- Email: [email protected]
The Surgical Management of Thyroid-related Upper Eyelid Retraction
The Surgical Management of Thyroid-related Upper Eyelid Retraction RA Y DIXON, MD
Abstract: Excision of Moller's muscle can usually correct thyroidrelated upper eyelid retraction, A transcutaneous approach to Moller's muscle was used in 22 eyelids, The findings at surgery included diffuse eyelid scarring, disinsertion of the levator aponeurosis, fat herniation, 'and changes resembling dermatochalasis, Identification and correction of these factors, complemented anterior resection of Moller's muscle and influenced final eyelid position and cosmesis , [Key words: eyelid retraction surgery,] Ophthalmology 89:52-57, 1982
Upper eyelid retraction is frequently related to a thyroid disorder. Correction may be necessary to improve eyelid function and protection for the globe or for cosmetic reasons. Various pharmacological agents have been investigated in the management of thyroidrelated retraction. Of these, the best results are obtained with sympatholytic agents such as guanethidine and thymoxamine, but they do not offer a long lasting, comfortable, and convenient form of treatment. 1 The response to these drugs confirms the role of sympathetically innervated Muller' s muscle. The surgical methods for the correction of upper eyelid retraction include: levator tenotomy 2.3 or recession,4.5 Muller's muscle resection 6 • 7 or myectomy 5 and combined levator tenotomy and Mullerectomy. 6.7 Procedures aimed at the levator aponeurosis are sometimes associated with poor results, and best results are obtained from those procedures that include meticulous excision of Muller's muscle. 6 However, it has been realized that there is a non-hormonal component of retraction, and there is now awareness of other causes for retraction. These include eyelid inflammation, levator action, and subcutaneous adhesions. 8 In addiFrom the Department of Ophthalmology, Henry Ford Hospital, Detroit, Michigan , Presented in part at the Eighty-fifth Annual Meeting of The American Academy of Ophthalmology, Chicago, November 2-7, 1980, Reprint requests to Ray Dixon, MD, Henry Ford Hospital, 2799 W. Grand Boulevard, Detroit, MI 48202,
52
tion, there are sometimes other eyelid changes that affect eyelid position and cosmesis. The ideal surgical method should allow identification of Muller's muscle and eyelid abnormalities, which may contribute to retraction, eyelid position, and cosmesis. This report outlines such a procedure, used in 22 eyelids , that approaches these goals. In this series, insertional abnormalities of the levator aponeurosis were identified in eyelids with as much as 8 mm of retraction.
PATIENT SELECTION AND MANAGEMENT Twelve patients were treated surgically for upper eyelid retraction to relieve exposure keratitis and/or for cosmetic effect. There were 11 females and one male. All were euthyroid with stable eyelid and orbital involvement for at least six months prior to surgery. Ten patients had bilateral correction, the remaining two , unilateral correction (Table O. Each patient was evaluated before operation to exclude optic neuropathy and other eyelid and orbital pathology. Retraction was measured in millimeters from the upper limbus to the eyelid margin. Eyelid height, contour, crease , and levator excursion were recorded. Medication included 50-75 mg of meperidine and 5-10 mg of diazepam given intramuscularly 45 minutes before surgery. An intravenous infusion 0161-6420/8210100/0521$00.80 © American Academy of Ophthalmology
DIXON • THYROID-RELATED UPPER EYELID RETRACTION
Table 1. Patient Summary Retraction:j: (mm)
Reduction of Retractiont (mm)
Patient Number
Age
Sex
00
as
Procedures
00
as
1·
55
F
6
5
6
5
2·
61
F
6
5
6
5
3·
42
F
8
8
8
8
4
47
F
2
3
5
53
F
5
5
6·
38
F
3
3
7
70
F
5
3
8
44
F
4
4
9
53
F
3
3
10· 11·
46 61
F F
7
7 3
12
21
M
Mullerectomy Fat Excision Blepharoplasty Mullerectomy Blepharoplasty Mullerectomy Blepharoplasty Mullerectomy Excision of scar tissue Blepharoplasty Mullerectomy Fat Excision Blepharoplasty Mullerectomy Excision of scar tissue Blepharoplasty Mullerectomy Blepharoplasty Mullerectomy Blepharoplasty Mullerectomy Fat excision Blepharoplasty Mullerectomy Mullerectomy Fat exci si 0 n Mullerectomy
4
2 5
5
3
3
4
3
4
4
3
3
7
7 3 3
• Disinsertion of the levator aponeurosis identified at surgery. = mm difference in pre- and post-operative palpebral fissure. Retraction measured (mm) from limbus to eyelid margin.
