Retraction of the eyelid

Full-face Lip Eyelid peel close-up of the eyelids 30 days after treatment - note the significant retraction of the eyelid. 

The eyelid skin is the thinnest of the whole human body. Hypodermis has no lipidic stractures, replaced with a more or less fibrous subcutaneous fascia. 3rd-grade bums damage the derma and the orbicularis occuli. Deep 2nd-grade and 3rd-grade bums cause major retractions with palpebral eversion and permanent nonocclusion. These phenomena of retraction of the skin and orbicular level are more important in the cases of extended facial bums, in which there is also the retraction of the facial tissues surrounding the eyelids. 

Miscellaneous Muscular Responses.— Dilatation of the pupil, retraction of the upper eyelid, and protrusion of the eyeball relaxation of the bronchi, relaxation of the detrusor, and contraction of the sphincters in the bladder. Inhibition of movement, and contraction of the sphincters of the intestine. 

Class 1 disease, formerly termed mild or noninfiltrative disease, is characterized by upper eyelid retraction (Figure 32-1) and occurs in more than 90% of patients with hyperthyroidism. This sign may initially occur unilaterally or bilaterally and is often asymmetric. A helpful diagnostic sign often associated with eyelid retraction is the lid tug sign, in which the retracted upper lid offers a sensation of increased resistance on attempted manual lid... 

Eyelid retraction can produce findings in several associated tests that may correlate with the onset of the ophthalmopathy. Marginal reflex distance can be used to assess upper eyelid retraction. A light sonrce is placed in front of a patient in primary gaze to prodnce a corneal reflex. This distance between the corneal reflex and the upper eyelid margin is measured. The normal measurement is 4 to 5 mm. Another possible finding is a rednction in the tear breakup time of one or both eyes. EyeUd retraction causes an increase in the ocular surfece area that must be covered by the tear film, and there is an associated decrease in blink frequency in Graves patients. An increase in tear osmolarity also affects the mechanics of tear stability in these patients. The combination of these factors affects stability of the tear film. 

Superior limbic keratoconjunctivitis is associated with thyroid dysfimction and appears to be a prognostic marker for severe Graves ophthalmopathy. Approximately one-half of patients with superior limbic keratoconjunctivitis have eyelid retraction and one-half have eyelid lag. Whether eyelid retraction is causative or merely associated is unclear. Several patients exhibited resolution of the superior limbic keratoconjunctivitis after eyelid retraction surgery or orbital decompression. 

Dapiprazole HCl (Rev-Eyes) is an a-adrenergic blocking agent introduced for the treatment of iatrogenically induced mydriasis. One of the side effects of this topical agent is ptosis. In theory, this effect could potentially be useful for early eyelid retraction of Graves disease. Other side effects, however, include burning on instillation and moderate to severe conjimctival injection. There has been no published study about the efficacy of dapiprazole to relieve eyelid retraction in class 1 disease. 

Clinically, it was reasonable to investigate the problem with her. Apart from surgery, what treatment options were there to lift the curtain of the upper eyelids After a quick look at the question, a peel seemed to be the only option. Alpha-hydroxy acids (AHAs) were ruled out immediately because of the risks involved and the fact that they are ineffective on the eyelids. Trichloroacetic acid (TCA) was ruled out, as the high concentrations needed to get the skin to retract would be dangerous and in any event ineffective. There was therefore only one option left phenol. I have not encountered many problems with regular use of full-face phenol peels and, on the contrary, have found them to be very successful. The results achieved locally on the eyelids have often been remarkable (Figure 36.2). 

Although the eyelid retraction commonly seen in the patient with Graves disease (Fig. 3) is due to the effects of high thyroid hormone concentration, not all of the eye signs are caused this way. Rather, the thyroid and orbital muscle may have a common antigen which is... 

Fig. 8.13. Sixty-three-year-old dark-skinned woman before (a) and 2 months after (b) deep peeling. Note the effect on the upper eyelid retraction and dramatic improvement of upper lip wrinkles...

Clinically, the practitioner may observe conjimctival chemosis and erythema, abnormal eyelid position (lid retraction), lid lag, and proptosis. Conjunctival injection is most marked over the involved rectus muscles. Nervousness, palpitations, weight loss, hyperhidrosis, and heat intolerance are systemic symptoms occurring in more than 80% of hyperthyroid patients. Other signs, such as tremor, hyperreflexia, tachycardia, skin changes, stare, and eyelid lag, are observed in more than 60%. Additionally, goiter is present in more than 95% of Graves disease patients. In most cases, however, the laboratory confirmation of thyrotoxicosis is helpful to corroborate the diagnosis. 

There are two basic categories of thyroid-related orbitopathy infiltrative and noninfiltrative. Approximately 90% of patients have noninfiltrative disease. Noninfiltrative (class 1) thyroid-related eye disease is characterized by the mildest form of ocular involvement, with eyelid retraction but minimal proptosis. This occurs in up to 50% of patients with toxic diffuse goiter and can begin at any age, but patients tend to be yoimger, and female persons outnumber male persons in a ratio of up to 6 1. 

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