Eye (1989) 3, 385-390

The Surgical Management of Dysthyroid Related Retraction Using Mersilene Mesh

R. N. DOWNESl and K. JORDAW Cambridge

Summary The use of Mersilene mesh as a spacer material in the surgical management of seven patients with dysthyroid-related eyelid retraction is presented. To date, fourteen have been operated on using this material with an average follow-up of nine months. It appears that Mersilene mesh is a realistic alternative to preserved in the surgical management of such cases.

The use of synthetic mesh materials has not In upper eyelid retraction a standard previously been described in the English liter­ anterior approach was performed. 7.8 The leva­ ature in eyelid surgery. The experiences tor-aponeurosis complex was identified and reported by other disciplinesi'6 using Mer­ mobilised with careful attention to complete silene mesh suggest that it may be a valuable division of the lateral horn. The posterior substitute for preserved sclera in the manage­ ment of dysthyroid related lid retraction. Table I Patient details A prospective clinical trial was undertaken { using Mersilene mesh as a lid spacer material 5 Female in cases of upper and lower eyelid retraction 7 patients arising from dysthyroid eye disease. 2 Male Age range 25 yr-52 yr. Materials and Methods Average 41 yr. Seven patients with dysthyroid eye disease All clinically and biochemically euthyroid for at had Mersilene mesh inlay procedures per­ least 6 months at the time of operation. formed (Table I). Surgery was undertaken on a total of fourteen eyelids; four upper and ten Table II Previous ophthalmic surgery lower lids. Previous eye surgery had been per­ formed in five patients (Table II). The 1 Patient - (L) orbital decompression for patients were fully evaluated pre-operatively compressive optic neuropathy - Bilateral inferior rectus recessions with particular emphasis upon superior and inferior scleral show in the primary position of 2 Patients - Bilateral lateral tarsorrhaphies ( ) (3 out of4 opened spontaneously post­ gaze Table III . All patients complained of operatively) ocular discomfort and poor cosmesis. All gave informed consent to the planned surgical 1 Patient - Bilateral levator myotomies procedures. 1 Patient - Upper lid scleral inlay

From: iOphthalmic Department, New Addenbrookes Hospital, Cambridge and 20phthalmic Department, Princess of Wales Hospital, RAF Ely, Cambs. Correspondence to: Sqn Ldr R N Downes, Consultant Ophthalmic Surgeon, Princess Mary's Hospital, RAF Halton, Aylesbury, Bucks HP22 5PS 386 R. N. DOWNES AND K. JORDAN

Table III Pre-operative measurements (in primary the fornix. The lower lid retractors were position of gaze) divided from the tarsal border exposing the Upper lids suborbicularis plane, and mobilised using Range 4-5 mm superior scleral show blunt dissection inferiorly in this plane. A Average 4.7 mm superior scleral show Mersilene mesh spacer was cut to size using Lower lids dimensions adopted for sclera,s.9 with hori­ Range 2-5 mm inferior scleral show zontal dimensions equal to those of the tarsus Average 3.5 mm inferior scleral show and a vertical height of twice the pre-opera­ tive scleral show. The mesh was sutured inferiorly to the free border of the lower eye­ lid retractors and superiorly to the inferior tarsal border using 6/0 vicryl. The was sutured to the tarsal margin so that the mesh was completely covered, using a con­ tinuous vicryl suture. Full thickness bolster sutures were used in some cases. Two lower lid traction sutures, one medial and one lat­ eral, were taped to the brow for 48-72 hours post-operatively. Lateral andlor medial tar­ sorrhaphies were performed in certain cases. All surgery was performed under general anaesthesia. Fig. 1. Close up photograph of Mersilene mesh spacer, demonstrating mesh configuration. The mesh is cut horizontally in the direction arrowed. Results A significant improvement in eyelid position was achieved in all cases (Table IV). Figures plane of dissection was between the levator 2-5 illustrate two patients. To date, the eyelid complex and Muller's muscle such that the height has been maintained in all patients with latter structure with conjunctiva remained an average follow-up of nine months (range attached to the superior tarsal border. A 5-16 months). All the patients were pleased spacer of Mersilene mesh was fashioned based with the post-operative cosmetic result and upon the measurements widely adopted for the majority reported a marked improvement sclera8.9 i.e. horizontal dimensions equal to in, or abolition of, ocular discomfort. Signifi- those of the tarsus and vertical dimensions twice the amount of pre-operative scleral Table IV Post-operative measurements (in primary show laterally, one and one half times the position of gaze) scleral show centrally and medially. Mersilene mesh has a specific fibre-junction configur­ Upper lids ation. To avoid excessive horizontal laxity the (Total 4) All within 1 mm of the superior limbus mesh is cut as illustrated in Figure 1. The mesh I-significant lateral peaking was sutured to the free inferior border of the Lower lids levator complex superiorly and the superior (Total 10) tarsal border inferiorly using continuous 6/0 Range 0-2 mm inferior scleral show vicryl. Interrupted absorbable sutures were Average 0.6 mm inferior scleral show used to close the skin and reform the skin crease. A central upper lid traction suture was Table V Complications taped to the cheek for 48 hours post­ operatively. 2 Patients - Mesh 'erosion' through conjunctiva In lower eyelid retraction a conventional 1 Patient - Chronic papillary posterior approach was adopted.7.H The con­ 2 Patients - Localised lid tenderness (both in lower lid) junctiva was incised along the lower tarsal 3 Patients - Intermittent, chronic discharge border and extensively undermined down to DYSTHYROID RELATED EYELID RETRACTION AND MERSILENE MESH 387

