Eyelid Retraction Surgery Research Articles

Lower eyelid retraction repair using autologous auricular scapha cartilage.

To assess the efficacy of lower eyelid retraction surgery utilizing autologous auricular scapha cartilage (located within the anterior surface groove between the helix and anti-helix) and to present the surgical outcomes in a patient cohort. Medical records of 21 patients who underwent lower eyelid retraction surgery with scapha cartilage were retrospectively reviewed. Retractions, present for an extended duration (6months to 20years), exhibited 1mm or more inferior scleral show, attributed to prior lower eyelid blepharoplasty, facial palsy, or as a normal anatomical variation. Surgical interventions included lateral canthotomy, cantholysis, incision of the subtarsal conjunctiva-lower eyelid retractors, lower eyelid retractor lysis, cartilage graft suturing to the defect area without conjunctival cover, and tightening of the lateral canthal corner in all patients. A total of 29 eyelids in 21 patients underwent surgery without intraoperative complications. Over a mean follow-up period of 11months (range: 6-30months), lower lid retraction improved in 96.5% of eyelids. Postoperative margin-to-reflex distance measurements (MRD2) significantly decreased compared to preoperative values (p = 0.001; p < 0.01). Average improvements in MRD2-a (midpupil to lower lid) and MRD2-b (lateral limbus to lower lid) were 1.77 ± 0.80 and 2.04 ± 0.81, respectively (p = 0.001; p < 0.01). Four eyelids (4/29) required revision due to canthal corner loosening, with correction necessitating periosteal flaps. All four patients had previously undergone two or more repairs elsewhere. The graft was visible in two lids but did not require further revision. One patient experienced mild helix deformity at the donor site, which did not warrant additional intervention. In cases of lower lid retraction associated with middle/posterior lamellar shortening, utilizing an autologous auricular scapha cartilage spacer graft offers notable benefits. These advantages comprise straightforward harvesting with minimal donor site complications, stability without experiencing shrinkage, a softer texture in comparison to posterior cartilage, a concave shape that facilitates proper fitting on the globe, and its autologous nature.

Upper Eyelid Contour Changes After Orbital Decompression in Graves Orbitopathy.

To evaluate the effect of orbital decompression on the upper eyelid contour. A paired cross-sectional analysis of the upper eyelid contour was performed for 103 eyes of 66 patients who underwent orbital decompression. A control group of 26 normal subjects was also included. The eyelid contour of all participants were measured with Bézier lines adjusted to the eyelid contour and 9 midpupil eyelid margin (MPD) distances from a horizontal line bisecting the pupil. One central, corresponding to the margin reflex distance (MRD 1), and 8 equally distributed medially and laterally at 20% of the interval between the lines. Patients were classified as with flare if the height of the most lateral MPD relative to the MRD 1 was above the upper limit of the controls. Preoperatively 63 of the 103 contours were classified as flare + (F+). After decompression MRD1 showed a mean decrease of 0.4 mm and the location of the contour shifted 0.8 mm medially. These changes were not correlated with proptosis reduction. Orbital decompression decreased the lateral curvature of the contours especially for the F+ lids. In 40% of the F+ eyelids the flare sign disappeared after decompression. Orbital decompression affects the lateral eyelid contour and diminishes the amount of lateral eyelid retraction surgery necessary to correct the flare sign. In 40% of the patients, the eyelid contour is normalized with proptosis reduction only.

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 &lt; 0.001). All upper eyelid measurements, i.e., UEL (p &lt; 0.001), UMA (p &lt; 0.001), UCA (p = 0.004), and ULA (p &lt; 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.

