Eyelid retraction is when the upper lid is pulled or retracted upwards and the lower lid is retracted downwards. This is usually due to thyroid eye disease but it may also be due to facial nerve palsy and scarring after trauma or surgery.
It may become difficult to close the eyelids causing redness and irritation of the eye. The sclera, or white of the eye, may be seen between the eyelid margin and the cornea overlying the coloured part of the eye (iris). This ‘scleral show’ can be very noticeable.
Top - lower eyelid retraction following infection and trauma; 2nd image - after lower eyelid retraction surgery: upper eyelid skin flap moved to lower lid and dermis fat graft to inner aspect of the eyelid; 3rd image - right upper eyelid retraction; Bottom - after surgery to lower the upper lid by an internal scarless procedure
What are the benefits of surgery?
The operation should put the eyelid back into the correct position by raising a lower eyelid or lowering an upper lid. This should improve the redness and irritation of the eye if you experience this. There will also be a cosmetic improvement by reducing the scleral show.
What is eyelid retraction surgery?
Most operations are carried out under local anaesthetic with or without sedation. After anaesthetic drops have been put in both eyes, an injection of local anaesthetic is given just beneath the skin of the upper eyelid. This is similar to dental anaesthesia and usually takes less than 30 seconds to give. Local anaesthetic with sedation involves an anaesthetist administering intravenous sedation via a drip so that you are very relaxed and may not remember having the operation. General anaesthetic means that you are completely asleep.
Are there alternatives to surgery?
It is not possible to correct the problem without surgery but it may be possible to improve the symptoms with simple measures. Artificial tear drops can be used to maintain wetting of the ocular surface. This may improve the discomfort.
What will happen if I decide not to have surgery?
The eyelid retraction may stay the same or gradually get worse. The retraction does not usually damage the eye. In rare cases the eye may become over exposed and dry out. This can lead to ulceration of the eye. It may well be possible with simple artificial tear drops to be comfortable without surgery.
What will happen before surgery?
Before the operation you will be seen in the clinic by Mr. McCormick. He will ask you about the eyelid problem. He will also ask about other medical problems you have, medications you take and any allergies (bring a list or the tablets themselves with you). He will examine your eyes. If you are to proceed with surgery the operation will be discussed in detail. This will include any risks or possible complications of the operation and the method of anaesthesia. You will be asked to read and sign a consent form after having the opportunity to ask any questions. If you are to have a general anaesthetic or local anaesthetic with sedation you will also see a preoperative assessment nurse. She/He will carry out blood tests and an ECG (heart tracing) if required. She/He will also advise you if you need to starve before the operation. If simple local anaesthesia is used you will not need any of these investigations and you will not need to starve prior to surgery.
What should I do about my medication?
Mr. McCormick will want to know all the medication that you take and about any allergies you have. In some cases you may be asked to stop or reduce the dose of blood thinning tablets like: warfarin, aspirin, clopidogrel (plavix), dipyridamole (persantin). This decision is made on an individual basis and you should only do so if it is safe and you have been instructed by your GP, surgeon or anaesthetist. This will be discussed with you before surgery. You should avoid non steroidal anti inflammatory medications for 2 weeks prior to surgery. Other medication should be taken as usual.You should avoid herbal remedies for 2 weeks prior to surgery as some of these may cause increased bleeding at the time of surgery.
What are the risks and possible complications of surgery?
All surgery caries a risk of bleeding and infection, both are fortunately uncommon in these operations. Infection might present as increased swelling and redness of the skin. There might also be yellow discharge from the wound. It is treated with antibiotics. Bleeding may present as fresh blood oozing from the site of surgery or a lump appearing near the wound after the operation. Simple pressure on the area is usually enough to control minor bleeding. A collection of blood (haematoma) may be massaged and will usually settle without further surgery. A haematoma collecting in the orbit, behind the eye, may compress the nerve of vision and threaten eyesight. It is extremely rare for this to occur after eyelid surgery. It presents as pain, loss of vision and a bulging forwards of the eyeball. It is an emergency and as such is initially treated in an accident and emergency department. Whenever the skin is incised a scar may form. Every attempt is made by the surgeon to minimise and hide scars but sometimes they can be visible. The surgical correction could be over done and the lid roll inwards. Equally the operation may be under done and remain rolled out. Both of these are rare but further surgery should correct the problem. The eyelid is in close proximity to the eyeball. Although extremely unlikely, whenever surgery is carried out close to the eye there is a potential risk of damage to the eye and therefore to eyesight. You will have the opportunity to discuss the risks and benefits of surgery and anaesthesia with Mr McCormick and the anaesthetist prior to surgery.
What should I expect after surgery?
Usually a pad will be placed on the eye, which will remain until the following day when you can remove it. For 10 days the wound should be cleaned using boiled water that has cooled down and sterile cotton wool balls. After the pad is removed, antibiotic ointment should be applied to the skin wound and the eye three times a day for 2 weeks. It is normal for there to be swelling of the eyelid following surgery. This gets worse over the first 48 hours then starts to improve. It may take up to 6 weeks to resolve. Usually the skin sutures used are dissolvable and will be left to fall out by themselves. There may be some mild aching at the outer corner of the eye. This settles after 6-8 weeks and is due to the suture that reattaches the lid to the bone. The time when you can return to normal activities varies from person to person. Many are happy to do so after 2 – 3 days and the vast majority after a week.
If an eye pad is placed it should remain until the next morning when you may remove it. For the first 10 days clean the wound using either sterile water sachets or boiled water that has cooled down and sterile cotton wool balls. Chloramphenicol ointment to the eye and wound, three times a day for 2 weeks. Follow up appointment 1 week later.