Turn-over orbital septal flap and levator recession for upper-eyelid retraction secondary to thyroid eye disease

Background

A turn-over septal flap has been reported as a spacer for levator lengthening in a single case report. This study reports the preliminary outcomes of this technique in a series of patients with upper-lid retraction (ULR) associated with thyroid eye disease (TED) causing symptomatic exposure keratopathy (EK).

Methods

Retrospective, multicenter study of 12 eyelids of 10 patients with TED undergoing a transcutaneous levator-lengthening technique using the reflected orbital septum (OS) as a spacer. Change in palpebral aperture (PA) and contour, position of the skin crease (SC), symptoms of EK, and complications were recorded.

Results

The average age was 47.5 years. Two patients were excluded, as their septa were found to be very thin at surgery. At an average of 13 months postoperatively, the PA was reduced by 2.5 mm on average (P<0.001) and was within 1 mm of the contralateral eyelid in 11 cases (92%); the position of the SC was within 1 mm of the desired position in all cases. EK resolved in all cases. Complications included one case of overcorrection and one case of recurrent lateral flare.

Conclusions

The turn-over orbital septal flap technique may be a viable option as an autogenous spacer for the treatment of ULR in TED. This technique may be possible in cases where the OS has been opened by previous surgery but may not be feasible in patients in whom the septum is very thin.     

Surgical method and results of levator aponeurosis transposition for Graves' eyelid retraction

Predictability of final eyelid height and contour following surgical correction of eyelid retraction remains problematic. We describe our surgical method and results with the distal levator aponeurosis transposition procedure for eyelid retraction. The procedure consists of disinserting the distal levator aponeurosis from the tarsal plate and excising Muller's muscle. The lateral three-fifths of the distal aponeurosis is fashioned into a flap that is disinserted laterally, rotated inferiorly 90 degrees, and attached to the tarsal plate. Distal levator transposition is useful in the management of dysthyroid retraction and in the reduction of the margin reflex distance (MRD) asymmetry between upper eyelids. However, it shares with other eyelid lowering procedures, the disadvantage of poor predictability of final MRD.     

异体巩膜矫正甲状腺相关眼病上睑退缩并内翻

目的 评估异体巩膜移植延长上睑提肌矫正甲状腺相关眼病上睑退缩并内翻的疗效.方法 对17例（21眼）上睑退缩并内翻的静止期甲状腺相关眼病患者行异体巩膜移植延长上睑提肌矫正上睑退缩并内翻,观察其临床效果.结果 术后所有患者睑裂宽度均较术前缩小,差异有统计学意义（t=2.94,P=0.028）,患者自觉症状不同程度减轻或消失,随访6个月和1年无上睑退缩或内翻复发.结论 异体巩膜移植延长上睑提肌能有效矫正甲状腺相关眼病上睑退缩并内翻.     

Treatment of lower eyelid retraction by expansion of the lower eyelid with hyaluronic Acid gel

PURPOSE: To report our preliminary experience utilizing a nonsurgical alternative in the treatment of lower eyelid retraction: expansion and reinforcement of the lower eyelid with hyaluronic acid gel. METHODS: Retrospective review of patients with lower eyelid retraction treated with hyaluronic acid gel. Pretreatment, post-treatment, and follow-up photographs were digitized and overall outcomes assessed. Measurements of inferior scleral show were standardized and compared. RESULTS: Sixty-five procedures (31 patients; 14 male; mean age 58 years, range, 33-78 years) with lower eyelid retraction of various etiologies were treated with hyaluronic acid gel. A mean change in scleral show of 1.04 mm was found when pre- and post-treatment measurements were compared. The overall mean follow-up period was 6.2 months (range, 1-12 months). During the interval from initial treatment to follow-up visit (mean 4.6 months, range, 1-12 months), the effect of the hyaluronic acid gel diminished, with a mean increase in inferior scleral show of 0.52 mm. Twelve patients underwent a second, and 6 patients underwent a third, maintenance treatment with an improvement in scleral show of 0.87 mm and 1.13 mm, respectively. Complications were minor and included swelling, redness, bruising, and tenderness at the sites of injection. CONCLUSIONS: Based on our preliminary results, hyaluronic acid gel shows promise as a treatment modality for the management of lower eyelid retraction. Long-term follow-up will better clarify the required frequency of maintenance injections, the degree of hyaluronic acid gel retention, and the position of the lower eyelid over time.     

