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264 19 Thyroid Eye Disease
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a b
c d
Fig.19.6 Muscle insertion suture placement. a Grasp and lift the muscle insertion with toothed
forceps to stabilize it. b Place the suture needle tip flatly against the sclera under the insertion.
c Entering the insertion angle, advance the needle and exit 1/2 to 1 mm anterior to the insertion.
d Lift the needle slightly to check the strength of the bite
(i) Remove the needle from the sclera.
3. Muscle insertion suture placement (Fig. 19.6):
The sclera is thinnest just beneath a muscle insertion (about 1/4 mm thick) so
this is a bad place to insert a suture bite. The sclera anterior to the insertion is
twice as thick. Entering the angle between the muscle insertion and the sclera
reproducibly positions the needle at the correct depth within this thicker sclera.
(a) Grasp and lift the muscle insertion with toothed forceps to stabilize it
(Fig. 19.6a).
(b) Place the suture needle tip flatly against the sclera under the insertion
(Fig. 19.6b).
(c) Entering the insertion angle, advance the needle and exit 1/2 to 1 mm
anterior to the insertion (Fig. 19.6c).
(d) Lift the needle slightly to check the strength of the bite (Fig. 19.6d).
19.5.3 Eyelid Recession
The final step in the surgical treatment hierarchy is the correction of eyelid retraction, an extremely common sign of TED. It is the last option in the sequence
because both orbital decompression and squint surgery can significantly affect eyelid position. Only consider lid margin recession after decompression surgery and/
or squint surgery have either been performed or ruled out.
19.6 Upper Lid Blepharotomy [3] 265
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Eyelid tissues in TED behave very differently from those of normal lids. Fibrosis is particularly strong in the peri lacrimal area in the upper lid. It is the cause
of lateral lid retraction, sometimes called ‘lateral flare’.
Lid retractors exert their action on the lid margin in four ways. Three are well
recognized:
1. The levator aponeurosis anterior attachment to skin, responsible for the lid
crease,
2. The levator aponeurosis posterior insertion to the middle and distal part of the
tarsal plate and
3. Muller’s muscle attachment to the proximal edge of the tarsal plate.
4. The fourth, generally overlooked, attachment is that of the levator/superior
rectus common tendon sheath which terminates as the superior suspensory liga-
ment of the fornix (it prevents upper fornix prolapse). Normally this attachment
has no effect on lid margin position because its only connection to the lid is via
elastic conjunctiva. However, the conjunctival fibrosis of TED transfers levator
pull directly to the tarsal plate. You see this clearly during TED lid recession
surgery. Having divided all three retractor attachments mentioned above, the
lid still moves normally until the conjunctiva is also cut. The simplest and
most effective lid margin recession operation, blepharotomy divides all four
attachments.
19.6 Upper Lid Blepharotomy [3]
Blepharotomy, as its name suggests, is a full thickness eyelid incision, parallel
with the lid margin at the level of the skin crease externally and through to above
the upper border of the tarsal plate internally. Carry it out under local anaesthesia
so that you can adjust the length of the blepharotomy according to its lid lowering
effect. Initially cut only the lateral 1/3 of the lid. If this proves insufficient extend
the incision medially in stages until you achieve the desired effect. I recommend
that you always leave the medial 1/3 intact as cutting it causes a late medial droop
contour deformity. Other authors leave an intact central ‘bridge’ instead. No postoperative traction or dressing is required. What you see on the operating table is
the lowering you ultimately get from this procedure.
19.6.1 Case Selection
Dry phase TED patients with symptomatic upper lid retraction.
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19.6.2 Steps (Fig. 19.7)
1. Mark the upper lid skin crease (usually at about 7–8 mm in Caucasians)
(Fig. 19.7a).
2. Place a protecting plate under the upper lid and ask your assistant to hold it
pushed up in the upper fornix.
3. Make a full thickness incision of the lateral 1/3 of the eyelid with a no. 15
scalpel blade (Fig. 19.7b). Extend this laterally to the orbital rim to avoid lateral
tethering from perilacrimal fibrosis.