*
t Reduction retraction
set up at surgery allowed supplemental medication and intravenous fluids. All cases were operated in the supine position under local anesthesia by the author. Assessment of eyelid height during the procedure was done by sitting the patient up with assistance. In bilateral cases, both eyelids required identical surgery and were operated at the same sitting. Mullerectomy was necessary in all cases. The surgical method allowed correction of abnormalities seen both clinically and at surgery.
The levator aponeurosis normally lies beneath the orbital fat superiorly and extends horizontally to insert on the anterior tarsal surface. If it was disinserted, Muller's muscle could be seen to be continuous with the superior tarsal border, since it was no longer cov-
SURGICAL METHOD Prior to anesthetic infiltration, the lowest eyelid skin crease was marked, and in patients with excess skin, this was also outlined. Anesthesia was obtained with topical proparacaine and subcutaneous 2% xylocaine with 11100,000 epinephrine. After the skin crease incision, the orbicularis was separated into the pretarsal and preseptal segments by sharp scissors. Orbital septum could be identified in a plane beneath orbicularis and was often thickened and scarred (Fig 1). Excision of scar tissue was done after identification and inspection of the aponeurosis.
Fig 1. Surgical method. Upper eyelid is on stretch. Retractors grasp skin and orbicularis muscle. Orbital septum is thick and scarred.
53
OPHTHALMOLOGY • JANUARY 1982 • VOLUME 89 • NUMBER 1
ered by aponeurosis (Fig 2). Muller's muscle was further identified by its horizontal vessels. 9 A dis inserted aponeurosis fused to the orbital septum anterior to the orbital fat pad was an occassional finding (Fig 2). An intact aponeurosis should be dis inserted from its tarsal insertion to allow access to Muller's muscle. By carefully injecting .25-.5 ml of xylocaine with epinephrine beneath Muller's muscle, additional anesthesia and hemostasis could be obtained, and the muscle was ballooned from the conjunctiva. Starting at the midtarsal border, the muscle was tented upwards with fine-toothed forceps and opened with iris scissors. A plane beneath Muller's muscle could be achieved easily in most cases, but with difficulty where there was a long history of inflammation. Once in this plane, blunt dissection allowed separation of Muller's muscle from the conjunctiva. Small conjunctival button holes could be repaired with fine absorbable sutures tied anteriorly. Stripping of this muscle was continued to the fornix. Temporally, careful dissection prevented injury to the palpebral lacrimal gland. The entire muscle was then excised (Fig 3). Meticulous excision of herniating orbital fat at this time can improve the cosmetic result. The desired eyelid· height was achieved by reinserting the aponeurosis on the anterior surface of conjunctiva or tarsus. In cases with disinsertion prior to surgery, it was necessary to separate the aponeurosis from orbital septum before reinsertion (Fig 4). Excess skin was excised as estimated. Skin closure was done with interrupted or continuous 6-0 nylon sutures. A 4-0 black silk eyelid traction suture taped to the cheek for 24 hours helped to main-
Fig 3. After stripping Miiller's muscle from conjunctiva, complete excision is performed.
tain the correction achieved at surgery. A firm bandage was applied and could be removed on the morning after surgery. Patients received frequent ocular lubrication in the postoperative period and could be discharged on the day after surgery.
RESULTS Retraction was adequately corrected in all cases, and the patients were pleased with the cosmetic out-
Fig 2. Aponeurosis disinsertion. Miiller's muscle is not covered by aponeurosis and is identified by horizontal vessels (h) and at insertion to superior tarsal border. Disinserted aponeurosis (A) is indistinguishable from septum anterior to orbital fat. Fold in aponeurosis (arrow) is not true lower edge.
54
Fig 4. Mobilization of disinserted aponeurosis by separation from orbital septum.
DIXON • THYROID-RELATED UPPER EYELID RETRACTION
come. In addition to Mullerectomy, the following procedures were performed: blepharoplasty (18 eyelids), excision of scar tissue beneath the orbicularis (4 eyelids), and excision of herniating orbital fat (7 eyelids) (Table 1). Disinsertion of the levator aponeurosis was seen in 11 eyelids (Table 1), two of which required reinsertion for symmetry by the first week after surgery. Cases 1, 2, and 3 are illustrated further.
