Full thickness eyelid transsection (blepharotomy) for upper eyelid lengthening in lid retraction associated with Graves' disease

Abstract

Aim: To report on a modified technique for upper eyelid lengthening in lid retraction associated with Graves' disease.

Methods: A prospective consecutive interventional case series. 41 patients, 38 women and three men, with a mean age of 55 years (range 32-75 years) were included. Full transsection of the upper eyelid with optional transsection of the lateral horn was performed in 60 lids. A central bridge of conjunctiva was left intact in the pupillary axis. Before and after surgery, the skin crease, palpebral aperture, and scleral show were measured and the contour of the lid margin was assessed. The overall result was graded as "perfect," "acceptable," and "failure."

Results: The mean period review was 6 months (range 2-36 months). Preoperatively, upper eyelid retraction varied from 1 mm to 7 mm; mean scleral show was 2 mm in 45 lids, the palpebral aperture was in the desired height (SD 1 mm) in 53 of 60 lids (88%) and was reduced by 3 mm (mean), the skin crease remained unchanged (SD 1 mm) in 44 of 60 lids (73%). The result was considered "perfect" in 43 and "acceptable" in 14 of 60 lids after one or two surgical approaches. In three lids, the surgery had failed.

Conclusion: In contrast with other surgical techniques the surgical approach presented here is easy to perform and still leads to very satisfying and predictable postoperative results.

Figure 1

Principle of full thickness eyelid transsection (blepharotomy), sagittal plane (left). Schematic drawing showing central conjuctival bridge and temporal incision of lateral horn (right).

Figure 2

Intraoperative steps of eyelid transsection in a patient with severe upper eyelid retraction (see patient in fig 3A, B). (A) Skin incision in skin crease level. (B) Transsection in a horizontal plane through the orbicularis muscle. (C) Transsection of levator complex and conjunctiva in the lateral third of the upper lid. (D) Branches of scissors indicating full eyelid transsection. (E) Horizontal transsection of the temporal part of the conjunctiva. (F) Dissection of the lateral horn. (G) Upper eyelid after subtotal (medial and lateral) horizontal blepharotomy, before wound closure; arrow indicates the remaining bridge of intact conjunctiva centrally, above the pupil. (H) Skin closure with a 6–0 silk suture with running locked stitches.

Figure 3

(A) Female patient with severe upper lid retraction, after bilateral orbital decompression. (B) Same patient after bilateral upper lid lengthening using full thickness horizontal blepharotomy (left upper lid lengthening procedure shown in fig 2).

Figure 4

(A) Male patient with marked upper eyelid retraction in Graves’ disease. (B) Same patient 6 months after upper eyelid lengthening, primary position. (C) Patient in downgaze, documenting skin crease in normal position.