Treatment Of Upper Eyelid Retraction Research Articles

Ocular surface and the upper eyelid contour after surgical treatment of upper eyelid retraction in thyroid eye disease

BACKGROUND: Most of the thyroid eye disease (TED) patients have dry eye syndrome. Upper eyelid retraction (UER) is the most common TED symptom and one of dry eye causes. There are two groups of UER surgical treatment methods: transconjunctival and transcutaneous, which can influence on upper eyelid contour, tear film and ocular surface.
 AIM: To evaluate the influence of different methods of UER surgery on upper eyelid contour and ocular surface.
 MATERIALS AND METHODS: 12 patients (19 eyes) were included in the study. Visual acuity test, measurements of UER and palpebral fissure height, Shirmer 1 test, LIPCOF-test and tear break-up time test, Meibomian gland dysfunction staging, corneal and conjunctival fluorescein staining and determination of the ocular surface disease index (OSDI) were performed before surgery and 1 week, 1 and 3 months after. Patients were divided into two groups. Patients of group 1 had UER less than 4 mm and they underwent an upper tarsal muscle extirpation. Patients of group 2 had UER 4 mm and more and they underwent a recession of the levator palpebrae superioris muscle apouneurosis.
 RESULTS: In all patients UER and the height of the palpebral fissure decreased 7 days after surgery and increased again after 3 months, and the dynamics of this change was more pronounced in group 2. There was one patient (both sides) with poor upper eyelid contour after surgery in both groups. BCVA and OSDI improved, while other parameters had a large scatter of data.
 CONCLUSIONS: We have found that surgical treatment of UER caused by TED improves the contour of the eyelid, increases visual acuity and leads to a subjective improvement in the condition of the ocular surface.

Surgical Approach to the Treatment of Upper Eyelid Retraction Caused by Prominent Filtration Bleb

Objective: To report on the technique of upper eyelid lengthening in patients with upper eyelid retraction not associated with Graves' disease but associated with bleb exposure and exposure keratitis. Case series: We present three patients (four eyes) with a history of glaucoma who underwent trabeculectomy with an active bleb with symptoms associated with bleb and corneal exposure due to retraction of the upper eyelid not associated with Graves' disease. All patients underwent surgical treatment to lengthen the upper eyelid by percutaneous complete blepharotomy with complete dissection of the orbicularis muscle, aponeurosis of levator palpebral muscle, Muller’s muscle and dissection of nasal and temporal conjunctiva reaching the superior border of the tarsus. In addition, the lateral horns of the levator muscle were resected, while preserving a strip of intact conjunctiva directly above the bulging bleb. Before and after surgery, the following measurements were made: including, visual acuity, retraction measurement, presence symptoms of dry cornea and bleb, MRD, and upper eyelid contour. Results: Preoperative upper lid marginal reflex distance (MRD) was measured. In addition, conjunctival staining of the bleb and cornea was recorded. Visual acuity ranged from 6/12 to 6/36. Upper eyelid retraction ranged from 3mm to 7.5mm, this was measured by calculating the marginal reflex distance (MRD) of the upper retracted eyelid minus 4.5 mm, representing the normal MRD. Amounts of lubricating drops used by patients per day was also recorded and quantified. The following postoperative measurements were recorded: MRD of upper eyelid; specifically including upper eyelid contour and position, present or absence of upper eyelid ptosis. Visual acuity improved by one line in the first postoperative week and maximum up to three lines after a month. A good cosmetic result was achieved. Conclusion: Blepharotomy is a surgical procedure suitable for the treatment of severe eyelid retraction. Preservation of the bridge of the intact conjunctiva over the bleb protects the bleb from traumatization in the postoperative period. This makes possible to use the blepharotomy in cases of eyelid retraction with exposure of the filtration bleb, and also maintain the correct contour of the upper eyelid.