CASE REPORTS Case 1. A 55-year-old chemically euthyroid female with a long history of retraction was referred for management of exposure keratitis. Exophthalmometer readings were 24 bilaterally. There was 6 mm upper eyelid retraction on the right and 5 mm on the left (Fig 5). Slit-lamp examination showed central and inferior punctate corneal staining bilaterally. At surgery, disinsertions of the aponeurosis were identified (Fig 6) but not repaired. Muller's muscle, herniating orbital fat, and excess skin were excised. Twenty-one months after surgery, there was complete correction on both sides, right lower eyelid entropion (Fig 7), and evidence of aponeurosis disinsertions (Fig 8). Case 2. A 61-year-old hypothyroid female with a two-year history of stable eyelid retraction and exophthalmos was evaluated in May 1979. There was obvious exophthalmos and upper eyelid retraction measured 6 mm on the right and 5 mm on the left (Fig 9). Slit-lamp examination showed diffuse upper corneal staining. In August 1979, resection of Muller's muscle was performed. Aponeurosis disinsertions seen at surgery were not repaired. Excess eyelid skin was excised bilaterally after Mullerectomy. When last seen in September 1980, there was no retraction, and the upper eyelids protected the globes (Fig 10). Case 3. A 42-year-old euthyroid female had a two-year history of stable exophthalmos with final exophthalmometer readings of 21. There was 8 mm upper eyelid retraction bilaterally (Fig 11). Muller's muscle was approached through an anterior incision. The levator aponeurosis on either side was found disinserted and fused to orbital septum anterior to the orbital fat pad. Bilateral Mullerectomy corrected retraction on the right, but produced 2 mm overcorrection on the left. This was overcome by dissecting the free edge of the aponeurosis and reinserting it on the conjunctiva above tarsus seven days after surgery. Twelve months after initial surgery, palpebral fissures measured equal at 9 mm (Fig 12).
Fig 5. Case 1: Before operation upper eyelid retraction measured 6 mm on the right and 5 mm on the left.
Fig 6. Case 1: Disinsertion of levator aponeurosis at surgery; forceps holds disinserted edge of aponeurosis.
Fig 7. Case 1: Twenty-one months after bilateral repair of upper eyelid retraction. Right lower eyelid entropion has also developed.
DISCUSSION Thyroid-related retraction may be seen as an isolated finding or in combination with other eyelid and orbital changes, and can be seen in various thyroid metabolic states. 10 There is good inference of diffuse orbital and eyelid involvement even in cases appearing to have only eyelid retraction. 10 Reduction of retraction after topical administration of sympatholytic agents proves sympathetic overaction or hypersensitivity in this condition. A hormonal basis for retraction is further supported by its variability, which may be related to the general sympathetic discharge. Circulating thyroid hormones may contribute to retraction by potentiating the effect of catecholaminesy,12 Muller's muscle is the only sympathetically innervated eyelid structure, and in many cases, it accounts for all upper eyelid retraction. With time, other causes of retraction may be operative, as early cases respond to-
55
OPHTHALMOLOGY. JANUARY 1982 • VOLUME 89 • NUMBER 1
Fig 11. Case 3: 8 mm bilateral upper eyelid retraction and stable endocrine exophthalmos.
Fig 8. Case 1: After repair of upper eyelid retraction. Cornea seen through thinned eyelid. In thin areas only conjunctiva and skin remain above the tarsus and the aponeurosis is disinserted.
Fig 12. Case 3: Twelve months after repair. The eyelids now protect the globes.
Fig. 9. Case 2: Stable orbitopathy with 6 mm right and 5 mm left eyelid retraction.
