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Purpose To evaluate the effects of the concomitant use of spacer grafts in lateral tarsal strip surgery in patients with facial nerve palsy-related lower-eyelid retraction. Methods Patients who underwent lateral tarsal strip surgery to correct facial nerve palsy-related lower-eyelid retraction were retrospectively reviewed. Postoperative decreases in marginal reflex distance-2 values at 1, 2 and 6 months were measured along with the effects of spacer grafts. Results Forty-five patients (28 males) were included (mean age: 59.56 years). Mean preoperative marginal reflex distance-2 was 6.87 ± 1.34 mm. Twenty patients underwent lateral tarsal strip surgery only (lateral tarsal strip-only); 25 patients underwent lateral tarsal strip surgery using spacer grafts (lateral tarsal strip + graft). Median (interquartile range) follow-up duration was 12.0 (6.0–23.0) months. Retraction was significantly improved and maintained at 1, 2 and 6 months postoperatively in all patients (mean marginal reflex distance-2: 3.78 ± 1.06 mm, 4.30 ± 1.23 mm and 4.72 ± 1.11 mm, respectively). Surgical outcomes were significantly better in the lateral tarsal strip + graft than in the lateral tarsal strip-only group (Δmarginal reflex distance-2: 3.92 vs. 2.05 mm at 1 month, p Conclusion The concomitant use of spacer material in lateral tarsal strip surgery yielded better surgical outcomes than lateral tarsal strip surgery alone. The use of spacer grafts should be considered for correcting severe facial nerve palsy-related lower-eyelid retraction.

To report the etiopathogenesis and clinical features of blepharoptosis in patients with thyroid eye disease. A 10-year retrospective interventional study. The etiopathogenesis, laterality, clinical features, and management of Blepharoptosis in thyroid eye disease (TED) were assessed. A total of 1000 patients of TED were evaluated in the 10-year period, of which 55 (5.5%) presented with Blepharoptosis. The average age at presentation was 44.8 years, and 31 (56.4%) were males. Of the 41 cases where referral diagnosis was available, TED was suspected in only 2 cases. Of the 55, 25 patients were inactive (TED duration ≥ 12 months), and 29 were silent presenters (TED duration ≤ 12 months, but clinical activity score ≤ 3). Ptosis was the primary presenting symptom in 14 cases. Ptosis was aponeurotic in 38 cases, myasthenic in 13 cases, congenital in 2 cases, and indeterminate in 2 cases. Orbital imaging was available in 26 cases, of which fat disease was noted in 14 cases. Average amount of ptosis was 2.21 mm (range 1-6 mm). Lower eyelid retraction (average 2.1 mm) was noted in 49 patients. Surgical management was performed in 10 patients, of which 4 underwent a unique combined surgery (orbital decompression with levator reattachment/resection). In patients with TED, blepharoptosis constitutes 5.5% at presentation to a tertiary eye care centre. Blepharoptosis masks upper eyelid retraction as a clinical sign of TED. Commonest cause was acquired aponeurotic ptosis. A combined levator surgery is possible with orbital decompression in such cases.

Purpose: To present the benefits of the addition of a conjunctival flap when correcting lower eyelid retraction using an auricular cartilage graft. Methods: An auricular cartilage graft was obtained either from the concha o the scaphoid fossa. When preparing the receiving bed, the conjunctival incision was made 2 mm below the inferior margin of the lower eyelid tarsus, therefore, a conjunctival flap arising from the inferior border of the tarsus was obtained. The cartilage graft was placed in the lower eyelid. The inferior border of the graft was sutured to the retractors and conjunctiva using absorbable sutures. The superior border was sutured to the inferior tarsus, so that de conjunctival flap covered the superior portion of the graft. Results: Fourteen patients underwent the surgical technique. No corneal complications were observed in the early or late postoperative period. Donor site complications were not encountered. Conclusions: The confection of a conjunctival flap that lines the superior portion of an auricular cartilage graft in the lower eyelid provides protection against corneal postoperative complications until the graft is epithelized.

To compare the incidence of lower eyelid malposition following repair of isolated orbital floor fractures with that of complex orbitofacial fractures (defined as multi-wall fractures or prior orbital fracture repairs requiring revision) by oculofacial plastic surgeons via a transconjunctival or swinging eyelid approach.Retrospective review of 175 patients who underwent surgical repair of orbital fractures at our institution. The primary outcomes were the occurrence of lower eyelid malposition (ectropion, entropion, and eyelid retraction) and the need for subsequent surgical correction.Of 95 patients with isolated orbital floor fractures, 4 developed eyelid malposition (4.2%), 1 of which required surgical repair (1.1%). Of 80 patients with complex orbitofacial fractures (48 multi-wall fractures, 32 secondary revisions), 10 had pre-operative eyelid malposition and were excluded from further analysis. Fourteen of the remaining 70 patients developed postoperative eyelid malposition (20%), 3 of which required surgical repair (4.3%). The difference in the occurrence of eyelid malposition between groups was statistically significant (The incidence of lower eyelid malposition following orbital fracture repair via a fornix-based approach was significantly higher for the repair of complex orbitofacial fractures than for isolated floor fractures. However, very few patients in either group required surgical repair for eyelid malposition. Surgical factors including implant material did not affect outcomes.

