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The inflammation that occurs in thyroid eye disease can cause swelling, fatty infiltration/degeneration, and scarring of the eyelid muscles resulting in eyelid retraction (the eyelids being pulled away from the eye). In mild cases, individuals will experience dry, gritty eyes that feel "sandy" or irritated. In more severe cases, some people may have impaired eyelid closure and experience dry spots on the cornea. This can lead to severe eye infections and scarring with vision loss. Eyelid surgery can help reduce eye exposure so that the eyelids are more adequately able to protect the front of the eye.
Additionally, thyroid eye disease may result in significant swelling of the fat in the upper or lower eyelids making the eyelids appear puffy and unsightly. Surgery can improve these problems as well.
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To improve upper eyelid retraction, surgical loosening of the upper eyelid retractor muscles (levator muscle and Mueller's muscle) and release of scar tissue in the muscles can allow the upper eyelids to come down to a more normal level. This surgery is typically performed with local injections and minimal IV sedation in order to permit patient cooperation during the surgery. Patients are placed in a sitting upright position at the end of surgery to ensure adequate surgical correction. Adjustments made during surgery diminish the risk of asymmetry following surgery. Despite meticulous attention to eyelid height during surgery, the eyelids may heal differently resulting in eyelid asymmetry. Frequently, the asymmetry is not bothersome and further surgery can be avoided. In up to 10-15% of patients, additional "touch-up" procedures may be needed to correct significant asymmetries. Significant upper eyelid retraction repair is typically considered medically necessary and is usually covered by most insurance carriers. Mild cases of eyelid retraction may be considered cosmetic.
At the time of upper eyelid retraction repair, patients may elect to have excessive fatty tissue and redundant skin folds excised. Upper eyelid blepharoplasty (see Dr. Klapper's Blepharoplasty patient information) is frequently considered cosmetic and not covered by most insurance carriers.
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The same puffiness and tissue response that occurs in the upper eyelids may also develop in the lower eyelids. Lower eyelid retraction may result in exposure of the white portion of the eye. This may contribute to eye exposure, dryness, and irritation. Surgical procedures can improve the protection of the eye and the appearance of the lower eyelid. With lower eyelid surgery, the scarred muscle can be loosened and spacer material inserted to boost the eyelid upward. Spacer grafts used might include ear cartilage or hard palate (upper mouth) mucosa. To be able to reposition the outer edge of the lower eyelid upward, the outside tendon must be tightened. Despite meticulous measurements of spacer materials, the eyelids may heal differently resulting in eyelid asymmetry. Frequently, the asymmetry is not bothersome and further surgery can be avoided. Additional "touch-up" procedures are infrequently indicated to correct significant asymmetries. Significant lower eyelid retraction repair is typically considered medically necessary and is usually covered by most insurance carriers.
At the time of lower eyelid retraction repair, patients may elect to have excessive fatty tissue and redundant skin folds excised. Lower eyelid blepharoplasty (see Dr. Klapper's Blepharoplasty patient information) is frequently considered cosmetic and not covered by most insurance carriers.
- Bruising and swelling
There is usually more bruising and swelling with surgery for thyroid eye problems than the standard "baggy eyelid operation" (blepharoplasty). In thyroid eye disease, the arterial and venous vasculature to the eyelids and orbit is increased. This results in a greater tendency to develop postoperative swelling. This also makes surgery more challenging and involved than 'standard' eyelid surgery. Oral corticosteroids, ice packs, rest, and head-of-bed elevation may help to limit bruising and swelling.
- Postoperative stiffness of the eyelids
Even though the eyelid position is improved following surgery, stiffness caused by scar tissue may persist after surgery. It is impossible to remove every bit of scar tissue imposed by the underlying thyroid eye disease process.
- Eyelid Asymmetry
Most patients with thyroid eye disease have some degree of upper and/or lower asymmetry prior to reconstructive surgery. A mild amount of eyelid asymmetry should be expected after surgery. Significant amounts of asymmetry can occur in up to 15% of patients. Further surgery may be indicated in these individuals.
- Anesthesia during surgery
If a person is having surgery limited to the upper eyelids, then local injection with mild IV sedation is performed. Patient cooperation is critical to ensure adequate eyelid height adjustment. Patients are placed in the upright, sitting position during surgery to assess the degree of eyelid correction.
If lower eyelid surgery is also necessary, then deeper anesthesia is frequently employed.
Surgery is performed as an outpatient and patients will frequently go home within an hour after the operation is completed. Ice packs, rest, head-of-bed elevation, topical antibiotic ointment, and a tapering dose of prednisone is recommended the first week after surgery. Most patients will take 5-10 days off of work to recover. Full recovery may take 3-6 months.
Stephen R. Klapper, M.D., F.A.C.S. is a board certified Ophthalmologist and has completed extensive fellowship training in Ophthalmic Plastic and Reconstructive Surgery. In addition to his clinical practice Dr. Klapper has published numerous scientific articles in peer reviewed journals and presented several papers at regional, national, and international meetings on topics related to the field of eyelid and facial plastic surgery. Dr. Klapper's practice is limited to adult and pediatric cosmetic and reconstructive eyelid and facial surgery, tear duct surgery, orbital disease, thyroid eye disease and the anophthalmic patient. Dr. Klapper also has extensive experience performing facial Botox® injections and Restylane® lip and facial fold injections.
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Contact our office to discuss your eyelid problem with Dr. Klapper or a member of his staff. (317) 818-1000
