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. 1995;93:371–389.

The differential diagnosis and classification of eyelid retraction.

G B Bartley 1
PMCID: PMC1312066  PMID: 8719687

Abstract

PURPOSE: Classification schemes are useful in the formulation of differential diagnoses. Thoughtful commentary has been devoted to the classification of blepharoptosis, but the causes of eyelid retraction have received less attention in published reports. Although eyelid retraction most frequently is associated with Graves' ophthalmopathy, numerous other entities may cause the sign. This study was undertaken to provide a more comprehensive differential diagnosis and classification of eyelid retraction. METHODS: A series of patients with eyelid retraction was studied, and pertinent published reports were reviewed. RESULTS: Forty-four patients with different causes for eyelid retraction are described. Normal thyroid function and regulation were confirmed in all patients in whom Graves' ophthalmopathy could not be excluded by clinical, biochemical, or historical criteria. CONCLUSION: Based on a series of patients and reported cases, a differential diagnosis for eyelid retraction is proposed using a classification system comprising three categories (neurogenic, myogenic, and mechanistic).

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Selected References

These references are in PubMed. This may not be the complete list of references from this article.

  1. ASKENASY H., WIJSENBEEK H., HERZBERGER E. Retraction nystagmus and retraction of eyelids due to arteriovenous aneurysm of midbrain. AMA Arch Neurol Psychiatry. 1953 Feb;69(2):236–241. doi: 10.1001/archneurpsyc.1953.02320260094007. [DOI] [PubMed] [Google Scholar]
  2. BERLIN L. Compulsive eye opening and associated phenomena. AMA Arch Neurol Psychiatry. 1955 Jun;73(6):597–601. doi: 10.1001/archneurpsyc.1955.02330120001001. [DOI] [PubMed] [Google Scholar]
  3. Ballen P. H., Rochkopf L. Congenital retraction of the upper lid. Ophthalmic Surg. 1987 Sep;18(9):689–690. [PubMed] [Google Scholar]
  4. Bartley G. B., Gorman C. A. Diagnostic criteria for Graves' ophthalmopathy. Am J Ophthalmol. 1995 Jun;119(6):792–795. doi: 10.1016/s0002-9394(14)72787-4. [DOI] [PubMed] [Google Scholar]
  5. Bartley G. B., Gorman C. A. Hepatic cirrhosis as a doubtful cause of eyelid retraction. Am J Ophthalmol. 1991 Jan 15;111(1):109–110. doi: 10.1016/s0002-9394(14)76910-7. [DOI] [PubMed] [Google Scholar]
  6. Bartley G. B. The epidemiologic characteristics and clinical course of ophthalmopathy associated with autoimmune thyroid disease in Olmsted County, Minnesota. Trans Am Ophthalmol Soc. 1994;92:477–588. [PMC free article] [PubMed] [Google Scholar]
  7. COOPER J. C. Eye movements associated with myoclonus. Am J Ophthalmol. 1958 Aug;46(2):205–210. doi: 10.1016/0002-9394(59)90010-8. [DOI] [PubMed] [Google Scholar]
  8. Cohen M. M., Lessell S. Retraction of the lower eyelid. Neurology. 1979 Mar;29(3):386–389. doi: 10.1212/wnl.29.3.386. [DOI] [PubMed] [Google Scholar]
  9. Collin J. R., Allen L., Castronuovo S. Congenital eyelid retraction. Br J Ophthalmol. 1990 Sep;74(9):542–544. doi: 10.1136/bjo.74.9.542. [DOI] [PMC free article] [PubMed] [Google Scholar]
  10. Conway S. T. Lid retraction following blow-out fracture of the orbit. Ophthalmic Surg. 1988 Apr;19(4):279–281. [PubMed] [Google Scholar]
  11. Daroff R. B., Hoyt W. F., Sanders M. D., Nelson L. R. Gaze-evoked eyelid and ocular nystagmus inhibited by the near reflex: unusual ocular motor phenomena in a lateral medullary syndrome. J Neurol Neurosurg Psychiatry. 1968 Aug;31(4):362–367. doi: 10.1136/jnnp.31.4.362. [DOI] [PMC free article] [PubMed] [Google Scholar]