Purpose: Lower eyelid management is challenging. The conchal cartilage is often considered a spacer of choice for treating lower eyelid retraction. However, dermis graft has also recently been shown to be a viable spacer. The aim of this study was to compare the efficacy of dermis graft to that of conchal cartilage graft in this indication. Methods: A retrospective comparative study was conducted in patients who underwent lower eyelid lengthening with autologous dermis graft (group 1) or autologous conchal cartilage graft (group 2). The main outcome measure was the reduction in inferior scleral show (ISS) assessed by three independent masked surgeons. Secondary outcome measures was the assessment of lagophthalmos and corneal keratitis. Complications were also recorded. Results: Twenty-five eyelids of 23 patients were included: 11 and 14 eyelids, respectively in group 1 (dermis graft) and group 2 (conchal cartilage graft). Patient mean follow-up was 12.3 (±12.5) and 7.1 (±7.7) months, respectively. No statistical differences in postoperative ISS reduction, lagophthalmos and exposure keratitis was observed ( p = 0.540, p = 0.946, p = 0.934, respectively). Three patients experienced a grade I Clavien–Dindo complication in group 1 and one patient experienced a grade II complication in group 2 ( p = 0.540). Conclusion: Autologous dermis grafts and conchal cartilage grafts provide favorable outcomes without major complications.

To investigate the efficacy of Permacol™, a decellularized porcine dermal–derived membrane, as a spacer in the management of lower eyelid retraction. The efficacy of sizing and insertion was investigated, as well as complications. The literature was also reviewed to compare this material with other porcine-derived grafts in use for the management of lower eyelid retraction. This was a retrospective case series observing all patients who received lower eyelid Permacol implants by the two senior authors (AAM, TGH) for the management of lower eyelid retraction. Patient demographics, indications for surgery, graft size, degree of postoperative lid advancement, and complications were reviewed. A total of 12 patients (16 eyelids) received Permacol implants for correction of lower eyelid retraction during the study period of 18 months (January 2015 to July 2017). Ten procedures were related to thyroid eye disease, 3 for reconstruction, 2 postcosmetic lower lid blepharoplasty, and one acquired anophthalmic socket. The average preoperative inferior scleral show (ISS) was 1.74 mm, and the average postoperative ISS was 0.82 mm. There was a mean lower eyelid elevation of 0.91 mm (p

PURPOSE: The present study aimed to compare lower eyelid retraction (LER) in individuals with a positive orbital vector with that of individuals with a negative orbital vector. MATERIALS AND METHODS: This cross-sectional study was conducted on 123 normal individuals including 64 men and 59 women aged 20–80 years. After the individuals underwent Hertel exophthalmometry, two side-view and front-view photos were taken using a camera. The orbital vector angle and the extent of scleral show were then measured in millimeter, using the Photoshop software. Eventually, the recorded data were analyzed through statistical software. RESULTS: The findings of this study showed that LER has a significant correlation with orbital vector angle and the extent of proptosis (P < 0.05). The mean value of orbital vector angle in individuals without LER was 9.76°, while this figure was calculated to be − 13.65° in individuals with LER. The mean protrusion value based on Hertel exophthalmometry was 14.08 mm in individuals without LER and 16.27 mm in individuals with LER. The extent of scleral show had a significant correlation with proptosis and orbital vector angle (P = 0.01), with a mean value of − 0.41 mm in individuals without LER and 0.94 mm in participants with LER. CONCLUSIONS: The prevalence of LER and scleral show is positively correlated with the extent of proptosis and negatively correlated with orbital vector angle.

PURPOSE This study aimed to assess upper and lower eyelid shapes and changes in patients wearing ocular prostheses. METHODS The authors retrospectively reviewed the clinical records of patients wearing ocular prostheses. Clinical manifestations, including superior sulcus deepening, ptosis, upper and lower eyelid entropion, upper and lower eyelid ectropion, upper and lower eyelid retraction, and upper and lower eyelid socket contracture were investigated. RESULTS For those patients who underwent evisceration, the most common clinical manifestations of the eyelid were superior sulcus deepening and ptosis (35%, respectively), whereas lower eyelid entropion and lower eyelid retraction were the second most common manifestations (25%, respectively). Among those patients who underwent enucleation, the most common eyelid changes were lower eyelid entropion (45.5%), and ptosis and lower eyelid socket contracture were the second most common alterations (36.4%, respectively). Finally, superior sulcus deepening, upper eyelid entropion, and lower eyelid retraction occurred in 27.3% of patients, respectively. CONCLUSIONS Upper eyelid ptosis, superior sulcus deepening, and lower eyelid entropion and retraction were the most common clinical manifestations in patients wearing ocular prostheses. When following up with patients with ocular prostheses, it is important to check these eyelid changes and consider making appropriate corrections.

