Eyelid Retraction Surgery Research Articles

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.

Simultaneous Orbital Decompression and Correction of Upper Eyelid Retraction versus Staged Procedures in Thyroid-Related Orbitopathy

To evaluate the outcome of eyelid retraction surgery in thyroid-related orbitopathy (TRO) patients in 2 different surgical settings: done simultaneously with orbital decompression or as a staged procedure after orbital decompression. Retrospective, comparative, nonrandomized clinical study. Ninety-six patients (158 eyes). A review of electronic medical records of TRO patients who underwent surgery for upper eyelid retraction and orbital decompression at the Jules Stein Eye Institute in 1999 to 2003 was performed. Data regarding eyelid position, comprehensive eye examination, surgical outcome, and complications were analyzed. Anatomical and functional success based on margin reflex distance (MRD1; < or = 5 mm was graded as mild retraction; > 5 mm and < 7 mm, moderate; and > 7 mm, severe), and patients' discomfort. One hundred fifty-eight eyelid retraction surgeries were performed on 96 TRO patients (18 male and 78 female; mean age, 48 years); mean follow up time was 15 (+/-12) months. Group 1 consisted of patients undergoing simultaneous eyelid retraction surgery and orbital decompression and comprised 97 cases (surgeries). Group 2 included 61 cases of staged surgery: orbital decompression and eyelid retraction at a later stage. The groups had similar surgical outcomes, and > 85% had a better eyelid position postoperatively. Reoperation rates for residual or recurrent eyelid retraction were similar, overcorrection was higher in group 2 (5% vs. 0%, P = 0.03). Changes in MRD1, lagophthalmos, and exophthalmos were similar (P > 0.05, independent samples t test). Correction of eyelid retraction was effective in treating patients' discomfort and exposure keratopathy (P = 0.04, chi2). No severe complications occurred after orbital decompression or eyelid retraction surgery in this group of patients. Transconjunctival Muller's muscle recession for correction of eyelid retraction in mild to moderate TRO patients, performed simultaneously with deep lateral wall orbital decompression, resulted in acceptable eyelid position in two thirds of our patients. Overcorrection and consecutive ptosis occurred less often after combined orbital decompression and eyelid retraction surgery than after isolated eyelid repositioning surgery. If confirmed in prospective controlled studies, eyelid-repositioning surgery performed at the time of orbital decompression may decrease the number of total procedures and compress the time needed for surgical rehabilitation.

THE SURGICAL TREATMENT OF GRAVES' ORBITOPATHY: A Decade of Progress

The total rehabilitation of the patients with Graves' ophthalmopathy is sometimes possible only with sequential surgical procedures. Elective surgical treatment is normally delayed until the inflammatory phase subsides and stability is established, usually 1 to 3 years after onset. Additionally, the metabolic status should be well controlled before elective surgical treatment. Generally, eyelid and motility measurements should remain stable for a period of 6 months before any surgical intervention. 44 Exceptions to delaying surgical repair until stability are severe exposure keratopathy requiring eyelid surgery or progressive optic neuropathy unresponsive to corticosteroid or radiation therapy, which prompts orbital decompression. The overall risk of the need for surgery was estimated as 2.5 times greater in patients older than 50 years than in younger patients. 3 This may be related to the presence of more severe ophthalmopathy in older patients. 33 A systematic surgical approach was introduced in 1986. 75 The usual sequence of reconstruction of the Graves' patient with severe orbitopathy is orbital decompression and strabismus surgery followed by eyelid retraction surgery and other eyelid surgery. Orbital decompression may influence the muscle function and eyelid position. In addition, muscle surgery especially if it involves the vertical rectus muscles; may change eyelid retraction. Despite the usefulness of a systematic conceptual approach, the treatment must be individualized to each patient, as the disease does not follow a uniform course, and the manifestations differ in severity. The first stage of surgical rehabilitation, when necessary, is the orbital decompression. It is indicated to reduce excessive proptosis, to relieve orbital congestion, and to treat compressive optic neuropathy. 6,31,53,74 The goal of strabismus surgery in Graves' orbitopathy is usually to achieve single binocular vision in the primary and reading positions. Stable motility measurements should be achieved muscle surgery. Many patients have restriction of the inferior rectus muscles and benefit from some degree of bilateral inferior rectus recessions. Adjustable sutures frequently are used. Surgery for eyelid retraction and other abnormalities follows strabismus surgery. There are numerous eyelid abnormalities described in dysthyroid ophthalmopathy. The most frequent are upper and lower eyelid retraction, lagophthalmos, ptosis, dermatochalasis, lacrimal gland prolapse and mechanical medial lower eyelid entropion. The eyebrow fat pad may also be enlarged in patients with Graves' orbitopathy. In selected cases, the brow fat may need to be debulked when performing a blepharoplasty to achieve the desired aesthetic result. 21 Cosmetic reduction of herniated fat pads and eyebrow fat pads is generally performed last.

Surgery for upper eyelid retraction: three techniques

This paper is based on the author's experience with 145 operations on 181 upper eyelids in 100 patients using three techniques for recession of the upper eyelid. The results include 15 years' experience with adjustable sutures in upper eyelid recession surgery.Each chart was reviewed by the author. Patient data was entered into a database and analyzed. The operations used were (1) The prewhitnall levator recession (Trans Am Ophthalmol Soc. 1988: 86: 725-793). This operation is unique in that it is performed on the levator muscle proximal to Whitnall's ligament. (2) Recession of the levator aponeurosis and (3) the Henderson operation (Arch Ophthalmol 1965; 74: 205-216). Adjustable sutures were used in all prewhitnall recessions, about half of the levator aponeurosis recessions and none of the Henderson operations.Complications were divided between over and undercorrection. There were 24% reoperations in 73 patients with thyroid eye disease and 14% reoperations in 17 patients with overcorrected ptosis. The overall reoperation rate was 23%. Adjustable sutures were effective in prewhitnall recessions but less so in levator aponeurosis recessions. There were fewer Henderson operations but the results were good.The prewhitnall operation is good for marked bilateral eyelid retraction in thyroid eye disease. It is technically challenging but has advantages. Recession of the levator aponeurosis can be used for thyroid eye disease and overcorrected ptosis. The Henderson operation is useful in lesser degrees of eyelid retraction. The need for reoperation is an acceptable occurrence and can be expected in up to one fourth of patients.

Internal Vertical Eyelid Shortening to Treat Surgically Induced Segmental Blepharoptosis

In a procedure to relieve segmental blepharoptosis after surgery for thyroid eyelid retraction and carcinoma, I applied a clamp to the internal eyelid tissues over the blepharoptotic segment, and excised the tissues held in the clamp. The procedure was successful in four patients.