|Year : 1984 | Volume
| Issue : 2 | Page : 93-96
Surgical treatment of lid retraction
SM Betharia, Y Dayal, BR Kalra
Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
S M Betharia
Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Betharia S M, Dayal Y, Kalra B R. Surgical treatment of lid retraction. Indian J Ophthalmol 1984;32:93-6
Lid retraction is a common problem and affects at least 50 per cent of patients with Grave's disease. Sometimes it may be the very first presenting sign. Treatment of lid retraction is required both for cosmetic and functional reasons as it produces ocular irritation and exposure keratopathy. The medical treatment for lid retraction due to thyrotoxicosis by using 5 per cent Guanethidine drops does not produce lasting clinical results. The purpose of this communication is to present the surgical treatment of lid retraction by Muller's muscle excision with or without levator tenotomy in four cases of lid retraction of endocrinological origin.
| Materials and methods|| |
4 cases of thyrotoxicosis with exophthalmos and on treatment with eltroxin in one case were subjected to Muller's Muscle excision with levator tenotomy [Table - 1].
Preoperative assessment and steps of Surgery:
In the preoperative assessment proper measurement of palpebral aperture and the position of the lid margin in relation to the upper limbus is determined and the extent of scleral show noted. The routine thyroid investigations are done. Compensatory unilateral lid retraction due to ptosis in the other eye is ruled out.
Surgical Steps: The operation is done in local infiltration anaesthesia using 2% Xylocaine is injected beneath the conjunctiva to balloon out the conjunctiva and separate it from underlying Muller's muscle. Another injection of 1 ml of Xylocaine 2% is given between the plane of Muller's muscle and L.P.S. After incising the conjunctiva the Muller's muscle is seen and is carefully dissected out from levator palpebrae superioris and 10 mm of Muller's muscle is excised. Partial thickness full width tenotomy of L.P.S. is done just above the upper border of tarsal plate in case the retraction is gross (2 mm of sclera is visible above the upper limbus) Scleral show. The lid margin is brought at the upper border of the pupil or at the middle of the pupil on the operation table depending on the amount of lid retraction. Complete haemostasis is achieved and the conjunctival suturing is done with 6 zero plain catgut. Pressure bandage is given for 24 hours and hot fomentation, antibiotics and anti-inflammatory drugs are given for one week.
There were no complications in case No. 1, 2 and 3. Whereas in case No. 4 where the lid margin was brought down to cover the whole of the pupillary area, the lid margin showed ptosis even after 2 months post-operatively and a repeat surgery in the form of attaching levator on the upper border of the tarsal plate had to be performed. This case also developed hematoma emphasizing the value 64 of complete haemostasis during surgery. [Figure - 1][Figure - 2][Figure - 3][Figure - 4]a & b.
| Discussion|| |
Various surgical procedures on Muller's muscle and levator palpebral superioris for treating lid retraction change the position from lying down to sitting up again and again till the final adjustment of the lid margin in relation to the limbus is done. Buffam and Rootman reported similar technique wherein appropriate degree of ptosis on the table is achieved but no quantification is done for the amount of droop needed in relation to the amount of retraction.
We advocate Muller's muscle excision alone for small degree of retraction and the lid margin is brought at the upper border of the pupil.
If the retraction is severe with more than 1 mm of scleral show then the partial thickness whole width levator tenotomy should be done and the lid margin should be brought down so that it covers half the pupillary area.
We emphasize that the lid margin must droop at the time of surgery so that it comes to desirable level after 3 to 4 weeks postoperatively. A generous tenotomy should be done specially on the lateral '/3rd of the lid as this is the area which usually shows residual retraction.
| Summary|| |
The surgical treatment of lid retraction by Muller's muscle excision with or without levator tenotomy is presented. The lid margin should be brought on the operation table at the upper border of the pupil in case of mild retraction and upto middle of the pupil in cases of severe retraction. The lid subsequently comes to a desirable level after 3 to 4 weeks of operation.
| References|| |
Werner S.C. and Ingbar S.H. The Thyroid (3rd edition), New York. 1971, p. 535.
Walsh F.B. and Hoyt W.I., 1969, (3rd edition) vol. 1,304: 309.
Blaskovics L.. 1961. Atlas of Ophthalmic Surgery.,p. 76.
Goldstein J., 1934, Arch. Ophthalmol., l l: 389.
Henderson J.W., 1965. Arch. Ophthalmol. 74: 205
Putterman A.M. and Urist M.: 1972. Arch.Ophthalmol. 87: 401.
Buffam F.V. and Rootman J. 197S. International Ophthalmology clinics, Vol. 18, 75: 86.
Hildreth H.R and Silver B., 1967. Arch. Ophthalmol. 77: 230.
[Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4]
[Table - 1], [Table - 2]