344 BritishJournal ofOphthalmology, 1991,75,344-347 Lid lengthening by sclera interposition for eyelid

retraction in Graves' ophthalmopathy Br J Ophthalmol: first published as 10.1136/bjo.75.6.344 on 1 June 1991. Downloaded from

Maarten Ph Mourits, Leo Koornneef

Abstract Table I Patient's characteristics The efficacy of scleral grafts for eyelid Upper lid Lower lid lengthening in patients with thyroid related lengthening lengthening upper and/or lower lid retraction was evaluated No. ofpatients 47 22 in 62 consecutive patients with Graves' oph- No. ofeyelids 78 30 thalmopathy who underwent lid surgery in the Female/male ratio 4:1 2:1 Mean age and range (yr): M 47 (26-64) 48 (29-60) last 3 5 years. Seventy-eight upper and 30 F 55 (48-68) 56 (42-68) lower lids were lengthened by scleral interposi- tion. A good or acceptable result was achieved in 50% of all operated upper lids after one Seventy-eight upper and 30 lower lids were procedure. This percentage increased to 75% corrected. Information on the patients is sum- after a second and to 77% after a third pro- marised in Table 1. cedure. Persistent temporal retraction and The diagnosis of Graves' ophthalmopathy was nasal overcorrection were the major complica- based on clinical signs and symptoms and tions. In lower lid lengthening the success coronal CT scans of the orbit. All patients were percentage was 90% after one operation. We euthyroid and had stable eye disease for at least conclude that scleral grafting for upper eyelid half a year prior to lid surgery. Many patients lengthening has no distinct advantage in com- had been treated with immunosuppressive treat- parison with other lengthening techniques. ment, radiotherapy, orbital decompression, and Scleral implants to lengthen lower lids are very extraocular muscle surgery. effective. The indication for surgical correction was cosmesis in all patients, but the majority com- plained ofocular discomfort as well, and luxation Even after successful treatment with cortico- ofthe globe was imminent in two. steroids or orbital irradiation many patients with Preoperative evaluation consisted in measure- Graves' ophthalmopathy need surgical repair for ments ofpalpebral fissure and scleral show in the rehabilitation. This may yield excellent results primary position of gaze at 12 and 6 o'clock, lid provided surgery is deferred till ocular and margin to lid crease distance definition, and http://bjo.bmj.com/ orbital symptoms have become stable.' Disfigur- exophthalmometer readings. Pre- and post- ing proptosis can be treated by orbital decom- operative photographs were taken ofall patients. pression, while the field of binocular single The outcome of surgery was evaluated after vision can be restored by extraocular muscle three months. Second and third procedures were surgery.23 Eyelid lengthening with or without performed if no cosmetically acceptable result dermatochalasis correction is usually the final had been achieved. The final cosmetic result was step of surgical rehabilitation. evaluated by the patients and the surgeons. on September 30, 2021 by guest. Protected copyright. Many different techniques have been des- Upper lid correction was considered to be good if cribed to lengthen eyelids in Graves' ophthalmo- (1) the upper 1 5 to 2-0 mm of the cornea at the pathy. In 1979 Callahan and Callahan stated that 12 o'clock position was covered by the lid; (2) the recession of the eyelid retractors is best achieved lid margin contour was smooth; (3) the lid crease with scleral grafts.4 Indeed the use of sclera for was within 7 to 10 mm of the lid margin; and (4) lower lid lengthening has been generally there was bilateral symmetry (Figs 1 and 2A, B). accepted. However, there is disagreement about An acceptable result was considered to be 1 to 2 its use in the treatment of thyroid related upper mm over or under correction or mild asymmetry, lid retraction. For this condition sclera has been requiring no further surgery (Figs 3A, B). If the advocated by some,56 while its efficacy has been lid margin of the lower lid touched the limbus at questioned by others.79 Unfortunately, suffi- the 6 o'clock position and the contour was cient data on surgical outcome are lacking in smooth, lower lid correction was considered to most ofthese studies. be good (Figs 4A, B). When there was a gap We on a large series of consecutive Department of report between the lid and the limbus of no more than Ophthalmology (Orbital patients in whom sclera has been used for both 1 mm, it was considered acceptable. Centre), University of upper and lower lid lengthening. The outcome of Amsterdam, The our treatment method is compared with that of Netherlands other methods. M P Mourits /==5-1.5-2.0 mm L Koornneef Correspondence to: */(^ 8 \< 9.0-10.0mm Dr M P Mourits, Orbita Centrum, Academisch Patients and methods Medisch Centrum A-2 116, From January 1986 till July 1989 62 consecutive Meibergdreef9, 1105 AZ Amsterdam, the Netherlands. patients with thyroid related eyelid retraction Accepted for publication underwent lid lengthening by scleral interposi- Figure I Drawing showing contour and position ofeyelids 22 November 1990 tion at the Orbital Centre of Amsterdam. in ideal situation. Lid lengthening by sclera interpositionfor eyelid retraction in Graves' ophthalmopathy 345 Br J Ophthalmol: first published as 10.1136/bjo.75.6.344 on 1 June 1991. Downloaded from