Fig. 2. Pre-operative appearance. Fig. 3. Post-operative appearance of patient illus­ trated in Figure 2 fo ur months after insertion of Mer­ silene mesh spacers in all four eyelids.

Fig. 4. Pre-operative appearance. Fig. 5. Post-operative appearance of patient illus­ trated in Figure 4 six months after bilateral lower lid Mersilene mesh inlay procedures and left levator com­ plex recession. cant lateral peaking of the upper eyelid similar although asymptomatic area of lower occurred in one patient who had a similar eyelid mesh exposure. The exposed mesh was appearance of the contralateral lid following a excised and covered with conjunctiva in each scleral inlay. Subsequent bilateral upper lid case with no further problems and no effect on explorations were performed with adequate the eyelid position. release of the lateral horns: satisfactory upper eyelid contours resulted. Discussion A number of complications were encoun­ The current management of significant lid tered (Table V) the most troublesome of retraction in dysthyroid eye disease is some­ which was a chronic, unilateral papillary con­ what controversial. 715 Whilst it is generally junctivitis in one patient who had undergone agreed that a lid spacer material is required bilateral lower lid Mersilene inlays. Topical for the correction of 2 mm or more of lower antibiotics and steroids were required with eyelid retraction no such consensus exists gradual resolution of the condition over regarding the management of upper eyelid several months. Three patients noticed retraction. Some authors believe that an localised tenderness of the lids. No cause was upper eyelid can be satisfactorily lowered, found in two cases which resolved spon­ whatever the amount of retraction, with sur­ taneously. The third case demonstrated a gery directed towards recessing and/or weak­ small area of mesh exposure through the con­ ening the levator complex.ll-l3 Others believe junctiva of the upper lid. One patient had a that a lid spacer is required to correct in excess 388 R. N. DOWNES AND K. JORDAN of 3 mm of upper eyelid retraction. 7.8.91. 0.1416. If proven record. Additionally sclera acts, at a lid can be lowered adequately without resort least in the initial post-operative period, as a to the use of foreign materials then so much lid spacer. This feature is felt to be particularly the better but it is our experience that a more important when used in the lower eyelid. Pre­ reliable lid height can be achieved with a served sclera does however have certain dis­ single operative procedure if a spacer material advantages8.911.16. (Table VI) not least of which is used to lengthen the retractor complex. is a variable and unpredictable absorption A variety of materials have been used in the which can result in an unsatisfactory finaleye­ surgical management of eyelid retrac­ lid position. As a result of these disadvantages tion.8.9.11.16 Sclera, fascia, cartilage, tarsus and the use of a synthetic nonabsorbable mesh collagen film have all been employed as lid material, instead of sclera, was considered. spacers. The most popular and widely used is Non absorbable meshes are currently preserved sclera. It is easily implanted, inex­ manufactured using a variety of materials. pensive, usually readily available and has a Polyester mesh appears to have certain advan­ tages which prompted the use of Mersilene mesh in this clinical study. Table VI Preserved sclera Nylon becomes significantly weakened after prolonged implantation and the mesh­ Advantages Widely used; proven 'track record' collagen adhesions are less regular than these Availability found with polyester. 1.17 Metallic meshes Inexpensive and easily implanted create a marked tissue inflammatoryresponse 'Lid stiffener' and the sites of fibre junctions are subject to Disadvantages stress fatigue. Carbon fibre materials frag­ Variable absorption ment after three months or so and produce a Lid bulk/oedema Antigenic response progressive resorption of surrounding col­ Overlying skin changes lagen as a result of inflammationcaused by the Cyst formation fibre breakdown.3 Availability; 24-hour preparation Mersilene mesh is an interlocking polyester H.!. V. status fibre mesh.1 61. 7 It is manufactured using a Corneal irritation machine knitting process which interlocks each fibre, thus preventing unravelling. This Table VII Clinical applications of Mersilene mesh allows cutting of the mesh into different shapes and sizes without significantly disrupt­ 1. General surgery - diaphragmatic defects ing adjacent junction sites. Histological find­ - hernia repairs - rectal/urogenital slings ings in animal studies have shown that the mesh is initially covered with a thin fibrous 2. Vascular surgery - vascular prostheses layer. Subsequent fibrovascularingrowth into 3. Orthopaedic surgery - ligament/tendon the open meshwork occurs, intimately inte­ - repairs/replacement grating the mesh and contact tissue. Clinical studies have confirmed these findings.I.3·16.17 Table VIII Mersilene mesh Mersilene mesh has been available for thirty years or so and extensively used in a variety of Advantages clinical settings (Table VII). Interestingly, Readily available and inexpensive et 1 Easily prepared, shaped and implanted Peyman at. 8•19 when studying intraocular Strong, durable and flexible lens fixationin rabbit eyes reported fibroblas­ Provision of permanent scaffolding for fibrovascular tic and pigmented epithelial cell ingrowth into ingrowth polyester mesh within five days of implan­ Well tried and tested in various clinical settings tation resulting in consistent and localised Disadvantages adhesion to the posterior iris. In comparison Foreign material with teflon, nylon, silk and catgut, polyester ? Flexible Probably requires conjunctival cover mesh produced maximal adhesion with mini­ mal post-operative inflammation. The advan- DYSTHYROID RELATED EYELID RETRACTION AND MERSILENE MESH 389

