Dr. Nitin Soni, S19234, Dr. Animesh Sahu, Dr. Narendra Patidar, Dr. ram kishore shandilya
Introduction : Eyelid retraction is said to occur when in primary gaze upper eyelid is covering less than 2mm of limbus or lower lid scleral show is present. Common causes of upper lid retraction are thyroid orbitopathy ( the most common cause) and scarring of the tarsal plate due to trachoma. Common causes of lower lid retraction are facial palsy and thyroid orbitopathy. Waller has established a system for grading the degree of eyelid retraction in thyroid eye disease (TED) patients. For upper eyelid retraction, a measurement of 1–2 mm is mild, 2–5 mm is moderate, and greater than 5 mm is severe. Lower lid retraction is graded as mild at 1–2 mm, moderate at 3 mm, and severe at greater than 3 mm. Similar to the upper eyelid, the lower eyelid can be lengthened either through an anterior or posterior approach. Various grafts can be used such as auricular cartilage, nasal septum, upper lid tarsus, hard palate mucosa, acellular human dermis and donor sclera.
Indications for Surgical Correction
Scleral show both above or below the corneoscleral limbus resulting in lagophthalmos and cosmesis is the indication for surgery. Excess exposure of the ocular surface results in tear film instability and drying, with corneal epithelial erosion and can lead to significant corneal breakdown with recurrent corneal erosion, neurotrophic changes, and secondary corneal ulceration. Medical therapy, including topical lubricant drops and ointments, patching, and moist chambers, may be employed to improve corneal breakdown. When more conservative measures are insufficient to correct these corneal changes, surgical intervention to alter eyelid position is employed. Various modalities of surgical treatment are
- Tarsorrhaphy
- Levator marginal myotomy
- Levator recession and mullerectomy
- Full thickness blepharotomy
- Spacer grafts
Spacer Grafts – Various grafts which can be used are auricular cartilage, nasal septum, upper lid tarsus, hard palate mucosa, acellular human dermis and donor sclera
Scleral Spacer Graft (SSG) – Donor sclera is grafted between tarsus and the retractors by anterior or posterior approach
Successful surgical management of eyelid retraction depends on measures that lengthen the vertically shortened posterior lamella, in addition to addressing coexisting anatomic abnormalities. Placement of the scleral spacer graft is one surgical option. The purpose of this study is to provide a detailed description of the surgical technique, and to retrospectively review the outcomes of a series of patients.
Aim: To retrospectively review and evaluate the efficacy and surgical outcomes of SSG for correction of lid retraction
Methods:
Study Design – A retrospective, noncomparative chart review of 19 eyelids of 15 patients who underwent SSG for correction of lagophthalmos between May 2016 to April 2017. Patient lists were generated using billing codes for repair of lid retraction as well as by reviewing surgical logs. The medical records were reviewed for the identified patient’s etiology of eyelid retraction, demographic information including age, gender, laterality, involvement of upper or lower lid, clinical history, treatment, additional surgical procedures and surgical outcomes.
Patients were included who had lid retraction associated with lagophthalmos secondary to TED , facial palsy, post surgical eyelid retraction and others.
Pre and postoperative MRD1 for upper lid retraction and MRD2 in cases of lower lid retraction and vertical PAH, scleral show (SS) measured for each eyelid, amount of lagophthalmos in mm were noted. The eyelid distraction test was performed by grasping the lower eyelid skin over the central aspect of the lower eyelid tarsal plate, pulling the lower eyelid away from the globe, and measuring the distance between the globe and the posterior aspect of the lower eyelid. Horizontal laxity was diagnosed when the measurement exceeded 5 mm. Success was defined by correction of lagophthalmos and decrease in SS.