提上睑肌中央腱膜切断术治疗甲状腺相关眼病上睑退缩

目的：评估提上睑肌中央腱膜切断术矫正甲状腺相关眼病上睑退缩的临床疗效。方法：对35例52眼以上睑退缩为主要表现的静止期甲状腺相关眼病患者采用提上睑肌中央腱膜切断术矫正退缩的上睑,并观察其临床疗效。结果：术后所有患者上睑退缩均得以矫正,自觉症状不同程度减轻或消失。结论：提上睑肌中央腱膜切断术能有效矫正甲状腺相关眼病的中度上睑退缩。     

改良提上睑肌缩短术治疗重度先天性上睑下垂

目的 探讨重度先天性上睑下垂的手术方法。方法 对25例(32只眼)提上睑肌肌力为0～3mm的重度先天性上睑下垂患者行改良提上睑肌超常量缩短联合上横韧带徙前术。结果 32只眼术后上睑缘高度及弧度、重睑形成均良好。结论 改良提上睑肌超常量缩短术对矫正重度先天性上睑下垂效果良好。     

Levator-Muller's recession using labial mucosa as a spacer in severe eyelid retraction

ObjectiveTo evaluate the use of labial mucosa as a spacer for levator-Muller's recession in correction of severe eyelid retraction.DesignRetrospective interventional study.ParticipantsWe retrospectively reviewed records of 4 patients with severe upper eyelid retraction not associated with cicatricial diseases of the conjunctiva.MethodSurgical 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.ResultsThere 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).ConclusionsLabial 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.     

甲状腺相关眼病上睑退缩的治疗

目的：探讨甲状腺相关眼病上睑退缩的治疗方法。方法：回顾分析临床资料完整的90例123眼甲状腺相关眼病上睑退缩的治疗效果。治疗方法包括保守观察、全身和局部糖皮质激素治疗、局部肉毒杆菌毒素注射和手术治疗等。治疗后平均随访1．4年。结果：用全身和局部糖皮质激素治疗34例49眼中，上睑退缩完全消失4例6眼，明显改善13例20眼，无效17例23眼；局部肉毒杆菌毒素注射20例26眼中，上睑退缩完全消失8例9眼，明显改善9例11眼，无效3例6眼，持续时间6w至2年，注射后并发上睑下垂4例5眼；提上睑肌延长术11例15眼中，术后上睑退缩完全消失7例10眼，明显改善2例3眼，复发1例1眼，轻度过矫1例1眼；上睑退缩伴患眼下斜视15例15眼，行患眼下直肌后退术，其中术后上睑退缩完全消失14例14眼，明显改善1例1眼；10例18眼未作任何治疗，经平均2年随访观察发现2例4眼上睑退缩完全消失，1例2眼有明显改善。结论：甲状腺相关眼病上睑退缩宜采用综合治疗措施。发病初期或活动期病例用全身和局部糖皮质激素和局部注射肉毒杆菌毒素治疗效果好，静止期或保守治疗效果不好的患者宜行提上睑肌延长术治疗，伴有下斜视的患者行斜视矫正术可同时矫正斜视与上睑退缩。     

Treatment of upper eyelid retraction associated with thyroid eye disease with subconjunctival botulinum toxin injection

OBJECTIVE: To study the effectiveness of botulinum toxin injections, via a subconjunctival approach, in the management of upper eyelid retraction associated with thyroid eye disease. DESIGN: Prospective, non-comparative, interventional case series. PARTICIPANTS: Eleven patients with upper scleral exposure associated with thyroid eye disease who declined conservative or conventional surgical management. INTERVENTION: One or more treatments with injections of botulinum toxin into the subconjunctival space at the superior margin of the tarsal plate, via a conjunctival approach. MAIN OUTCOME MEASURES: Upper eyelid position in relation to the upper limbus, patient satisfaction, and complications. RESULTS: All patients experienced some improvement in the amount of lid retraction after injections. The amount of lid lowering varied between patients and lasted between 1 and 40 months. A lid position acceptable to the patient was obtained in 10 patients. Four patients had ptosis lasting from 1 to 3 weeks, and three patients had transient diplopia lasting 1 day to 3 weeks. CONCLUSIONS: This subconjunctival method of botulinum toxin injection provides an effective treatment for upper eyelid retraction associated with thyroid eye disease that is easy to administer and well tolerated by patients with few side effects.     

