Management of Eyelid Retraction

Eyelid retraction reported in about 90% of patients with thyroid associated orbitopathy; it may involve the upper or lower eyelid and may occur isolated or in association with proptosis. The causes of upper eyelid retraction include increased sympathetic tone in Müller’s muscle, fibrosis of the levator complex, scarring and/or inflammation of the orbital septum, exophthalmos, restriction of the inferior rectus muscle with increase in tone of the superior rectus and levator muscle. Procedures to address upper eyelid retraction include surgery and temporary measures, such as injections of steroids, botulinum toxin type A, and hyaluronic acid filler. Various surgical procedures to correct upper eyelid retraction, such as Müllerectomy, graded levator muscle disinsertion, and full-thickness eyelid blepharotomy are thoroughly described. The outcome of surgery for upper eyelid retraction can be sometimes unsatisfactory, irrespective of surgical experience, and the possibility of revisional surgery should be discussed with patients. Upper eyelid retraction is not addressed by orbital decompression. Lower eyelid retraction in thyroid associated orbitopathy may be secondary to proptosis determining a vertical displacement, it may derive from an increased adrenergic stimulation of lower lid retractors, or due to fibrosis of retractors. It can be addressed by decompression where indicated. Residual displacement can be corrected by retractor recession with or without insertion of an autogenous (hard palate, dermis) or non-autogenous spacer between the lid retractors and the lower tarsal edge. There is not one spacer graft material that is superior to others, with advantages and disadvantages associated with the various available materials.