Introduction
Corneal exposure is the most serious sequel to eyelid retraction. It may also occur with the eyelids in a normal position if there is poor closure, especially in the presence of reduced tear production, a poor Bell’s phenomenon or reduced corneal sensitivity. In these situations, or if there is cosmetic asymmetry even without exposure, an upper lid may need to be lowered or a lower lid raised.
Classification
Retraction with:
No shortage of skin or conjunctiva
Shortage of skin
Shortage of conjunctiva
Choice of operation
If the lid retraction is due only to a shortage of skin an ectropion as well as retraction of the lid is likely. The treatment is a skin graft or a Z -plasty (see Ch. 7 ).
If the retraction is due to cicatricial changes in the conjunctiva an entropion also results and lengthening of the posterior lamella is necessary (see Ch. 6 ).
The procedures described in this chapter are appropriate if there is no shortage of the skin or the conjunctiva – the retraction is due to shortened lid retractors.
In the upper lid excise Muller’s muscle alone to achieve a lid drop of about 2 mm ( 11.1 ). Recess both Muller’s muscle and the levator aponeurosis, without a spacer, to achieve about 3 mm ( 11.2 , 11.3 ). Full-thickness lid recession of the upper lid retractors and conjunctiva ( 11.4 ) is a simple procedure for any degree of retraction. The results are slightly less predictable.
The use of a spacer in either the upper lid ( 11.5 , 11.6 ) or the lower lid ( 11.7 ) allows 4 mm or more of correction. A spacer is always preferable in the lower lid but it is usually not required in the upper lid. Sclera, as a spacer, is used less than it was in the past but is still satisfactory; alternatives are discussed in Ch. 2 , Sect. D .
Lower lid retraction due to mild skin shortage, but without ectropion, may often be corrected by raising the cheek tissues and overlying skin ( 11.9 ).
Persistent lower lid retraction that is difficult to correct may require the support of a sling of autogenous fascia lata (see 7.14 ).
The lateral canthus and lateral third of the lower lid may need to be raised separately as an adjunct to lower lid retractor recession. This can be achieved with a plication suture ( 10.5m–r ) or a lateral tarsal strip ( 7.2 ). A small lateral tarsorrhaphy ( 11.11 ) may sometimes be needed. Occasionally, the whole lateral canthus may need to be elevated. Raising the tendon alone may be sufficient ( 10.5s–w ). Surgery to raise more significant displacement of the lateral (or medial) canthus is discussed in Ch. 18 , Sect. B .
In the presence of a facial palsy, an alternative to retractor recession in the upper lid is implantation of a gold weight ( 11.7 ).
Muller’s muscle
11.1
Muller’s muscle excision
Insert a traction suture into the upper lid and evert the lid over a Desmarres retractor. Make a short, full-thickness incision into the tarsal plate close to its upper border (arrows) to enter the postaponeurotic space ( Diag. 1.17 ).
Reflect the conjunctiva and Muller’s muscle, attached to the thin strip of superior tarsal border, down toward the eye and identify Muller’s muscle – a thin, rather vascular sheet of muscle inserting into the strip of tarsus. Dissect upwards in the postaponeurotic space (see Diag 1.17 ) opening the fine connective tissue between Muller’s muscle posteriorly, in the floor of the space, and the levator aponeurosis anteriorly, in the roof of the space, for about 10 to 12 mm until the origin of Muller’s muscle from the levator is reached (see also 9.2a–c ).
Excise the strip of tarsus and close the conjunctiva to the cut border of the tarsal plate with a continuous 7/0 or 8/0 absorbable suture. The knots should be buried or brought out through the tissues to the skin. Tape a traction suture to the cheek for 24 to 48 hours (see 2.22b ) depending on the degree of retraction.
If Muller’s muscle has been incompletely excised, retraction in part of the lid will persist resulting in a poor curve. If marked, the remaining fibres should be excised.
Muller’s muscle
11.1
Muller’s muscle excision
Insert a traction suture into the upper lid and evert the lid over a Desmarres retractor. Make a short, full-thickness incision into the tarsal plate close to its upper border (arrows) to enter the postaponeurotic space ( Diag. 1.17 ).
Reflect the conjunctiva and Muller’s muscle, attached to the thin strip of superior tarsal border, down toward the eye and identify Muller’s muscle – a thin, rather vascular sheet of muscle inserting into the strip of tarsus. Dissect upwards in the postaponeurotic space (see Diag 1.17 ) opening the fine connective tissue between Muller’s muscle posteriorly, in the floor of the space, and the levator aponeurosis anteriorly, in the roof of the space, for about 10 to 12 mm until the origin of Muller’s muscle from the levator is reached (see also 9.2a–c ).