Figure 2 Pre- and postoperative appearance of a patient with unilateral upper eyelid retraction. Good result. Figure 2B.

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Figure 3 Pre- and postoperative appearance of a patient with unilateral upper eelid retraction. Slight asymmetry, acceptable result. Figure 3A. Figure 3B.

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Figure 4 Pre- and postoperative appearance of a patient with unilateral, left-sided lower lid retraction. Good result. Figure 4A. Figure 4B. http://bjo.bmj.com/ SURGICAL TECHNIQUE these assessments the patient is asked to open The approach is much as described for ptosis and close his eyes. When the result is satisfac- surgery previously.," A horizontal line is drawn tory, the skin is closed with 6-0 silk sutures. on the eyelid at about 7 mm from the lid margin In second and third procedures the eyelid is to mark the place of the future skin crease. After opened up through the former scar. The scleral eversion ofthe superior eyelid, 2 ml oflignocaine implant is dissected free and adjusted or

2% with epinephrine is injected into the subcon- replaced. on September 30, 2021 by guest. Protected copyright. junctival area. Thus the conjunctiva is separated In lower lids the approach is transconjunctival. from Muller's muscle. The upper eyelid is then After infiltration of the subconjunctival space further anaesthetised subcutaneously with with local anaesthetic the conjunctiva is incised approximately 3 ml of local anaesthetic. A hori- over the lower border of the tarsal plate. The zontal incision in the skin crease is made through lower lid retractors are identified and dissected the skin-muscle layer parallel to the muscle fibres offthe conjunctiva and the tarsus and freed ofthe on to the tarsal plate. By going upward in the orbital septum. A scleral graft of about three direction ofthe upper roofofthe orbit the orbital times the lid retraction in millimetres is sutured septum is visualised. The septum is opened, the to the retractors and the tarsal plate with 5 0 orbital fat is freed, and below the fat the levator Vycril. The conjunctiva is closed with a running aponeurosis isidentified. The levator aponeurosis 6-0 catgut suture. together with Muller's muscle are dissected off the tarsal plate, and the medial and lateral horns are transacted. The conjunctiva, however, is left Results unimpaired, thus protecting the cornea. Special The outcome of surgery was evaluated at a fixed care is taken to cut all fibrotic strands in the interval three months postoperatively. Follow- lacrimal gland region. A scleral graft is sutured to up varied from 05 to 3*5 years. The results of the tarsal plate and the levator muscle with upper lid lengthening are given in Table 2 and interrupted 5 0 Vicryl sutures. In upper lids the Fig 5. Less retraction postoperatively was seen in vertical height of the implant is approximately all patients, and ocular discomfort disappeared twice the amount of eyelid retraction, laterally in all but two. The cosmetic result was good or some millimetres more than medially. However, acceptable in 50% after one procedure and in the final determination of the levator recession 77% after a maximum ofthree procedures. Final and thus of the graft size is based on the evaluation showed mild or severe overcorrection operation table appearance ofthe lid margin. For or medial dropping in seven lids and temporal 346 Mourits, Koornneef