Table IX patients expressed concern about resultant cosmesis, particularly of the medial canthal Surgical technique-upper lid Anterior approach region, when the proposed surgery was out­ Mesh interposed between levator aponeurosis lined. Therefore where possible these pro­ and tarsus cedures were omitted using instead temporary Horizontal dimensions = tarsus medial and lateral traction sutures, taped to Vertical dimensions: 72 2 x scleral show laterally the forehead for hours. The results suggest 1.5 x scleral show centrally and medially that in certain cases, usually those with iso­ Upper lid traction suture 48 hours lated lower eyelid retraction, permanent lat­ Recommendations-upper lid eral and medial lid apposition may not be Mersilene dimensions: necessary. 1. 5 x scleral show medially and centrally Only one patient required re-operation for 2 x scleral show laterally an unsatisfactory lid position. This was the Eye pads and upper lid traction suture 48 hours Routine topical antibiotics ± oral antibiotics result of failure to free adequately the lateral horn of the levator complex rather than any inherent problem arising from the use of Mer­ Table X silene. We did however encounter a number of complications. One patient developed a Surgical technique-lower lid Conjunctival approach unilateral chronic papillary conjunctivitis, Mesh interposed bctween infcrior retractors which did however fully resolve with pro­ and tarsus longed topical antibiotic and steroid therapy. Horizontal dimensions = tarsus The patient concerned had bilateral Mer­ Vertical dimensions: silene inlays; the contralateral lid gave no such 2 x scleral show Conjunctival cover problems. This suggested a local mesh abnor­ Full thickness bolstcr sutures mality as the causative factor rather than a Medial and lateral Frost sutures 72 hours generalised reaction to the mesh. When Mer­ Recommendations-lower lid silene mesh is cut with scissors, the divided Mersilene dimensions: fibres adjacent to mesh junctions become 1. 5 x scleral show frayed. It is possible that one or several cut Horizontal length = tarsus Medial and lateral Frost sutures for 72 hours fibre edges traumatised or perforated the Full thickness bolster sutures for 10-14 days overlying conjunctiva (although the latter was Eye pads 48 hours not apparent on slit lamp examination) setting Routine topical antibiotics up a local conjunctival reaction. Frank + oral antibiotics (I week) exposure of an area of mesh was seen in two cases. In one patient an area of localised mesh exposure through the conjunctiva was appar­ tages and disadvantages of Mersilene mesh ent on eversion of the upper eyelid. Micro­ are summarised in Table VIII. scopic examination revealed that the exposed The results using Mersilene mesh compare mesh formed part of the lower cut margin of favourably with those generally reported the inlay. It seemed likely that this free margin when sclera has been used as a lid spacer. had eroded through the adjacent conjunctiva. Although the polyester mesh is relatively thin The mesh was carefully trimmed and and flexible this did not seem to be dis­ resutured, with closure of the overlying con­ advantageous when used in the lower eyelid. junctiva; the patient has not experienced Our findings suggest that a relatively rigid, further problems. The case of asymptomatic inflexible material such as sclera or cartilage localised mesh exposure was complicated by may not be as advantageous as is usually inadvertent removal of the continuous con­ assumed. It has been suggested that perma­ junctival suture two weeks post-operatively, nent medial and lateral canthal support, in the although it is possible that limited fibre ero­ form of lateral tarsorrhaphy and medial sion through the conjunctiva also occurred. canthoplasty, is necessary to obtain a satis­ Localised mesh excision and resuturing factory lower eyelid position. Some of our resolved the problem. 390 R. N. DOWNES AND K. JORDAN