Fig 10. Case 2: Thirteen months after bilateral Miillerectomy and blepharoplasty.
tally to adrenergic blockade, whereas the response in longstanding cases can be incomplete. 1 Other factors that produce retraction include contraction and fibrosis of the levator muscle and adhesions between the levator and the overlying tissues. 8 Pharmacological testing in retracted eyelids could theoretically separate mechanical causes from the hormonal component of retraction. Failure to recognize all factors contributing to retraction may explain poor results noted with some surgical methods. Other findings in retracted upper eyelids include: scar tissue, skin changes resembling
56
dermatochalasis, fat herniation, tissue laxity, and disinsertion of the levator aponeurosis. Insertional abnormalities of the levator aponeurosis were identified in 11 eyelids at surgery. These were not evident on clinical evaluation. Similar changes explain many types of acquired ptosis, such as senile ptosis, 9 neuromyopathic ptosis,1a ptosis after cataract surgery,9.14 and following trauma. 9 Its occurrence in eyelids with thyroid-related retraction is surprising, but serves to emphasize that there are no uniform findings in all such eyelids. Eyelid inflammation and edema, which often precede retraction in these patients, could explain these changes. This etiology has also been postulated for disinsertions after cataract surgery .14 Procedures aimed at the levator aponeurosis are, therefore, not appropriate for all patients with retraction. At surgery for retraction, a disinserted aponeurosis may be reinserted appropriately for the desired eyelid height and contour. Thus, in case 3, reinsertion on the left was effective in overcoming overcorrection. As in case 1, it is not always necessary to reinsert the aponeurosis. At 21 months after surgery, this patient showed clinical evidence of dis insertions, even though the palpebral fissures were adequate. Also, lower eyelid entropion in this patient may have been caused by retractor disinsertion, a wellrecognized finding in acquired lower eyelid entropion. Insertional abnormalities of the levator aponeurosis in normal eyelids are commonly associated with blepharoptosis of varying degrees, and correction is usually necessary. In retracted eyelids, these findings
DIXON • THYROID-RELATED UPPER EYELID RETRACTION
require individual considerations and can complement surgical repair of retraction. Surgery to correct upper eyelid retraction should, therefore, be aimed primarily at Miiller's muscle, but allow identification and correction of abnormalities that contribute to retraction, eyelid function, and cosmesis. An anterior surgical approach facilitates recognition and correction of all eyelid changes and has the following additional advantages: the conjunctiva is not incised, there are no sutures next to the globe, inspection of all eyelid structures is possible, excess skin and herniated orbital fat can be excised, and there is less risk of damage to the lacrimal ducts that open at the supratemporal aspect of the palpebral conjunctiva and fornix. This method allows early discharge from hospital.
REFERENCES 1. Dixon RS, Anderson RL, Halt MU. The use of thymoxamine in eyelid retraction. Arch Ophthalmol, 1979; 97:2147-50. 2. Blaskovics L, cited by Berens C, King JH Jr. Atlas of Ophthalmic Surgery. Philadelphia: JP Lippincott, 1961; 76. 3. Henderson Jw. Relief of eyelid retraction: a surgical procedure. Arch Ophthalmol 1965; 74:205-16.
4. Goldstein I. Recession of the levator muscle for lagophthalmos in exophthalmic goiter. Arch Ophthalmol 1934; 11 :389-93. 5. Baylis HI, Cies WA, Kamin DF. Correction of upper eyelid retraction. Am J Ophthalmol 1976; 82:790-94. 6. Putterman AM, Urist M. Surgical treatment of upper eyelid retraction. Arch Ophthalmol 1972; 87:401-5. 7. Chalfin J, Putterman AM. MOiler's muscle excision and levator recession in retracted upper eyelid; treatment of thyroid-related retraction. Arch Ophthalmol 1979; 97:1487-91. 8. Grove AS Jr. Levator lengthening by marginal myotomy. Arch Ophthalmol 1980; 98:1433-8. 9. Anderson RL, Dixon RS. Aponeurotic ptosis surgery. Arch Ophthalmol1979; 97:1123-8. 10. Hodes BL, Frazee L, Szmyd S. Thyroid orbitopathy: an update. Ophthalmic Surg 1979; 10(11):25-33. 11. Coulombe P, Dussault JH, Jetarte J. Catecholamines metabolism in thyroid diseases. I. Epinephrine secretion rate in hyperthyroidism and hypothyroidism. J Clin Endocrinol Metab 1976; 42:125-31. 12. Coulombe P, Dussault JH, Walker P. Catecholamine metabolism in thyroid disease. II. Norepinephrine secretion rate in hyperthyroidism and hypothyroidism. J Clin Endocrinol Metab 1977; 44:1185-9. 13. Anderson RL, Dixon RS. Neuromyopathic ptosis: a new surgical approach. Arch Ophthalmol1979; 97:1129-31. 14. Paris GL, Quickert MH. Disinsertion of the aponeurosis of the levator palpebrae superioris muscle after cataract extraction. Am J Ophthalmol 1976; 81 :337 -40.