Excise the strip of tarsus and close the conjunctiva to the cut border of the tarsal plate with a continuous 7/0 or 8/0 absorbable suture. The knots should be buried or brought out through the tissues to the skin. Tape a traction suture to the cheek for 24 to 48 hours (see 2.22b ) depending on the degree of retraction.
If Muller’s muscle has been incompletely excised, retraction in part of the lid will persist resulting in a poor curve. If marked, the remaining fibres should be excised.
Recession of Muller’s muscle and levator
Choice of operation
If a spacer is not used a posterior approach ( 11.2 ) is easier but the skin crease will be raised in relation to the lashes. This is not important in bilateral cases but the resulting asymmetry in unilateral cases may be uncosmetic. To avoid this result, use an anterior approach to recess the upper lid retractors ( 11.3 ) and set the skin crease at the level of the opposite side. If the anterior approach is used excess fat and/or skin may also be excised.
If a spacer is used the anterior approach to the levator ( 11.5 ) is usually preferred but the posterior approach ( 11.6 ) may be used.
11.2
Upper lid retractor recession without spacer – posterior approach
Expose the levator aponeurosis and deepen the incision through it to expose the orbicularis muscle (see Figs 9.2b–f , Diag 1.17 ). Dissect superiorly between the levator aponeurosis and the orbicularis muscle, a few millimetres at a time, reassessing the lid position at each step. Aim at a slight overcorrection.
In thyroid lid retraction the lateral end of the lid may remain high. See the comment in 11.3d.
In persistent or recurrent retraction the upper lid retractors and the conjunctiva may be sutured (although this is not essential) to the orbicularis muscle in their recessed position using continuous or interrupted 6/0 or 7/0 absorbable sutures. Try to bury the knots or bring them through the tissues to the skin.
Insert a traction suture (see 2.22b ) and tape it to the cheek for 48 hours.
If the retraction is undercorrected lid massage and traction on the lashes (see Complications and Management for procedures 9.1–4 , p. 203 ) may lower the lid further during the first 4 to 6 postoperative weeks. Reoperation will be needed if this is ineffective. If the lid is too low wait for 6 weeks to see how much it will rise. If it stays too low advance the retractors and resuture to the orbicularis muscle at the correct position.
A poor lid curve which does not resolve is due to unequal pull of the upper lid retractors. Reopen the wound and adjust that part of the retractors to achieve a satisfactory curve.
11.3
Upper lid retractor recession without spacer – anterior approach
Make a skin crease incision at the intended level. Expose the levator aponeurosis and orbital septum (see 9.1a–c ). Open the septum and dissect out the upper lid retractors as far as the superior fornix (see 9.3e–j ).
Note – If the level of the skin crease is to be lowered, it is important to free the existing skin crease to avoid a double skin crease. The general rule is that the skin crease in the upper lid forms at the highest level of skin fixation to the deep tissues. This is normally at the level of the insertion of the levator aponeurosis into the orbicularis muscle (see Diag. 1.16 ). To free the tissues at the level of the (higher) existing skin crease, dissect superiorly, deep to the orbicularis muscle, between the orbicularis and the levator aponeurosis/orbital septum until the deep attachment at the skin crease has been freed. Open the septum to allow the preaponeurotic fat pad to prolapse to the level of the new skin crease to discourage reattachment at the previous level. At the end of the procedure close the skin with deep fixation sutures to establish the new skin crease at the new, lower level.
Retract the preaponeurotic fat pad and pull down on the levator aponeurosis to expose Whitnall’s ligament.
A marked excess of fat in the medial and central compartments may be excised at this stage if necessary ( Fig. 10.1o,p ).
Note – In retraction due to thyroid eye disease the lateral end of the lid is often difficult to lower to a satisfactory level. In these cases cut the lateral horn of the levator and reassess (11.3d). If the lid is still high laterally cut the lateral end of Whitnall’s ligament (11.3e) and continue to free the tissues laterally, taking care to avoid damage to the lacrimal gland, until a satisfactory curve is achieved.
This step, and step 11.3e, can be omitted if the lateral end of the lid is not retracted relative to the rest of the lid margin. If it is retracted, for example as in dysthyroid lid retraction, cut the lateral horn and reassess the curve of the lid. If it is still retracted laterally proceed to 11.3e.
Continue the cut superiorly beyond the lateral horn to cut the lateral third of Whitnall’s ligament. Reassess the lid curve. It should now be satisfactory but some further freeing of the tissues laterally may be needed to achieve the desired result.
Reattach the upper lid retractors to the tarsal plate with three loose hang-back nonabsorbable 6/0 sutures which support the lid at the intended level. If the further dissection described in 11.3d and 11.3e was necessary to overcome persistent lateral retraction, omit the lateral hang-back suture.
Close the lid, taking bites into the tissues overlying the tarsal plate rather than the levator aponeurosis (see 9.1h ) which has been recessed. Insert a traction suture (see Fig. 2.22b ) and tape it to the cheek for 48 hours.