Purpose: This study evaluates causes and treatment of lower eyelid retraction with co-existing entropion in Thyroid Eye Disease (TED) patients of East Asian ancestry. Methods: The medical records for 25 eyelids from 15 TED patients with lower eyelid retraction and entropion who had undergone combined orbital decompression and lower eyelid retraction correction surgery at the Second Hospital of Dalian Medical University from January 2017 to December 2018 were prospectively reviewed. We build a numerical model of biomechanics to analyze von Mises stress and displacement at the lower eyelid. Results: The mean follow-up duration was 6 ± 2 months. The difference of mean exophthalmos was 5.16 ± 1.21 mm ( t = 21.26, p = 4.479E-17 Conclusions: This study shows that the lower eyelid retraction with coexistent entropion is attributable to the unique anatomical features of patients of East Asians ancestry. We corrected the lower eyelid retraction and entropion during the orbital decompression operation. The results show that this method is safe and effective. It can simultaneously improve the symptoms of TED patients such as exophthalmos, lower eyelid retraction, and entropion, with minimal complications.

Postblepharoplasty lower eyelid retraction is challenging and multifactorial and may occur after transcutaneous lower eyelid surgery. Surgical correction is difficult and unpredictable. Patient psyche is often negatively affected. This combination of events can limit patient satisfaction, so significant preoperative counseling to educate patients and modulate expectations is critical. The combination of midface lifting, implantation of a posterior lamellar spacer graft, and canthal suspension (standard surgery) has led to variable degrees of functional and aesthetic improvement. This article reviews the typical presentation, outlines the steps of standard surgery, and touches on other modalities of treatment that may improve patient satisfaction.

Summary Background Lower blepharoplasty is one of the commonest cosmetic surgeries performed in the United States. The delicate balance of the lower eyelid may be detrimentally altered in lower blepharoplasty, leading to lower eyelid retraction with the attendant functional and cosmetic consequences. Marginal reflex distance-2 (MRD2) is an insensitive measure for subtle lower eyelid retraction, and the MRD2 at the lateral limbus (MRD2limbus) and tarsal marginal show (TMS) may be more sensitive in identifying eyelid retraction and eversion. Methods This is a cohort study of consecutive patients undergoing lower blepharoplasty with skin pinch removal, laser resurfacing, or skin pinch removal with prophylactic lateral canthal resuspension. Mean follow-up was 22.1 weeks. Results There was no significant difference in MRD2 after surgery after either laser resurfacing, skin pinch, or skin pinch with canthoplasty, either after surgery or between groups. MRD2limbus was significantly increased after surgery in the skin pinch only group (p Conclusions MRD2limbus and TMS are more sensitive markers for lower eyelid retraction than MRD2. Subtle eyelid retraction and eversion occur after anterior lamellar work and can be prevented with prophylactic lateral canthal resuspension.

The authors conducted a retrospective case series of patients undergoing a lateral tarsal strip procedure with "en glove" placement of an acellular porcine dermal collagen matrix for correction of mild to moderate lower eyelid retraction. A detailed description of this minimally invasive technique with retrospective analysis of outcomes is provided. CLINICAL QUESTION/LEVEL OF EVIDENCE:: Therapeutic, IV.

Aesthetic canthal suspension can be an effective adjunct to lower eyelid blepharoplasty. Understanding the anatomy and function of the lateral canthal tendon is critical for preoperative evaluation and surgical decision making. In this article, the authors discuss the lateral canthal terminology, anatomy, and aging changes. Various canthal suspension procedures, including open and closed canthal suspension, commissure sparing open canthoplasty, and canthopexy, are described. Finally, the preoperative evaluation, postoperative course, and complications of surgery are reviewed.

