What is eyelid retraction?

Eyelid retraction is when the upper lid is pulled or retracted upwards and the lower lid is retracted downwards. 

This is usually due to thyroid eye disease but it may also be due to facial nerve palsy and scarring after trauma or surgery.

It may become difficult to close the eyelids causing redness and irritation of the eye. 

The sclera, or white of the eye, may be seen between the eyelid margin and the cornea overlying the coloured part of the eye (iris).

This ‘scleral show’ can be very noticeable.


What are the benefits of surgery?

The operation should put the eyelid back into the correct position by raising a lower eyelid or lowering an upper lid.

This should improve the redness and irritation of the eye if you experience this.

There will also be a cosmetic improvement by reducing the scleral show. 


What is eyelid retraction surgery?

Most operations are carried out under local anaesthetic without sedation. After anaesthetic drops have been put in both eyes, an injection of local anaesthetic is given just beneath the skin of the upper eyelid. This is similar to dental anaesthesia and usually takes less than 30 seconds to give. 

Local anaesthetic with sedation involves an anaesthetist administering intravenous sedation via a drip so that you are very relaxed and may not remember having the operation. 

General anaesthetic means that you are completely asleep. 


Are there alternatives to surgery?

It is not possible to correct the problem without surgery but it may be possible to improve the symptoms with simple measures.

Artificial tear drops can be used to maintain wetting of the ocular surface. This may improve the discomfort.


What will happen if I decide not to have surgery?

The eyelid retraction may stay the same or gradually get worse. 

The retraction does not usually damage the eye. In rare cases the eye may become over exposed and dry out. This can lead to ulceration of the eye. 

It may well be possible with simple artificial tear drops to be comfortable without surgery.


What will happen before surgery?

Before the operation you will be seen in the clinic by Mr. McCormick. 

He will ask you about the eyelid problem. He will also ask about other medical problems you have, medications you take and any allergies (bring a list or the tablets themselves with you). 

He will examine your eyes. 

If you are to proceed with surgery the operation will be discussed in detail. This will include any risks or possible complications of the operation and the method of anaesthesia. 

You will be asked to read and sign a consent form after having the opportunity to ask any questions. 

If you are to have a general anaesthetic or local anaesthetic with sedation you will also see a preoperative assessment nurse. She/He will carry out blood tests and an ECG (heart tracing) if required. She/He will also advise you if you need to starve before the operation. 

If simple local anaesthesia is used you will not need any of these investigations and you will not need to starve prior to surgery. 


What should I do about my medication?

Mr. McCormick will want to know all the medication that you take and about any allergies you have. 

In some cases you may be asked to stop or reduce the dose of blood thinning tablets like: warfarin, aspirin, clopidogrel (plavix), dipyridamole (persantin). This decision is made on an individual basis and you should only do so if it is safe and you have been instructed by your GP, surgeon or anaesthetist. This will be discussed with you before surgery. 

You should avoid non steroidal anti inflammatory medications for 2 weeks prior to surgery. Other medication should be taken as usual.

You should avoid herbal remedies for 2 weeks prior to surgery as some of these may cause increased bleeding at the time of surgery.




What are the risks and possible complications of surgery?


Infection might present as increased swelling and redness of the skin. There might also be yellow discharge from a wound. Infection is treated with antibiotics.
Bleeding may present as fresh blood oozing from the site of surgery or a lump appearing near the wound after the operation. Simple pressure on a skin wound is usually enough to control minor bleeding. In rare cases, a deeper haematoma may require a return to theatre to prevent loss of vision.
Loss of vision: Total loss of vision in an eye due to this surgery is extremely rare ( less than 0.1% or 1 in 1000 operations ). A blood haematoma collecting in the orbit, behind the eye, may compress the nerve of vision and threaten eyesight. It is extremely rare for this to occur. It presents as pain, loss of vision and a bulging forwards of the eyeball and is an emergency. If not treated quickly it can lead to permanent loss of vision.
Scar: Whenever the skin is incised a scar may form. Every attempt is made by the surgeon to minimise and hide scars but sometimes they can be visible.
Further surgery: Your surgeon will take great care to correct the eyelid abnormality by exactly the correct amount. No operation has a 100% success rate and in very small numbers of cases, further surgery is required. This is less than 1 in 100 cases. Emergency return to theatre due to bleeding is extremely rare.

Skin puckering: If deep sutures are placed, there is a risk of puckering of the skin above them or discomfort. This is usually temporary but may necessitate further surgery to remove the suture if persistent.

Loss of sensation: After surgery there may be numbness of some of the skin around the incision. This is usually temporary returning gradually over months. Rarely it is permanent and may involve larger areas like the forehead.

Inflammation: Swelling and bruising of the skin after surgery always occurs but in varying degrees. A big improvement will be noticed after 2 weeks, with most resolved 3 months later. Rarely inflammation may cause small lumps to form called granulomas. Most resolve spontaneously but some require further surgery.

Altered appearance: One of the goals of surgery may be to positively improve appearance. Some people may be unhappy with the appearance after surgery due to: asymmetry of facial features; eyelid contour or eyelid position changes.
What type of anaesthesia will I have?
Three types of anaesthesia are used for these procedures: local anaesthetic alone; local anaesthetic with intravenous sedation; general anaesthesia.
You will choose one of them based on the advice of your surgeon.
Local anaesthetic involves an injection just under the skin with a tiny needle. It is similar to dental anaesthesia. Initially the injection is painful but after 10 – 15 seconds the area becomes numb.
Local anaesthesia with Intravenous Sedation means that you are breathing for yourself and don’t have a breathing tube inserted but you are very relaxed and sleepy and often don’t remember the operation or the local anaesthetic injection.
General anaesthetic means you are completely asleep with a breathing tube inserted.

What are the risks of anaesthesia?

You will have the opportunity to discuss the risks of anaesthesia with your surgeon and anaesthetist prior to surgery. It is worth noting that modern anaesthesia in all its forms is extremely safe.
Local anaesthetic may cause bruising, bleeding and swelling. There is a theoretical risk of the needle penetrating the eye and causing loss of vision.
Intravenous sedation should be carried out by an anaesthetist in a controlled environment. In this way it is very safe. There is a risk of loss of airway, which theoretically could lead to brain injury or death.
General anaesthetic has an extremely low risk of heart attack, stroke and death. The risk very much depends upon your general health and will be assessed prior to surgery.
Anaesthetic risks can usually be greatly reduced by thorough pre operative assessment, which you will receive.

What should I expect after surgery?

Usually a pad will be placed on the eye, which will remain until the following day when you can remove it. For 10 days the wound should be cleaned using boiled water that has cooled down and sterile cotton wool balls. 

After the pad is removed, antibiotic ointment should be applied to the skin wound and the eye three times a day for 2 weeks. 

It is normal for there to be swelling of the eyelid following surgery. This gets worse over the first 48 hours then starts to improve. It may take up to 6 weeks to resolve. 

Usually the skin sutures used are dissolvable and will be left to fall out by themselves.

There may be some mild aching at the outer corner of the eye. This settles after 6-8 weeks and is due to the suture that reattaches the lid to the bone.

The time when you can return to normal activities varies from person to person. Many are happy to do so after 2 – 3 days and the vast majority after a week.