The success rate of TED upper eyelid retraction reoperations

Müllerotomy with anterior graded Müller muscle disinsertion for Graves upper eyelid retraction: validation of surgical outcomes using Bézier curves

PURPOSE

To assess with Bézier curves the outcomes of Müllerotomy with anterior graded Müller muscle disinsertion for the treatment of Graves upper eyelid retraction (UER).

METHODS

Eighty-six eyelids of 52 inactive GO patients operated from November 2018 to June 2021 were included in this study. All measurements were performed on Bézier curves adjusted to the upper lid contour with a previously validated algorithm. Lid contour was classified regarding grade of superposition (GS) as excellent (GS > 90%), good (GS 85-90%) or poor (< 85%). Surgical success was defined as complete or partial if postoperative grade of asymmetry was < 10% with an excellent or good lid contour, respectively.

RESULTS

The mean age was 51 ± 10.4 years with a range from 31 to 78 years and a mean follow-up of 14.4 ± 7.4 months. There was a significant improvement of median GS (p < 0.0001) from preoperative (74.3%; 10.7 IQR) to postoperative values (91.7%; 6.3 IQR). A normalization of postoperative contour peak (- 0.69; 1.27 SD) and MPLD90 (4.2 mm; 0.8 SD) was noticed (p < 0.0001). Postoperative lid contour was excellent in 62 (72%), good in 16 (19%) and poor in 8 eyelids (9%). Surgical success was achieved in 42 patients (81%), from which 34 (81%) were complete. Reintervention was required in 14 eyelids (16%).

CONCLUSIONS

Measuring surgical outcomes with Bézier curves allows an automated, complete and objective assessment, giving more consistency to our data compared to previous reports. Müllerotomy with graded Müller muscle disinsertion is a safe and effective procedure for Graves UER, offering predictable results.

Hyaluronic acid gel injection for dysthyroid upper eyelid retraction in Asian patients

PURPOSE

To evaluate the role of hyaluronic acid (HA) filler injection in the management of upper eyelid retraction (UER) in thyroid eye disease (TED).

METHODS

Retrospective interventional series of all patients with TED who had undergone HA injection, from February 2011 to April 2013 by a single surgeon (Y-DK) in a tertiary medical institution. Outcome measures: Mean margin reflex distance 1 (MRD1) pre- and post-filler.

RESULTS

There was a total of 13 patients and 17 eyes included in the study. The injection dosage for 15 eyes was 0.5 ml, one patient had 0.35cc on the right eye and 0.65cc on the left eye. Mean MRD1 at presentation was 6.21 mm. There was a mean decrease in MRD1 of 2.01 mm (p < .001) at 1 month post filler, 2.06 mm (p < .001) at 6 months post filler and 2.61 mm (p < .001) at 1 year post filler. There was no correlation between pre-filler MRD1 and change in MRD1 at various time points post-filler, nor any correlation between pre-filler upper scleral show (USS) and change in USS post-filler. There was also no correlation found between clinical activity score (CAS) and change in MRD1, as well as duration of thyroid eye disease (TED) and change in MRD1. Complications included mild upper lid lumpiness on downgaze (n = 4, 23.5%) which improved but persisted with time. There were no untoward intravascular or vision-threatening complications.

CONCLUSION

Transconjunctival HA injection is an effective treatment option for TED-related UER in both active and inactive TED patients in an East Asian population, with a potentially long-lasting effect.

Upper Eyelid Retraction in Graves' Ophthalmopathy: Our Surgical Experience on 153 Cases of Full-Thickness Anterior Blepharotomy with Mullerectomy

BACKGROUND

We present our experience on 153 cases of full-thickness anterior blepharotomy with mullerectomy (FTABM) in the treatment of upper eyelid retraction (UER) related to Graves' ophthalmopathy (GO).

METHODS

We included all the patients who underwent a graded FTABM between 1^st January 2015 and 30^th June 2020 for UER GO-related. The analysis included: pre-/post-operative conjunctival symptoms, epiphora, GO-Quality of Life Questionnaire (QoL), lagophthalmos, marginal reflex distance (MRD-1) index, eyelid symmetry within 1mm. The statistical analysis was designed to detect postoperative improvement in objective and subjective clinical features. Outcomes were analysed through Chi-squared test for dichotomous variables and through Wilcoxon-Mann-Whitney test for continuous variables.

RESULTS

Of the 111 patients, 42 underwent a bilateral procedure, while 69 a monolateral. Conjunctival symptoms were reported in 32% of cases before surgery and in 12.4% after FTABM (p < 0.001). Epiphora was complained by 29.6% of patients preoperatively and in 12.4% postoperatively (p < 0.001). Preoperative lagophthalmos was found in 12.4% (mean value of 0.34 ± 0.76 mm) of eyelids, and in 2.6% (mean value 0.05 ± 0.19 mm) eyelids (p = not significant) postoperatively. Pre-operative GO-QoL was 24.9 ± 4.4 mm; while post-operative GO-QoL was 35.3 ± 5.5 mm (p < 0.001). The MRD-1 varied from 10.12 ± 2.1 mm preoperatively, to 4.3 ± 0.6 mm (p < 0.001) after surgery. Asymmetric palpebral fissure was noted in 94 (84.7%) patients before surgery and in 7 (6.3%) after the procedure (p < 0.001).