Purpose: The aim of this study was to test the discomfort experienced during intravitreal injections with eyelid retraction between an eyelid speculum, cotton-tipped applicator (CTA), and unimanual eyelid retraction techniques. Methods: In total, 99 patients receiving intravitreal bevacizumab were enrolled into this prospective study. Participants were randomized to one of the three methods, given subconjunctival 2% lidocaine and then injected in the superior temporal quadrant. Immediately after the procedure, each patient was given a visual analog scale (VAS) to rate their discomfort. Results: The mean pain scores for eyelid retraction with unimanual, CTA, and speculum groups were 0.788 (standard deviation [SD] 0.70, 95% confidence interval [CI] 0.448–1.128), 0.945 (SD 1.28, 95% CI 0.600–1.291), and 1.561 (SD 1.28, 95% CI 1.210–1.912), respectively. A one-way analysis of variance (ANOVA) test revealed a significant difference between the groups (P = 0.006). Post hoc analysis also revealed a difference in mean pain scores between the speculum and both the CTA and the unimanual methods. Conclusion: Our study shows that the unimanual and CTA methods for eyelid retraction are significantly less painful for patients compared to the speculum method. Patient comfort is of the utmost importance as intravitreal injections are performed millions of times a year with most patients requiring multiple injections.

Importance In cases of epiblepharon with lower eyelid retraction secondary to glaucoma, correcting epiblepharon alone is ineffective. Combined surgery should be performed to obtain satisfactory outcomes. Objective To investigate outcomes after surgery to correct epiblepharon with lower eyelid retraction secondary to buphthalmos in children. Methods A retrospective analysis of six eyes in four patients was performed included lower lid retractor recession combined with marginal rotation with tarsal fixation. The margin reflex distance‐2, lagophthalmus, resolution of clinical symptoms, and complications were assessed during 6 to 12 months of follow‐up. Results In all cases, epiblepharon and lagophthalmus were corrected, symptoms of photophobia and epiphora were relieved, and the corneal epithelium was repaired. The margin reflex distance‐2 decreased and remained normal during the follow‐up period, but slightly regressed within 6 months postoperatively. Interpretation Epiblepharon caused by buphthalmos in children is often associated with lower eyelid retraction. Lower lid retractor recession combined with marginal rotation with tarsal fixation fundamentally solves the problems of high eyelid tension, lower eyelid retraction, and epiblepharon and reduces the recurrence rate.

PURPOSE To describe and evaluate the use of a lateral tarsoconjunctival suspension flap (TCSF) for the management of post blepharoplasty lower eyelid retraction. METHODS Two-center, retrospective chart review of patients who received a lateral TCSF between 2010 and 2018 for correction of post blepharoplasty lower eyelid retraction. The postoperative follow-up was a minimum of 3 months. Pre- and postoperative lower eyelid position (margin reflex distance 2 on standard photographs), degree of ocular surface disease, symptoms, complications, and need for further intervention were recorded. Pre- and postoperative photographs were scored using an objective grading system for cosmetic surgical results (MDACS). RESULTS Forty-eight eyelids from 30 patients met inclusion criteria for this study. Twenty (67%) of the patients were female. Age ranged from 55 to 89 (mean, 73.2). After the TCSF, ocular surface exposure improved in all cases. Lower eyelid retraction (average margin reflex distance 2 pre- vs. postintervention) improved in 98% of cases. Objective scoring of appearance improved; the mean MDACS score was 8 pre- and 3 post-TCSFs (p < 0.0001). One patient required midface lift and lateral canthoplasty 7 months later for undercorrected eyelid retraction. Another case required partial resection due to visibility of the flap in the interpalpebral zone. Postoperative pyogenic granulomas were noted in 8% (4/48) of eyelids. CONCLUSIONS The lateral TCSF was safe and effective in improving both functional and esthetic parameters in this series of post blepharoplasty eyelid retraction patients.

Dry eye is often seen secondary to the complications of lagophthalmos, eyelid retraction, or lacrimal gland injury. However, individuals with preexisting eye dry syndrome can have exacerbations or increased severity of their symptoms, even when there is no frank lagophthalmos. Patients who have undergone laser vision correction are at an increased risk for developing dry eye following blepharoplasty. In this population of patients, extreme care should be taken to avoid lagophthalmos and lower eyelid retraction. However, even without lagophthalmos, this population is at risk for developing significant dry eye after blepharoplasty. It is advisable that blepharoplasty should not be attempted sooner than 6 months following laser vision correction. Patients in this population should be identified during the preoperative assessment and informed of the potential for increased risk of complications.

Prominent eyes increase the risk of postoperative complications, such as lower eyelid retraction, following standard lower eyelid blepharoplasty and other eyelid surgery. Thus, patients with a “negative vector” relationship may require adjustments in surgical technique for optimal outcomes. Often the scleral show in patients with highly prominent, or proptotic, eyes is best treated by reducing the prominence via orbital bone decompression. The lateral wall is usually the first option, especially using minimally invasive approaches, due to lower risks and the possibility of outcome customization.

The major clinical eyelid findings associated with thyroid eye disease (TED) are varied, but most often involve upper and lower eyelid retraction, contour abnormalities, eyelid edema, prolapsed orbital fat, conjunctival injection and chemosis, and meibomian gland dysfunction. The exact causes of these changes remain a matter of controversy, but numerous hypotheses have been proposed, most with limited experimental support.