Single-stage Orbital Decompression, Strabismus and Eyelid Surgery in Moderate to Severe Thyroid Associated Orbitopathy

ABSTRACT Purpose To evaluate the outcome of orbital decompression, strabismus and/or eyelid surgery in patients with moderate to severe thyroid-associated orbitopathy, when combined approach is preferred. Methods Retrospective, comparative, non-randomized review of 45 patients operated on from 2015 to 2018. Simultaneous decompression, eyelid and/or strabismus surgery was performed in 34 eyes of 20 subjects (group 1). Patients with multi-step procedures were used as control groups: group 2 included patients with staged decompression and eyelid retraction surgery (15 cases, 19 eyes); group 3 included patients with staged decompression and vertical strabismus surgery (10 cases, 13 eyes). Mean follow-up was 2.9 ± 1.8 years. Mann Whitney two-tailed test was used for paired data, and Fisher’s exact test for categorical data; p <.05 were considered statistically significant. Results Changes in margin reflex distance were not significantly different among patients of subgroup 1A (11 patients, one-step decompression/eyelid surgery) and group 2 (p >.05). Improvement in postoperative diplopia were not significantly different among patients of subgroup 1B (9 cases, one-step decompression/strabismus/eyelid surgery) and group 3 (p >.05). One patient of group 1 had recurrent dysthyroid optic neuropathy that recovered with steroid treatment. No other complications occurred in the one-step surgery group. Conclusions Simultaneous orbital decompression, strabismus and/or eyelid surgery resolved dysthyroid optic neuropathy, decreased proptosis, improved diplopia and eyelid position with a range comparable to that of a multi-step technique. If confirmed in prospective controlled studies, a one-stage approach might be advised to reduce the costs and time needed for rehabilitation in selected patients.

Anaesthesia for ophthalmic procedures in patients with thyroid eye disease.

Thyroid eye disease is an autoimmune inflammatory disorder of the orbit in adults. It causes inflammation, expansion and fibrosis of orbital fat, muscles and the lacrimal gland, leading to facial disfigurement, functional disability and, in severe cases, blindness. Overall, approximately 20% of affected patients need some form of surgical intervention requiring anaesthesia. This narrative review explores the background of thyroid eye disease, surgical procedures performed and their implications for anaesthesia. General anaesthesia is used for orbital decompression procedures, strabismus correction surgery and complex oculoplastic procedures. Local anaesthetic infiltration or regional anaesthesia under monitored anaesthesia care are the techniques most commonly employed for eyelid retraction surgery. It is important to limit the volume of local anaesthetic agent used during infiltration and continuously monitor the orbital volume and ocular pressure with a ballottement technique. In addition, the contralateral eye should be checked and, if necessary, protected against corneal exposure. Retrobulbar, peribulbar and sub-Tenon's blocks are best avoided. Topical anaesthesia has been used for some strabismus correction surgery but its use is limited to motivated and cooperative patients only.

Acellular xenogenic dermal matrix as a spacer graft for treatment of eyelid retraction related to thyroid associated ophthalmopathy

