gms | German Medical Science

An increase of volume and fibrosis of orbital soft tissues are responsible for the typical pathology in Graves' disease, leading to exophthalmos, extraocular motility disorders, lid-retraction and eyelid swelling. Eyelid disease can be corrected functionally and cosmetically with a number of surgical procedures.

Stabilized thyroid metabolism, minimal disease activity and no smoking are pre-conditions for successful eyelid surgery. Surgical rehabilitation in Graves' disease is performed in stages. Significant proptosis is a poor condition for lid-lengthening procedures and should be corrected before. Extraocular muscle surgery also has to be completed before performing eyelid surgery.

Upper eyelid lengthening in patients with Graves' ophthalmopathy is often difficult, because the results were somehow unpredictable. Not only the desired lid height, but also the lid contour and skin crease can cause unfavourable results. Many different techniques have been used, until recently the anterior blepharotomy became more and more established. This simplified technique is based on a graded full-thickness horizontal eyelid transsection and avoids some of the above-mentioned problems.

Under local anaesthesia by a transcutaneous approach all layers of the lid including parts of the conjunctiva are transsected. The surgery can be graded intraoperatively and final adjustment is performed with the patient sitting in upright position with almost no overcorrection. No traction sutures or spacers are used. The wound is closed with a running locked skin suture. Post-operatively lid height and contour can be modified by pulling and massaging.

In contrast to the upper eyelid, lower lid lengthening usually needs the use of spacers. Autologous material like hard palate or simply sclera are interposed between the lower lid retractors and the tarsal plate. Intraoperatively overcorrection is necessary.

Reduction of abundant soft tissue is achieved by blepharoblasty. This procedure is the last step in surgical rehabilitation. For a good result in upper lid blepharoplasty, the sub-brow fat pad and the medial fat pad have to be addressed and reduced sufficiently. On the other hand, skin resection should be performed rather conservative in order to avoid any lid retraction, which is in particular essential in the lower eyelids.