  12. Davidson S. I. THE EYE IN DYSTROPHIA MYOTONICA: WITH A REPORT ON ELECTROMYOGRAPHY OF THE EXTRA-OCULAR MUSCLES. Br J Ophthalmol. 1961 Mar;45(3):183–196. doi: 10.1136/bjo.45.3.183. [DOI] [PMC free article] [PubMed] [Google Scholar]
  13. FISHER M. Left hemiplegia and motor impresistence. J Nerv Ment Dis. 1956 Mar;123(3):201–218. doi: 10.1097/00005053-195603000-00001. [DOI] [PubMed] [Google Scholar]
  14. Frueh B. R. The mechanistic classification of ptosis. Ophthalmology. 1980 Oct;87(10):1019–1021. doi: 10.1016/s0161-6420(80)35135-x. [DOI] [PubMed] [Google Scholar]
  15. Galetta S. L., Gray L. G., Raps E. C., Schatz N. J. Pretectal eyelid retraction and lag. Ann Neurol. 1993 May;33(5):554–557. doi: 10.1002/ana.410330522. [DOI] [PubMed] [Google Scholar]
  16. Gay A. J., Salmon M. L., Windsor C. E. Hering's law, the levators, and their relationship in disease states. Arch Ophthalmol. 1967 Feb;77(2):157–160. doi: 10.1001/archopht.1967.00980020159002. [DOI] [PubMed] [Google Scholar]
  17. Gillies W. E., Harris A. J., Brooks A. M., Rivers M. R., Wolfe R. J. Congenital fibrosis of the vertically acting extraocular muscles. A new group of dominantly inherited ocular fibrosis with radiologic findings. Ophthalmology. 1995 Apr;102(4):607–612. doi: 10.1016/s0161-6420(95)30977-3. [DOI] [PubMed] [Google Scholar]
  18. Gonnering R. S. Pseudoretraction of the eyelid in thyroid-associated orbitopathy. Arch Ophthalmol. 1988 Aug;106(8):1078–1080. doi: 10.1001/archopht.1988.01060140234031. [DOI] [PubMed] [Google Scholar]
  19. Hawes M. J. Cherubism and its orbital manifestations. Ophthal Plast Reconstr Surg. 1989;5(2):133–140. doi: 10.1097/00002341-198906000-00010. [DOI] [PubMed] [Google Scholar]
  20. Hepler R. S., Hoyt W. F., Loeffler J. D. Paradoxical synkinetic levator inhibition and excitation. An electromyographic study of unilateral oculopalpebral and bilateral mandibulopalpebral (Marcus Gunn) synkineses in a 74-year-old man. Arch Neurol. 1968 Apr;18(4):416–424. doi: 10.1001/archneur.1968.00470340102009. [DOI] [PubMed] [Google Scholar]
  21. JOHNS R. J., KNOX D. L., WALSH F. B., RENKEN H. J. Involuntary eye movements in a patient with myasthenia and hyperthyroidism. Arch Ophthalmol. 1962 Jan;67:35–41. doi: 10.1001/archopht.1962.00960020037006. [DOI] [PubMed] [Google Scholar]
  22. Kansu T., Subutay N. Lid retraction in myasthenia gravis. J Clin Neuroophthalmol. 1987 Sep;7(3):145–150. [PubMed] [Google Scholar]
  23. Keane J. R. Lid-lag in the Guillain-Barré syndrome. Arch Neurol. 1975 Jul;32(7):478–479. doi: 10.1001/archneur.1975.00490490082009. [DOI] [PubMed] [Google Scholar]
  24. Keane J. R. Spastic eyelids. Failure of levator inhibition in unconscious states. Arch Neurol. 1975 Oct;32(10):695–698. doi: 10.1001/archneur.1975.00490520065010. [DOI] [PubMed] [Google Scholar]
  25. Kirkham T. H. Familial Marcus Gunn phenomenon. Br J Ophthalmol. 1969 Apr;53(4):282–283. doi: 10.1136/bjo.53.4.282. [DOI] [PMC free article] [PubMed] [Google Scholar]
  26. Kirkham T. H. Paradoxical elevation of eyelid on smiling. Am J Ophthalmol. 1971 Jul 30;72(1):207–208. doi: 10.1016/0002-9394(71)91617-5. [DOI] [PubMed] [Google Scholar]
  27. Klee G. G., Hay I. D. Biochemical thyroid function testing. Mayo Clin Proc. 1994 May;69(5):469–470. doi: 10.1016/s0025-6196(12)61645-0. [DOI] [PubMed] [Google Scholar]
  28. Kleiman M. D., DiMario F. J., Jr, Leconche D. A., Zalneraitis E. L. Benign transient downward gaze in preterm infants. Pediatr Neurol. 1994 Jun;10(4):313–316. doi: 10.1016/0887-8994(94)90128-7. [DOI] [PubMed] [Google Scholar]
  29. LEBENSOHN J. E. Parinaud's syndrome, from obstetric trauma with recovery. Am J Ophthalmol. 1955 Nov;40(5 Pt 1):738–740. [PubMed] [Google Scholar]