4. Check the effect that this has on the lid position by getting the patient to look
up and down.
a
b
d
c
1/3
2/3
e
Fig.19.7 Blepharotomy. a Mark the upper lid skin crease. b Make a full thickness incision of the
lateral 1/3 of the eyelid with a no. 15 scalpel blade. c To lower the lid further, extend the incision
medially in stages. d Do not incise more than the lateral 2/3 of the lid. e Suture only the skin and
orbicularis incision with a continuous suture
19.8 Lower Lid Retractor Recession 267
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5. To lower the lid further, extend the incision medially in stages, always stopping
between stages to assess the lid’s height (Fig. 19.7c).
6. Do not incise more than the lateral 2/3 of the lid (Fig. 19.7d).
7. Suture only the skin and orbicularis incision with a continuous 6/0 or 7/0 suture
(Fig. 19.7e).
8. No dressing is required.
19.6.3 Note
This operation can be performed transconjunctivally by everting the lid over a
Desmarres retractor leaving the skin uncut. However, repeated lid eversion is both
difficult and uncomfortable for the patient, and the repeated stretching makes the
correct endpoint harder to determine.
19.7 No Spacers
Much has been written about interposing ‘spacers’ of various materials between the
recessed levator aponeurosis and the upper tarsal plate border. They serve no useful
purpose. They do not prevent further post-operative fibrosis. As foreign bodies
they only add to it, and they can become infected or extrude. In theory spacers
hold the divided retractors a set distance from the tarsal plate, yet in practice
the recommendation is to make them two or three times wider than the desired
recession (which negates their purpose). As thyroid lids already have increased
fibrosis, late drift only occurs if the retractors have been completely cut (hence
leave the medial 1/3 intact).
Spacer use has been particularly recommended for ‘lifting’ a retracted lower
lid. To do so it would need to be stiff (e.g., cartilage or porous polypropylene) and
be fixed to the orbital rim. At best this leads to a static lower lid, at worst to an
ectropion.
19.8 Lower Lid Retractor Recession
19.8.1 Considerations and Principle
Full thickness external lower lid blepharotomy is possible but unnecessary as generally the lower lid can be everted easily and all the layers cut from the conjunctival
surface, sparing the skin. However, because the only lifting force on the lower lid
is the orbicularis, apply upward lid margin traction with a suture overnight to avoid
an under-correction. Tightening the lid margin over a prominent eye will not help
to raise a retracted lower lid. Add additional active lower lid lift from the upper
lid levator muscle by performing a medial canthoplasty and a short (4–5 mm),
268 19 Thyroid Eye Disease
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a
b
Fig.19.8 Belt or braces. a Tightening a lower lid margin in the presence of a prominent eye
pushes the eye upwards and the lid slips downwards relative to the eye. b Performing a medial
canthoplasty and lateral tarsorrhaphy transfers upper lid lift to the lower lid
permanent, lateral tarsorrhaphy (Fig. 19.8). The latter is also helpful in masking
proptosis but should only be performed after the lid retractors have been recessed.
19.8.2 Case Selection
Dry phase TED patients with symptomatic lower lid retraction.
19.8.3 Steps
1. Insert a 4/0 monofilament tarsal traction suture. Use this to evert the lower lid
over a large Desmarres lid retractor (Fig. 19.9a, b).
2. Make an incision along the length of the conjunctiva, just proximal to the tarsal
plate. Deepen this incision to divide the underlying retractors. Ensure that it
extends medially and laterally as far as the canthi (Fig. 19.9b).
3. Remove the Desmarres retractor and pull the lower lid upwards using the trac-
tion suture. With the lid stretched upwards feel for any remaining restricting
bands through the skin and divide them with scissors (Fig. 19.9c, d). The lower
lid should now no longer be retracted. Furthermore, the lid should not move
down when the patient looks down.
4. Tape the lower lid traction suture to the forehead on stretch and apply antibiotic
ointment and a pressure dressing overnight (Fig. 19.9e).
