A retracted upper eyelid leads to incomplete blinking, and reduced closure of the eye during sleep. The result is imperfect lubrication of the very sensitive surface of the eye (the cornea). This leads to irritation and a red eye, and cycles of dryness and reflex watering of the eye. Adequate lubrication with drops (artificial tears) will relieve many of these symptoms, but eyelid surgery may be required for persistent upper eyelid retraction and symptoms of irritation.
In what circumstances does an upper eyelid require lowering?
The most common indication for eyelid lowering is “burnt out” stable thyroid eye disease, although where there is significant proptosis (bulging or protrusion of the eyes), this should be addressed first (see information on thyroid eye disease, and orbital decompression). On rare occasions, eyelid lowering may also be required for severe lid retraction in the acute (inflammatory) phase of thyroid eye disease where the cornea is at risk of ulceration.
Other indications include upper lid retraction in chronic facial nerve palsy, and following trauma.
How is the eyelid lowered?
The eyelid can be lowered by releasing the muscles within the lid that are responsible for lifting the eyelid (the levator muscle and Muller’s muscle), under local anaesthetic (with or without sedation) on a day case basis.
For small degrees of lowering, this can be achieved via the under surface of the eyelid without an external skin incision, avoiding a visible scar. More significant degrees of lid retraction are addressed via an incision in the upper eyelid skin crease. The retractor muscles are released within the eyelid allowing the eyelid to drop. The amount of retractor muscle release is graded depending on the degree ofeyelid retraction. The skin incision is closed with fine stitches which are usually removed 10-14 days after surgery. Antibiotic ointment is instilled in the eye and a dressing placed over the eye which is removed 1 – 2 days later. Over the following few days, ice packs may be applied for short periods over the closed lids to reduce subsequent lid swelling.
What are the risks of surgery?
The three most common risks of surgery are as follows:
(i) Over or under correction. Over correction (droopy lid) is typically immediately apparent on the first post operative review. Although under correction (residual retraction) is less common, gradual re-retraction sometimes occurs over the following weeks as healing occurs. Corrective surgery similarly carries risks of over and under correction.
(ii) Contour changes: correction of severe degrees of retraction sometimes leads to a slight flattening of the natural ‘almond’ contour of the lid.
(iii) Enhancement of accessory lid skin folds: As the retractor muscle is released, an accessory (second) fold within the lid skin can become more apparent.
Additional risks include:
Irritation from the sutures, or from preservatives in prescribed drops
Damage to the eye or eyesight – this risk is very small in the hands of a specialist oculoplastic surgeon
How long is the recovery phase?
Eyelid swelling and a degree of bruising are common after surgery, but typically settle within 2-3 weeks and swelling can be reduced with cold compresses. Occasionally, the sensation within the eyelid can be disrupted, with a gradual return to normal over several weeks. In the event that there is significant over or under-correction, further corrective surgery may be required.