Eyelid Retraction Repair
Obadah Moushmoush, MD
Michael Richard, MD
LOWER EYELID RETRACTION
DISEASE DESCRIPTION
Lower eyelid retraction refers to a malposition of the lower eyelid in which there is visible sclera beneath the corneal limbus, termed inferior scleral show. This can occur for a variety of reasons including neurogenic, myogenic, and mechanical causes, but it also commonly occurs as an involutional process as a result of decreased neurogenic tone, laxity of the lateral canthal tendon, and loss of midface support due to aging changes.
MANAGEMENT OPTIONS
Conservative medical management with lubrication, moisture shields, autologous serum
Hyaluronic acid filler injection
Lateral tarsorrhaphy
Anterior lamellar full-thickness skin graft if retraction is caused by cicatricial changes in the anterior lamella
Midface lift
Posterior lamellar spacer graft
Raising a lower eyelid can be difficult owing to the curve of the eyeball where the lower lid apposes the globe. When teaching the principles of this anatomic region to residents, we use the analogy of a fat man’s belly and his belt. The globe represents a fat man’s belly and the lower eyelid is his belt. When the fat man tightens his belt, his belly protrudes farther over his pants because the path of least resistance is for the belt to slide farther under his belly. Similarly, tightening a retracted lower eyelid will produce anatomic forces that run counter to any attempts to lift the lower lid. For this reason, lifting of the lower lid often requires grafting of a composite material into the posterior lamella to “push” the lid superiorly.
 FIGURE 11.1. Preoperative photograph of patient with bilateral lower lid retraction. She has 2.5 mm of inferior scleral show on the right and 2.0 mm of inferior scleral show on the left. |
INDICATIONS FOR SURGERY
Significant retraction of the lower lid with inferior scleral show contributing to evaporative tear loss or lagophthalmos with resultant ocular surface disease (Figure 11.1).
SURGICAL DESCRIPTION
Lower Eyelid Retraction Repair Using Porcine Acellular Dermal Matrix (Enduragen) Spacer Graft
Perform a lateral canthotomy and inferior cantholysis. Clamp the lateral canthus with a small curved hemostat. Use Westcott scissors to cut across the clamped area down to the lateral orbital rim. Rotate the scissors inferiorly to strum the inferior crus of the lateral canthal tendon. Cut and release the inferior crus entirely.
Dissect along the lateral and inferior orbital rim in the preperiosteal plane and release the orbitomalar ligament.
Make a transconjunctival incision about 2 to 3 mm inferior to the inferior border of the tarsus extending for the length of the eyelid.
Dissect the lower eyelid retractors and conjunctiva from the orbital septum to create a recipient bed for the graft (Figure 11.2).
Use a 1 mm thick piece of porcine acellular dermal matrix (Enduragen) as a spacer graft.
FIGURE 11.2. A recipient bed is dissected by making a transconjunctival incision 2 to 3 mm below the inferior border of the tarsus. The conjunctiva and lower eyelid retractors are then dissected from the orbital fat.
FIGURE 11.3. The Enduragen graft is sized according to the amount of preoperative inferior scleral show. In this patient, the grafts are taken from a 2 cm × 5 cm × 1 mm implant. Each graft is 25 mm in length and 10 mm in height (10 mm is the maximal graft height that we implant into the posterior lamella). Note that the ends are tapered, more so nasally than temporally.
Cut the graft to the appropriate size depending on the amount of retraction, negative vector, degree of anterior lamellar cicatrization, and symptomatic exposure present. (We use an algorithm where we assume that a 7 mm tall graft will improve 1 mm of inferior scleral show and each 1 mm of graft height beyond that will improve another 0.5 mm of inferior scleral show. We do not use this algorithm strictly but rather incorporate the algorithm into decision making along with the aforementioned factors (Figure 11.3)).
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
