Management of the Prominent Eye

Key Points

•There are a variety of congenital and acquired causes of a prominent globe.

•Thyroid eye disease (TED-Graves exophthalmos) is the most common medical cause of a prominent eye.

•Identifying the etiology of globe prominence is critical before proceeding with eyelid surgery.

•Globe prominence poses unique risks with eyelid surgery and predisposes the patient to various potential postoperative ocular and eyelid complications.

•Understanding how to avoid the pitfalls of surgery on patients with prominent globes is essential to successful surgical outcomes.

•Familiarity with more complex orbital/eyelid procedures (i.e., orbital decompression, lid recession, mucosal grafting, and advanced lid suspension techniques) is necessary to appropriately perform surgery on patients with a prominent globe.

•If the surgeon lacks experience and comfort with these procedures, the assistance of a specialized eyelid/orbital surgeon is warranted.

•There are a number of variations to standard blepharoplasty surgery techniques in patients with prominent globes, which will prevent poor outcome and patient dissatisfaction. it is incumbent upon the surgeon treating these patients to understand these principles.

26.1Introduction

The presence of a prominent globe poses a unique set of risks to the patient and eyelid surgeon, ranging from worsening aesthetic appearance to ocular exposure and visual distur-

J.B. Holds (*)

Clinical Professor, Departments of Ophthalmology

and Otolaryngology Head and Neck Surgery, St. Louis University School of Medicine, Director, Ophthalmic Plastic and Cosmetic Surgery, Inc., Des Peres, MO, USA

e-mail: jholds@sbcglobal.net

bance [1]. For this reason, special attention must be given to this unique patient population in order to prevent poor outcomes. A prominent globe may be acquired with disease states, such as thyroid eye disease (TED-Graves exophthalmos), or be due to the congenital position of the globe and surrounding bony and soft tissue anatomy, as in craniofacial syndromes (Crouzon’s disease) [2]. In addition, globe prominence may be seen with increased axial length of the globe (as in moderate to high myopia).

Eyelid retraction can independently create or enhance the appearance of globe prominence and may result from relative proptosis as described, or be due to trauma, or other congenital or acquired processes. For example, a patient with thyroid disease may develop eyelid retraction and the appearance of proptosis without any axial shift in the globe position. True proptosis adds to the eyelid retraction (upper and lower lids) in TED. The patient with proptosis of the eye and eyelid retraction is much more difficult to correct surgically.

A prominent globe should be diagnosed and managed prior to any aesthetic enhancement. For example, patients with TED commonly present with complaints relating to sagging of the pretarsal skin, fullness of the superior sulcus, or fat herniation in the lower eyelid. Proceeding immediately to a classic subtractive upper and lower blepharoplasty will at the very least give a suboptimal result, if not leave the patient with incurable exposure symptoms, tearing, or an unsightly cosmetic result. Cosmetic treatments in the periocular area, using modified techniques focused on achieving aesthetic improvement at minimal risk, must sometimes be preceded by surgery that directly addresses the globe and/or orbital rim position.

In this chapter, I will review the various treatment options which the eyelid surgeon should consider when evaluating the patient with globe prominence. I will focus on TED as this is the typical etiology of globe prominence that is most commonly encountered. However, the treatment modalities can be employed with other causes of globe prominence. Some treatments mandate referral to a specialist, while others are less complex but necessary procedures for any surgeon who commonly performs eyelid surgery.