Upper Eyelid Retraction in Graves' Ophthalmopathy: Our Surgical Experience on 153 Cases of Full-Thickness Anterior Blepharotomy with Mullerectomy.

We present our experience on 153 cases of full-thickness anterior blepharotomy with mullerectomy (FTABM) in the treatment of upper eyelid retraction (UER) related to Graves' ophthalmopathy (GO). We included all the patients who underwent a graded FTABM between 1st January 2015 and 30th June 2020 for UER GO-related. The analysis included: pre-/post-operative conjunctival symptoms, epiphora, GO-Quality of Life Questionnaire (QoL), lagophthalmos, marginal reflex distance (MRD-1) index, eyelid symmetry within 1mm. The statistical analysis was designed to detect postoperative improvement in objective and subjective clinical features. Outcomes were analysed through Chi-squared test for dichotomous variables and through Wilcoxon-Mann-Whitney test for continuous variables. Of the 111 patients, 42 underwent a bilateral procedure, while 69 a monolateral. Conjunctival symptoms were reported in 32% of cases before surgery and in 12.4% after FTABM (p < 0.001). Epiphora was complained by 29.6% of patients preoperatively and in 12.4% postoperatively (p < 0.001). Preoperative lagophthalmos was found in 12.4% (mean value of 0.34 ± 0.76mm) of eyelids, and in 2.6% (mean value 0.05 ± 0.19mm) eyelids (p = not significant) postoperatively. Pre-operative GO-QoL was 24.9 ± 4.4mm; while post-operative GO-QoL was 35.3 ± 5.5mm (p < 0.001). The MRD-1 varied from 10.12 ± 2.1mm preoperatively, to 4.3 ± 0.6mm (p < 0.001) after surgery. Asymmetric palpebral fissure was noted in 94 (84.7%) patients before surgery and in 7 (6.3%) after the procedure (p < 0.001). FTABM is an effective procedure to treat UER GO-related. The technique manages to prevent complications of UER and determine good aesthetics. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 . Level IV, therapeutic study.

Triamcinolone acetonide injection in the treatment of upper eyelid retraction in Graves' ophthalmopathy evaluated by 3.0 Tesla magnetic resonance imaging.

Purpose:To evaluate changes in the levator palpebrae superioris (LPS) muscle on 3.0 T magnetic resonance imaging (MRI) after triamcinolone acetonide injection for treating upper lid retraction (ULR) with Graves’ ophthalmopathy (GO) and to explore the value of LPS muscle quantitative measurement for clinical treatment.Methods:Patients with GO showing ULR were studied retrospectively and they underwent 3.0 T MRI scans before and after subconjunctival injection o f triamcinolone acetonide. The largest thickness (T) and highest signal intensity (SI) of LPS muscle on the affected eyes were measured in the sequences of coronal T2-weighted, fat-suppressed fast spin echo imaging (T2WI-fs) and T1-weighted, fat-suppressed, contrast-enhanced fast spin echo imaging (T1WI-fs + C), respectively. The SI ratio (SIR) (LPS muscle SI/ipsilateral temporalis SI) was calculated individually. Depending on the therapeutic effect, patients were divided into effective group and non-effective group. Independent t-test was used to compare SIR and T of LPS muscle in different treatment groups before treatment, and paired sample t-test was used to compare SIR and T of LPS muscle before and after treatment. Then cut-off level for predicting therapeutic effect and the receiver operating characteristic curve (ROC) curve were analyzed.Results:Sixty-two patients (77 eyes) were enrolled. After treatment, the T of LPS muscle showed significant decrease in all sequences in both effective and non-effective treatment groups. However, changes in SIR of LPS muscle in the two groups were different; SIR of LPS muscle on T2WI-fs and T1WI-fs + C decreased after treatment in the effective group (PT2 < 0.001, PT1 + C < 0.001) and SIR of LPS muscle showed no statistically difference in all sequences (all P > 0.05) in the non-effective group. There was a correlation between SIR of LPS muscle before treatment and after treatment with triamcinolone acetonide injection, which was that SIR of LPS muscle in the effective treatment group was lower than that in the non-effective treatment group on T1WI-fs + C (P < 0.001). SIR of LPS muscle on T1WI-fs + C showed 87.5% sensitivity and 66.7% specificity to predict therapeutic effect (area under the ROC curve [AUC] = 0.840).Conclusion:In GO patients with ULR, 3.0 T MRI can be used to evaluate the response of triamcinolone acetonide injection. SIR of LPS may be a predictor of its efficacy.

