller Muscle Recession With Levator Disinsertion for Correction of Eyelid Retraction Associated with Thyroid-Related Orbitopathy

To evaluate the efficacy of transconjunctival Müller muscle recession and graded levator disinsertion for eyelid retraction in patients with thyroid-related orbitopathy (TRO). Retrospective consecutive case series. Medical record review of 78 TRO patients (107 eyelids) who underwent surgery for upper eyelid retraction in a 5-year period was performed. Main outcome measures were anatomic and functional success, minimal reflex distance (MRD), lagophthalmos, eyelid asymmetry, and patient discomfort. One hundred seven eyelid retraction surgeries were performed on 78 TRO patients (63 women, mean age 49 years); mean follow-up time was 16.7 months. Upper eyelid position, lagophthalmos, exposure keratopathy, and patients' discomfort markedly improved after surgery (P < .001). Marginal reflex distance (MRD1) decreased an average of 2.6 mm from 6 mm pre-operatively to 3.4 mm post-operatively (P < .001); lagophthalmos decreased an average of 0.6 mm from 1.3 mm pre-operatively to 0.4 mm post-operatively (P = .006) Failure rate was 8.4%, most improved with a second surgery. Overcorrection was noticed in three cases (2.8%). Eyelid asymmetry improved from a mean of 1.0 mm pre-operatively to 0.4 mm post-operatively (P = .001); more than 80% of patients showed eyelid asymmetry of 1 mm or less. Transconjunctival Müller muscle and levator recession is safe and effective in correction of mild, moderate, or severe eyelid retraction in TRO patients. The failure rate is less than 10% and may be addressed by a second surgery.

The effect of Müllerectomy on Kocher sign.

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

Spontaneous Resolution of Upper Eyelid Retraction in Thyroid Orbitopathy

This study was conducted to document in the literature case reports of spontaneous resolution of eyelid retraction in patients with thyroid orbitopathy. Two cases of thyroid orbitopathy associated with eyelid retraction were observed without surgical treatment. Spontaneous resolution of upper eyelid retraction occurred during an 8- to 12-month period.

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

BACKGROUNDSeveral 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...

Levator palpebrae superioris muscle: MR evaluation of enlargement as a cause of upper eyelid retraction in Graves disease.

Sympathetic stimulation of the Müller muscle may be responsible for most of the medically reversible cases of eyelid retraction in patients with Graves disease. The authors studied 21 patients with class I Graves ophthalmopathy (GO), 32 patients with Graves disease without ophthalmopathy (GD), and 12 control subjects. T1-weighted spin-echo magnetic resonance (MR) imaging was performed with a 0.5-T superconducting system. The thickness of the levator palpebrae superioris muscle was determined from sagittal MR images. The thickness of the levator muscles in patients with GD did not differ from the thickness in control subjects, but the levator muscles in patients with GO were significantly thickened (P < .01). The thickness of the levator muscles in patients with GO was significantly greater than in those of patients with GD (P < .01). In 64 orbits of patients with GD, 3% of levator muscles were thickened. In 33 of 40 (83%) orbits of patients with GO presenting with upper eyelid retraction, the levator muscles were thickened. Sagittal MR imaging demonstrated thickening of the levator muscles in patients with persistent upper eyelid retraction. The authors conclude that a thickened levator muscle probably causes upper eyelid retraction in patients with GO.

Eyelid Retraction Treated by Levator Marginal Myotomy

Upper eyelid retraction in patients with ophthalmic Graves' disease may be due to: (1) overaction of Müller's muscle; (2) overaction of the levator muscle; (3) contraction of the levator; and (4) subcutaneous adhesions anterior to the levator. A new operation is described to lengthen the levator by performing partial width (marginal) myotomies. If present, subcutaneous adhesions can also be divided during this operation. Histologic features of levators and Müller's muscles from patients with upper eyelid retraction are discussed.