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Eyelid retraction
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
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Retraction with:
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No shortage of skin or conjunctiva
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Shortage of skin
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Shortage of conjunctiva
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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
11.1a
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 ).
11.1c
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 ).
11.1d
11.1e
11.1f
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.
Complications and management
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
11.2b
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.
11.2c
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.
Complications and management
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
11.3a
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.
11.3b
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.
11.3d
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.
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.
11.3f
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.
Complications and management
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.
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