Eyelid Retraction
In ophthalmology, eyelid retraction is a common occurrence. Its diagnosis and treatment necessitate a systematic approach that begins with a thorough medical history. It's critical for the doctor to be aware of any conditions that could make the retraction worse. A thorough medical history and physical examination will aid the physician in avoiding misdiagnosis and surgical intervention that is unnecessary.
Epidemiology
It is thought that circulating T lymphocytes in Graves’ disease patients are directed against cross-reactive antigens in the orbit. These activated T cells and macrophages produce cytokines, which trigger the autoimmune response that leads to pathology. 90% of people with Graves’ disease will experience eyelid retraction at some time throughout their treatment. 91% of people diagnosed have hyperthyroidism, 1% have hypothyroidism, 3% have Hashimoto thyroiditis, and 5% have euthyroidism. A thorough medical examination by an endocrinologist is essential.
Eyelid Retraction Pathophysiology
Overactivity of the levator muscle, enhanced sympathetic tone resulting in Muller muscle contraction, proptosis of the eye globe, fibrosis with contracture of the levator aponeurosis, and adhesions of the levator to the orbital septum are among the many factors linked to upper lid retraction in patients with thyroid ophthalmopathy. It is thought that the superior rectus-levator complex overcompensates and causes the upper lid to retract as a result of the inferior rectus muscles' restrictive myopathic nature. Inferior rectus contracture, over-contraction of the inferior tarsal muscle with enhanced sympathetic tone, proptosis, and previous surgical recession of the inferior rectus muscle can all cause retraction of the lower lid. Trauma and surgery are examples of cicatricial factors to consider.
Eyelid Retraction Causes
Retraction of the eyelid can be caused by a variety of factors. Thyroid-related ophthalmopathy is the most common cause. Trauma and surgery are two examples of cicatricial causes. Aberrant third nerve regeneration, unilateral ptosis with contralateral overaction of the levator palpebrae muscle, Collier's sign of dorsal midbrain syndrome, hyperkalemic periodic paralysis, and chronic systemic corticosteroid use are all non-cicatricial origins.
Injured nerve fibers cause misdirection syndrome, which is characterized by abnormal regeneration of the third nerve. There may be considerable and uncontrolled development when the nerves heal. When you try to downgaze, your upper lids will retrace. Overactivity of the levator palpebrae muscle due to an excessive attempt to lift the ptotic eye might cause contralateral upper lid retraction in patients with unilateral ptosis. The retraction is usually improved when the ptosis is corrected. As a result of lesions in the rostral midbrain, dorsal midbrain syndrome, also known as Parinaud's syndrome, causes a slew of neuro-ophthalmic problems. Pineal tumors and midbrain infarction are the most common causes. This can cause lid lag and pathological lid retraction.
Eyelid Retraction Surgery Preparation
The upper eyelid should ideally be 1-1.5 mm inferior to the limbus at 12 o'clock. MRD1 (margin reflex distance), the distance between the corneal light reflex and the upper lid margin, is the most relevant measurement for documentation and monitoring of upper eyelid retraction. Retraction is defined as any measurement greater than 5 mm. It's sometimes helpful to assess MRD1 with the lights turned down low, as this helps to avoid artificially low values caused by photophobia, which is common in these patients. The inferior limbus is generally where the lower eyelid meets the lower limbus. The MRD2 measurement, which is the distance between the corneal light reflex and the lower lid margin, is the most helpful for documenting and monitoring lower eyelid retraction. Retraction is defined as any measurement greater than 5 mm. It's also important to figure just how much lagophthalmos there is after gentle lid closure. The cornea should be closely checked for symptoms of exposure keratopathy, and the tear film should be assessed. Photographs taken before to surgery are necessary for documentation and postoperative comparison. A non-enhanced CT scan with axial pictures and coronal reconstruction may be useful if thyroid-associated ophthalmopathy is predicted, allowing the surgeon to view probable extraocular muscle hypertrophy and rule out other orbital disease such as vascular or neoplastic entities. Because iodinated contrast can aggravate thyroid-associated ophthalmopathy, it's vital to avoid it in these patients.
Upper Eyelid Retraction Surgery
Limiting scleral show, minimizing lagophthalmos, reducing corneal exposure, and restoring a more normal look are the goals of surgical treatment of upper eyelid retraction. The surgical method is determined on the retraction's source and severity.
Eyelid Retraction Repair with Gold Weight
The surgical method for paralytic lagophthalmos is determined on the amount of orbicularis function and the desired operative outcome. To reduce lagophthalmos and corneal exposure, many patients benefit from a weight put within the eyelid. This weight can be formed of gold or platinum, and if cosmesis is a concern, thin profile weights are available.
