CHAPTER 13 Treatment of Upper Eyelid Retraction: Internal Approach

Upper eyelid retraction, a manifestation of thyroid ophthalmopathy, often continues after the underlying systemic disease has been successfully treated. Upper eyelid retraction not only is cosmetically deforming because the amount of exophthalmos is exaggerated, but also contributes to corneal and conjunctiva exposure and to ocular irritation.

Upper eyelid retraction surgery occasionally is combined with retraction surgery of the lower eyelid, with or without lateral tarsorrhaphies (see Chapter 18). If there is minimal upper eyelid retraction, the surgery can be combined with an upper eyelid skin muscle-fat excision without eyelid reconstruction; if the retraction is moderate or severe, the external tissue excision is deferred to a second sitting since I am concerned that tightening of the skin might interfere with the results of the upper eyelid retraction surgery.

Upper eyelid retraction can be performed in patients who do not require orbital decompression or strabismus surgery. If strabismus surgery is required, the eye muscle surgery is performed first. Usually, thyroid surgery is considered once the eyelid retraction, ocular proptosis, and strabismus are stable for at least 6 months.

In this chapter, I describe a technique that Urist and I reported on in 1972, in which Müller’s muscle is excised and the levator aponeurosis is recessed from an internal approach.¹ The procedure is performed with sensory but not motor anesthesia. The eyelid level is controlled intraoperatively while the patient is seated up on the operating table.

Treatment of upper eyelid retraction not only places the upper eyelid in a more normal position but also decreases the exophthalmic appearance and relieves ocular irritation and keratopathy.

Anatomy

Müller’s muscle in the upper eyelid originates from the levator aponeurosis approximately 15 mm above the superior tarsal border and inserts onto the superior tarsal border (Fig. 13-1). This muscle spans the horizontal dimension of the eyelid, is firmly attached to conjunctiva on its posterior surface, and is loosely attached to the levator aponeurosis on its anterior surface. Müller’s muscle resembles other smooth muscle tissue and is approximately 1 mm thick.

Figure 13-1 A, Cross-section of upper and lower eyelids depicting structures in various layers. B, Müller’s muscle.

Surgical technique

Anesthesia

In this procedure, only local anesthesia is used. Anesthesia given in this manner maintains the eyelid level at its preoperative position while providing an absence of lid sensation. The patient is given no preoperative medication. Lidocaine hydrochloride (0.25 ml of a 2 percent concentration) with epinephrine is injected subcutaneously into the center of the upper eyelid just above the lid margin.

A 4-0 silk suture is placed in the center of the upper eyelid 2 mm above the eyelash line, through the skin, orbicularis muscle, and anterior tarsus (Fig. 13-2). Topical 0.5 percent tetracaine drops are applied to the eye, and a scleral lens is placed over the globe to protect it during surgery.

Figure 13-2 Placement of traction suture.

Conjunctival dissection

With a Desmarres retractor, the surgeon everts the upper eyelid to expose the superior palpebral conjunctiva. The upper palpebral conjunctiva is flooded with 0.5 percent tetracaine drops. Cotton-tipped applicators saturated with tetracaine also are rolled over the conjunctiva. Then, 0.25–0.5 ml of 2 percent lidocaine with epinephrine is injected subconjunctivally adjacent to the superior tarsal border over the entire width of the eyelid (Fig. 13-3).

Figure 13-3 Subconjunctival administration of an anesthetic agent.

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