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Case 43a
by Professor Chua Chung Nen
A 23 year-old woman who
was due to have her wedding shots taken in two weeks time was distraught to
find that she had a right upper eyelid retraction. Examination revealed
right eyelid retraction with lid lag. There was not obvious proptosis. Her
thyroid status examination suggested euthyroid and her TSH was normal.
However, there was antibodies to the thyroid gland strongly suggesting this
is a case of thyroid ophthalmopathy. She asked for some urgent treatment in
order not miss the big day.
Figure 1a and b. Right eyelid
retraction with lid lag due to Grave's disease.
a. How
may the right upper eyelid be lowered?
Thyroid ophthalmopathy is the most common
cause of eyelid retraction in adults and children1. It may be unilateral
or bilateral and may occur in the setting of elevated thyroid function
tests or euthyroidism.
The other cause of unilateral eyelid
retraction that is often forgotten is contralateral ptosis (due to
Hering's law of equal innervation). However, lid lag and the presence of
thyroid antibodies in this patient exclude this as a cause2.
There are several ways to lower upper
eyelid retraction including:
i. Operation to lower the eyelid and this
may be Muller's muscle disinsertion or levator recession
ii. Insertion of a gold weight to cause
mechanical lowering of the eyelid
iii. Botulinum toxin injection to paralyse
the levator/Muller muscle complex to lower the lid3.
Unfortunately, none of the above is
suitable for one reason or another. Operation to lower a newly developed
lid retraction is not advisable until the retraction has become stable
usually at least one year from the onset. In addition, it is unlikely
that the post-operative swelling will be fast enough for a good photo
shot.
Botulinum toxin may be useful in lowering
the upper eyelid but the exact dose is not determined and excessive
drooping of the eyelid will worsen her appearance
b.
Suggest a non-invasive way of improving her appearance for photo-shot.
In this case, the
patient was given 2.5% topical phenylephrine to increase the palpebral
aperture of the contralateral eyelid to reduce the differences in
palpebral apertures of the eyes. In addition, she was advised to have
her photographs taken with her chin lowered or in a sitting position
with her eyes looking which appear to make the two eyes appear more
equal.
Figure 2 a
and b. After instillation of 2.5% phenylephrine, the left palpebral aperture
increased
by about
1.5mm reducing the differences in the palpebral aperture (right). This
differences
were further
reduced by having the patient tilting her chin and looked up (Left).
References:
1.Uretsky SH, Kennerdell
JS, Gutai JP. Graves' ophthalmopathy in childhood and adolescence. Arch
Ophthalmol. 1980;98:1963-1964.
2.Pseudoretraction of the
eyelid in thyroid-associated orbitopathy. Gonnering RS.Arch Ophthalmol. 1988
Aug;106(8):1078-80.
3. Botulinum toxin type A in upper lid retraction of Graves'
ophthalmopathy.J Clin. Ebner R. Neuroophthalmol. 1993 Dec;13(4):258-61.
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