Observations on the Efficacy of Two Methods for the Treatment of Upper Eyelid Retraction in Thyroid-Associated Ophthalmopathy

Objective To observe the clinical efficacy of periocular injection of triamcinolone acetonide (TA) and subpalpebral injection of botulinum toxin type A (BTXA) for the treatment of thyroid-associated ophthalmopathy (TAO) with mild unilateral upper eyelid retraction. Method This was a prospective randomized controlled study. A total of 68 cases of stable thyroid-associated ophthalmopathy with mild upper eyelid retraction were collected at Hankou Aier Eye Hospital from Jan. 2015 to Dec. 2018 and randomly divided into two groups. Group A contained 33 patients who were administered TA by periocular injection once every 3 weeks for a total of 3 times. Group B contained 35 patients who were given a single subpalpebral administration of BTXA. The efficacy in the two groups was observed. Results Compared with the two groups, the effective rate in both groups was 100% at 1 week and 1 month after treatment. The effective rate of Group A remained 100% at 3 months after treatment, and that of Group B decreased to 88.6%. At 1 week after treatment, the degree of correction in Group B was greater than that in Group A (p < 0.001). At 1 month after treatment, it was not significantly different between the two groups (p > >>0.05). At 3 months after treatment, it was less in Group B than in Group A (p < 0.001). In Group A, there was one case of transient amaurosis, two cases of periorbital hemorrhage and swelling, and one mild case of sunken eyes. In Group B, four cases experienced recurrence after 3 months. Conclusion Periocular injection of TA and subpalpebral injection of BTXA offer definite therapeutic efficacy for mild upper eyelid retraction associated with thyroid disease. The former has a long treatment period, large procedural risks, and stable efficacy. The latter is a simple procedure with a short treatment period but can easily recur.

An algorithm for Botulinum toxin A injection for upper eyelid retraction associated with thyroid eye disease: long-term results

ABSTRACT Purpose To evaluate the efficacy and complications of transconjunctival Botulinum toxin A injections performed according to an algorithm, for the management of upper eyelid retraction associated with thyroid eye disease. Methods Seventy one eyes of 60 patients at the inactive stage, who had undergone Botulinum toxin A injection were reviewed retrospectively. Botulinum toxin A was injected transconjunctivally, just above the superior tarsal border of the upper eyelid in doses between 2–15 units according to an algorithm, depending on the amount of retraction. Margin-reflex distances were measured according to the photographs taken under standard conditions before and after the injections at the tenth day, then the second month and the fourth month. Additional Botulinum toxin A injections were performed in patients who had an undercorrection on the tenth day. Complications such as diplopia and ptosis were recorded. Results The study included 38 females, 22 males with a mean age of 43.3 ± 13.1. Normal margin-reflex distances (3–4 mm) were reached in the 58 of 71 eyes (81.7%). Additional injections were needed in eight eyes (11.2%) for residual retraction on the tenth day. Ptosis was the major complication in four eyes for 1–3 weeks after injection. Upper eyelid retraction recurred after 5.1 ± 0.9 months in all patients. Conclusion In the treatment of upper eyelid retraction due to thyroid eye disease, transconjunctival injection of Botulinum toxin A is an effective, safe, transient, and repeatable method with few complications in patients. The algorithm used in this study resulted in high success rate in long-term follow-up.

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).

