Terminology
Upper eyelid retraction is stated when the upper lid position is less than 2 mm below the superior corneal limbus. Lower lid retraction is stated when the lower lid position is belowthe level of inferior limbus.
Graves' orbitopathy is the main cause of upper lid retraction.
Lid retraction can be isolated or associated with other signs of dysthyroid orbitopathy : proptosis, diplopia with restriction of extraocular muscles, orbital fat prolapse.
 Moderate bilateral upper eyelid retraction and upper eyelid orbital fat prolapse associated with Graves' orbitopathy |
 Result after transcutaneous mullerectomy combined with upper lid blepharoplasty |
 Preoperative |
 Postoperative |
Treatment
Surgical treatment depends on the severity of upper lid retraction :
-upper lid retraction up to 3 mm. may require a müllerectomy via transconjunctival or transcutaneous approach.
-upper lid retraction exceeding 4 mm. may be corrected by a mullerectomy associated with a levator resection. Adjustable sutures or interposition of autogenous or foreign material may be useful to set the lid height at the good position.
Causes of lower lid retraction may be eyelid trauma, inferior rectus muscle recession, orbital floor fracture operation or proptosis.
A mild lower lid retraction ( less than 2 mm. ) may require a recession of lower lid retractors, via a transconjunctival approach.
 Bilateral upper eyelid retraction associated with Graves' orbitopathy |
 Result after bilateral ajustable levator and Müller's muscle recession |
 Preoperative |
 Postoperative |
A marked lower lid retraction ( more than 2 mm. ) should be treated with a lower lid retractor lenghtening : a graft of hard palate mucosa is interposed between the inferior tarsal border and the recessed lower lid retractors : about 2 mm. of interposed graft corrects 1 mm. of lid retraction.
General considerations
Enucleation may constitute ultimate treatment for management of a blind, painful and disfigured ( phthisical or microphthalmic ) eye.
Enucleation with insertion of an orbital implant may be used for intraocular malignancy. Enucleation associated with evisceration and insertion of an orbital implant is indicated when intraocular malignancy has been excluded.
Enucleation with evisceration and orbital implant insertion :
A 360° peritomy is performed as close to the corneoscleral limbus as possible in order to preserve a maximal conjunctiva that will ensure adequate socket for ocular prosthesis.
The rectus muscles are isolated, tied with double 6/0absorbable suture and cut from the globe. The superior and inferior oblique muscles are isolated and cut. The optic nerve is cut. Enucleation is performed with scissors. The enucleated globe is eviscerated on the operating table : Cornea is excised along the limbus.
The ocular contents are eviscerated, taking care to clean all the uveal tissue off the scleral shell. An orbital implant (hydroxyapatite) is inserted into the scleral envelope to maintain volume. The scleral-covered orbital implant is inserted into the intraconal fat and the rectus muscles are sutured to the sclera in order to enhance ocular motility. Tenon's capsule and conjunctiva are closed separately in two layers with 6/0 absorbable interrupted sutures. A light shell is inserted which helps to maintain the fornices during one month. Ocular prosthesis is fitted at that time.
 Blind, painful and disgraceful right eye |
 Enucleation and orbital implant (text in French) |
Anophthalmic socket and secondary orbital implant
Removal of the globe results in an orbital volume deficit corresponding to the lost of volume of the globe, to additional soft tissue removed during operation and orbital fat atrophy. Usually the orbital volume deficit requires a large ocular prosthesis with a poor motility associated with a deep superior sulcus syndrome.
A secondary orbital implant may be inserted to correct an orbital volume deficit in an anophthalmic socket : the implant should be covered by autologous material as fascia lata or temporalis aponeurosis, in order to be well integrated in the deep orbital soft tissues.
Dry eye syndrome
With drying of the eye, the cornea may develop keratitis which needs to be treated with lubricants and ointment.
When medical treatment is not sufficient, keratitis can be relieved by punctal occlusion, to prevent existing tears from draining away. Punctum plugs can provide a temporary occlusion of the lacrimal system.
If successful, a lasting surgical punctal occlusion may be proposed. Surgical punctal occlusion may include a conjunctival graft over the lacrimal punctum, procedure which is reversible if necessary.
 View of lacrimal punctum |
 Conjunctival graft over lacrimal punctum |
Epiphora
Epiphora is realised when an obstructed lacrimal passage leads tears to spill onto the the cheek.
Different lacrimal obstructions may cause an epiphora :
-lacrimal punctum stenosis may require surgical opening of the punctum.
-canalicular stenosis may necessitate a lacodacryocystorhinostomy with insertion of a glass tube between the medial canthus and nose. The tube is able to drain tears into the nose.
- obstructions of the lacrimal sac or nasolacrimal duct are indications for dacryocystorhinostomy : in this procedure the bone between the lacrimal sac and the nose is removed then the lacrimal sac and the nasal mucosa are opened and sutured together to create a mucosal anastomosis.