The primary outcome measure was the surgical success rate, defined by resolution of lid retraction and lagophthalmos on follow-up clinical examination as
judged by the surgeon. An additional outcome measure included viability of the spacer graft, which was defined as survival of the initial graft without replacement or removal and without complications including hematoma formation, graft contracture, or need for additional surgery
| Upper lid lengthening | Lower lid lengthening | |||||
| No. Of patients/eyelids | 4 | 12 | ||||
| No. Of eyelids | 4 | 15 | ||||
| Female : Male ratio | 6(40%) | 9(60%) | ||||
| Mean age and range |
|
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Surgical Technique –
Upper Lid SSG – A horizontal line is drawn on the eyelid at about 8-10 mm from the lid margin to mark the place of the future skin crease. After eversion of the superior eyelid, 2 ml of lignocaine 2% with epinephrine is injected into the subconjunctival area. Thus the conjunctiva is separated from Muller’s muscle. The upper eyelid is then further anaesthetised subcutaneously with approximately 3 ml of local anaesthetic. A horizontal incision in the skin crease is made through the skin-muscle layer parallel to the muscle fibres on to the tarsal plate. By going upward in the direction of the upper roof of the orbit the orbital septum is visualised. The septum is opened, the orbital fat is retracted, and below the fat the levator aponeurosis is identified. The levator aponeurosis together with Muller’s muscle are dissected off the tarsal plate, and the medial and lateral horns are transected. The conjunctiva, however, is left unimpaired, thus protecting the cornea. Special care is taken to cut all fibrotic strands in the lacrimal gland region. A scleral graft is sutured to the tarsal plate and the levator muscle with interrupted 5-0 vicryl sutures. In upper lids the vertical height of the implant is approximately is in the ratio of 2:1 to 4:1 to the amount of eyelid retraction, laterally 1.5 mm more than medially. However, the final determination of the levator recession and thus of the graft size is based on the on table appearance of the lid marginas the patient is asked to open and close the eye. When the result is satisfactory, the skin is closed with 6-0 silk sutures. Adjuvant surgical procedure such as mullerectomy, levator recession, LTS or MCS is done according to the need in the same sitting.
Lower lid SSG – The approach is transconjunctival. After infiltration of the subconjunctival space with local anaesthetic the conjunctiva is incised over the lower border of the tarsal plate. The lower lid retractors are identified and dissected off the conjunctiva and the tarsus and freed of the orbital septum. A scleral graft in the ratio of 3:1 of the lid retraction in millimetres is sutured to the retractors and the tarsal plate with 5-0 vicryl. The conjunctiva is closed with a running 6-0 catgut suture.
The height of any graft is generally unimportant in lower eyelid retraction. Once the capsulopalpebral fascia has been recessed off the inferior border of tarsus, the lid will elevate. This is dependent on good elasticity remaining in the medial and lateral canthal tendons.
Results
19 eye lids of 15 patients were diagnosed with lid retraction. Cause of lid retraction which were included were
| Facial palsy | 8(42.10%) |
| TED | 3(15.18%) |
| Post Surgical | 2(10.52%) |
| CPEO | 1(5.26%) |
| Treacher Collins Syndrome | 1(5.26%) |
40% were males and 60% females. Mean patient age was 49.93 years (15-81years) Mean follow up was of 11.13 months. Average delay in presentation was 50.8 months (03-240 months). SSG was effective in reducing PAH (p value <0.0001), lagophthalmos (p value<0.00001), MRD1 (p value = 0.03), MRD2 (p value<0.00001) and effectively reducing the SS (p value <0.001).)
11 out of 15 patients underwent adjuvant surgical procedure
| LTS | 1(5.26%) |
| MCS | 1(5.26%) |
| LTS + MCS | 4(21.05%) |
| Mullerectomy | 4(21.05%) |
| Mullerectomy with LPS recession | 1(5.26%) |
| LPS resection | 1(5.26%) |
Surgical outcomes were evaluated during the final follow-up visit.
Upper lid correction was considered to be Good if (1) the upper 1.5 to 2 mm of the cornea at the 12 o’clock position was covered by the lid; (2) the lid margin contour was smooth; (3) the lid crease was within 7 to 10 mm of the lid margin; and (4) there was bilateral symmetry . An Acceptable result was considered to be 1 to 2 mm over or under correction or mild asymmetry, requiring no further surgery. Results were Poor when more than 2 mm of under or over correction was present requiring repeat surgery.
Lower lid correction was considered to be Good if (1) the margin of the lower lid touched the limbus at the 6 o’clock position (2) the contour was smooth. It was Acceptable when there was a gap between the lid and the limbus of no more than 1 mm and was Poor when the gap between the lid margin and limbus was more than 1 mm requiring repeat surgery.
| GOOD | 15(78.94%) |
| ACCEPTABLE | 3(15.78%) |
| POOR | 1(5.26%) |
3 out of 15 patients developed lid inflammation postoperatively which took more than 1 month to resolve, in 3 patients acceptable result was there and in 1 patient there was poor result requiring further surgery.