Clinical efficacy of transcutaneous triamcinolone acetonide injection for upper eyelid retraction and swelling in patients with thyroid eye disease.

AimTo evaluate the efficacy of transcutaneous triamcinolone acetonide (TA) injection for the treatment of upper eyelid retraction and swelling in thyroid eye disease (TED) patients.Patients and methodsThis is a case series. Three euthyroid TED patients with features of both upper eyelid retraction and swelling were recruited. TED signs appeared within 6 months prior to treatment. Next, 0.5 mL of TA (40 mg/mL) was transcutaneously injected targeting the orbital fat around the levator palpebrae superioris (LPS) muscle. At each visit, eyelid retraction was evaluated by palpebral fissure height and the presence of scleral show above the superior corneoscleral limbus. Eyelid swelling was judged by the appearance of upper eyelid bulging and the lack of an eyelid sulcus. In addition, the LPS muscle, orbital and retro-orbicularis oculi fat were observed using MRI before and after treatment.ResultsTwo patients had resolution of their upper lid retraction and swelling within 12 months. In the other patient who had proptosis, eyelid retraction resolved, while eyelid swelling remained mild. In all cases, MRI revealed that treatment resulted in thinner LPS muscle and reduced fat swelling. In addition, both high-intensity signals on T2 images and prolonged T2 relaxation time were normalized. No adverse signs were observed.ConclusionTranscutaneous TA injection was effective as a treatment for upper eyelid retraction and swelling in euthyroid TED patients who had signs within 6 months prior to treatment. Transcutaneous TA injection induced reduction of LPS muscle enlargement and fat tissue swelling. These reductions by transcutaneous TA injection were verified using MRI.

Evaluation of Graded Transcutaneous Levator Muscle Recession with Mullerectomy for Treatment of Upper Eyelid Retraction in Dysthyroid Patients

Purpose: To evaluate the efficacy, advantages and disadvantages of graded transcutaneous levator muscle recession with mullerectomy for treatment of dysthyroid upper eyelid retraction. Design: Randomized, prospective and interventional case series. Methods: This prospective interventional case series comprised 20 eyes of ten patients. Inclusion criteria included patients with bilateral upper eyelid retraction, with or without other manifestations of thyroid orbitopathy, without diplopia and with stable thyroid state for at least 6 months. All patients were subjected to graded transcutaneous levator muscle recession with mullerectomy after full ophthalmological assessment. All patients included in the study have signed a written consent and the study has been approved by the ethical committee of AL-AZHAR faculty of medicine. Results: Postoperatively the mean decrease of MRD1 was 2.87 mm. Mean improvement of lagophthalmos was 0.78 mm. Mean increase of upper lid crease height was 0.65mm. Good lid contour achieved in 85.9%. Temporal flare persisted in one lid (5%) and nasal ptosis was reported in two eye lids (10%). Conclusion: According to this study graded transcutaneous mullerectomy with levator muscle recession is a good and a reliable surgical technique for correction of dysthyroid upper lid retraction and is successful as a lengthening procedure for retracted upper eyelid regardless the severity of retraction with significant symptomatic and cosmetic improvement.

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.

Traitement de la rétraction palpébrale supérieure associée à l’ophtalmopathie dysthyroïdienne en phase active inflammatoire avec l’injection de toxine botulique A