Objective: To evaluate the efficacy and safety of an acellular xenogenic dermal matrix (AXDM) as a spacer graft in the surgery to treat upper and/or lower eyelid retraction (UER/LER) in patients with thyroid associated ophthalmopathy (TAO). Methods: This was a retrospective case series study. From January 2016 to December 2017, all the TAO patients who underwent the eyelid retraction surgery with an AXDM as a spacer graft in Shanghai Ninth People's Hospital, Shanghai Jiaotong University School of Medicine were included in the study. The follow-up duration was at least 6 months. Eyelid height, ocular discomfort symptoms, and complications were recorded and used to evaluate the efficacy and safety. The treatment outcomes were divided into good, acceptable and unacceptable outcomes. Nonparametric test was used to compare the efficacy of upper and lower eyelid surgery. Results: Eighty patients (102 eyes) were included, consisting of 43 patients (56 eyes) with UER and 37 patients (46 eyes) with LER. The UER patients included 34 females (median age, 37 years) and 9 males (median age, 47 years). The LER patients included 20 females (median age, 39 years) and 17 males (median age, 40 years). At 6 months after surgery, ocular discomfort was relieved in 79.0% (64/81) eyes; photophobia was relieved in 69.5% (41/59) eyes; tearing was relieved in 94.9% (37/39) eyes; lagophthalmos was relieved in 80.7% (67/83) eyes. In patients with UER, the margin reflex distance was lowered from 8.0 (7.5, 8.0) mm to 3.5 (3.4, 4.0) mm (Z=-6.587, P<0.01). The upper scleral show was lowered from 3.0 (3.0, 3.5) mm to 0 mm (Z=-6.616, P<0.01). In patients with LER, the margin reflex distance was lowered from 8.5 (7.5, 9.0) mm to 5.5 (5.5, 6.0) mm (Z=-5.979, P<0.01). The lower scleral show was lowered from 3.0 (2.5, 3.5) mm to 0.0 (0.0, 0.5) mm (Z=-5.965, P<0.01). In total, 71.3% (57 cases) of the patients acquired good outcomes, 22.5% (18 cases) acquired acceptable outcomes, and 6.3% (5 cases) had recurrence, and no significant difference was found between the patients with UER and LER (33, 8, 2 cases vs. 24, 10, 3 cases, Z=-1.176, P>0.05). No other complications, such as infection, rejection, and dislocation, were observed. Conclusion: AXDM as a spacer graft can be a reasonable and safe alternative for eyelid retraction in TAO patients, achieving both the functional and aesthetic improvements. (Chin J Ophthalmol, 2019, 55: 821-827).

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.

Combined orbital decompression and lower eyelid retraction surgery

PurposeOrbital decompression and lower eyelid retraction surgery are traditionally performed separately in staged fashion, which may be unnecessary. Herein, we evaluate the safety and efficacy of combined orbital decompression and lower eyelid retraction surgery. MethodsRetrospective analysis of patients undergoing combined orbital decompression and lower eyelid retraction surgery in patients with or without Graves orbitopathy, by one surgeon from 2016 to 2017. Patients with previous orbital or lower eyelid surgery were excluded. Surgical technique for orbital decompression included eyelid crease lateral-wall decompression, transconjunctival inferolateral-wall decompression, or transcaruncular medial-wall decompression, or combination. Surgical technique for lower eyelid retraction surgery described previously. Analysis included 34 surgeries (19 patients). Preoperative and postoperative photographs at longest follow-up visit were standardized and analyzed. ResultsEtiologies of lower eyelid retraction included thyroid eye disease (13 patients) and inherited (6 patients). Etiologies of proptosis included thyroid eye disease (13 patients) and inherited with shallow orbits and/or poor maxilla (6 patients). All 34 eyelids demonstrated improvement of lower eyelid position. The mean improvement of marginal reflex distance was 2.4 mm (range, 1.7–2.9 mm). There was one case of mild overcorrection and once case of prolonged chemosis. The average follow-up was 9 months (range, 6 months to 1 year). ConclusionsThis study demonstrates improvement of lower lid position in patients undergoing simultaneous orbital decompression and correction of lower eyelid retraction, irrespective of the etiology of lower eyelid retraction and proptosis or orbital decompression technique. Combined procedures may reduce the number of total procedures, patient anxiety, recovery time, and costs, without compromising the results.

Commentary on: Lower Eyelid Retraction Surgery Without Internal Spacer Graft.

Commentary on: Lower Eyelid Retraction Surgery Without Internal Spacer Graft.

Causes and Surgical Outcomes of Lower Eyelid Retraction.