Table 2 Final outcome ofupper lid lengtheningprocedures by sclera implantation for thyroid related eyelid retraction

Result Br J Ophthalmol: first published as 10.1136/bjo.75.6.344 on 1 June 1991. Downloaded from Success Amount of retraction Number Good Acceptable Total Failure 1-3 mm 25 20% 52% 72% 28% 4-5 mm 36 33% 53% 86% 14% 6-10 mm 17 18% 47% 65% 35% 1-10 mm 78 26% 51% 77% 23% Figure 6A. obliquity in another seven lids (Figs 6A, B). Asymmetry was seen in four patients, and a thickened eyelid for longer than one month in two. Other complications such as a dry eye, loss oflashes, or extrusion ofthe graft did not occur. A No recurrence of retraction was seen in this group. The results of lower lid lengthening are given in Table 3 and Figs 7A, B. After one operation all but three patients had a good or acceptable Figure 6B. result. Within a year, a recurrence of retraction was noted in two patients. Figure 6 Pre- and postoperative appearance ofa patient with bilateral upper eyelid retraction. Typical persistent temporal retraction with resulting oblique lid edge. Unacceptable result. Discussion The difficulty of surgical correction of upper lid retraction in Graves' ophthalmopathy is illus- third procedure. In these patients we found trated by the numerous procedures described to considerable fibrosis in the lacrimal gland recess the lid retractors. Henderson's mifl- region, which tended to recur after repeated lerotomy is insufficient to obtain enough reces- procedures. We suggest that this excessive sion in most patients.91' Groves's levator mar- fibrosis may be caused by the scleral implant. tends to lead to Despite the fact that Putterman defined his ginal myotomy'2 unpredictable criteria for success oflid surgery in less detail, he results. His own series was too small to draw appears to have excellent results from a graded conclusions from. Several other techniques'"" Muller's muscle excision and levator recession have not been analysed in large enough numbers without the use of sclera: 80% of his 32 patients to demonstrate a high rate ofsuccess. had a satisfactory result after one intervention.717 http://bjo.bmj.com/ We have used scleral grafts to lengthen upper Thaller et al also reported good results in two- and lower lids in patients with Graves' ophthal- thirds of 30 patients after levator recession mopathy because we expected more predictable without the use of sclera. Levator recession with and favourable results. After one procedure, scleral graft in their hands was less predictable.9 however, only 50% of all operated upper lids Although it is impossible to make a statistical were satisfactory. It has been suggested that comparison between their procedures and our

scleral grafts cause lid thickening, cysts, and on September 30, 2021 by guest. Protected copyright. corneal damage,'6 but in our patients (medial) method, these reports and our experience with overcorrection and/or obliquity ofthe lid edge as scleral grafts indicate that sclera does not in- a result ofpersistent temporal retraction were the most important complications. Meticulous dis- Table 3 Final outcome oflower lid lengtheningprocedures section of the lateral part of the levator by sclera implantationfor thyroid related eyelid retraction aponeurosis could not prevent this. To avoid Result persistent temporal retraction we have used grafts that were so tapered they were wider Success temporally than medially, as suggested by Number Good Acceptable Total Failure Dryden and Soll.5 In spite of this, temporal 30 63% 34% 97% 3% retraction was noted even after a second and