  30. LEWIS I. C., MACGREGOR A. G. Congenital hyperthyroidism. Lancet. 1957 Jan 5;272(6958):14–16. doi: 10.1016/s0140-6736(57)92434-0. [DOI] [PubMed] [Google Scholar]
  31. Layzer R. B., Lovelace R. E., Rowland L. P. Hyperkalemic periodic paralysis. Arch Neurol. 1967 May;16(5):455–472. doi: 10.1001/archneur.1967.00470230007002. [DOI] [PubMed] [Google Scholar]
  32. Leatherbarrow B., Kwartz J., Sunderland S., Brammar R., Nichol E. The 'baseball' orbital implant: a prospective study. Eye (Lond) 1994;8(Pt 5):569–576. doi: 10.1038/eye.1994.139. [DOI] [PubMed] [Google Scholar]
  33. Leone C. R., Jr, Lewis R. Congenital upper eyelid retraction. J Pediatr Ophthalmol. 1976 Nov-Dec;13(6):350–352. [PubMed] [Google Scholar]
  34. Lepore F. E. Unilateral ptosis and Hering's law. Neurology. 1988 Feb;38(2):319–322. doi: 10.1212/wnl.38.2.319. [DOI] [PubMed] [Google Scholar]
  35. Lyon D. B., Gonnering R. S., Dortzbach R. K., Lemke B. N. Unilateral ptosis and eye dominance. Ophthal Plast Reconstr Surg. 1993 Dec;9(4):237–240. doi: 10.1097/00002341-199312000-00002. [DOI] [PubMed] [Google Scholar]
  36. Mauriello J. A., Jr, Palydowycz S. B. Upper eyelid retraction after retinal detachment repair. Ophthalmic Surg. 1993 Oct;24(10):694–697. [PubMed] [Google Scholar]
  37. Meyer D. R., Wobig J. L. Detection of contralateral eyelid retraction associated with blepharoptosis. Ophthalmology. 1992 Mar;99(3):366–375. doi: 10.1016/s0161-6420(92)31963-3. [DOI] [PubMed] [Google Scholar]
  38. Miller N. R. Hepatic cirrhosis as a cause of eyelid retraction. Am J Ophthalmol. 1991 Jul 15;112(1):94–95. doi: 10.1016/s0002-9394(14)76223-3. [DOI] [PubMed] [Google Scholar]
  39. PARRY R. An unusual case of the Marcus Gunn syndrome. Trans Opthal Soc U K. 1957;77:181–185. [PubMed] [Google Scholar]
  40. Perez R. B. The eye-popping reflex of infants. J Pediatr. 1972 Jul;81(1):87–89. doi: 10.1016/s0022-3476(72)80379-2. [DOI] [PubMed] [Google Scholar]
  41. Pratt S. G., Beyer C. K., Johnson C. C. The Marcus Gunn phenomenon. A review of 71 cases. Ophthalmology. 1984 Jan;91(1):27–30. doi: 10.1016/s0161-6420(84)34331-7. [DOI] [PubMed] [Google Scholar]
  42. Price N. C., Collin J. R. Congenital horizontal tarsal kink: a simple surgical correction. Br J Ophthalmol. 1987 Mar;71(3):204–206. doi: 10.1136/bjo.71.3.204. [DOI] [PMC free article] [PubMed] [Google Scholar]
  43. Puklin J. E., Sacks J. G., Boshes B. Transient eyelid retraction in myasthenia gravis. J Neurol Neurosurg Psychiatry. 1976 Jan;39(1):44–47. doi: 10.1136/jnnp.39.1.44. [DOI] [PMC free article] [PubMed] [Google Scholar]
  44. Putterman A. M., Urist M. J. Upper eyelid retraction after blowout fractures. Arch Ophthalmol. 1976 Jan;94(1):112–116. doi: 10.1001/archopht.1976.03910030056014. [DOI] [PubMed] [Google Scholar]
  45. Putterman A. M., Urist M. J. Upper eyelid retraction after glaucoma filtering procedures. Ann Ophthalmol. 1975 Feb;7(2):263–266. [PubMed] [Google Scholar]
  46. Robin A. L., Pollack I. P., deFaller J. M. Effects of topical ALO 2145 (p-aminoclonidine hydrochloride) on the acute intraocular pressure rise after argon laser iridotomy. Arch Ophthalmol. 1987 Sep;105(9):1208–1211. doi: 10.1001/archopht.1987.01060090066029. [DOI] [PubMed] [Google Scholar]
  47. Rovit A. J., Deupree D. M., Zang Y. F., Biglan A. W. Treatment of congenital unilateral upper eyelid retraction with a marginal myotomy procedure. Ophthalmic Surg. 1988 Dec;19(12):872–875. [PubMed] [Google Scholar]
  48. Rubin P. A., Bilyk J. R., Shore J. W. Orbital reconstruction using porous polyethylene sheets. Ophthalmology. 1994 Oct;101(10):1697–1708. doi: 10.1016/s0161-6420(94)31113-4. [DOI] [PubMed] [Google Scholar]