PurposeTo investigate the causes of lower eyelid retraction and evaluate the outcomes of various surgical procedures.MethodsWe conducted a retrospective medical record review of patients who underwent lower eyelid retraction surgery performed by a single surgeon at Kim's Eye Hospital between 2006 and 2013. We investigated the causes of lower eyelid retraction, clinical history, characteristics, treatment, and surgical outcomes. Preoperative and postoperative margin reflex distance 2 and inferior scleral show were measured for each eyelid. Success was defined as a positive eyelid elevation and a decrease in inferior scleral show.ResultsA total of 19 lower eyelids were treated in 14 patients with lower eyelid retraction. For cosmetic reasons, surgical correction for congenital lower eyelid retraction was performed on seven eyelids (36.8%). Ten eyelids (52.6%) exhibited secondary lower eyelid retraction after surgery. One eyelid (5.3%) was affected by facial palsy and one eyelid (5.3%) exhibited exophthalmos of an unknown origin. We adopted a selective approach based on lower eyelid retraction severity. Spacer grafting via a subconjunctival approach was the most commonly performed surgical technique (13 eyelids, 68.4%). The lateral tarsal strip procedure was used to horizontally tighten three eyelids (15.8%). At the time of the procedure, one of these eyelids (5.3%) also received an adjuvant suborbicularis oculi fat lift. Autogenous dermis fat grafting was performed on two lower eyelids (10.5%), whose retraction was caused by fat and soft tissue loss. Cosmetic outcomes were satisfactory in all cases.ConclusionsTo achieve satisfactory surgical outcomes, surgeons should adopt an approach based on the severity of lower eyelid retraction. Mild lower eyelid retraction can be corrected without grafts. When retraction is severe and exceeds 2 mm, spacer grafts that push the lower eyelid margin upwards and support it from below are required.

Lower Eyelid Retraction Surgery Without Internal Spacer Graft

Internal eyelid spacer graft is routinely placed during lower eyelid retraction surgery, which may be unnecessary. To evaluate the efficacy of lower eyelid retraction surgery without internal graft in select cases. 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. 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. 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.

Customized Orbital Decompression Surgery Combined with Eyelid Surgery or Strabismus Surgery in Mild to Moderate Thyroid-associated Ophthalmopathy.

PurposeTo evaluate the efficacy and safety of customized orbital decompression surgery combined with eyelid surgery or strabismus surgery for mild to moderate thyroid-associated ophthalmopathy (TAO).MethodsTwenty-seven consecutive subjects who were treated surgically for proptosis with disfigurement or diplopia after medical therapy from September 2009 to July 2012 were included in the analysis. Customized orbital decompression surgery with correction of eyelid retraction and extraocular movement disorders was simultaneously performed. The patients had a minimum preoperative period of 3 months of stable range of ocular motility and eyelid position. All patients had inactive TAO and were euthyroid at the time of operation. Preoperative and postoperative examinations, including vision, margin reflex distance, Hertel exophthalmometry, ocular motility, visual fields, Goldmann perimetry, and subject assessment of the procedure, were performed in all patients. Data were analyzed using paired t-test (PASW Statistics ver. 18.0).ResultsForty-nine decompressions were performed on 27 subjects (16 females, 11 males; mean age, 36.6 ± 11.6 years). Twenty-two patients underwent bilateral operations; five required only unilateral orbital decompression. An average proptosis of 15.6 ± 2.2 mm (p = 0.00) was achieved, with a mean preoperative Hertel measurement of 17.6 ± 2.2 mm. Ocular motility was corrected through recession of the extraocular muscle in three cases, and no new-onset diplopia or aggravated diplopia was noted. The binocular single vision field increased in all patients. Eyelid retraction correction surgery was simultaneously performed in the same surgical session in 10 of 49 cases, and strabismus and eyelid retraction surgery were performed in the same surgical session in two cases. Margin reflex distance decreased from a preoperative average of 4.3 ± 0.8 to 3.8 ± 0.5 mm postoperatively.ConclusionsThe customized orbital decompression procedure decreased proptosis and improved diplopia, in a range comparable to those achieved through more stepwise techniques, and had favorable cosmetic results when combined with eyelid surgery or strabismus surgery for mild to moderate TAO.

