Neelam Pushker, Rachna Meel, Mandeep S. Bajaj
To evaluate the use of labial mucosa as a spacer for levator-Muller’s recession in correction of severe eyelid retraction.
Retrospective interventional study.
We retrospectively reviewed records of 4 patients with severe upper eyelid retraction not associated with cicatricial diseases of the conjunctiva.
Surgical correction of eyelid retraction was performed by Levator-Muller’s recession using autologous mucosal graft (from lip) as a spacer through transconjunctival approach. Eyelid height and contour were the main outcome measures evaluated after surgery.
There was resolution of dry eye symptoms in all 4 cases. In 2 cases the corrected eyelid height was within 1 mm of the desired lid position. The lid contour was good in 2 cases and satisfactory in 2 cases because of mild lateral flare. The eyelid height remained stationary till the last follow-up, which ranged from Eyelid height and contour were the main outcome measures evaluated after surgery. 6–30 months (mean: 18 months).
Labial mucosal graft as a spacer for levator-Muller’s recession is a good option for correction of severe upper eyelid retraction. It provides stable eyelid position within 3 months of surgery with no corneal complications.
Nahyoung Grace Lee, Larissa Habib, Jonathan Hall & Suzanne K. Freitag
Purpose: To report a simple, highly effective technique of simultaneous transconjunctival repair of upper and lower eyelid retraction in patients with thyroid eye disease (TED).
Methods: A retrospective interventional case review was conducted on 22 eyes of 19 TED patients. The lower eyelid was recessed with placement of a tarsoconjunctival spacer graft harvested from the upper eyelid. The upper eyelid was then recessed through the conjunctival incision used to harvest the tarsal graft. A temporary tarsorrhaphy was placed for 5–7 days. The postoperative outcome was assessed by measuring the margin reflex distance of the upper eyelid (MRD1), inferior scleral show (ISS), and lagophthalmos.
Results: The absolute change in MRD1 ranged from 0 to 5 mm with an average of 1.86 ± 1.34 mm. The absolute change in ISS ranged from 0 to 2 mm with an average of 1.3 ± 0.49 mm. One patient had postoperative lagophthalmos and 17 of 19 had improvement in their ocular surface exposure symptoms. None of the patients’ grafts were observed to undergo absorption during the postoperative course.
Conclusions: This technique of harvesting a free tarsoconjunctival graft from the upper eyelid as a posterior spacer for the lower while simultaneously recessing the upper eyelid through the same incision is an effective and durable method of correcting eyelid retraction in TED.
Segal, Kira L.; Elner, Susan G.; Elner, Victor M.
Purpose: To evaluate the results of permanent medial tarsorrhaphy and to describe the surgical technique.
Methods: Medial tarsorrhaphy was performed on 30 eyelids with symptomatic exposure keratopathy secondary to eyelid malposition. Observational, retrospective review of preoperative and postoperative examination findings was performed.
Results: Average age of the cohort was 66 years (31–91). Medial tarsorrhaphy was performed to correct eyelid retraction (100%), exposure keratopathy (80%), lagophthalmos (57%), and ectropion (17%) in patients with cranial nerve VII palsy (47%), Graves eye disease (13%), eczema (7%), floppy eyelid syndrome (7%), after Mohs reconstruction (7%), orbital myositis (3%), and neurofibromatosis (3%). Seventy-three percent (73%) of patients had an average of 3 surgeries (N = 22, standard deviation = 1.12, range = 2–7) before undergoing medial tarsorrhaphy. Medial tarsorrhaphy was performed in combination with another procedure in 53% of cases. Palpebral fissure decreased postoperatively an average of 1.1 mm (N = 20; p = 0.005), inferior scleral show decreased 0.72 mm (N = 22; p = 0.03), lagophthalmos decreased 0.4 mm (N = 15; p = 0.27), and superficial punctate keratopathy improved by 61% (N = 27; p = 0.009). Ectropion completely resolved in 4 of 10 patients (40%). Seven patients (23%) required additional surgery following tarsorrhaphy an average of 8 months later (range = 2–16). In 1 patient (3%), a tarsorrhaphy opened prematurely, and 1 patient (3%) requested partial opening of the tarsorrhaphy. Average duration of follow up was 13 months (N = 30, standard deviation = 14.97, range = 0.2–45.7).
Conclusions: Medial tarsorrhaphy is a safe and effective primary or salvage technique to address complex causes of eyelid retraction, lagophthalmos, ectropion, and exposure keratopathy.
Jun Soo Byun, Jeong Kyu Lee
To assess the relationships between eyelid position and levator palpebrae superioris (LPS)-superior rectus (SR) complex and inferior rectus (IR) muscle volume in patients with Graves’ orbitopathy (GO) with unilateral upper eyelid retraction.
This was a cross-sectional observational study of 48 patients with GO with unilateral upper eyelid retraction. To measure muscle volume, computerized tomography scans were performed, and 3D images were analyzed. Digital photographs were taken, and vertical eyelid height was measured using computed eyelid analysis software. The measured muscle volumes and eyelid heights were assessed, and correlation analysis was performed. To verify the parameters that are predictive for the presence of upper eyelid retraction, receiver operating characteristic curves were analyzed, and logistic regression was performed.
