J. Clin. Nturo-ophthalmol. 4: 163-166,1984,

Unilateral Eyelid Retraction Secondary to Contralateral Ptosis in Dysthyroid Ophthalmopathy

LAWRENCE LOHMAN, M.D. JOHN A. BURNS, M.D. WILLIAM R. PENLAND, M.D. KENNETH V. CAHILL, M.D.

procedure. An extemallevator resection was per­ Abstract formed on the ptotic lid with satisfactory results. A pilltient with dysthyroid eye dise~ presented with unilillter~llid retnction secondary to ~ contrill­ Case Report Iilltnu ptosis. While others hillVe reported si.milu findings i.n various underlying diseue prOCf:SSf:S. to Our 57-year-old white female had a history of the best of our knowledge this is the first c~ in visible goiter first noted in childhood. In 19~, the liter~ture with dysthyroid ophthilllmop~thy. she underwent a thyroidectomy after presenbng iIInd the first where the rHults of surgiCillI m~n~ge­ with symptoms of thyrotoxicosis along with ex­ ment ue presented. The import~nce of testing for ophthalmos, lid congestion, and double vision. rf:tr~ction elev~tion Sf:conduy lid by millnuilll of the The eye signs and symptoms improved in a 3­ ptotic p~rtner is stre$Sf:d. year period following her surgery. In 1977. the patient again began to notice ·puffiness· of her eyelids along with a staring appearance on the right and drooping of the left upper lid. She was Dysthyroid ophthalmopathy is a clinical entity hospitalized in May and July of 1978, after pre­ well known to most ophthalmologists, Blodi di­ senting with decreasing vision. Vision was 20/40 vided the eye findings of Graves' disease into two (right eye) and 20/200 (left eye), with visual fields groups. The noninfiltrative signs consist mainly interpreted as consistent with optic nerve of lid retraction and infrequent blinking. Infiltra­ compression. Lid retraction was present in the tive changes may cause chemosis and lid edema, right eye and ptosis was present in the left eye. exophthalmos. extraocular muscle inv~lvem.en.t. CT scan of the orbits, orbital ultrasound, and and may lead to optic nerve damage. PtOSIS .IS orbital tomograms were all consistent with thy­ less frequently recognized and reported tha~ hd roid ophthalmopathy. The patient was treated lag and retraction, and some of these .palien~s with systemic steroids with some improvement have concomitant evidence of myasthema gravIs 2 in vision. Orbital decompression was discussed on Tensilon testing. •• with the patient, but she was not anxious to This report documents a case of ptOSIS 1ft dys­ proceed with any surgical intervention at that thyroid ophthalmopathy. The patient displayed time. Vision remained at a fairly constant level upper lid retraction on the opposite side. T~ere thereafter. was no evidence of myasthenia gravis. On tesbng. The patient was referred to us in March 1980 the retraction appeared to be a secondary devia­ for evaluation of the marked lid changes which tion related to the contralateral ptosis rather than had remained stable for several years. The patient a direct effect of the underlying thyroid disease. felt her appearance prevented her from achieving Recognition of this relationship m~de it poss~ble a normal life-style and acceptance by others. The to offer good cosmesis, normal Vl~ual functi~n, best-corrected visual acuity was 20/50 (right eye) and control of exposure with a smgle surgical and 20/70 (left eye). A marked stare was present on the right and a ptosis on the left (Fig. 1). Palpebral fissures measured 16 mm on the right and 6.5 mm on the left. There was a 3-mm From the Deputnwnl 0( Ophtn.lmoklgy (ll), N.E. Ohio College of Mf:dicine. Kenl. Ohio; ~rtmenl of Ophlhal~­ superior scleral show on the right. Manual ele­ ogy OAB, KVC).. The Ohio State Univf:T'Sity, Columbus. OhIO; vation of the ptotic left lid resulted in an imme­ and Duconess Hospit..1(WRp). EV'fISvilko. Indian... diate and nearly equal amount of lowering of the

September 1984 163 Unilateral Eyelid Retraction

Figure I. Lid retraction right eye; ptosis left eye.

Figure 2. Effe<:t of manually elevating left uppt'r lid.

opposite retracted lid, giving a seesaw effect (Fig. excellent results which can be seen in postoper­ 2). Patching of the left eye for 15 minutes also ative photographs (Figs. 4 and 5). resulted in lowering of the right upper lid to a normal level (Fig. 3). Exophthalmometer readings were 28 mm (right eye) and 27 mm (left eye). Discussion Fullness was present in both upper lids. There We have described a case of thryoid eye disease was some limitation of eye movement on up gaze, with a unilateral ptosis. The opposite upper lid but otherwise extraocular muscle function was displayed retraction secondary to the contralat­ good and no diplopia was present. Mild inferior eral ptosis rather than being elevated as a direct punctate staining of the right cornea was present. result of the underlying thyroid problem. Others Schirmer testing was normal. Fundus exam have reported similar eyelid findings with varying showed slight pallor of the disc on the left. Ten­ causes of ptosis. Ptosis and lid retraction of the silon testing was negative. The eye findings re­ fellow eye have been observed in familial or mained constant on repeated examination. The congenital ptosis,M third nerve palsy,5.6 patient underwent a 9-mm external levator resec­ trauma,6.7 myasthenia gravis,2.6·9 and in ptosis of tion of the left upper lid in May 1980, and had . undetermined etiology.? The mechanism pro-

1M Journal of Clinical Neuro-ophthalmology Figuf~ 3. Effect of patching left eye.