Discussion
Upper eyelid retraction is a functional and cosmetic disease process that poses a threat to vision and can be psychologically debilitating to patients. Eyelid retraction increases the vertical height of the palpebral fissure and therefore increases the area of exposure of the cornea. This results in increased ocular discomfort, foreign body sensation, photophobia, epiphora, other symptoms of exposure keratopathy, and alteration in appearance and disfigurement.
Upper eyelid retraction presents a difficult surgical challenge, especially in patients with thyroid-related orbitopathy. Numerous surgical procedures have been devised in attempts to improve the predictability of postoperative results. In thyroid-related orbitopathy the upper eyelid is more commonly retracted than the lower eyelid, though both may be affected, and the lateral aspect of the upper eyelid is frequently more retracted than the medial aspect. The increased vertical interpalpebral fissure height, with exposure of superior and/or inferior sclera, creates an appearance of staring by the patients. Such a cosmetic appearance is very displeasing to patients and contributes strongly to their search for treatment and intervention. Patients with thyroid-related orbitopathy are very aware of how their facial and ocular features differ from their former appearance. They generally perceive their new appearance as unsightly, especially if it is asymmetrical. In thyroid-related orbitopathy, a variety of pathophysiologic mechanisms in varying combinations may lead to the retraction. These include inflammatory fibrosis of Müller’s muscle, abnormal sympathetic tone in Müller’s muscle, proptosis, contracture of the inferior rectus muscle with superior rectus hyperactivity, and overmedication with thyroid replacement. Eyelid retraction may also result from surgical overcorrection of blepharoptosis or blepharoplasty or both and is due to a shortening of the anterior eyelid lamellae from excessive skin removal or a levator resection that is too extensive. Traumatic cases usually result from cicatrix formation. Cicatricial retraction may develop secondary to trauma or as a sequel to severe inflammation, such as with herpes zoster ophthalmicus. Eyelid retraction may be secondary to topical or systemic medications or central nervous system causes. Upper eyelid retraction may be associated with levator muscle enlargement. Inoue and colleagues demonstrated hypertrophy of the levator muscle in 100% of patients with eyelid retraction secondary to thyroid-related orbitopathy with magnetic resonance imaging scans of the orbit
The lower eyelid is supported and maintained by the medial canthal tendons, lateral canthal tendons, capsulopalpebral fascia, tarsus, and orbicularis oculi muscle. Lower eyelid retraction is usually caused by contraction of the lower eyelid retractor (capsulopalpebral fascia and inferior tarsal muscle) and the posterior lamella as a result of various pathological changes in the structures supporting the lower eyelid -. TAO is reported to be a common cause of shortening of the lower eyelid posterior lamella. Shortening of the posterior lamella can also occur because of injuries and scars, and after lower eyelid blepharoplasty. Lower eyelid retraction can also occur after facial palsy Additionally, shortening of the posterior lamella because of exophthalmos can cause lower eyelid retraction. In addition, rare cases of idiopathic congenital lower eyelid retraction have also been reported. Conservative treatment, such as administration of artificial tears, is used when symptoms are not severe, and surgical correction is required in cases of severe exposure keratitis. Surgery to correct lower eyelid retraction can be approached with grafting or nongrafting techniques. The decision to use grafts is based on the The purposes of spacer graft surgery are to create a recess in the capsulopalpebral fascia and support the tarsus with the graft and consequently push the lower eyelid vertically up to a normal anatomic height and position. degree of retraction, and surgical procedures vary based on the causes and degrees of retraction. Mild lower eyelid retraction can be corrected without grafts
Long-standing facial palsy often occurs with lower eyelid retraction and midface ptosis because the paralysis of the orbicularis oculi and the progressive weakening of tendinous structures (medial and lateral canthal tendons, etc.) weaken lower eyelid support. These types of cases require surgery, such as the lateral tarsal strip procedure, to correct horizontal laxity and support the lateral canthal angle.
There are reports in the literature on the surgical management of eyelid retraction. Henderson et al used mullerectomy to correct upper lid retraction but it is useful only in cases of mild retraction of upto 2 mm. Grove et al used levator marginal myotomy but has unpredictable results. Levator recession and mullerectomy can be used for correction of lid retraction but in some cases there is need of structural support for that spacer graft is required.
In our procedure sclera is used as spacer graft for both upper and lower lid retraction with or without adjuvant surgical procedures has shown good surgical outcomes with less no of complications. The limitation of this study was that the medical records were retrospectively analyzed and the sample size was small, but the overall surgical success rate was good.
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