Restorative Lid Surgery in Thyroid Eye Disease

People with overactive thyroid glands (hyperthyroidism) may experience changes around their eyes. The most common abnormalities are prominent eyes, a staring expression, infrequent blinking and the eyes may not move well together causing double vision. It can also cause progressive visual loss and possibly blindness if the condition is not treated promptly.

“Starey Eyes” or Dysthyroid upper and lower lid retraction

Both eyelids may be affected, called “upper lid retraction” when it affects the upper and “lower lid retraction” when it affects the lower lids. The upper and lower lids can also get puffy and alter the facial appearance of the affected person dramatically.

If the lid retraction is left untreated, it can lead to sore, watery eyes, sensitivity to light and wind, scratches and infections of the surface of the eye which may be sight threatening, thus, it is important to have the condition treated before permanent damage occurs to the eye.

How can lid retraction be treated?

Temporary relief of ocular discomfort can be achieved by using artificial tears and ointments to help lubricate the eye, In addition having a Botox injection to weaken the scarred muscle (that has caused the upper lid to retract), can also be highly effective in certain select cases.

Surgery is generally undertaken once thyroid function has been stable for at least 6 months.

Surgical correction can be varied and depends on whether the protruding eyeball needs to be repositioned in its normal position within the bony socket (orbital decompression) or whether the upper and lower lid retraction needs corrective eyelid surgery.

Secondary upper lid retraction, requires an operation on the muscle that moves the eyeball (squint surgery), while primary lid retraction the eyelid muscle is operated on. Lower lid retraction can be treated by operating on the lower lid muscle or inserting a spacer graft like buccal mucous membrane (inner moist lining of mouth) or an acellular cadaveric dermis graft.

Surgical Correction

The aim of surgical correction is to restore the anatomy, by addressing the various causative factors. Lid surgery can be performed from the skin side (transcutaneous or anterior approach) or from the inner side of the upper lid (transconjunctival or posterior approach).

Thyroid Eye Disease

Surgery can range from a simple 60 minute procedure (eye lid surgery) to a more complicated 90 minute procedure (orbital decompression).

What are the potential risks & complication of surgical correction of upper lid retraction?

The risks of lid lowering surgery include

  1. Infection: this is very rare, occasionally the stitches may have an infective or inflammatory response, which settles with oral and topical antibiotics.
  2. Scarring (generally hidden in the skin fold). Normally stitches are visible for the first week, then, when they are removed, a faint scar is visible. The scar may seem a bit thickened & red for 6 to 12 weeks, becoming almost invisible after that period. Not every scar heals equally well. A thickened or reddened scar can be improved with silicone scar remodeling gel, but the treatment needs to be continues for months to have a good result.
  3. Large bruise or haematoma. This is minimised by avoiding heavy exercise for 2 weeks after surgery, stopping aspirin and other anticoagulants (if safe so to do) 2 weeks pre operatively, and regular use of ice packs. A haematoma may mean you have to go back into theatre to have the blood clot evacuated and then be re-stitched with the risk of a worse scar.
  4. Theoretical risk to vision. Any eyelid surgery carries the risk that an undiagnosed infection or bleed could damage the optic nerve. This is so rare that in comparison a normal car journey is a much greater risk to your vision.
  5. Asymmetry of eyelid shape, height or upper lid fold : this is rare, but can occur. Often asymmetry may be due to lid bruising and settles spontaneously as swelling resolves. Rarely, this may require revision surgery. Occasionally pre existing asymmetry of the face, eyebrow or eyeball position, may be responsible, however this will be discussed with you prior to the operation by your surgeon.
  6. Temporary poor blink, as the muscle that shuts the eyelid has been cut to access the muscle that lifts the eyelid. Generally blink returns to normal within 12 weeks.
  7. Recurrence of lid retraction : This can occur early post surgery (3 months) or late (after a few years), due to recurrent scarring, or reactivation of thyroid eye disease.  This will need to be corrected by re-operation.
  8. Contra lateral lid retraction: The eyelids are a pair, and often when one eyelid is retracted, the  contra lateral eyelid can appear to be in a “normal” position. However, immediately after surgery, the “normal” eyelid can appear to be retracted. This can correct itself within a few weeks or require a lid lowering correction.
  9. Overcorrection or ptosis : Rarely the upper lid retraction can be over treated surgically, resulting in a droopy eyelid. This will need to be corrected by re-operation.

The risks of lower lid retraction surgery are similar; however your surgeon will discuss the differences.