Graded Full-Thickness Anterior Blepharotomy for Upper Eyelid Retraction

Abstract

Background: A chief morbidity of Graves eye disease is upper eyelid retraction that results in exposure keratopathy and cosmetic deformity. Objective: To assess the efficacy of graded anterior blepharotomy to treat upper eyelid retraction. Methods: Fifty eyelids of 32 patients with Graves eye disease-associated upper eyelid retraction, causing symptomatic ocular exposure, were treated with graded, transcutaneous, full-thickness, anterior blepharotomy. Preoperative and postoperative ocular exposure symptoms, upper eyelid position, lagophthalmos, and keratopathy were compared. Results: At a meanϮSD of 8.5Ϯ8.1 months' (range, 2-35 months) follow-up, more than 90% of preoperative symptoms resolved or improved. Upper eyelid position (PϽ.001), lagophthalmos (PϽ.001), and keratopathy (PϽ.01) were significantly improved. Mild contour abnormalities (all Յ1 mm) occurred in 7 of 50 eyelids. Eyelid crease recession or asymmetry occurred in 4 of 22 patients with postoperative eyelid crease measurements. Complications of ptosis, wound dehiscence, and a full-thickness hole each occurred once. The meanϮSD time taken to perform the procedure was 31.5Ϯ8.9 minutes per eyelid. Conclusions: Graded anterior blepharotomy for upper eyelid retraction is a safe and highly effective surgery for upper eyelid retraction associated with symptomatic Graves eye disease. This technique achieves excellent functional and cosmetic outcomes.

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

“…Seventy percent of patients (n ¼ 7/10) were euthyroid at the time of surgery and 70% had received steroid treatment for that condition. The average follow-up was 13 months (range [6][7][8][9][10][11][12][13][14][15][16][17][18][19][20]. The indication for eyelid lowering was lagophthalmos in five (42%) (mean degree of lagophthalmos was 1.9 mm (range 1-6.5 mm)), foreign body sensation in eight (67%), photophobia in seven (58%), and symptomatic epiphora in three (25%).…”

“…Using the graded fullthickness anterior blepharotomy procedure, first communicated by Koornneef in 1999, Elner et al 15 reported an average postoperative MRD of 3.07-3.57 mm and 93% patient satisfaction. A series by Hintschich and Haritoglou 16 reported that 95% of operated lids achieved a 'perfect' or an 'acceptable' result while using full-thickness blepharotomy to treat TED lid retraction, which compares well to the results reported with this technique.…”

“…1,2 These techniques are based on weakening or lengthening the upper-eyelid retractors and include anterior or posterior approaches to graded recession or resection of Mü ller's muscle, [3][4][5] levator aponeurosis (LA)/muscle, [6][7][8] or both, 5,[9][10][11][12][13][14] full-thickness blepharotomy, [15][16][17] levator lengthening by marginal myotomy, 18,19 z-myotomy, 20 castellated levator aponeurotomy, 21 reattachment of the recessed levator to the tarsus by various spacers (sclera, 22,23 mersilene mesh, 24,25 sutures, 26,27 adjustable sutures, 28,29 orbital septal flap, 30 pretarsal soft tissues, 31 and deep temporal fascia 32 ), pedicle tarsal rotation flap, 33 or medial transposition of the lateral horn of the LA. 34 The orbital septum (OS) arises from the arcus marginalis and terminates inferiorly as it attaches to the LA; it can be used as a vascularized turn-over flap to act as a spacer between the recessed LA-Muller's muscle complex-Muller's muscle complex and the tarsal plate.…”

The Diagnosis and Treatment of Thyroid-Associated Ophthalmopathy

“…Mullerectomy and levator resection should be used in the case of more severe retraction. Full-thickness blepharotomy also has been described as therapeutic [16]. Lateral flare is treated with lateral dissection of Muller's muscle and release of the lateral horn of the levator aponeurosis between the two lobes of the lacrimal gland.…”

Advances in Surgical Rehabilitation in Thyroid Eye Disease

“…Unfortunately, the basic paradigm of repositioning the insertions of the extraocular muscles has remained unchanged for a century, and in bad Graves' strabismus when the muscles are fibrotic and damaged, even the best strabismus surgery cannot re-create normal fields of binocular vision. Eyelid repositioning surgery has also undergone incremental advances, with smaller incisions (e.g., minimal incision en-glove lysis of the lower eyelid retractors with dermis grafting) (32)(33)(34). Nonsurgical treatment with hyaluronic acid gel may be useful for temporary improvement in some cases (35).…”