15 Repair of Upper Eyelid Retraction (Internal and External)
Retraction of the upper eyelid may lead to significant ocular surface vulnerability and discomfort. This most commonly occurs in the setting of thyroid eye disease, but can also be seen in congenital eyelid malformation, or following surgery or trauma. The proper eyelid height can be restored by an external or internal approach, with external levator recession providing the maximal eyelid recession. These procedures can be further augmented with use of fixed or adjustable sutures for additional eyelid contour enhancement. Intraoperative eyelid height assessment is essential. Obtaining reliable results can be particularly challenging in patients with thyroid eye disease. Serious postoperative complications are rare.
Ocular surface protection.
Restoration of eyelid height, contour and symmetry.
The external approach to upper eyelid retraction repair allows for complete levator complex access and maximal upper eyelid recession via full thickness blepharotomy. The internal approach avoids a visible scar, but permits a more limited eyelid recession.
Patients should expect a lowered upper eyelid height, with improved ocular protection and comfort. Patients should be warned about the frequent need for reoperation to achieve and maintain an ideal eyelid height and contour, particularly those patients with thyroid eye disease. 1
15.4 Key Principles
An external approach through an eyelid crease incision can be utilized for recession of the levator muscle, the levator aponeurosis, and Müller muscle (often in combination) to achieve a desired amount of eyelid lowering. 2
An internal approach through the superior palpebral conjunctiva provides access to Müller muscle and levator aponeurosis for smaller scale eyelid recessions.
Eyelid retraction repair can be performed with and without the use of sutures, which can be placed in a fixed or adjustable fashion. 3
Some recession techniques utilize spacer grafts derived of sclera, deep temporal fascia, 4 and Müller-conjunctivo-tarsal tissue from the contralateral eyelid. 5 These techniques will not be outlined in this chapter.
Upper eyelid retraction is defined as an upper eyelid position elevated beyond the ideal 1 to 2 mm below the superior limbal border. Etiologies of upper eyelid retraction include thyroid eye disease, congenital causes (including congenital fibrosis syndrome), iatrogenic or overcorrected ptosis following ptosis or blepharoplasty surgery, and trauma. Pseudoretraction can be seen in cases of proptosis. In few cases, upper eyelid retraction can be seen after glaucoma filtering and scleral buckle surgeries. 6
Upper eyelid retraction may induce lagophthalmos and significant corneal exposure, leading to globe-threatening keratopathy and discomfort, as well as an undesirable ocular appearance and exacerbated disfigurement from the often-concomitant proptosis.
Upper eyelid retraction repair is undertaken to provide corneal protection, relieve ocular discomfort, and promote cosmetic rehabilitation.
Eyelid retraction repair should not be performed in cases of active thyroid disease, particularly those requiring orbital decompression or strabismus surgery. Most recommend that a patient be biochemically and symptomatically euthyroid for at least 6 months prior to surgical recession. 7 The height of the eyelid should also be stable for approximately 6 months. Alternatives to surgery must also be considered in patients who are unable to stop blood thinners. As this surgery involves postseptal tissue, risk of retrobulbar hematoma is greater than preseptal surgery.
15.7 Preoperative Preparation
Preoperative evaluation should include bilateral eyelid contour assessment and measurement of marginal reflex distance, eyelid excursion, and lagophthalmos. A detailed slit-lamp examination should be performed to assess for consequential corneal pathology, including keratopathy and corneal thinning. In addition, external photography should document preoperative eyelid position. If the patient is on blood thinners, these should be held for an appropriate period of time to avoid postseptal hemorrhage. The patient should be made aware that their cooperation is necessary during surgery and that surgical eyelid recession should be performed under conscious sedation anesthesia to allow for patient participation in intraoperative eyelid height assessment. During surgery, very low–volume local anesthetic (<1 mL) should be used, with careful measures taken not to infiltrate and paralyze the levator complex.
15.8 Operative Technique
Proximal Levator Muscle Recession
Indicated in severe bilateral upper eyelid retraction.
Recommended anesthesia: general anesthesia (due to patient discomfort with muscle belly manipulation, often thickened from fibrosis, with inability to locally anesthetize the muscle belly to allow for its functional intraoperative assessment).
An upper eyelid crease incision is made through skin and orbicularis. The orbital septum is opened and preaponeurotic fat is carefully retracted to expose the levator aponeurosis. Dissection is proceeded to expose the levator muscle proximal to Whitnall ligament. A muscle hook is passed under the muscle belly from medial to lateral, and the entire levator muscle is transected. A mattress suture using 6–0 monofilament polypropylene is placed first through transected distal levator muscle and then through the proximal cut end of the muscle, after which both needle ends are externalized through the anterior upper eyelid edge and secured with rubber bolsters. Using this technique, fine adjustments can be made over the first 2 postoperative weeks by augmenting suture tension.
Advantages to recessing the levator muscle belly include maximizing recession by completely devitalizing the muscle, addressing the area of primary thyroid orbitopathy pathology in the muscle belly and preserving the distal tarsus insertion for maintenance of good eyelid contour. The Müller muscle and levator aponeurosis complex are also left intact for future refinement of eyelid position, if necessary.