57
Abstract: Excision of Moller's muscle can usually correct thyroidrelated upper eyelid retraction, A transcutaneous approach to Moller's muscle was used in 22 eyelids, The findings at surgery included diffuse eyelid scarring, disinsertion of the levator aponeurosis, fat herniation, 'and changes resembling dermatochalasis, Identification and correction of these factors, complemented anterior resection of Moller's muscle and influenced final eyelid position and cosmesis , [Key words: eyelid retraction surgery,] Ophthalmology 89:52-57, 1982
Upper eyelid retraction is frequently related to a thyroid disorder. Correction may be necessary to improve eyelid function and protection for the globe or for cosmetic reasons. Various pharmacological agents have been investigated in the management of thyroidrelated retraction. Of these, the best results are obtained with sympatholytic agents such as guanethidine and thymoxamine, but they do not offer a long lasting, comfortable, and convenient form of treatment. 1 The response to these drugs confirms the role of sympathetically innervated Muller' s muscle. The surgical methods for the correction of upper eyelid retraction include: levator tenotomy 2.3 or recession,4.5 Muller's muscle resection 6 • 7 or myectomy 5 and combined levator tenotomy and Mullerectomy. 6.7 Procedures aimed at the levator aponeurosis are sometimes associated with poor results, and best results are obtained from those procedures that include meticulous excision of Muller's muscle. 6 However, it has been realized that there is a non-hormonal component of retraction, and there is now awareness of other causes for retraction. These include eyelid inflammation, levator action, and subcutaneous adhesions. 8 In addiFrom the Department of Ophthalmology, Henry Ford Hospital, Detroit, Michigan , Presented in part at the Eighty-fifth Annual Meeting of The American Academy of Ophthalmology, Chicago, November 2-7, 1980, Reprint requests to Ray Dixon, MD, Henry Ford Hospital, 2799 W. Grand Boulevard, Detroit, MI 48202,
52
tion, there are sometimes other eyelid changes that affect eyelid position and cosmesis. The ideal surgical method should allow identification of Muller's muscle and eyelid abnormalities, which may contribute to retraction, eyelid position, and cosmesis. This report outlines such a procedure, used in 22 eyelids , that approaches these goals. In this series, insertional abnormalities of the levator aponeurosis were identified in eyelids with as much as 8 mm of retraction.
PATIENT SELECTION AND MANAGEMENT Twelve patients were treated surgically for upper eyelid retraction to relieve exposure keratitis and/or for cosmetic effect. There were 11 females and one male. All were euthyroid with stable eyelid and orbital involvement for at least six months prior to surgery. Ten patients had bilateral correction, the remaining two , unilateral correction (Table O. Each patient was evaluated before operation to exclude optic neuropathy and other eyelid and orbital pathology. Retraction was measured in millimeters from the upper limbus to the eyelid margin. Eyelid height, contour, crease , and levator excursion were recorded. Medication included 50-75 mg of meperidine and 5-10 mg of diazepam given intramuscularly 45 minutes before surgery. An intravenous infusion 0161-6420/8210100/0521$00.80 © American Academy of Ophthalmology
DIXON • THYROID-RELATED UPPER EYELID RETRACTION
Table 1. Patient Summary Retraction:j: (mm)
Reduction of Retractiont (mm)
Patient Number
Age
Sex
00
as
Procedures
00
as
1·
55
F
6
5
6
5
2·
61
F
6
5
6
5
3·
42
F
8
8
8
8
4
47
F
2
3
5
53
F
5
5
6·
38
F
3
3
7
70
F
5
3
8
44
F
4
4
9
53
F
3
3
10· 11·
46 61
F F
7
7 3
12
21
M
Mullerectomy Fat Excision Blepharoplasty Mullerectomy Blepharoplasty Mullerectomy Blepharoplasty Mullerectomy Excision of scar tissue Blepharoplasty Mullerectomy Fat Excision Blepharoplasty Mullerectomy Excision of scar tissue Blepharoplasty Mullerectomy Blepharoplasty Mullerectomy Blepharoplasty Mullerectomy Fat excision Blepharoplasty Mullerectomy Mullerectomy Fat exci si 0 n Mullerectomy
4
2 5
5
3
3
4
3
4
4
3
3
7
7 3 3
• Disinsertion of the levator aponeurosis identified at surgery. = mm difference in pre- and post-operative palpebral fissure. Retraction measured (mm) from limbus to eyelid margin.