1 100- w 100 r 0 Z 80 zcc 80 ACCEPTABLE RESULT 0 w a. 60- w 60 - Ci)U) EL W RESULT CD) ~~~~~~~~~ACCEPTABLE wch 40 0 40 4CD 0 GOOD RESULT us 20

v I 2

NUMBER OF PROCEDURES NUMBER OF PROCEDURES Figure S Diagram showing success percentage ofupper lid Figure 7 Diagram showing success percentage oflower lid lengthening in relation to number ofprocedures. lengthening in relation to number ofprocedures. Lid lengthening by sclera interpositionforeyelid retraction in Graves'ophthalmopathy 347

crease the success rate of upper lid lengthening. 4 Callahan MA, Callahan A. Surgery for endocrine ophthalmo- pathy. In: Callahan MA, Callahan A, eds. Ophthalmic plastic On the other hand, our data do not prove that lid and orbital surgery. Alabama: Aesculapius, 1979: 146.

lengthening with sclera yields less acceptable 5 Dryden RM, Soll DB. The use of scleral transplantation in Br J Ophthalmol: first published as 10.1136/bjo.75.6.344 on 1 June 1991. Downloaded from cicatricial entropion and eyelid retraction. Ophthalmology results. We believe that, until it has been demon- 1977: 83: OP669-78. strated that the more difficult procedure has a 6 Doxanas MT, Dryden RM. The use of sclera in the treatment of dysthyroid eyelid retraction. Ophthalmology 1981; 88: higher success rate, the simpler method should 887-94. be the one of choice. For this reason we do not 7 Putterman AM. Surgical treatment of thyroid-related upper eyelid retraction. Graded Muller's muscle excision and recommend scleral grafts for upper lid lengthen- levator recession. Ophthalmology 1981; 88: 507-12. ing in Graves' ophthalmopathy. 8 Waller RR, Samples JR, Yeatts RP. Eyelid malpositions in Graves' ophthalmopathy. In: Gorman CA, et al, eds. The eye Sclera for lower lid lengthening, on the con- and orbit in thyroid disease. New York: Raven, 1984: 263-99. trary, is known to support the lid as a semi-stiff 9 Thaller VT, Kaden K, Lane CM, et al. Thyroid lid surgery. Eye 1987; 1: 609-14. spacer against gravity.9 This might explain our 10 Hylkema HA, Koornneef L. Treatment of ptosis by levator satisfactory results in lower lid surgery. resection with adjustable sutures via the anterior approach. BrJ Ophthalmol 1989; 73: 416-8. 11 Henderson JW. Relief of eyelid retraction. Arch Ophthalmol 1 Mourits MP, Koornneef L, Wiersinga WM, Prummel MF, 1%5; 74: 205-16. Berghout A, van der Gaag R. Clinical criteria for the 12 Grove AS. Upper eyelid retraction: treatment by levator assessment of disease activity in Graves' ophthalmopathy: a marginal myotomy. Orbit 1982; 1: 21-31. novel approach. BrJ Ophthalmol 1989; 73: 639-44. 13 Schimek RA. Surgical management ofocular complications of 2 Mourits MP, Koornneef L, Wiersinga WM, Prummel MF, Graves' disease. Arch Ophthalmol 1972; 87: 655-64. Berghout A, van der Gaag R. Orbital decompression for 14 Baylis HI, Cies WA, Kamin DF. Correction of upper eyelid Graves' ophthalmopathy by inferomedial, by inferomedial retraction. AmJ7 Ophthalmol 1976; 82: 790-4. plus lateral, and by coronal approach. Ophthalmology 1990; 15 Beyer-Machule CK. Surgical treatment of thyroid-related 97: 636-41. eyelid retraction. Int Ophthalmol Clin 1989; 29: 232-6. 3 Mourits MP, Koornneef L, van Mourik-Noordenbos, et al. 16 Harvey JT, Anderson RL. The aponeurotic approach to eyelid Extraocular muscle surgery for Graves' ophthalmopathy. retraction. Ophthalmology 1981; 88: 513-24. Does prior treatment influence surgical outcome? 17 Putterman AM, Urist M. Surgical treatment of upper eyelid BrJ Ophthalmol 1990; 74: 481-3. retraction Arch Ophthalmol 1972; 87: 401-5. http://bjo.bmj.com/ on September 30, 2021 by guest. Protected copyright.