To evaluate the efficacy of transconjunctival botulinum toxin type A (BTX-A) in the treatment of upper eyelid retraction in the active inflammatory phase of dysthyroid orbitopathy, establish the ideal dose, and evaluate side effects. This is a comparative, prospective study in patients with thyroid orbitopathy, conducted at the Conde Ophthalmology Institute in Valenciana, Mexico. The patients included had dysthyroid orbitopathy in the inflammatory phase, and they were treated with subconjunctival injection of botulinum toxin type A (BTX-A) in the upper eyelid. Five units (group 1) and ten units (group 2) of BTX-A, in a single subconjunctival dose were applied to the non-dominant eye. We evaluated visual acuity, margin-to-reflex distance (RPM1), crease height, ocular motility, diplopia and keratitis, before and after administration of the toxin. The patients were followed at one, 4 and 16 weeks, with the Student t-test as a statistical analysis. At week 4, 15 patients (100%) showed a reduced margin to reflex distance. The mean result for group 1 was -1.75mm (range -1 to -2.5mm) and group 2 was -2mm (range -1 to -4mm). Statistically significant differences were seen between pre-treatment and week 4 in both groups, but no differences between doses. Complete improvement of keratitis and lagophthalmos was observed in 5 and 2 patients, respectively. Visual acuity, ocular motility and crease height did not change in 93% of the patients. One patient (group 1) exhibited complete ptosis and vertical diplopia, which resolved spontaneously at week 6. Transconjunctival BTX-A application is safe and effective for the treatment of eyelid retraction in dysthyroid orbitopathy. No difference was found between doses. No severe side effects were reported.

Diagnosis and treatment of upper eyelid retraction in thyroid-associated ophthalmopathy

Thyroid associated ophthalmopathy (TAO) is often shown as upper eyelid retraction, conjunctival hyperemia and edema, proptosis, diplopia, strabismus and decreased visual acuity.It is difficult to make a certain diagnosis in the early stage of TAO.Patients suffering from TAO often have upper eyelid retraction at the early stage of disease, which affects appearance and causes feelings of discomfort and decreased visual acuity.Learning more about upper eyelid retraction contributes to the early diagnosis and treatment of TAO.Although upper eyelid retraction with TAO has distinctive manifestations, it is easy to misdiagnose.The differential diagnosis includes congenital eyelid retraction, neurological disorders, high axial myopia, glaucoma filtering bleb, and so on.Family history, clinical manifestations and TAO related examinations should also be taken into consideration.Comprehensive treatments should be adopted.Glucocorticoids and eyelid retraction surgeries are current mainstay of treatment.There are controversies on the application of glucocorticoids about the specific dosage, while agreement achieved that the cumulative dose should not be more than 8 g in one stage in order to reduce the risk of liver failure and other adverse events.Different operation methods should be chosen according to the degrees of retraction and causes of disease for each type of patients.In addition, special attentions should be paid to the decrease of muscle strength in the temporal side.Individual analysis is needed in order to diagnose and treat upper eyelid retraction with TAO.Early diagnosis and intervention can improve the appearance, visual function and quality of life of the patients. Key words: Thyroid-associated ophthalmopathy; Upper eyelid retraction; Diagnosis; Treatment

Levator recession with adjustable sutures in management of upper eyelid retraction

Purpose To assess the efficacy of levator recession with adjustable sutures in treatment of upper eyelid retraction. Patients and Methods Patients with upper eyelid retraction were included in this prospective, non-randomized, interventional case series study. All patients underwent correction of upper eyelid retraction with levator recession using adjustable sutures ,and were followed up every week for a month, then monthly for three months. In each visit, the margin reflex distance (MRD1) and palpebral fissure (PF) were measured. Results The included patients of the present work were classified into 3 groups: Group A: lid retraction secondary to over correction of ptosis, group B: thyroid related lid retraction, and group C congenital lid retraction. Among the 17 patients that participated in the follow-up examination, mean age ± SD was 21.12 ± 13.73 years (range 7–52 years). Eight were males and nine were females. Mean ± SD (range) of central height of the palpebral fissure was 13.79 ± 1.37 mm (10–16 mm) preoperatively, and 11.04 mm (9–12 mm) at follow up. Mean ± SD (range) of MRD1 was 6.77 ± 0.86 mm (5–8 mm) preoperatively, and 4.78 mm (4.5–5 mm) at follow-up. Conclusion Levator recession with adjustable sutures is effective technique in treatment of upper eyelid retraction of all degrees with different causes. However,increase the number of cases with long term follow up are recommended.