下直肌后退联合下睑筋膜头分离复位在甲状腺相关眼病患者斜视矫正术的应用

目的探讨甲状腺相关眼病患者下直肌后退术中下睑退缩的防治措施。方法 回顾性病例研究。广州中山大学中山眼科中心2007年1月至2011年12月行下直肌后退术的甲状腺相关眼病患者24例,其中男18例,女6例;平均年龄（47.8±10.7）岁。甲状腺相关眼病患者下直肌后退术中除充分分离下直肌与下睑的联系外,同时将与下直肌相联的下睑筋膜头分离并标记,下直肌后退后将下睑筋膜头缝回到下直肌原肌止点处。结果 下直肌后退量2.5～8.0 mm,平均为（5.31±1.16）mm,仅5例在术后出现轻度的下睑退缩,术后下睑位置总量改变为0。2例患者显示下方巩膜暴露,但睑裂大小无改变。所有患者术后无下睑其他外观改变。结论 下直肌后退术中充分分离下睑与下直肌的联系,同时分离下睑筋膜头并缝回到下直肌原肌止点处可有效防治甲状腺相关眼病患者下直肌后退术后的下睑退缩。     

Upper eyelid retraction from inferior rectus restriction in dysthyroid orbit disease

Findings from orbital computed tomography scans have shown inflammatory enlargement of the levator palpebralis superioris complex to be a likely cause of eyelid retraction in dysthyroid (Graves's) ophthalmopathy. We have studied a subgroup of nine dysthyroid patients in whom the eyelid retraction occurs as a relative malposition of the globe and eyelid due to inferior rectus restriction. Our explanation of this phenomenon in nine patients is based on Hering's law. Increased innervation required for a fixating superior rectus muscle to overcome a severely restricted inferior rectus muscle causes an unrestricted levator muscle to open the eyelid abnormally wide relative to the globe. The retraction is best demonstrated with fixation of the involved eye. We have performed inferior rectus recession to correct this type of eyelid retraction in three of our patients.     

Correction of lower eyelid retraction with a porous polyethylene (Medpor) lower eyelid spacer--Medpor spacer in lower eyelid retraction

BACKGROUND: The correction of lower eyelid retraction remains a challenge with established techniques having disadvantages. A recently described alternative is implantation of an ultrathin high density porous polyethylene lower eyelid spacer (Medpor LES). We report our experience on implanting this Medpor LES, especially in patients with lower eyelid retraction due to Graves' orbitopathy. PATIENTS AND METHODS: All patients receiving a Medpor LES between March 2003 and November 2004 in the Rotterdam Eye Hospital were included. Indications and preceding procedures as well as the degree of proptosis were noted. Preoperative and postoperative lower eyelid retraction were compared by measuring scleral show inferior to the limbus (LSS). Postoperative complications, recurrent retraction and secondary surgical procedures were recorded. RESULTS: Out of 12 patients (16 eyelids) in whom a Medpor LES was inserted 8 patients suffered from Graves' orbitopathy. Mean follow-up was 7.5 months (range 4 - 11 months). Final cosmetic outcome was good in 8/16 eyelids and improved in 7/16 eyelids. Lower eyelid retraction (LSS) was reduced significantly (1.34 mm +/- 0.214 (mean +/- std. error of mean), p = 0.004). Complications included eyelid contour deformity (4/16 eyelids), remaining irritation of the eye (1/16) and problems in down gaze (4/16) as well as recurrent lower eyelid retraction (2/16) requiring further surgery in 3 of 11 patients. CONCLUSIONS: In selected patients, insertion of a Medpor lower eyelid spacer may be a good alternative to correct lower eyelid retraction.     

Anatomic considerations in upper eyelid retraction

A series of anatomically correct orbital drawings are created to examine the major integrating factors that determine upper eyelid position on the eye. The principal upper eyelid force planes can be identified as (1) the eyelid vertical retractor plane slightly divergent from the orbital axis, (2) the eyelid protractor plane nearly tangent to the orbital aperture, and (3) the upper eyelid tarsalligamentous plane swinging from within the horizontal orbital rims. These forces are governed by variation in orbital size and shape, globe size and position, and the length-tension characteristics of the eyelid retractors, protractors, and lamellae. Enhanced lateral upper eyelid retraction occurs in part because the eye in primary position looks away from the orbital axis and projects more lateral sclera. When the eye gazes laterally, coincident with the orbital axis, enhanced lateral upper eyelid retraction disappears.