19.8 Lower Lid Retractor Recession 269
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a
b
c d
e
Fig.19.9 Posterior Lower lid retractor recession. a Insert a tarsal traction suture and use this to
evert the lower lid over a large Desmarres lid retractor. b Incise the conjunctiva just proximally
to the tarsal plate. Deepen this incision to divide the underlying retractors. c Pull the lower lid
upwards, using the traction suture, to feel for any remaining restricting bands. d Divide any bands
with scissors. e Tape the lower lid traction suture to the forehead on stretch
5. Remove the traction suture the following day and assess the lower lid position.
Should there be an under-correction instruct the patient to push and hold the
lower lid upwards for a couple of minutes at least twice a day for the first two
months to stretch the internal scar.
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19.8.4 Note
This technique has also been used to recess the upper lid and is the basis of
the ‘Henderson procedure’. The latter is less predictable than the Koornneef
blepharotomy and not recommended.
19.9 Take Home Message
•
Periocular triamcinolone injections are an excellent option for managing
moderate active thyroid eye disease.
•
When recessing fibrosed extraocular muscles suture them directly to the sclera
to avoid late drift.
References
1. Clinical Activity Score Mourits MP (1997Jul) Prummel MF, Wiersinga WM, Koornneef L. Clin
Endocrinol (Oxf) 47(1):9–14
2. Ebner R, Devoto MH, Weil D, Bordaberry M, Mir C, Martinez H, Bonelli L, Niepomniszcze
H (2004Nov) Treatment of thyroid associated ophthalmopathy with periocular injections of triamcinolone. Br J Ophthalmol. 88(11):1380–6. https://doi.org/10.1136/bjo.2004.046193.PMID:
15489477;PMCID:PMC1772392
3. Elner VM, Hassan AS, Frueh BR (2003) Graded full-thickness anterior blepharotomy for upper
eyelid retraction. Trans Am Ophthalmol Soc 101:67–73
Conclusion
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20
Thank you if you’ve made it this far. Believe me it took a lot longer to write than
to read (Fig. 20.1).
Hopefully you’ve noticed that I’ve reduced my message to a few common
themes that have kept cropping up. For example, lid margin repair (Chap. 5)is
almost the same whichever part of the lid you perform it on, and it crops up
again in entropion and ectropion correction (Chaps. 8 and 9) and lid reconstruction (Chap. 14). Retractor plication is similar whether you perform it for a ptosis
correction in the upper lid (Chap. 10) or as part of an anterior lamellar repositioning in either lid, or as a retractor plication for lower lid entropion or ectropion
(Chaps. 8 and 9).
Fig.20.1 A good read
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
V. Th a l l e r, Eyelid Surgery, https://doi.org/10.1007/978-3-031-31527-5_20
271
272 20 Conclusion
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Keeping eyelid surgery as simple and safe as possible has been my intention
throughout this manual. All the techniques I have described have worked reliably
well for me. Therefore, I commend them to you. Naturally, many alternative techniques exist, each with its champions. And no doubt in time you will develop your
own modifications and favourites. Things do move on and so must we.
I hope that you have found at least some the concepts and techniques
interesting and that they are useful in your future practice. May they enable you
to generate fewer revisions from your routine surgery and give you more time to
devote to the more challenging problems that I have steered clear of.
There is, of course, much more to being a good surgeon than mere technique.
Listen to your patients as they have much to teach you. Follow up your own
outcomes personally, not just as a human courtesy but to complete the feedback
loop from which your techniques can evolve. Care about your patients and you
will inspire their trust and confidence. These are invaluable on the rare occasions
when a surgical outcome is suboptimal. And be realistic. Explain what is and is
not surgically possible. Under promise and overachieve! But above all, enjoy your
work and never stop learning.
10 Lid Commandments
1. Thou shalt do least harm.
2. Thou shalt use the meibomian orifice, not the grey line.
3. Thou shalt always attempt to close wounds directly.
4. Remember, nothing lasts, suture tension least of all.
5. Revere the upper lid.
6. Believe in the magic suture and white line.
7. Thou shalt not strip.
8. Thou shalt replace volume lost.
9. Suppress active and recess for inactive thyroid eye disease.
10. Speak no ill of thy less informed colleagues.
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