a

b

Fig. 1.17 Chronic progressive external ophthalmoplegia. (a) Frontalis recruitment preoperative; (b) frontalis recruitment postop with Supramid

way of imparting lifting power from the frontalis muscle. The stitch is passed through, starting at the tarsal stab incisions, and tightened until the lid margin has been lifted to the desired level; this cannot be too much in patients at corneal risk (Fig. 1.17). The stitch is then tied in the forehead wound and the knot is sutured to the under-surface of the frontalis muscle in the forehead wound with a long acting absorbable suture (e.g. 6/0 Vicryl). The forehead wound is closed with similar sutures, in two layers (subcutaneous then cutaneous) to avoid extrusion, whereas the skin of the other stab incisions can be closed directly. It is possible to minimise surgery further by deleting the top forehead incision altogether if the brow lift is particularly powerful, and passing the suspension material in a rectangular shape (four stab incisions), rather than a pentagon.

1.6 Lid Retraction

1.6.1 Introduction

The upper lid margin normally sits 1–2 mm below the upper limbus. Retraction is defined as an upward

displacement and has a variety of causes including trauma, iatrogentic (for example post ptosis repair), neurogenic (unopposed levator contraction in VII nerve palsy) and metabolic, of which the most common is thyroid associated ophthalmopathy (TAO). Factors contributing to TAO retraction include inflammation, fibrosis and adrenergic stimulation of the eyelid retractors. Retrac-tion leads to both cosmetic and functional problems, including exposure keratopathy. Medical treatment is the first option but, if this fails, surgical intervention may be required. This, however, should be performed when the disease has been quiescent for 6–12 months, and performed earlier only in exceptional circumstances, such as severe exposure keratitis. Where surgery is required, orbital surgery for proptosis should precede extra-ocular muscle surgery, which in turn should precede lid surgery [65].

Most mild to moderate TAO upper lid retraction responds well to levator weakening procedures. Various modifications of these have been introduced over time, including either complete recession or formal excision of Muller’s muscle, graded division of the lateral horn of the levator aponeurosis, graded myomectomies, and the use of adjustable sutures [18, 34, 35, 36, 59, 72]. However more serious upper lid retraction with obvious upper scleral show and severe lag on downgaze usually indicates a considerable amount of fibrosis. To lower the lid, additional vertical height is required. This is provided by grafting a spacer. The favoured material for this is donor sclera. However, owing to the variability in resorption of the sclera, long-term results have been disappointing particularly in the upper lid [27, 52]. As a result, other methods have been sought, particularly in northern Europe where the use of banked/donor sclera has been partly abandoned following the advent of variant Creutzfeldt– Jakob disease for fear of prion contamination.

1.6.2 Koornneef Blepharotomy

Koornneef was developing a much simpler method of total blepharotomy. This was a radical extension of Harvey and Anderson’s technique and involved detachment of all structures from the superior tarsal border through an anterior approach. It has been promoted by those he taught prior to his untimely death, and widely adopted, with some modifications, owing to its more satisfactory and predictable results [28, 30, 37, 53].

Patient selection: the salient changes in thyroid eye disease are upper lid retraction with lid margin contour deformity and consequent exposure keratopathy. The Koornneef blepharotomy procedure was originally designed for patients with severe upper lid retraction in thyroid ophthalmopathy, who would have normally required lid lowering by adding a spacer, such as a scleral graft, in order to lower the lid to allow normal closure. Increasingly it is also being used in a graded manner for less severe retraction.

Method: after deciding where to set the skin crease with a marker pen, the lid is everted and 1–2 mL of vasoconstrictive local anaesthetic is injected sub-con- junctivally. A similar volume is injected subcutaneously, followed by a little pressure on the lid to dissipate the fluid. After the skin incision is made, the skin and orbicularis above it are dissected free from the septum. A protective guard is then placed between the lid and the globe. A full thickness blepharotomy is achieved just above the superior border of the tarsus by incising septum/aponeurosis, Muller’s muscle and conjunctiva, extending horizontally all the way to the lateral canthal corner. Following haemostasis, the skin is closed with interrupted or running skin sutures, reforming the skin crease, by including the tarsus in the suture. The lid is

padded for 24 h. This encourages stability of the clot that forms in the space created by the incision, and its subsequent organisation and scarring acts as the spacer.

Modifications: because the lid curve can be flattened by this procedure, certain modifications have been introduced to counteract this. Rather than including the entire conjunctiva in the full thickness horizontal incision, a small web can be preserved centrally or para-centrally, where the natural peak of the lid curve would be (Fig. 1.18). It can be thinned or Z-plastied to lengthen it as required. Alternatively, a single long acting absorbable mattress suture on hangback – reaching across the blepharotomy from the tarsus to the recessed levator complex – can be introduced to restore curvature of the upper lid margin. However it has the disadvantage of irritating the top third of the cornea on lid closure. A temporary bandage contact lens should therefore be placed on the cornea until the discomfort has resolved.

If the medial end of the lid is in a normal position or already slightly ptotic, the blepharotomy is not extended medial to the natural peak of the lid curvature. In cases of temporal flare, the full-thickness dissection is extended laterally to the superior crus of the lateral