A Patient with Severe Eyelid Retraction

Thyroid eye disease also known as Graves' ophthalmopathy can cause severe eyelid retraction. This can result in severe dry eyes and visual impairment. This patient who was treated for Graves' disease has eyelid retraction for the past 3 years. Despite regular use of artificial tear, the eyes were always uncomfortable. She previously had botox rejection to lower the eyelid but find this costly as the procedure was repeated every 2 to 3 months. There are different ways of correcting the retraction depending on the severity, in this case I performed full thickness upper lid recession as shown below.

Severe right upper lid retraction.

The skin crease (site of the double eyelid) is marked.

Skin incision is made along the marked line.

A vertical incision is made deep to the conjunctiva and extended 

along the whole length.

A button hole is made in the conjunctiva.

The conjunctiva is cut and extended along for 2/3 of its length

on the lateral side.

The height is assessed to make sure the eyelid cover the top part 

of the cornea.

Only the is closed with 6/0 nylon.

An Unexpected Finding

This 21 year-old man was involved in a motorbike accident one year ago. At the time he was treated for multiple lacerations in a peripheral hospital. However, three months later, he developed a discharging sinus from the lateral side of his right eyelid and the eye became progressively higher.

Right eye higher than left and there was a discharging sinus (arrowed).

The local doctor did debridements a few times and put the patient on different courses of oral antibiotic but to no avail. A CT scans showed a mass in the orbital floor and was reported as possible bony granuloma. The patient was referred to my centre for removal of the granuloma.

CT scans showing a right orbital floor mass.

The orbital floor was explored by performing a lateral cantholysis to swing open the lateral orbital floor. To our surprise, a piece of wood with silver coating was found. The wood was integrated with the surrounding tissue and was removed piecemeal. The wound was irrigated with gentamicin and closed with lateral tarsal strip procedure.

A foreign body was found at the orbital floor during the exploration.

Wood removed by piece meal.

A large cavity was left after removal of the foreign body.

End of the surgery.