Eye (1989) 3, 385-390 The Surgical Management of Dysthyroid Related Eyelid 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 eyelids 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 sclera 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 conjunctiva 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 conjunctivitis 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.!.