*
t Reduction retraction
set up at surgery allowed supplemental medication and intravenous fluids. All cases were operated in the supine position under local anesthesia by the author. Assessment of eyelid height during the procedure was done by sitting the patient up with assistance. In bilateral cases, both eyelids required identical surgery and were operated at the same sitting. Mullerectomy was necessary in all cases. The surgical method allowed correction of abnormalities seen both clinically and at surgery.
The levator aponeurosis normally lies beneath the orbital fat superiorly and extends horizontally to insert on the anterior tarsal surface. If it was disinserted, Muller's muscle could be seen to be continuous with the superior tarsal border, since it was no longer cov-
SURGICAL METHOD Prior to anesthetic infiltration, the lowest eyelid skin crease was marked, and in patients with excess skin, this was also outlined. Anesthesia was obtained with topical proparacaine and subcutaneous 2% xylocaine with 11100,000 epinephrine. After the skin crease incision, the orbicularis was separated into the pretarsal and preseptal segments by sharp scissors. Orbital septum could be identified in a plane beneath orbicularis and was often thickened and scarred (Fig 1). Excision of scar tissue was done after identification and inspection of the aponeurosis.
Fig 1. Surgical method. Upper eyelid is on stretch. Retractors grasp skin and orbicularis muscle. Orbital septum is thick and scarred.
53
OPHTHALMOLOGY • JANUARY 1982 • VOLUME 89 • NUMBER 1
ered by aponeurosis (Fig 2). Muller's muscle was further identified by its horizontal vessels. 9 A dis inserted aponeurosis fused to the orbital septum anterior to the orbital fat pad was an occassional finding (Fig 2). An intact aponeurosis should be dis inserted from its tarsal insertion to allow access to Muller's muscle. By carefully injecting .25-.5 ml of xylocaine with epinephrine beneath Muller's muscle, additional anesthesia and hemostasis could be obtained, and the muscle was ballooned from the conjunctiva. Starting at the midtarsal border, the muscle was tented upwards with fine-toothed forceps and opened with iris scissors. A plane beneath Muller's muscle could be achieved easily in most cases, but with difficulty where there was a long history of inflammation. Once in this plane, blunt dissection allowed separation of Muller's muscle from the conjunctiva. Small conjunctival button holes could be repaired with fine absorbable sutures tied anteriorly. Stripping of this muscle was continued to the fornix. Temporally, careful dissection prevented injury to the palpebral lacrimal gland. The entire muscle was then excised (Fig 3). Meticulous excision of herniating orbital fat at this time can improve the cosmetic result. The desired eyelid· height was achieved by reinserting the aponeurosis on the anterior surface of conjunctiva or tarsus. In cases with disinsertion prior to surgery, it was necessary to separate the aponeurosis from orbital septum before reinsertion (Fig 4). Excess skin was excised as estimated. Skin closure was done with interrupted or continuous 6-0 nylon sutures. A 4-0 black silk eyelid traction suture taped to the cheek for 24 hours helped to main-
Fig 3. After stripping Miiller's muscle from conjunctiva, complete excision is performed.
tain the correction achieved at surgery. A firm bandage was applied and could be removed on the morning after surgery. Patients received frequent ocular lubrication in the postoperative period and could be discharged on the day after surgery.
RESULTS Retraction was adequately corrected in all cases, and the patients were pleased with the cosmetic out-
Fig 2. Aponeurosis disinsertion. Miiller's muscle is not covered by aponeurosis and is identified by horizontal vessels (h) and at insertion to superior tarsal border. Disinserted aponeurosis (A) is indistinguishable from septum anterior to orbital fat. Fold in aponeurosis (arrow) is not true lower edge.
54
Fig 4. Mobilization of disinserted aponeurosis by separation from orbital septum.
DIXON • THYROID-RELATED UPPER EYELID RETRACTION
come. In addition to Mullerectomy, the following procedures were performed: blepharoplasty (18 eyelids), excision of scar tissue beneath the orbicularis (4 eyelids), and excision of herniating orbital fat (7 eyelids) (Table 1). Disinsertion of the levator aponeurosis was seen in 11 eyelids (Table 1), two of which required reinsertion for symmetry by the first week after surgery. Cases 1, 2, and 3 are illustrated further.