Correction of Lower Lid Retraction Using TarSys Bioengineered Grafts for Graves Ophthalmopathy

To investigate the efficacy of decellularized porcine-derived membrane (tarSys; IOP Inc), a bioengineered eyelid spacer graft, for lower lid retraction correction in patients with Graves ophthalmopathy. Retrospective observational case series study. This was a retrospective review of patients with Graves ophthalmopathy undergoing lower eyelid retraction surgery using decellularized porcine-derived membrane bioengineered eyelid spacer grafts from 2008 through 2011. Outcome measures included lower eyelid height (measured from the corneal light reflex to the lower eyelid margin, or marginal reflex distance-2 [MRD2]), reduction of lagophthalmos, cosmetic appearance, complications, and need for further surgery. Presurgery and postreconstruction photographs were reviewed for functional and cosmetic outcome. A total of 32 Graves patients and 37 eyelids underwent lower eyelid retraction surgery using decellularized porcine-derived membrane. There were 10 male and 22 female patients with mean age of 41.8 ± 8.6 years. Mean improvement in MRD2 was 1.4 ± 0.4 mm. Mean reduction of lagophthalmos was 1.3 ± 0.4 mm. There are statistically significant differences between preoperative and postoperative MRD2 and lagophthalmos (paired t test, both P < .0001). No evidence of infection and corneal erosion was noted and none of the patients needed further surgeries. Prolonged lower lid swelling and slight puffy appearance were noted for 6 patients. The swelling and puffy appearance resolved completely 3 months after surgery. Conjunctival granuloma formation was found in 1 patient. The cosmetic result was satisfactory in all cases. Decellularized porcine-derived membrane, a bioengineered graft, is effective for the management of lower lid retraction in patients with Graves ophthalmopathy. It can offer an alternate graft for eyelid reconstruction.

Aesthetic Considerations in Upper Eyelid Retraction Surgery

Classically, the aesthetic outcomes of eyelid retraction surgery in patients with thyroid-associated orbitopathy have been described in reference to eyelid margin position and marginal reflex distance. A critically important component of upper eyelid contour is the tarsal platform show (TPS). With this study, the authors aimed to assess the hypothesis that modification of the tarsal platform in posterior eyelid retraction surgery has a significant effect on the final aesthetic outcome. In a retrospective, observational, case-cohort study, the authors reviewed the medical records of 36 patients with thyroid-associated orbitopathy who underwent primary eyelid retraction surgery by 1 surgeon. Patients who underwent eyelid retraction surgery at the time of orbital decompression were excluded. The surgical technique consisted of posterior approach conjunctival release of Müeller muscle and graded recession of the levator aponeurosis. To address lateral flare, dissection was carried toward the lateral orbital rim with spreading of the lateral horn of the levator aponeurosis. Outcome measures were millimeters of TPS, millimeters of brow fat span, and symmetry of the eyelid margin position. Randomized preoperative and postoperative standardized photographs were evaluated in masked fashion by 4 surgeons to grade cosmetic outcomes. Fifteen patients (24 eyelids) met the inclusion criteria. Mean follow-up period was 6 months (range, 3-12). Mean TPS increased from 2.27 mm (standard deviation, 1.9 mm) to 4.77 mm (standard deviation, 1.7 mm; p < 0.05). Mean brow fat span remained unchanged, from 13.22 mm (standard deviation, 2.2 mm) to 13.25 mm (standard deviation, 1.9; p > 0.05). Evaluation of the aesthetic outcomes (eyelid contour, eyelid symmetry, and TPS) by 4 masked observers characterized the relevance of TPS in the postoperative aesthetics of eyelid contour and symmetry. In upper eyelid retraction surgery, the ability to control the TPS has a significant impact on the final aesthetic outcome. Posterior approach eyelid retraction surgery can control eyelid contour and can represent an ideal surgical approach in carefully selected patients. However, it has limited ability to control upper orbital volume and eyebrow and orbital fat (brow fat span). This can result in relative overelongation of the TPS. Factors such as ethnic characteristics, bony asymmetry, brow fat span, and premorbid TPS influence cosmetic outcomes achieved by the anterior or posterior approach. For optimal aesthetic results in eyelid retraction surgery, the decision for anterior versus posterior approach should be individualized.

