Lower Eyelid Retraction Repair at Time of Orbital Decompression for Thyroid Associated Ophthalmopathy

Abstract

Purpose:: The surgical management of thyroid associated ophthalmopathy (TAO) may involve 3 types of procedures (in order): 1.) orbital decompression, 2.) strabismus surgery, and 3.) eyelid retraction repair. Shorr et al described the rationale for a staged approach. Strabismus surgery is deferred until after decompression because of the potential for changes in ocular alignment. Eyelid retraction repair is delayed until after strabismus treatment since surgery to the vertical muscles can change the eyelid position by altering the eyelid retractor bands. We propose that performing a lower eyelid retractor recession via an inferior trans-conjunctival orbitotomy incision for decompression provides several advantages. The use of the same incision minimizes soft tissue trauma. Distracting the lid superiorly and allowing it to heal on stretch achieves tissue expansion that may prevent the need for later skin or posterior lamella grafting. Releasing the retractor band preemptively minimizes eyelid position changes after inferior rectus surgery. Ultimately, optimal results can be achieved while minimizing the number of procedures.

Methods:: This is a retrospective chart review of 49 lower eyelids in 35 consecutive patients with TAO were treated with a lower eyelid retraction repair at the same surgical setting as orbit decompression. The same surgical technique was utilized in each patient; we describe the procedure in detail. At a follow-up of 2 months to 2 years after the most recent TAO-related surgery (excluding lower eyelid revision), the lower eyelid was evaluated for position and MRD2. The cornea was inspected for exposure keratopathy due to lower lid malposition.

Results:: 44 of 49 (89.8%) of lower eyelids were in good anatomic position with the margin above the lower limbus and below the visual axis at the last follow-up visit. The average MRD2 was 5.2 mm before surgery and 3.8 mm after surgery. 5 eyelids (10.2%) were slightly overcorrected with greater than 30% obstruction of the lower visual field in primary gaze. A lid lowering procedure was performed on 3 eyelids; for the other two eyelids, the patient was not symptomatic and elected to forego additional surgery. 3 eyelids (4.1%) exhibited residual (mild) retraction and mild corneal exposure which required additional retraction repair. One lid (2%) required skin grafting.

Conclusions:: Lower eyelid retraction repair at the time of orbital decompression was effective in this series. Overcorrection was more likely than under-correction and the overall incidence of repeat eyelid surgery was low.

Keywords: orbit • eyelid • anatomy