Gold weight implants for management of thyroid-related upper eyelid retraction.

To evaluate the use of gold weight implantation in the upper eyelid in the treatment of upper eyelid retraction caused by thyroid ophthalmopathy as regards the cosmetic and functional results and the safety of the procedure. This is a surgical intervention case series study. The study was carried out in Ophthalmology Department in El-Minya University Hospital between January 2013 and January 2014. The study was approved by the ethical committee board of El-Minya University. Test weights were applied to the skin of the upper eyelid using special adhesive tape in the sitting position to determine the suitable implantable weight. Three interrupted nonabsorbable sutures (5/0 Dacron) were used to secure the gold weight to the tarsus. The orbicularis was closed using interrupted 6/0 vicryl sutures. The skin was closed using interrupted 6/0 nylon sutures. As regards the postoperative results, by the end of the follow-up period, improvement of eyelid retraction was present in all cases. Normal upper eyelid margin position (covering 2 mm of the cornea) was attained in 10 eyelids (76.92%). Undercorrection was observed in 3 eyelids (23.07%). Two eyelids covered 1 mm of the cornea, and 1 eyelid rested at the upper limbus. All patients (100%) were satisfied as regards the cosmetic results, with the degree of satisfaction ranging between very good for 3 patients and excellent for 4 patients. One patient had bilateral brick-shaped appearance. Gold weight implantation for treatment of thyroid-related upper eyelid retraction markedly improves the cosmetic appearance of the patient and, to a lesser extent, improves the manifestations of exposure with high patient satisfaction, and it is a relatively easy and safe procedure.

Periodic Unilateral Eyelid Retraction in a Pediatric Patient

We appreciate the interest of Drs Denadai and Bastos in our case report as they propose the use of botulinum toxin in the treatment of congenital eyelid retraction (1). Others (2–8) have also provided evidence of nonincisional techniques for the treatment of upper eyelid retraction, most commonly secondary to thyroid eye disease, using botulinum toxin or dermal fillers. Currently, the preferred surgical treatment of upper eyelid retraction is the full-thickness blepharotomy, which has proven to be safe, effective, and predictable in experienced hands (9–12). This is the technique that our patient underwent. Advantages include a finite number of patient visits and a single procedure. Disadvantages include all potential complications of eyelid surgery. In addition, the etiology of the eyelid retraction in our patient would never have been determined if we had not placed her under anesthesia! The advantages of botulinum toxin injection include topical or no anesthesia and a lack of the potential complications associated with surgery. One disadvantage of using botulinum toxin is potential under- and overcorrection due to variable diffusion patterns of the toxin based on the placement of the needle. Another disadvantage is indefinite number of office visits due to the temporary effect of the toxin (2.5 months in the case described by Drs Denadai and Bastos) and the inconvenience of repeated injections. Comparative cost of the 2 procedures is an interesting issue. This would be a finite amount for a one time surgical procedure but would certainly be higher with repeated injections of botulinum toxin over months to years. We submit that in a patient who is a good surgical candidate, a full-thickness blepharotomy performed by an experienced surgeon is preferred over repeated botulinum toxin injections for upper eyelid retraction. We agree that all advantages, disadvantages, risks, and benefits of the treatment options should be fully disclosed to the patient.

Transcutaneous Dysport Injection for Treatment of Upper Eyelid Retraction Associated with Thyroid Eye Disease