A review of combined orbital decompression and lower eyelid recession surgery for lower eyelid retraction in thyroid orbitopathy

Background/aimsEyelid retraction in thyroid orbitopathy is traditionally managed with staged surgery after orbital decompression. We review the benefit of concurrent inferior retractor recession at the time of orbital decompression when...

“En-Glove” Lysis of Lower Eyelid Retractors With AlloDerm and Dermis-Fat Grafts in Lower Eyelid Retraction Surgery

To describe a minimally invasive surgical technique using AlloDerm or dermis-fat grafts for lower eyelid retraction. A retrospective review of all patients undergoing lower eyelid retraction surgery via a minimal invasive, "en-glove" technique from 2005 through 2009. Charts were reviewed for the type of graft (AlloDerm or dermis-fat) used, the etiology of lower eyelid retraction, and the follow-up time. Outcome measures included lower eyelid height (measured from the corneal light reflex to the lower eyelid margin, or MRD2), reduction of lagophthalmos, cosmetic appearance, complications, and need for further surgery. Presurgery and postreconstruction photographs were reviewed and graded for functional and cosmetic outcome. A total of 8 patients underwent successful lower eyelid retraction surgery using this minimally invasive technique. Etiologies included thyroid eye disease and cicatricial paralytic lower eyelid retraction. Mean improvement in MRD2 was 1.5 mm for the AlloDerm group (4 patients, 7 eyelids) and 1.0 mm for the dermis-fat group (4 patients, 4 eyelids) after a minimum of 3 months' follow-up. The cosmetic result was satisfactory in all cases. "En-glove" lower eyelid retraction surgical technique offers a minimally invasive approach for the release of the lower eyelid retractors and allows for volume augmentation using either AlloDerm or dermis-fat spacer graft.

Lower Eyelid Epiblepharon Associated with Lower Eyelid Retraction

PurposeTo describe a series of patients with lower eyelid epiblepharon associated with lower eyelid retraction.MethodsWe retrospectively reviewed the medical records of patients who underwent surgery for lower eyelid retraction, epiblepharon, or thyroid-associated ophthalmopathy (TAO) between October 1999 and March 2007. Patients with both lower eyelid retraction and epiblepharon on preoperative examination were included in this study.ResultsTwenty-seven eyelids of 20 patients with both lower eyelid retraction and epiblepharon were enrolled. The underlying causes of lower eyelid retraction included congenital retraction (seven eyelids), congenital fibrosis of the extraocular muscles (CFEOM; seven eyelids), TAO (seven eyelids), post-operative cicatricial retraction (five eyelids), and facial nerve palsy (one eyelid). Eight of 27 eyelids were successfully corrected after the repair of retraction without the repair of epiblepharon, regardless of the cause of lower eyelid retraction. Another four eyelids with epiblepharon associated with TAO resolved after only orbital decompression. Cilia-everting sutures were additionally applied for epiblepharon in another 14 eyelids, 12 of which did not require the excision of a skin fold or the orbicularis muscles. Only one eyelid with mild retraction and epiblepharon underwent simple epiblepharon repair. Recurrence of retraction or epiblepharon developed in three eyelids during follow-up.ConclusionsIn cases with both lower eyelid retraction and epiblepharon, the retraction should be repaired first, and then the epiblepharon can be corrected selectively according to the severity of the case.