Preoperatively, the patient's MRD1, lagophthalmos, and orbicularis function are all meticulously measured. Preoperatively, the optimal implant weight is determined by applying several weights from a weight-sizing set to the exterior of the upper eyelid, approximately 2–3 mm above the lash line. On mild closure, an ideal weight will minimize lagophthalmos while still permitting the lid to clear the visual axis in primary gaze.
The surgery is usually performed as an outpatient surgery with intravenous sedation and local anesthesia; however, it can also be performed under general or local anesthesia if necessary. The upper eyelid crease is marked with a surgical marker. In a 50:50 mixture, 2% lidocaine with epinephrine and 0.5 percent bupivacaine with epinephrine are given in a 5 mL syringe using a 30-gauge needle. A bard parker blade is used to make a skin incision over the previously put marking. The surface of the tarsal plate is next exposed by dissecting through the orbicularis muscle with Westcott scissors, forceps, and high-temperature cautery. To prevent the gold weight from being exposed, a deep dissection is required. When the tarsal plate is sufficiently exposed, the weight is put over the tarsus and positioned so that the weight's two pre-drilled holes face the lashes. Proline suture is used to stitch the plate into place through the pre-drilled holes. To avoid damage of the cornea with the sutures, validated partial thickness bites are used. Using buried, interrupted Vicryl sutures, the orbicularis muscle is then re-adjusted over the weight. A running plain gut cutaneous suture is then used to re-adjust the skin edges. Ophthalmic ointment is applied to the wound and left on for one week after surgery.
Permanent Lateral Tarsorrhaphy
When the orbicularis function is lost and/or the cornea is badly injured due to lagophthalmos, a permanent lateral tarsorrhaphy can be used to generate a long-lasting adhesion between the upper and lower eyelids. The degree of eyelid closure required is determined by the severity of the lagophthalmos as well as the surgical objective.
The surgery is usually performed as an outpatient procedure with intravenous sedation and local anesthesia; however, it can also be performed under general anesthesia if necessary. On the upper and lower lids, a surgical marker is used to mark the required amount of closure. Using a 5-mL syringe and a 30-gauge needle, a 50:50 mixture of 2% Lidocaine with adrenaline and 0.5 percent bupivacaine with epinephrine is administered into the region. With a bard parker blade, the eyelid margin is taken from the upper and lower lids, preserving the lashes. Using a blade, both eyelids are separated into an anterior and posterior lamella over the length of the incisions. The dissection plane is extended for 3-4 mm, keeping it immediately anterior to the tarsus. After passing both needles of a double-armed Proline suture through a rubber band bolster, each arm is passed through the skin and exits deep into the lower lid incision. After that, both needles are passed into the upper lid incisions' depths, emerging through the skin. Both needles are tied after passing through a second rubber band bolter. If necessary, a second double-armed Proline suture can be put in the area before the stitch is tightened. When the sutures are tightened, the upper and lower eyelids splay open, creating a broad area for adhesion between them. There is no need for skin suturing. On the incisions and inside the eye, ophthalmic ointment is applied. Following surgery, the ointment is maintained, and the bolsters are removed in 8-10 days.
Mullerectomy
When thyroid ophthalmopathy causes retraction of the upper eyelid and exposure, a mullerectomy can yield a good result by vertically elongating the posterior lamella of the eyelid. This operation is performed through a posterior incision, which eliminates the need for an external incision and the resulting scar.
Preoperatively, the patient's MRD1, lagophthalmos, and palpebral fissure height are all meticulously measured. Mullerectomy surgery is performed on an outpatient basis under intravenous sedation and local anesthesia. Unless absolutely required, this procedure should not be performed under general anesthesia. In a 5-mL syringe with a 30-gauge needle, a 50:50 mixture of 2% Lidocaine with adrenaline and 0.5 percent bupivacaine with epinephrine is administered. The upper eyelid is everted, and a local anesthetic is administered at the superior tarsal border just beneath the conjunctiva. It is important to avoid injecting the levator muscle. The conjunctiva is hydro-dissected from Müller's muscle with this injection. A silk traction suture is put through the skin of the upper lid, right above the lash line, in the center. After that, a Desmarres retractor is used to evert the eyelid. At the superior border of the tarsus, a buttonhole incision is made temporally through the conjunctiva. The conjunctiva is then dissected away from the superior border of the tarsus over the temporal two-thirds of the eyelid with Westcott scissors. Thyroid patients have more temporal retraction; therefore, the incision normally doesn't need to go beyond the middle third of the eyelid. Pressure is used to achieve hemostasis. To avoid damaging the lacrimal ductules, it is best to avoid excessive cauterization. With Westcott scissors, the conjunctiva is then separated from its attachments to Müller's muscle.