Possible complications and their management are the same as those described previously for the posterior approach ( p. 288 ). In addition, despite every effort, the lateral end of the lid may still be high. Wait 6 months and attempt to divide the lateral tissue further if necessary.
If a double skin crease results despite the precautions described earlier (11.3a) it may be possible to eliminate it by further dissection between the orbicularis muscle and the levator at the level of the original (higher) crease.
Alternative procedure
Adjustable sutures
11.4
Full-thickness upper lid recession
In this procedure the conjunctiva is recessed in addition to the upper lid retractors. It is applicable to any degree of upper lid retraction.
Make an incision in the skin at the planned level of the lid crease. Deepen the incision through the orbicularis muscle and the upper lid retractors, at the level of the superior border of the tarsal plate, to expose the conjunctiva.
The skin crease may rise. If significant, it can be revised (see Note on 11.3a).
The lid level may remain high or, occasionally, low. If high, apply lash traction. To do this the patient looks down and grasps the lashes of the upper lid between finger and thumb. Forced upgaze against the pull on the lashes, repeated every 2 to 3 seconds, stretches the tissues attaching the upper lid retractors to the tarsal plate, lowering the lid. This manoeuvre should be repeated for about 30 seconds, three times a day until the lids are level or until 6 weeks after surgery when it will be less effective. If it has been unsuccessful or if the lid is low, the lid level may be adjusted surgically after about 6 months. The wound is reopened and the pull of the retractors is adjusted with hang-back sutures ( 11.3 ).
11.5
Upper lid retractor recession with spacer – anterior approach
Although upper lid spacers have a role in more marked upper lid retraction it is increasingly common to recess the upper lid retractors without a spacer. Hang-back sutures are preferred ( 11.3f ). If a spacer is inserted donor sclera is used less frequently than it was because of the small risk of transmitted infection. Autogenous ear cartilage or an alloplastic material such as Vicryl mesh are potential alternatives.
Cut a spacer using donor sclera or an alternative (see 2.17 – 2.18 ). The spacer should be about 15 mm transversely. Its vertical dimension will depend on the cause of the retraction. In thyroid eye disease allow twice the correction required to achieve a satisfactory lid level – i.e. for 5 mm retraction use a 10 mm spacer. If this appears too much at operation, it can be reduced to achieve a small amount of overcorrection. In other conditions cut the spacer 2 mm wider than the amount of lid drop required. The lateral end of the spacer, particularly in thyroid lid retraction, will usually need to be wider vertically than the medial end.
Alternative procedure
11.6
Upper lid retractor recession with spacer – posterior approach
With the upper lid everted make an incision close to the upper border of the tarsal plate, incise the levator aponeurosis and dissect the anterior surface of the levator free, opening the septum, as described for a posterior levator advancement (see Figs 9.2a–e ). Cut the lateral horn of the aponeurosis (see Figs 11.3d , e ) and, if necessary, the lateral end of Whitnall’s ligament. Dissect the conjunctiva free from Muller’s muscle as far as the fornix. Allow the retractors to recess until a satisfactory lid level is achieved. Prepare a spacer as described in 11.5d and suture its superior border to the recessed retractors using continuous 6/0 or 7/0 absorbable sutures. Suture the inferior border of the spacer, together with the conjunctiva, to the upper border of the tarsal plate using continuous 6/0 or 7/0 absorbable sutures. Insert a traction suture ( Fig. 2.22b ) and tape it to the cheek for 48 hours.
11.7
Gold weight implant ( ) 
Using trial weights with double-sided adhesive on the back, estimate the weight of gold implant.
Make an incision along the marked skin crease to expose the tarsal plate (see 9.1a ). Undermine the anterior lamella between the tarsal plate and the posterior surface of the orbicularis muscle as far as the lash roots taking care not to damage the roots.
Close the skin with a continuous fine absorbable suture without deep fixation.
The advantage of the two-layer closure is that no suture passes from the skin to the deep tissues which might increase the risk of infection around the gold weight. A traction suture may be placed in the lower lid (see 2.20a ) if necessary. Prescribe a prophylactic antibiotic for 1 week.
Mild ptosis is common following gold weight implantation. If it is cosmetically unacceptable a small levator aponeurotic advancement or resection (see 9.1 ) may be needed. However, this may reduce the effectiveness of the gold weight in closing the lid.
The colour of the gold weight may be just visible through the thinned orbicularis muscle in a facial palsy. Providing the weight is buried deep to the full thickness of the orbicularis this is usually minimal. An attractive material is platinum. It is less visible through the skin.
Inflammation or infection is uncommon. If antibiotics are ineffective the weight may need to be removed to allow the lid to settle. A new weight can then be implanted.
Extrusion of the weight through the skin may occur gradually over many months. The weight should be removed and replaced once the lid has healed.
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