CASE REPORTS Case 1. A 55-year-old chemically euthyroid female with a long history of retraction was referred for management of exposure keratitis. Exophthalmometer readings were 24 bilaterally. There was 6 mm upper eyelid retraction on the right and 5 mm on the left (Fig 5). Slit-lamp examination showed central and inferior punctate corneal staining bilaterally. At surgery, disinsertions of the aponeurosis were identified (Fig 6) but not repaired. Muller's muscle, herniating orbital fat, and excess skin were excised. Twenty-one months after surgery, there was complete correction on both sides, right lower eyelid entropion (Fig 7), and evidence of aponeurosis disinsertions (Fig 8). Case 2. A 61-year-old hypothyroid female with a two-year history of stable eyelid retraction and exophthalmos was evaluated in May 1979. There was obvious exophthalmos and upper eyelid retraction measured 6 mm on the right and 5 mm on the left (Fig 9). Slit-lamp examination showed diffuse upper corneal staining. In August 1979, resection of Muller's muscle was performed. Aponeurosis disinsertions seen at surgery were not repaired. Excess eyelid skin was excised bilaterally after Mullerectomy. When last seen in September 1980, there was no retraction, and the upper eyelids protected the globes (Fig 10). Case 3. A 42-year-old euthyroid female had a two-year history of stable exophthalmos with final exophthalmometer readings of 21. There was 8 mm upper eyelid retraction bilaterally (Fig 11). Muller's muscle was approached through an anterior incision. The levator aponeurosis on either side was found disinserted and fused to orbital septum anterior to the orbital fat pad. Bilateral Mullerectomy corrected retraction on the right, but produced 2 mm overcorrection on the left. This was overcome by dissecting the free edge of the aponeurosis and reinserting it on the conjunctiva above tarsus seven days after surgery. Twelve months after initial surgery, palpebral fissures measured equal at 9 mm (Fig 12).
Fig 5. Case 1: Before operation upper eyelid retraction measured 6 mm on the right and 5 mm on the left.
Fig 6. Case 1: Disinsertion of levator aponeurosis at surgery; forceps holds disinserted edge of aponeurosis.
Fig 7. Case 1: Twenty-one months after bilateral repair of upper eyelid retraction. Right lower eyelid entropion has also developed.
DISCUSSION Thyroid-related retraction may be seen as an isolated finding or in combination with other eyelid and orbital changes, and can be seen in various thyroid metabolic states. 10 There is good inference of diffuse orbital and eyelid involvement even in cases appearing to have only eyelid retraction. 10 Reduction of retraction after topical administration of sympatholytic agents proves sympathetic overaction or hypersensitivity in this condition. A hormonal basis for retraction is further supported by its variability, which may be related to the general sympathetic discharge. Circulating thyroid hormones may contribute to retraction by potentiating the effect of catecholaminesy,12 Muller's muscle is the only sympathetically innervated eyelid structure, and in many cases, it accounts for all upper eyelid retraction. With time, other causes of retraction may be operative, as early cases respond to-
55
OPHTHALMOLOGY. JANUARY 1982 • VOLUME 89 • NUMBER 1
Fig 11. Case 3: 8 mm bilateral upper eyelid retraction and stable endocrine exophthalmos.
Fig 8. Case 1: After repair of upper eyelid retraction. Cornea seen through thinned eyelid. In thin areas only conjunctiva and skin remain above the tarsus and the aponeurosis is disinserted.
Fig 12. Case 3: Twelve months after repair. The eyelids now protect the globes.
Fig. 9. Case 2: Stable orbitopathy with 6 mm right and 5 mm left eyelid retraction.
Fig 10. Case 2: Thirteen months after bilateral Miillerectomy and blepharoplasty.