Purpose: To evaluate the safety and efficacy of transcutaneous injections of botulinum toxin type A (Dysport) in the treatment of upper lid retraction associated with thyroid eye disease (TED).Methods: A total of 25 eyes of 16 patients including 11 female and 5 male subjects with stable TED condition were enrolled into the study. Mean age was 35.7 years (21–55). A transcutaneous injection of 20U Dysport was administered into each eyelid at the central superior tarsal border, aiming at the levator aponeurosis and Muller muscle. All patients were followed regularly for 4 to 6 months. Any complications, such as ptosis, diplopia, pain, or lid ecchymosis were recorded.Results: All patients experienced considerable reduction of palpebral fissure height. The mean lowering of the lid was 4.24 mm standard deviation (SD) =2.005, 2 weeks after intervention, and the effect remained for a minimum period of 4 months. There were temporary complications such as ptosis, which occurred in 4 patients for 4 weeks.Conclusions: A single transcutaneous injection of Dysport is safe and effective for treatment of lid retraction due to TED. Minor complications such as ptosis and diplopia may occur, however, this modality may offer temporary relief for patients with dysthyroid lid retraction awaiting orbital decompression or strabismus surgery or both.

Treatment of upper eyelid retraction associated with thyroid eye disease with subconjunctival botulinum toxin injection

Objective To study the effectiveness of botulinum toxin injections, via a subconjunctival approach, in the management of upper eyelid retraction associated with thyroid eye disease. Design Prospective, noncomparative, interventional case series. Participants Eleven patients with upper scleral exposure associated with thyroid eye disease who declined conservative or conventional surgical management. Intervention One or more treatments with injections of botulinum toxin into the subconjunctival space at the superior margin of the tarsal plate, via a conjunctival approach. Main outcome measures Upper eyelid position in relation to the upper limbus, patient satisfaction, and complications. Results All patients experienced some improvement in the amount of lid retraction after injections. The amount of lid lowering varied between patients and lasted between 1 and 40 months. A lid position acceptable to the patient was obtained in 10 patients. Four patients had ptosis lasting from 1 to 3 weeks, and three patients had transient diplopia lasting 1 day to 3 weeks. Conclusions This subconjunctival method of botulinum toxin injection provides an effective treatment for upper eyelid retraction associated with thyroid eye disease that is easy to administer and well tolerated by patients with few side effects.

Chemodenervation in Treatment of Upper Eyelid Retraction

Upper-eyelid retraction is a common sign of thyroid-associated eye disease (TAED), and these patients are highly bothered by the appearance of their eyes. In this study, botulinum toxin A (BTA) was injected into the levator palpebrae superioris muscle in 8 eyes of 4 patients in an attempt to control the abnormal elevation of the upper eyelid. BTA provided control of the upper-eyelid retraction, and the cosmetically acceptable effect lasted for 3-4 months. It was concluded that BTA is an effective method of treatment in this condition. Since it has a temporary effect, it can safely be used to provide relief of symptoms related to upper-eyelid retraction during unstabilized periods of TAED, which may last as long as several years in some patients.

Müller's Muscle in the Treatment of Upper Eyelid Retraction: A 12-Year Study

Müller's muscle is a sympathetically innervated muscle that can be excised to relieve upper eyelid retraction. A graded, controlled excision of Müller's muscle, with or without recession of the levator aponeurosis, using sensory without motor anesthesia is an excellent technique for releasing thyroid-related upper eyelid retraction. The procedure is simple, based on anatomic and physiologic principles, tailored to the individual patient intraoperatively, and yields consistently good results. In a 12-year study of this procedure, 96% of the treated lids attained lid levels within 1.5 mm of the opposite side. Only seven of 156 treated eyelids required additional surgery.

Is scleral transplantation necessary in the treatment of upper eyelid retraction?

Upper eyelid retraction caused by endocrine ophthalmopathy can be corrected by lengthening of the lid retractors. A number of operative procedures have been used for this purpose. In the more severe cases, it has been recommended that a graft be placed between the retractors and their former attachments. Sclera is commonly used but may induce a persistent tissue reaction making the results unpredictable. In the present study, 41 eyelids were operated with retractor recession via the conjunctiva. No graft was used. Surgery was easily performed and the intra-and postoperative troubles not important. The cosmetic and functional results were good and stable and point to the conclusion that scleral grafts are unnecessary in the surgical treatment of upper eyelid retraction.