Eyelid – Upper eyelid lowering in TED


A retracted upper lid leads to incomplete blinking, and reduced closure during sleep. The result is imperfect lubrication of the front of the eye, this leading to ocular redness and irritation, and cycles of dryness and watering. Adequate lubrication with drops will relieve many of these symptoms, but surgery may be required for persistent retraction and symptoms.

In what circumstances does an upper eyelid require lowering?

The most common indication for lid lowering is in stable thyroid eye disease, although where there is significant proptosis (bulging of the eyes), this should be addressed first (see information on thyroid eye disease, and orbital decompression). On rare occasions, lid lowering may also be required for severe lid retraction in the acute (inflammatory) phase of thyroid eye disease.

Other indications include upper lid retraction in facial nerve palsy (this typically improving within the first 6 weeks in Bell’s palsy), and any inflammatory disease which causes contracture of the under-surface of the eyelid (e.g. ocular cicatricial pemphigoid).

How is the eyelid lowered?

The eyelid can be lowered by releasing the muscle (the ‘retractor complex’) within the lid, under local anaesthetic (with or without sedation) and as a day case.

For small degrees of lowering, this can be achieved via the under-surface of the eyelid without an external incision. More significant degrees of lid retraction are addressed via a horizontal incision in the skin of the eyelid, this being linear and hidden within the natural crease (or fold) of the lid. The retractor muscles are released within the lid allowing the lid to drop, and this is graded depending on the degree of retraction. The incision is closed with a fine suture which is usually removed 7 – 10 days later. Antibiotic ointment is instilled and a dressing placed over the eye which is removed 1 – 2 days later. Over the following few days, ice packs may be applied for short periods over the closed lids to reduce subsequent lid swelling.

What are the risks of surgery?

The three most common risks of surgery are as follows:

(i) Over or under correction. Overcorrection (droopy lid) is typically immediately apparent on the first post operative review. Although undercorrection (residual retraction) is less common, gradual re-retraction sometimes occurs over the following weeks as healing occurs. Corrective surgery similarly carries risks of over and undercorrection.

(ii) Contour changes: correction of severe degrees of retraction sometimes leads to a slight flattening of the natural ‘almond’ contour of the lid.

(iii) Enhancement of accessory lid skin folds: As the retractor muscle is released, an accessory (second) fold within the lid skin can become more apparent.

How long is the recovery phase?

Eyelid swelling and a degree of bruising is common after surgery, but typically settles within 5 – 10 days and can be reduced with cold compresses or ice packs. Occasionally, the sensation within the eyelid can be disrupted, with a gradual return to normal over several weeks. In the event that there is significant over or under-correction, further corrective surgery may be required.