Figuf~ 4. One wet'k after extemallevator resKlion or left upper lid.

Figure 5. On~ year after external levator ~ection of left upper lid.

September 1984 1.5 Unilateral Eyelid Retraction

posed. to account for these finQngs has been an In Ntw Or/tflnS Acadtmy of OphthQlm%gy: Sym­ application of Hering's Law. The levators act as posium on Surgtry of tht Orbit and AdntXll, 1973, yoke muscles with equal innervation received by Beard, C Ed. CV. Mosby Co., 51. Louis, 1974, pp. each muscle. In the case of a unilateral ptosis WI-Ill. excessive innervation may be needed to produce 2. Lawlon, N.R.: Dysthyroid eye disease: Medical maximal elevation of the lid and fixation with investigators. Proc. R. Soc. Mtd. 70: 698-699, 1977. that eye. The excessive innervation can cause a 3. Gupta, l5., jain, 1.5., and Kumar, K.: lid retraction retraction on the opposite side. This concept is secondary to contralateral ptosis. Br. J. Ophthlllmol. supported by the finding that prolonged patching 48: 626-627,1964. of the ptotic side results in the return to a normal 4. Walsh, RoB., and Hoyt, W.F.: C/iniCll1 Nturo-Oph­ J 5 7 9 1 eel.). &. position of the elevated partner. • • . In the cases thQ/mo/ogy, Vol. (3rd Williams Wilkins, of myasthenia gravis, administration of edro­ Baltimore, 1960, pp. 304-318. phonium chloride results in improved position of 5. lain. 1.5.: Lid retraction in the non-paretic eye in. both lids. ~.. In our case, the retracted lid re­ acquired ophthalmoplegia. Br. J. Ophthalmol. 47: 757-759, 1963. sponded immediately to either patching or man­ 6. Schechter, R.O.: Ptosis with contralateral lid re­ ual elevation of the ptotic lid. Schechter has also traction due to excessive innervation of the levator noted cases which displayed the peculiar seesaw palpebrae superioris. Ann. Ophlhllimol. 10: 1324­ effect that we observed.' 1328, 1978. It is postulated that unequal visual acuities with 7. lewallen. W., Ir.: Jjd relTaction syndrome due to better vision in the ptotic eye, a tropia, or mono­ "secondary deviation: A.m. I. Ophlha/mol. 45: 565­ fixation syndrome with preference of fixation on 567, 1958. the ptotic side, may be required for the manifes­ 8. Gay, A.j., Salmon, M.L, and Windsor, CE.: Her­ tation of this syndrome.' However, in our case, ing's law, the levators, and their relationship in the better acuity was found in the retracted side, disease states. Arch. Ophlhll/mol. n: 157-160, and this was the dominant eye. Our case appears 1967. to dispute this theory. 9. Buffam. R.V .• and Rootman, ).: lid retraction-its Our case points out the importance of testing diagnosis and treatment. Inf. Ophlha/mol. elin. 18: for the underlying cause of unilateral eyelid re­ 75-86, 1978. traction in a patient with dysthyroid ophthalmo­ 10. Meltzer, M.A: Surgery for lid retraction. Ann. pathy. In the usual case of dysthyroid lid retrac­ Ophthalmol. 10: 102-106, 1978. tion, a recession of the lid retractor muscles is 11. Pultennan, AM., and Urisl, M.: Surgical treatment required to rrovide correction of exposure and of upper eyelid retraction. Arch. OphthQlmol. 87: asymmetry.l _u If, however, the lid retraction is 401-405,1972. associated with the ptosis of dysthyroid ophthal­ 12. Chalfin, J.. and Putterman, AM.: Muller's muscle mopathy, and Hering's Law can be demonstrated ~xci5ion and levator recession and retracted upper ltd. Treatment of thyroid-related retraction. Arch. to apply, then surgical correction should be lim­ Ophtha/mol. 97: 1487-1491, 1979. ited to the ptotic lid. 13. Grove, A.5.: Upper eyelid retraction and Graves' disease. Ophthalmology 88: 499-506, 1981. References 14. Harvey, J.T., and Anderson, R.L.: The aponeurotic approach to eyelid retraction. Ophtha/mology 88: I. BlocH, E.C: Ophthalmopathy of Graves' disease. 513-524, 1981.

'66 journal of Clinical Neuro-ophthalmology