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. 1998 Feb;82(2):174–180. doi: 10.1136/bjo.82.2.174

Correction of lower eyelid retraction in thyroid eye disease: a randomised controlled trial of retractor tenotomy with adjuvant antimetabolite versus scleral graft

J Olver 1, G Rose 1, P Khaw 1, J Collin 1
PMCID: PMC1722468  PMID: 9613385

Abstract

BACKGROUND/AIMS—Lower eyelid retraction in thyroid eye disease contributes to ocular discomfort and an unsightly appearance, especially if asymmetrical. The use of donor scleral grafts is effective in lengthening the lower eyelids but carries a risk of virus transmission. Other techniques, including those which do not use grafts, need to be compared with scleral grafts. Recurrent retraction is a recognised complication of thyroid eyelid surgery; therefore, the authors investigated the use of antimetabolites to reduce postoperative fibrosis.
METHODS—In this prospective randomised controlled trial of 25 patients (35 eyelids), the use of donor sclera in 20 lower eyelids (13 patients) was compared with partial tenotomy of the anterior part of the lower eyelid retractors (ALER) with adjuvant peroperative antimetabolite in 15 lower eyelids (12 patients). A 5 minute peroperative application of either 5-fluorouracil (25 mg/ml) in nine lower eyelids (eight patients) or mitomycin C (0.2 mg/ml) in six lower eyelids (four patients) was used to focally inhibit fibroblasts. Follow up ranged from 3 to 18 months (mean 7.8).
RESULTS—One month after surgery the results of both groups were similar. However, at 3 months after surgery the results of scleral grafting were better than tenotomy with antimetabolites: 3/12 patients (25%) treated with tenotomy and adjuvant antimetabolite required subsequent surgery using grafts for correction of recurrent retraction. There were no significant complications associated with the use of antimetabolites in the eyelid in the doses used in this study.
CONCLUSIONS—This randomised prospective trial shows that donor scleral grafts were more effective in the long term than partial tenotomy with adjuvant antimetabolite in the correction of lower eyelid retraction associated with thyroid eye disease. The use of peroperative antimetabolites in the lower eyelid was safe.

 Keywords: thyroid eye disease; lower eyelid retraction; scleral graft; antimetabolites

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Figure 1  .

Figure 1  

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The adjuvant antimetabolite is applied focally to each side of the anterior part of the lower eyelid retractors (ALER) consisting of the capsulopalpebral fascia and inferior tarsal muscle. Two soaked neurosurgical patties (with radio-opaque tie) are used. The cut upper end of the ALER is held in a muscle clamp and is not treated with antimetabolite.

Figure 2  .

Figure 2  

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(A) Change in lower margin reflex distance (mean (SEM); mm) after surgery. (B) Change in lower scleral show (mean (SEM); mm) after surgery.

Figure 3  .

Figure 3  

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Scleral grafts. (A) Case 1. Bilateral lower eyelid retraction in a patient who has had previous bilateral orbital decompression with later right medial and inferior rectus recession. She also has upper eyelid dermatochalasis which, combined with the lower eyelid retraction, has given her an apparent head tilt with chin down. (B) Case 1. One year after bilateral lower eyelid scleral grafts and upper eyelid blepharoplasty. The upper eyelid blepharoplasty has greatly improved her overall appearance. (C) Case 2. Left unilateral proptosis and marked lower eyelid retraction in a patient who has had previous inferior rectus recession. He had a variable mild left upper eyelid retraction and opted for lower eyelid surgery only. (D) Case 2. After a large sized scleral graft with vertical bolsters. (E) Case 2. Six months after left lower eyelid scleral graft. Note slightly bulky lower eyelid and skin crease lower than the unoperated right side.

Figure 4  .

Figure 4  

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Tenotomy and antimetabolite. (A) Case 3. Bilateral lower eyelid retraction in a thyroid patient who has had previous bilateral upper eyelid retraction surgery (levator recessions) and inferior rectus recession. (B) Case 3. Three months after bilateral lower eyelid partial tenotomy retractors and adjuvant antimetabolite (mitomycin C), there is no sustained improvement in the lower lid position. This patient subsequently had bilateral palatal mucosal grafts inserted into her lower eyelids. (C) Case 4. Bilateral lower lid retraction before tenotomy and adjuvant 5-fluorouracil. (D)Case 4. Level of lower eyelid maintained 6 months postoperatively.

Selected References

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