CONCLUSION

FTABM is an effective procedure to treat UER GO-related. The technique manages to prevent complications of UER and determine good aesthetics.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 . Level IV, therapeutic study.

Eyes wide shut: necessity and effect of adjunctive procedures after decompression surgery in patients with endocrine orbitopathy

BACKGROUND

Orbital decompression surgery is frequently the last therapeutic measure in the surgical treatment of endocrine orbitopathy (EO). Additional rehabilitative and corrective surgical treatments are often used to improve the resulting eyelid stigmata, such as an increased lid aperture and scleral show. The aim of the study was to evaluate the effect of adjunctive surgical procedures after orbital decompression surgery in patients with EO.

METHODS

A total of 120 orbitae from 65 patients with EO from 2010 to 2020 at a tertiary care center in Germany were retrospectively evaluated. Ocular surface area (OSA) and vertical palpebral fissures were three-dimensionally analyzed at the following stages: presurgical decompression, postsurgical decompression, and post-adjunctive surgical procedures. For the analysis of vertical palpebral fissures, predefined vertical line distances were measured on the upper and lower lids in the central, medial, and lateral pupillary regions.

RESULTS

The initial OSA was 2,98 ± 0.85 cm², and it decreased significantly after decompression surgery to 2.52 ± 0.62 cm². After adjunct surgical procedures, OSA further decreased to 2,31 ± 0,55 cm². Furthermore, a statistically significant reduction in all pupillary parameters was noted after each treatment step. More lid-lengthening procedures were performed on the lower lid than on the upper lid. Canthoplasty (n = 13) was the most frequently performed procedure during rehabilitation.

CONCLUSION

Surgical decompression surgery improves OSA and leads to a significant reduction in lid aperture. Adjunctive surgical procedures, addressing the upper and lower lid, have a significant influence on the ongoing clinical course and contribute to a reduction in OSA.

De Keizer R, Wubbels RJ, den Bosch WA, Paridaens D. Results of surgical correction of upper eyelid retraction in Graves' Orbitopathy

INTRODUCTION

Anterior levator disinsertion/reinsertion and Müllerectomy (ALDM) is generally performed to correct upper eyelid retraction in patients with Graves' orbitopathy (GO). We studied the outcome of this procedure and its correlation with clinical parameters.

PATIENTS AND METHODS

Retrospective analysis of results of ALDM in 305 consecutive euthyroid patients with burnt-out GO treated in our hospital between 1 January 2000 and 1 January 2016. From the patient files, we recorded data on age, gender, laterality of surgery, smoking history and previous interventions. For outcome analysis, we used a qualitative scoring system with subdivision into three categories (good (MRD-1 of 4-5 mm, smooth upper eyelid contour and left-right difference of < 1 mm); acceptable (MRD-1 of 3-<4 or> 5-6 mm), smooth upper eyelid contour and left-right difference of < 2 mm; poor: if none of the above criteria was met). We analysed the outcome per eyelid as well as per patient.

RESULTS

Of the 305 patients (471 eyelids), 166 underwent bilateral and 139 unilateral surgery. Regarding eyelids, the outcome of surgery was good in 71.6% (337/471) acceptable in 15.7% (74/471) and poor in 12.7% (60/471). Regarding patients, the outcome was good in 64.3% (196/305), acceptable in 15.7% (48/305) and poor in 20% (61/305). Concerning bilateral and unilateral surgery, the outcome was good in 60.8% (101/166) and acceptable in 16.9% (28/166) of patients after bilateral surgery, and good in 68.3% (95/139) and acceptable in 14.4% (20/139) of the patients after unilateral surgery (p = 0.17). Reoperation was performed in 16% (75 of 471) of eyelids and in 22 % (66 of 305) of patients. After secondary surgery, the cumulative success percentage was good in 78.6% (370/471) of eyelids and in 79% (241/305) of patients. We found no relation between surgical outcome and any other studied parameter, such as age, gender, smoking history and previous intervention such as extraocular muscle surgery and/or orbital decompression.

CONCLUSION

Correction of upper eyelid retraction yields a good result in 64.3% of patients and 71.6% of eyelids. With one additional procedure, the procedure proved was successful in 79% of patients and eyelids. We found no relation between the outcome of surgery and any other parameter, such as previous disease severity, previous interventions or smoking history. For comparative analysis, we recommend to report the outcome per patient rather than per eyelid.

Eyelid Surgery in Graves' Orbitopathy

Patients with Graves' orbitopathy often develop eyelid changes. These may be the result of a volume effect or a malposition. Both dermatochalasis with fat tissue increase and eyelid retraction may lead to functional or aesthetic impairment. The present article reviews indications, timing and principles for corrective eyelid surgery. If at all possible, surgical eyelid correction in Graves' orbitopathy should be performed once the disease became inactive and stabile. Surgical details of eyelid lengthening procedures for upper and lower eyelid retraction are presented. Meanwhile anterior blepharotomy became the primary procedure for upper eyelid lengthening. However, there is no such standard procedure for lower eyelid lengthening, although it is recommended to use a spacer. For blepharoplasty it is mandatory to distinguish between orbital fat prolapse and subbrow fat pad. A prolapse of the lacrimal gland should not be missed and generally, skin excision performed sparingly.