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Eyelid retraction and eyelid lag
Last reviewed: 04.07.2025
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Upper eyelid retraction (the position of the upper eyelid in which a white strip of sclera is visible between the edge of the eyelid and the limbus of the cornea when looking straight ahead) can be caused by hyperactivity of the levator muscle, contracture of this muscle, or hyperactivity of the smooth (Müllerian) muscle.
Eyelid lag is a phenomenon that is only observed when looking downward.
The main causes of eyelid retraction and eyelid lag are:
I. Supranuclear lesions (damage to the nuclear complex of the posterior commissure is required for eyelid retraction to occur):
- Processes at the level of the mesencephalon can lead to retraction of the eyelids, which is noticeable when looking straight ahead and when moving the gaze upward (as part of Parinaud's syndrome).
- Periodic retraction of the eyelids may be observed in the picture of an epileptic seizure or be a sign of tentorial herniation.
- Parkinsonism.
II. Neuromuscular and some somatic diseases (eyelid retraction and eyelid lag can be observed in the picture of the following diseases):
- Myasthenia
- Familial periodic paralysis
- Myotonic syndromes
- Hyperthyroidism (unilateral or bilateral eyelid retraction) is the most common cause of eyelid retraction.
- Severe liver dysfunction ( Summerskill symptom).
III. Other, rarer causes of retraction: retraction of the upper eyelid in the picture of congenital trigemino-oculomotor synkinesis (Marcus-Gun phenomenon); after aberrant regeneration of the oculomotor nerve; with irritation of the oculosympathetic fibers (Claude-Bernard syndrome): denervation hypersensitivity of the smooth muscle of the upper eyelid in a stressful situation is manifested by transient retraction of the eyelid on the affected side; with long-term therapy with corticosteroids; operations and other injuries to the eye muscles. Insufficient inhibition of m. levator ("spastic eyelids") can occur with damage to the brainstem; in these patients, the eyes may remain open during sleep.
Eyelid lag may also be observed in the following situations:
- progressive supranuclear palsy;
- Guillain-Barre syndrome.
"Plus-minus syndrome" (ipsilateral ptosis and contralateral upper eyelid retraction): the result of unilateral damage to the nucleus or root of the third (oculomotor) nerve with involvement of the nuclei of the posterior commissure or their connections. The most common cause is acute cerebrovascular accident.
Lower eyelid retraction is an early sign of facial nerve damage. Weakness and flaccidity of the lower eyelid may be an early sign of myasthenia and myopathy. Lower eyelid retraction is possible with exophthalmos, senile changes in the eyelids, after eye surgeries and with processes that cause contraction of the eyelid tissue (dermatitis, tumors, etc.). It may also be congenital.
Insufficient closure of the eyelids (during sleep, blinking or forced squinting) can sometimes be the cause of a serious complication (keratitis). Its causes (in addition to eyelid retraction): exophthalmos or (more often) weakness of the orbicularis oculi muscle (myasthenia gravis, chronic progressive external ophthalmoplegia, myotonic dystrophy, facial nerve neuropathy.
Diseases involving the retina and central nervous system.
- Pigmentary degeneration of the retina in such hereditary diseases as Kearns-Sayre syndrome, abetalipoproteinemia (Bassen-Kornzweig disease), Lawrence-Moon-Bard-Biedl syndrome, Friedreich's ataxia, Cockayne syndrome (hereditary autosomal recessive disease), Refsum disease, Hallervorden-Spatz disease, ceroid lipofuscinosis (cerebroretinal degenerations).
- Infectious lesions of the nervous system and retina: syphilis, fungal infections, tuberculosis, cytomegalovirus infection, herpes simplex, herpes zoster, subacute sclerosing panencephalitis, toxoplasmosis, Whipple's disease, HIV infection.
- Inflammatory diseases: sarcoidosis, multiple sclerosis, Behcet's disease, systemic lupus erythematosus, Vogt-Koyanagi-Harada syndrome, inflammatory bowel disease.
- Malignant neoplasms (sarcoma, lymphoma, leukemia, metastatic carcinoma).