Management of Graves' upper eyelid retraction (GUER): A review

Abstract

Graves' disease, a common autoimmune disorder, characteristically presents with upper eyelid retraction, causing significant functional and cosmetic concerns for affected individuals. The management of Graves' upper eyelid retraction has evolved significantly over recent years, with various surgical and non-surgical interventions. An ideal procedure is predictable and easily repeatable. This review provides a comprehensive overview of the contemporary approaches to managing Graves' upper eyelid retraction, encompassing both traditional and emerging techniques. It critically evaluates the surgical options for correcting Graves' upper eyelid retraction to achieve the desired eyelid contour, eyelid crease, tarsal platform show, and brow fat span. Their comparative effectiveness is meticulously explored, offering clinicians valuable insights into treatment selection. Moreover, this review also underscores combined orbital decompression with levator recession. Additionally, advancements in non-invasive modalities, including botulinum toxin, triamcinolone acetate injections, and hyaluronic acid fillers are discussed in detail. This review aims to facilitate informed decision-making and improve the overall outcomes for individuals affected by Graves' disease-associated upper eyelid retraction.

Figure 1

Diagramatic colored illustration of the cross-section of the upper eyelid. Levator palpebrae superioris (green), Müller muscle (below LPS-red), tarsus (gray)

Figure 2

Clinical grading of upper eyelid retraction. (a) Normal position of the upper and lower eyelids. (b) Mild, (c) moderate and, (d) severe upper eyelid retraction

Figure 3

Transconjunctival injection of filler for upper eyelid retraction. Over an everted eyelid, the filler is injected supra-tarsally in the sub-conjunctival plane and along the levator plane to stretch the levator and also add weight

Figure 4

(a) Clinical image showing bilateral mild eyelid retraction wih lateral flare in active TED. (b) Clinical image showing improvement in the upper eyelid position after inj. botulinum. (c) Transconjunctival injection of botulinum toxin into LPS muscle via the trans-conjunctival route. (d) Injection of triamcinolone acetonide (20 mg) in the retroseptal orbital space via the trans-cutaneous route

Figure 5

Illustration of levator aponeurosis recession (below Desmarre’s retractor) (green arrow), shown separated from the tarsus (white)

Figure 6

Diagramatic colored illustration of graded full-thinkness anterior blepharotomy. Upper eyelid (peach) with blepharotomy opening leaving a central bridge to maintain contour. A part of the underlying cornea (blue) and pupil (black) visible through blepharotomy

Figure 7

Intraoperative image of the posterior approach showing the tarsus (T), levator muscle (L), Müller muscle (M), and conjunctiva (C)

Figure 8

(a) Preoperative clinical image showing left eye proptosis with upper and lower eyelid retraction in TED. (b) Preoperative clinical image: Worm’s view showing left eye proptosis. (c) Postoperative clinical image after customized orbital decompression and LPS recession showing good symmetry. (d) Postoperative clinical image: Worm’s view showing resolution of left eye proptosis

Figure 9

(a) Clinical image showing left upper eyelid retraction with lateral flare. Tarsal platform show is relatively short on the left (green line). (b) Anterior approach levator recession lengthening of TPS on the left and improve symmetry and contour