The volume of the LPS/SR muscle complex in the eyes with upper eyelid retraction was increased in 41 eyes (85.4%). The mean volume of the LPS/SR complex was 0.92 ± 0.40 cm3 in the eyes with upper eyelid retraction and 0.72 ± 0.27 cm3 in the contralateral eyes (p < 0.0001). While there was no correlation between LPS/SR complex volume and margin reflex distance1 (MRD1, the vertical distance between the center of the pupil to the center of the upper eyelid margin) (R = 0.024, p = 0.869), MRD1 and MRD2 (the vertical distance between the center of the pupil and the center of the lower eyelid margin) in the retracted eyes were negatively correlated (R = − 0.441, p = 0.002). In patients with upper eyelid retraction without increased LPS/SR complex volume, IR volume and MRD2 of the contralateral eye were 0.48 ± 0.10 cm3 and 5.92 ± 0.45 mm, respectively. In the retracted eye, they were 0.37 ± 0.17 cm3 and 5.32 ± 0.59 mm, respectively (p = 0.018, and 0.028). Regression models incorporating LPS/SR complex volume, MRD1, and lid lag could predict the presence of upper eyelid retraction with an accuracy of 92.5%.
In patients with GO, increased LPS/SR complex volume in the retracted eye and increased IR volume of the contralateral eye were both associated with unilateral upper eyelid retraction. The combination of LPS/SR complex volume, MRD1, and lid lag can be used as a reliable index of upper eyelid retraction in patients with GO.
Katherine Anne Mcveigh, Rhys Harrison & Rebecca Ford
We aim to provide a snapshot of the current surgical practice for correction of entropion and ectropion, the two most common oculoplastic procedures carried out in the UK, by surveying 135 consultant oculoplastic surgeons via the tool Survey Monkey. Forty-seven (35%) consultants responded. For entropion, 44% of surgeons opted for lateral tarsal strip (LTS) + everting sutures (ES). Other first-line choices included LTS + transcutaneous retractor plication (21%), Quickert’s procedure (14%), ES (7%), and Wies procedure (5%). Important patient-related factors to consider were horizontal lid laxity and retractor dehiscence.
Regarding ectropion, LTS was most commonly practiced (35%), followed by LTS + transconjunctival retractor plication (28%), wedge excision (16%), and lateral canthoplasty (5%). The patient-related factors guiding choice were horizontal lid laxity, lateral canthal tendon laxity, and punctal position under traction. Responses found a wide range of preferred surgical techniques in practice. The factors guiding surgical choice were personal audit results (92% stated important/very important), familiarity with the technique (92%), and the technique being favoured by previous trainers (76%), suggesting current practice led by expert opinion, possibly due to a lack of evidence-based literature. This highlights the variety of core oculoplastic surgical techniques practiced and underlines the need for robust trials to guide surgical choice.
Slean, Geraldine R.; Silkiss, Rona Z.
Several antineoplastic treatments have been responsible for thyroid dysfunction and thyroid eye disease. Min, Vaidya, and Becker (2011) reported a case of euthyroid Graves orbitopathy after treatment with ipilimumab with the patient displaying proptosis and myositis in the setting of normal thyroid function tests and elevated thyroid antibodies. The authors report a case of a 76-year-old woman who developed right upper lid retraction and proptosis after 2.5 years of treatment with lenalidomide for multiple myeloma. Thyroid function tests were normal: thyroid-stimulating hormone 0.808 mIU/mL, total T3 102 ng/dL, free T4 1.48 ng/dL. Thyroid antibodies were elevated: thyrotropin receptor antibody 2.26 IU/L, thyroglobulin antibody 1043.1 IU/mL, and thyroid peroxidase antibody 38 IU/mL. A nuclear medicine thyroid scan was normal. Given the possible thyroid effects from lenalidomide, patients who receive this medication should be periodically evaluated for thyroid dysfunction and thyroid eye disease.
Jordan, David R. M.D., F.R.C.S.C, F.A.C.S.; Mainville, Norman M.D., F.R.C.S.C.; Klapper, Stephen R. M.D., F.A.C.S.
Rootman, Daniel B. M.D. M.S.; Golan, Shani M.D.; Pavlovich, Peter M.D.; Rootman, Jack M.D., F.R.C.S.C.
Kirkpatrick, Christopher A.; Shriver, Erin M.; Clark, Thomas J. E.; Kardon, Randy H.
Purpose: To describe the change in upper eyelid position in a self-reportedly normal population after the administration of topical 0.5% apraclonidine in each eye.
Methods: One hundred self-reportedly normal subjects received a 1-time administration of topical 0.5% apraclonidine in each eye. Digital photographs were taken at baseline and then 30 and 45 minutes following apraclonidine instillation. Marginal reflex distance 1 was determined via image analysis of acquired digital photographs (image-derived measurements are given the prefix “i” in this study). The horizontal corneal diameter was used as a constant measurement scale in each photograph.
Results: The mean increase in i-marginal reflex distance 1 post-administration of 0.5% apraclonidine was +0.70 ± 0.60 mm (range, −0.94 to +2.66 mm) after 30 minutes and +0.68 ± 0.59 mm (range, −0.69 to +2.54 mm) after 45 minutes. Of the 200 total eyelids in 100 subjects, 181 (90.5%) had an increase in i-marginal reflex distance 1 at 30 minutes. Of the 100 subjects, 85 (85%) had a bilateral increase in i-marginal reflex distance 1, 4 (4%) had a bilateral decrease, and 11 (11%) had a unilateral increase with a contralateral decrease.
Conclusions: Given its predominant small-amplitude upper eyelid elevating effect, topical apraclonidine may be a useful off-label alternative treatment for mild upper eyelid ptosis and in eyelid asymmetry due to eyelid retraction through use in the contralateral eye.
Arif O. Khan, Zabila Khan
Congenital cranial dysinnervation disorders are developmental abnormalities of cranial nerves that often include abnormal synkinesis. Among the most common ophthalmic congenital cranial dysinnervation disorders are Duane retraction syndrome and the Marcus-Gunn jaw-winking phenomenon. This report documents gustatory lid retraction as an unusual congenital cranial dysinnervation.