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Eyelid retraction
Last reviewed: 07.07.2025
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Retraction of the upper and lower eyelids occurs in approximately 50% of patients with Graves disease. The following mechanisms underlie retraction.
- Cicatricial contracture of the levator, together with the development of adhesions with the surrounding tissues of the orbit, leads to retraction of the eyelid, which is especially pronounced when looking downwards. Fibro-changed inferior rectus muscle can also lead to retraction of the lower eyelid.
- Secondary increase in the tone of the levator-superior rectus muscle complex due to hypotrophy caused by fibrosis and rigidity of the inferior rectus muscle is characterized by increased eyelid retraction when looking upward. Lower eyelid retraction due to increased tone of the inferior rectus muscle may also be secondary and caused by fibrosis of the superior rectus muscle.
- Humorally conditioned increased tone of the Müller muscle appears as a result of excessive sympathetic stimulation by thyroid hormones. This hypothesis is supported by cases of decreased eyelid retraction with local application of sympatholytics (guaietidine), and against - the absence of associated pupil dilation and the occurrence of retraction without hyperthyroidism.
[ Symptoms of eyelid retraction
The upper eyelid margin is normally located 2 mm below the limbus. Eyelid retraction may be suspected if the eyelid margin is at or above the upper limbus, revealing a strip of sclera (scleral exposure). The lower eyelid is located at the level of the lower limbus; if the sclera is exposed below the limbus, eyelid retraction may be suspected. Eyelid retraction may be isolated or combined with exophthalmos, which worsens the condition.
- Dalrymple's symptom is retraction of the eyelid with normal gaze direction.
- Von Graefe's symptom - the upper eyelid lags behind the eye when looking downward.
- Kocher's symptom is a surprised and frightened look, especially when looking closely at something.
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Treatment of eyelid retraction
Mild eyelid retraction does not require treatment, as spontaneous improvement often occurs. Efforts should be directed toward controlling hyperthyroidism. Surgery to reduce the size of the palpebral fissure may be considered in cases of severe but stable eyelid retraction and only after treatment of exophthalmos and strabismus. The surgical sequence for endocrine ophthalmopathy is orbit, strabismus, eyelid. The rationale for this sequence is that just as orbital decompression can affect muscle mobility and eyelid position, surgery on an extraocular muscle can change eyelid position. The main types of surgery are:
- Recession of the inferior rectus muscle when significant fibrosis is suspected.
- Müllerotomy (cutting off the Müller muscle) for mild eyelid retraction. In more severe cases, recession of the levator aponeurosis and the ligament supporting the superior conjunctival fornix are indicated.
- Recession of lower eyelid retractors with a scleral flap when the eyelid is drooping by 2 mm or more.