Oral Montelukast and Cetirizine for Thyroid Eye Disease

To study the efficacy of oral montelukast, a cysteinyl leukotriene receptor antagonist, in combination with cetirizine, a histamine-1 receptor antagonist, in the treatment of thyroid eye disease. Patients considering surgical correction of eyelid retraction for inflammatory symptoms of thyroid eye disease were offered a preoperative medical regimen of oral montelukast/cetirizine. Exclusion criteria included prior use of oral montelukast (i.e., for seasonal allergy or asthma), compressive optic neuropathy, severe ophthalmopathy requiring systemic corticosteroids, and orbital and/or muscle surgery. A 6-week course of oral cetirizine (10 mg every morning) and oral montelukast (10 mg every evening) was administered and patients subjectively rated their ocular surface dryness, tearing, itching, injection, eyelid swelling, eyelid retraction, double vision, proptosis, and visual clarity, at baseline, after 3 weeks and 6 weeks of medical therapy, and after 3 weeks off of the medications. Six of the 12 patients recruited for the study reported a subjective improvement in tearing, dryness, and itching. Less effect on diplopia and proptosis was noted after 6 weeks of medical therapy. Two of the patients who did not report response chose to proceed with eyelid retraction surgery and both had evidence of mast cell infiltration in their Müller muscle specimens. The response observed in this open-label trial suggests that oral montelukast and cetirizine may be an effective medical regimen for patients with thyroid eye disease who experience mild to moderate orbital congestion and inflammation.

Modified marginal myotomy for thyroid-related upper eyelid retraction

The purpose of this study is to report a modified marginal myotomy procedure for thyroid-related upper eyelid retraction using techniques of quantification and contour adjustment for blepharoptosis surgery, of which surgeons have more experience than of upper eyelid retraction surgery. Eleven upper eyelids of ten patients, average age 41.6 years, were operated on. All patients were clinically and biochemically euthyroid at operation without having had progression of eyelid and orbital changes for at least 6 months prior to surgery. Margin reflex distances of upper eyelids (MRD-1; normal, 2.0–5.5 mm) were measured preoperatively and 3 months postoperatively. Upper eyelid contours were also examined before and after surgery. Medial and lateral horns and the distal attachment of levator aponeurosis were incised to produce a levator flap, which was transversely incised in two positions. The edge of the incised levator was fixed on the appropriate part of the tarsus. MRD-1 values were considerably decreased in all cases, ranging from 2.5 to 6.0 mm (average, 3.8 mm). All final MRD-1 results ranged from 2.5 to 5.0 mm (average, 3.4 mm) and the laterality of MRD-1 was within 1 mm higher or lower than the contralateral eyelids, although a patient with bilateral retraction who had only unilateral operation did not show a symmetrical eyelid height to the contralateral one. All eyelids but one showed acceptable upper eyelid contours; the inconsistent eyelid temporally showed nasal flare, but finally acquired a good curvature. Our procedure effectively decreased upper eyelid height with good contour by utilising techniques from blepharoptosis surgery.

Subperiosteal Midface Lift with or without a Hard Palate Mucosal Graft for Correction of Lower Eyelid Retraction

To compare functional and surgical outcomes of a subperiosteal midface lift with and without the placement of a hard palate mucosal graft (HPMG) in patients with lower eyelid retraction. Retrospective, comparative, interventional case series. Thirty-four patients with lower eyelid retractions who underwent surgery at the Jules Stein Eye Institute in a 5-year period. Medical record review of all patients who underwent surgery for lower eyelid retraction by a subperiosteal midface lift with or without an HPMG. Preoperative and postoperative digital photographs were taken in all patients. Change in margin reflex distance 2 (MRD2), measured from the pupillary margin to the upper margin of the lower eyelid; patient discomfort; and surgical complications. Thirty-four patients (20 female; mean age, 64 years) participated in the study; 11 underwent bilateral surgery, with overall 43 surgeries performed. Eighteen patients (42%) had lower eyelid retraction secondary to previous transcutaneous lower eyelid blepharoplasty. Postoperatively, patients attained a better lower eyelid position, with improvement of lower eyelid height of 1.4 mm (P<0.001, 1-sample t test). Patients operated using an HPMG (12 surgeries) achieved a greater reduction in MRD2 postoperatively as compared with patients operated by subperiosteal midface lift alone (31 surgeries; 2.2 mm vs. 1.1 mm, respectively; P = 0.02, Wilcoxon Mann-Whitney). One patient needed reoperation secondary to symptomatic lower eyelid retraction postoperatively. The subperiosteal midface lift is effective in correction of lower eyelid retraction of various causes. The use of an HPMG spacer may enhance surgical outcomes and results in a better lower eyelid position.