Through Müller's muscle, another buttonhole incision is made temporally at the superior edge of the tarsus. This operation requires a thorough understanding of the anatomy of this muscle. Müller's muscle arises at Whitnall's ligament, 15-16 mm above the superior border of the tarsus, from the undersurface of the levator aponeurosis. This sympathetically innervated muscle attaches to the conjunctival fornix and inserts on the superior edge of the tarsus.
Müller's muscle is disinserted from the superior tarsal border along the temporal two-thirds of the eyelid after the buttonhole incision is formed. Using blunt and sharp dissection, Müller's muscle is meticulously separated from the levator aponeurosis. The patient is subsequently placed in an upright position with the eyelid turned back into place. The patient is instructed to open his or her eyes so that the surgeon can assess the upper eyelids' height and shape. Müller's muscle is infiltrated with the local anesthetic combination and a hemostat is clamped across the base of the muscle if the height and shape are satisfactory. A high-temperature cautery is then used to remove the muscle. If retraction persists, two forceps are used to grip the levator aponeurosis above the superior tarsal border and gradually stretch it vertically. Skin injury is avoided at all costs. This lengthening technique is titrated by stretching the levator muscle and evaluating lid position till the lid margin is 1 mm below the superior limbus and the shape is perfect. To reattach the conjunctiva to the superior tarsal border centrally, medially, and laterally, a buried, fast gut suture is employed in an interrupted method. After that, the silk suture is removed, and ophthalmic ointment is applied to the eye. The ointment is used for one week after surgery. Ptosis might last for up to a week after surgery. Within 3-4 weeks, the lid should be in a secure position. In the early postoperative period, downward eyelid massage may be beneficial for continued retraction.
Lower Eyelid Retraction Surgery
An anterior or posterior technique can be used to treat lower eyelid retraction. Doctors favor the posterior, transconjunctival technique with a spacer graft when there is a lot of retraction. The use of a spacer graft can elevate the lower eyelid by about 4-5 millimeters. This procedure can be utilized with a number of grafts. The sort of material utilized is determined by availability and the surgeon's level of comfort. For each millimeter of elevation, auricular cartilage and other spacer materials employ a ratio of 1 mm. Enduragen is a porcine cutaneous collagen that is acellular. The pre-hydrated product has a uniform thickness and can be cut to a desired size. The surgical method is the same regardless of the type of spacer employed. The material is positioned between the inferior tarsal border and the inferior fornix conjunctiva.
Recession of the capsulopalpebral fascia without the use of a spacer graft is another option for repairing lower eyelid retraction. A lateral tarsal strip procedure is paired with retraction of the lower lid retractors in this technique. The optimum surgical technique can be determined by paying close attention to the source and extent of the retraction prior to the surgery.
Preoperatively, the patient's MRD2, lagophthalmos, and palpebral fissure height are all meticulously measured. The operations are usually performed as an outpatient surgery with intravenous sedation and local anesthetic, although they can also be performed under general or local anesthesia if necessary.
Harvesting of Ear Cartilage Graft
The retro-auricular and preauricular areas are infiltrated with a 50:50 mixture of 2% Lidocaine with adrenaline and 0.5 percent bupivacaine with epinephrine using a 5 mL syringe and a 30-gauge needle to harvest the ear cartilage graft. To keep the ear forward, a silk traction suture is put in a mattress fashion across the skin of the helix and the preauricular skin. On the flattened part of the posterior ear just anterior to the helix, a surgical marker is utilized to mark an incision line of 24-25 mm in length. A bard parker blade is used to make an incision following the markings. With Westcott scissors, a dissection is carried down to expose the apex of the auricular cartilage. To assist in obtaining the right plane, the scissors can be pressed firmly on the cartilage. The cartilage graft is usually 24-25 mm in length. A metal ruler and high-temperature cautery are used to mark this length along the cartilage. The breadth of the ear cartilage is calculated using the amount of retraction, which is estimated preoperatively as MRD2. The width of the cartilage transplant is determined by a 1:1 ratio, which is marked above and below the straight line in either direction. If the required width is 4 mm, for example, 2 mm is defined anteriorly and 2 mm is defined posteriorly from the center of the drawn line on the cartilage. This location can easily provide a graft of roughly 30 mm in length and 8 mm in width. The ellipse of ear cartilage to be removed is next delineated using high-temperature cautery. A partial-thickness incision is created through the cartilage with a bard parker blade. To minimize incising the underlying skin, extreme caution is required. In one region, a full-thickness incision into the cartilage can be created, and the graft can subsequently be entirely excised with Westcott scissors. Prior to placing the transplant in the lower eyelid, Westcott scissors are used to remove any tissue connected to the graft. The ear cartilage defect should not be stitched. To correct the incision edges, a single plain gut suture is tied centrally in the auricular skin. The silk traction suture is then released, and the ear skin is repaired with a running plain gut suture. After surgery, ointment should be put to the incision.