tally to adrenergic blockade, whereas the response in longstanding cases can be incomplete. 1 Other factors that produce retraction include contraction and fibrosis of the levator muscle and adhesions between the levator and the overlying tissues. 8 Pharmacological testing in retracted eyelids could theoretically separate mechanical causes from the hormonal component of retraction. Failure to recognize all factors contributing to retraction may explain poor results noted with some surgical methods. Other findings in retracted upper eyelids include: scar tissue, skin changes resembling
56
dermatochalasis, fat herniation, tissue laxity, and disinsertion of the levator aponeurosis. Insertional abnormalities of the levator aponeurosis were identified in 11 eyelids at surgery. These were not evident on clinical evaluation. Similar changes explain many types of acquired ptosis, such as senile ptosis, 9 neuromyopathic ptosis,1a ptosis after cataract surgery,9.14 and following trauma. 9 Its occurrence in eyelids with thyroid-related retraction is surprising, but serves to emphasize that there are no uniform findings in all such eyelids. Eyelid inflammation and edema, which often precede retraction in these patients, could explain these changes. This etiology has also been postulated for disinsertions after cataract surgery .14 Procedures aimed at the levator aponeurosis are, therefore, not appropriate for all patients with retraction. At surgery for retraction, a disinserted aponeurosis may be reinserted appropriately for the desired eyelid height and contour. Thus, in case 3, reinsertion on the left was effective in overcoming overcorrection. As in case 1, it is not always necessary to reinsert the aponeurosis. At 21 months after surgery, this patient showed clinical evidence of dis insertions, even though the palpebral fissures were adequate. Also, lower eyelid entropion in this patient may have been caused by retractor disinsertion, a wellrecognized finding in acquired lower eyelid entropion. Insertional abnormalities of the levator aponeurosis in normal eyelids are commonly associated with blepharoptosis of varying degrees, and correction is usually necessary. In retracted eyelids, these findings
DIXON • THYROID-RELATED UPPER EYELID RETRACTION
require individual considerations and can complement surgical repair of retraction. Surgery to correct upper eyelid retraction should, therefore, be aimed primarily at Miiller's muscle, but allow identification and correction of abnormalities that contribute to retraction, eyelid function, and cosmesis. An anterior surgical approach facilitates recognition and correction of all eyelid changes and has the following additional advantages: the conjunctiva is not incised, there are no sutures next to the globe, inspection of all eyelid structures is possible, excess skin and herniated orbital fat can be excised, and there is less risk of damage to the lacrimal ducts that open at the supratemporal aspect of the palpebral conjunctiva and fornix. This method allows early discharge from hospital.
REFERENCES 1. Dixon RS, Anderson RL, Halt MU. The use of thymoxamine in eyelid retraction. Arch Ophthalmol, 1979; 97:2147-50. 2. Blaskovics L, cited by Berens C, King JH Jr. Atlas of Ophthalmic Surgery. Philadelphia: JP Lippincott, 1961; 76. 3. Henderson Jw. Relief of eyelid retraction: a surgical procedure. Arch Ophthalmol 1965; 74:205-16.
4. Goldstein I. Recession of the levator muscle for lagophthalmos in exophthalmic goiter. Arch Ophthalmol 1934; 11 :389-93. 5. Baylis HI, Cies WA, Kamin DF. Correction of upper eyelid retraction. Am J Ophthalmol 1976; 82:790-94. 6. Putterman AM, Urist M. Surgical treatment of upper eyelid retraction. Arch Ophthalmol 1972; 87:401-5. 7. Chalfin J, Putterman AM. MOiler's muscle excision and levator recession in retracted upper eyelid; treatment of thyroid-related retraction. Arch Ophthalmol 1979; 97:1487-91. 8. Grove AS Jr. Levator lengthening by marginal myotomy. Arch Ophthalmol 1980; 98:1433-8. 9. Anderson RL, Dixon RS. Aponeurotic ptosis surgery. Arch Ophthalmol1979; 97:1123-8. 10. Hodes BL, Frazee L, Szmyd S. Thyroid orbitopathy: an update. Ophthalmic Surg 1979; 10(11):25-33. 11. Coulombe P, Dussault JH, Jetarte J. Catecholamines metabolism in thyroid diseases. I. Epinephrine secretion rate in hyperthyroidism and hypothyroidism. J Clin Endocrinol Metab 1976; 42:125-31. 12. Coulombe P, Dussault JH, Walker P. Catecholamine metabolism in thyroid disease. II. Norepinephrine secretion rate in hyperthyroidism and hypothyroidism. J Clin Endocrinol Metab 1977; 44:1185-9. 13. Anderson RL, Dixon RS. Neuromyopathic ptosis: a new surgical approach. Arch Ophthalmol1979; 97:1129-31. 14. Paris GL, Quickert MH. Disinsertion of the aponeurosis of the levator palpebrae superioris muscle after cataract extraction. Am J Ophthalmol 1976; 81 :337 -40.
57