  49. SCHULTZ R. O., BURIAN H. M. Bilateral jaw winking reflex in association with multiple congenital anomalies. Arch Ophthalmol. 1960 Dec;64:946–949. doi: 10.1001/archopht.1960.01840010948019. [DOI] [PubMed] [Google Scholar]
  50. SUMMERSKILL W. H., MOLNAR G. D. Eye signs in hepatic cirrhosis. N Engl J Med. 1962 Jun 14;266:1244–1248. doi: 10.1056/NEJM196206142662402. [DOI] [PubMed] [Google Scholar]
  51. Safran A. B., Berney J., Safran E. Convergence-evoked eyelid nystagmus. Am J Ophthalmol. 1982 Jan;93(1):48–51. doi: 10.1016/0002-9394(82)90698-5. [DOI] [PubMed] [Google Scholar]
  52. Sanders M. D., Hoyt W. F., Daroff R. B. Lid nystagmus evoked by ocular convergence: an ocular electromyographic study. J Neurol Neurosurg Psychiatry. 1968 Aug;31(4):368–371. doi: 10.1136/jnnp.31.4.368. [DOI] [PMC free article] [PubMed] [Google Scholar]
  53. Schechter R. J. Ptosis with contralateral lid retraction due to excessive innervation of the levator palpebrae superiorus. Ann Ophthalmol. 1978 Oct;10(10):1324–1328. [PubMed] [Google Scholar]
  54. Schmidtke K., Büttner-Ennever J. A. Nervous control of eyelid function. A review of clinical, experimental and pathological data. Brain. 1992 Feb;115(Pt 1):227–247. doi: 10.1093/brain/115.1.227. [DOI] [PubMed] [Google Scholar]
  55. Shore J. W., Westfall C. T., Leone C. R., Jr, Newman R. K., Shagets F. W. Enophthalmos and upper eyelid retraction following osteoplastic frontal sinusotomy. Ophthal Plast Reconstr Surg. 1987;3(1):13–15. doi: 10.1097/00002341-198701000-00003. [DOI] [PubMed] [Google Scholar]
  56. Smitt M. C., Donaldson S. S. Radiotherapy is successful treatment for orbital lymphoma. Int J Radiat Oncol Biol Phys. 1993 Apr 30;26(1):59–66. doi: 10.1016/0360-3016(93)90173-s. [DOI] [PubMed] [Google Scholar]
  57. Soparkar C. N., Patrinely J. R., Cuaycong M. J., Dailey R. A., Kersten R. C., Rubin P. A., Linberg J. V., Howard G. R., Donovan D. T., Matoba A. Y. The silent sinus syndrome. A cause of spontaneous enophthalmos. Ophthalmology. 1994 Apr;101(4):772–778. doi: 10.1016/s0161-6420(94)31267-x. [DOI] [PubMed] [Google Scholar]
  58. Stout A. U., Borchert M. Etiology of eyelid retraction in children: a retrospective study. J Pediatr Ophthalmol Strabismus. 1993 Mar-Apr;30(2):96–99. doi: 10.3928/0191-3913-19930301-08. [DOI] [PubMed] [Google Scholar]
  59. Susac J. O., Smith J. L. Cyclic oculomotor paralysis. Neurology. 1974 Jan;24(1):24–27. doi: 10.1212/wnl.24.1.24. [DOI] [PubMed] [Google Scholar]
  60. Ticho U. Synkinesis of upper lid elevation occurring in horizontal eye movements. Acta Ophthalmol (Copenh) 1971;49(2):232–238. doi: 10.1111/j.1755-3768.1971.tb00948.x. [DOI] [PubMed] [Google Scholar]
  61. Varma R., Miller N. R. Primary oculomotor nerve synkinesis caused by an extracavernous intradural aneurysm. Am J Ophthalmol. 1994 Jul 15;118(1):83–87. doi: 10.1016/s0002-9394(14)72846-6. [DOI] [PubMed] [Google Scholar]
  62. Weinstein G. S., Myers B. B. Eyelid retraction as a complication of an embedded hard contact lens. Am J Ophthalmol. 1993 Jul 15;116(1):102–103. doi: 10.1016/s0002-9394(14)71754-4. [DOI] [PubMed] [Google Scholar]
  63. Yee R. D., Odeh-Nasrala N. Congenital, paradoxical retraction of the lower eyelid. Am J Ophthalmol. 1974 Dec;78(6):1027–1029. doi: 10.1016/0002-9394(74)90822-8. [DOI] [PubMed] [Google Scholar]
  64. Zolli C. I. Upper eyelid retraction in long-standing anophthalmic sockets. Ann Ophthalmol. 1983 Jul;15(7):621–624. [PubMed] [Google Scholar]
  65. van't HOFF W. Familial myotonic periodic paralysis. Q J Med. 1962 Oct;31:385–402. [PubMed] [Google Scholar]

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