Eyelid Retraction Repair with Graft
Using a 5-mL syringe and a 30-gauge needle, a 50:50 mixture of 2% Lidocaine with epinephrine and 0.5 percent bupivacaine with epinephrine is injected into the lower eyelid margin and inferior fornix. Within the eyelid margin, a double-armed TiCron suture with connected bolster is employed as a traction suture for the lower eyelid. If needed, a double-armed silk suture with a rubber band bolster can be utilized instead of the TiCron suture; however, silk tends to induce more inflammation of the eyelid edge during recovery. After that, the eyelid is everted with a cotton-tipped applicator. Using high-temperature cautery, the conjunctiva and lower lid retractors are removed from the inferior tarsal border down the length of the lower lid. When the lower lid retractors, the capsulopalpebral fascia and inferior tarsal muscle, are withdrawn from the inferior border of the tarsus, the lid will rise. The graft is now cut to the right size with identical dimensions to the ear cartilage graft when utilizing Enduragen. After that, the graft is put in the defect on the lower eyelid. Between the graft and the inferior border of the tarsus, multiple partial thickness, buried interrupted Vicryl sutures are inserted. Postoperative corneal irritation can be avoided by burying the knots at the inferior tarsal border. At the inferior margin of the graft to the conjunctiva, many interrupted Vicryl sutures are applied. The lower lid is then pulled superiorly with a traction suture and taped above the forehead with Mastisol and Steri-Strips, putting it on modest stretch while it heals. Two eye pads are taped above the surgical site with paper tape, and ophthalmic ointment is inserted within the eye. In most cases, the dressing and traction suture are removed within one week.
Eyelid Retraction Repair with Capsulopalpebral Fascia Recession
Using a 5-mL syringe and a 30-gauge needle, a 50:50 mixture of 2% Lidocaine with adrenaline and 0.5 percent bupivacaine with epinephrine is injected into the lateral upper and lower lids, the inferior fornix, and the periosteum of the lateral orbital rim. Crushing the lateral canthus with a hemostat and cutting a 10 mm incision straight out from the canthal angle with Westcott scissors is how a lateral canthotomy is done. The tips of the scissors are used to palpate the inferior crus of the lateral canthal tendon. The lower lids' lateral section is freed once the tendon is severed. To separate the conjunctiva and capsulopalpebral fascia, an incision is made along the length of the inferior tarsal border to the line of the punctum with Westcott scissors. The capsulopalpebral fascia is then gripped and dragged superiorly, while the inferior tarsal border is held and pulled inferiorly. The capsulopalpebral fascia is then separated from the surrounding tissue using high-temperature cautery. Cautery permits the procedure to move forward swiftly while maintaining hemostasis. The recessed capsulopalpebral fascia and conjunctiva are then attached to the deeper tissues around 8 mm inferior to the inferior tarsal border using three or four interrupted, hidden Vicryl sutures.
The focus then shifts to the formation of the lateral tarsal strip. The length of the strip is determined by pulling the edge of the lid laterally and marking the place on the lid margin where it touches the inner border of the lateral orbital rim with a Westcott scissor. With Westcott scissors or a bard parker blade, the lid margin and lashes are removed over this area. With scissors, a skin muscle flap is dissected from the anterior tarsal surface in this location. Scissors are used to make an incision through the conjunctiva and lower lid retractors along the inferior tarsal border of this segment. The conjunctiva on the posterior surface of the segment is then de-epithelialized with Westcott scissors or a blade. The strip is completed by clipping the tarsus in this place to a length of 2-3 mm using a vertical incision with scissors. To obtain good vision, dissection to the periosteum of the lateral orbital rim is performed using scissors and high-temperature cautery. From posterior to anterior, both arms of a double-armed Proline mattress suture are threaded through the tarsal strip, and each arm is then threaded through the periosteum of the lateral orbital rim internally. The suture is then tightened to the proper tension, allowing the lid to be moved 2-3 mm away from the globe. A deep, circular plain gut suture is used to repair the lateral canthal. Running plain gut is used to seal the skin of the lateral canthus. Ophthalmic ointment is applied to the wound and administered to the patient after surgery.
Conclusion
The surgical treatment of eyelid retraction necessitates a thorough examination of the patient. Both the time of surgery and the type of procedure chosen are critical and should be thoroughly discussed with the patient prior to the surgery. It's critical to emphasize the eyelid's variability in thyroid disease, as well as the limitations this condition places on the surgery's predictability. Reduce postoperative complications and enhance patient satisfaction by having a thorough discussion with the patient and using the proper procedure.