Careful preparation of the Mersilene inlay and polyester fibres. J Bone Joint Surg (Br)1982, 643: 682. combined with scrupulous suturing should 4 Bayer I, Feller N, Chaimoff CH: A new approach to minimise the likelihood of mesh exposure, but the nipple in Koch's reservoir ileostomy using the problem of localised fibre disruption asso­ Mersilene Mesh. Div Colon Rectum (USA)1981, ciated with freehand cutting of the mesh still 24: 428--31. 5 Adloff M and Arnaud JP: Surgical management of exists. The manufacturers of Mersilene mesh large incisional hernias by an intra peritoneal have been approached; they are currently Mersilene Mesh and an aponeurotic graft. Surg studying alternative means of cutting the Gynecol Obstet1987, 165: 204-6. 6 Meadows TH and Davies DR: Late reconstruction mesh and sealing the disrupted fibres in an of the patellar ligament using a dacron ligament attempt to obviate this problem. implant. J Roy Coli Surg Edin1987, 32: 322-3. Two patients were aware of localised eyelid 7 Collin JRO: Ptosis/Corneal Protection. In Collin JRO ed. A manual of systematic eyelid surgery. tenderness for several weeks post-operatively Edinburgh: Churchill Livingstone 1983, 69-71 although this had no obvious cause and settled and117-9. spontaneously. Three patients complained of R Dryden RM and Doxanas MT: Eyelid malpositions, a prolonged and intermittent mucoid dis­ part I. In McCord Jr. CD ed. Oculoplastic Sur­ gery. New York: Raven Press1982,97-105. charge. This settled with time and topical anti­ 9 Doxanas MT and Dryden RM: The use of sclera in biotic therapy and was probably related to the the treatment of dysthyroid eyelid retraction. slowly absorbable conjunctival suture. Ophthalmology1981, 88: 887-94. 10 Beyer CK and Albert DM: The use and fate of fascia Our recommendations for the use of Mer­ lata and sclera in ophthalmic plastic and recon­ silene mesh as a lid spacer are outlined in structive surgery. Ophthalmology1981, 88: 869- Tables IX and X. 86. II Harvey JT and Anderson RL: The aponeurotic approach to eyelid retraction. Ophthalmology Conclusion 1981,88: 513-24. 2 The results obtained, at least in the short 1 Grove AS: Upper eyelid retraction and Graves' disease. Ophthalmology 1981,88: 499-506. term, are most promising although further 13 Putterman AM: Surgical treatment of thyroid­ clinical evaluation is necessary. If a spacer related upper eyelid retraction. Ophthalmology material in lid surgery is deemed appropriate, 1981,88: 507-12. this study suggests that Mersilene mesh may 14 Shorr N and Seiff SR: The four stages of surgical rehabilitation of the patient with dysthyroid be a suitable alternative to preserved sclera. ophthalmopathy. Ophthalmology 1986, 93: 476-- 83. We would like to thank Mr P G Watson, Mr J Keast 15 Thaller VT, Kaden K, Lane CM, Collin JRO: Thy­ Butler and Mr A T Moore for their help and co-oper­ roid lid surgery. Eye1987, 1: 609-14. ation with this study, and Miss G Mason for her valu­ 16 Lisman RD and Smith BC: Eyelid surgery for thy­ able secretarial assistance. roid ophthalmology. In Smith BC, Della Rocca RC, Nesi FA and Lisman RD eds. Ophthalmic Plastic and Reconstructive Surgery St Louis: CV References Mosby Company1987, Vol 2: 1401-14. I Adler RH and Furne CN: Use of pliable synthetic 17 Product sheet-Mersilene Mesh: revised 9/85 from mesh in the repair of hernias and tissue defects. Ethicon Ltd. Surg Gynecol Obstet1959; 108: 199-206. 18 Peyman GA and Koziol J: Intraocular lens fixation 2 Nichols DA: The Mersilene Mesh gauze hammock with Dacron mesh: part I. Ophthalmic Surg1977, for severe urinary stress incontinence. Obstet 8: 58-64. Gynecol1973,41: 88-93. 19 Peyman GA, Koziol J, Janevicius R: Intraocular 3 Amis AA: Filamentous implant reconstruction of lens fixation with Dacron mesh: Part II. tendon defects: a comparison between carbon Ophthalmic Surg1977, 8: 87-93.