The Ophthalmology Department,  Universiti Malaysia Sarawak (UNIMAS), Kuching, Sarawak.

The Ophthalmology Department, Sarawak General Hospital, Kuching, Sarawak, East Malaysia.



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).




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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