Upper eyelid retraction (UER) is a condition where the upper eyelid rests at an abnormally high position, exposing more of the white part of the eye, known as the sclera, above the iris. This elevated position gives the eye a characteristic wide-eyed or staring appearance, often referred to as Dalrymple’s sign. UER is not simply a cosmetic concern; it significantly impacts eye function and comfort because the eyelid’s normal protective barrier is compromised. Understanding the mechanisms that cause UER and the available corrective options is important for effective management.
Understanding the Underlying Causes
The most frequent cause of upper eyelid retraction is Thyroid Eye Disease (TED), also known as Graves’ orbitopathy. This autoimmune inflammatory disorder affects the tissues surrounding the eye, causing inflammation and swelling of the eye muscles and orbital fat. UER is a common sign of TED, affecting up to 98% of patients with the disease.
The mechanism behind TED-related retraction is multifactorial, involving both over-stimulation and mechanical restriction of the muscles responsible for lifting the eyelid. One factor is increased sympathetic drive to the Müller’s muscle, causing this small muscle to contract and pull the eyelid higher than normal.
A primary contributing factor in TED is the inflammation and subsequent fibrosis, or scarring, of the levator palpebrae superioris muscle. As the main eyelid-elevating muscle becomes scarred and stiff, it shortens and tightens, permanently holding the eyelid in a retracted position. This fibrosis can also mechanically tether the levator aponeurosis to surrounding soft tissues.
UER can also result from other causes, including complications following prior eye or eyelid surgery, such as blepharoplasty. Scar tissue from trauma, like an injury or burn, can mechanically shorten the eyelid tissues. Neurological disorders, such as a lesion in the dorsal midbrain, or congenital factors, where an individual is born with an abnormality in eyelid positioning, are also potential causes.
Daily Life Impacts and Symptoms
The abnormal elevation of the upper eyelid creates physical discomfort and cosmetic concerns. A primary functional issue is the increased exposure of the ocular surface, known as lagophthalmos, which occurs because the eyelid cannot fully cover the eye. This inability is often exacerbated during sleep, leading to significant dryness and irritation.
Excessive exposure causes the tear film to evaporate too quickly. This results in symptoms such as foreign body sensation, grittiness, burning, and excessive tearing. Chronic dryness can lead to exposure keratopathy, which is damage to the cornea, potentially causing blurred vision and increased risk of infection. Patients may also experience photophobia, or discomfort in bright light.
The cosmetic impact is substantial, as the wide-eyed or startled expression can be distressing. The visible strip of sclera above the iris, referred to as “scleral show,” contributes to an unnatural appearance. When UER affects only one eye, the resulting asymmetry is particularly noticeable.
How Doctors Confirm the Diagnosis
Diagnosing and quantifying upper eyelid retraction requires a detailed clinical evaluation by an ophthalmologist or oculoplastic surgeon. The assessment begins with a comprehensive eye examination to observe the eyelid position in primary gaze. A key clinical measurement is the Margin-to-Reflex Distance 1 (\(\text{MRD}_{1}\)), which measures the vertical distance in millimeters between the center of the pupil’s light reflection and the margin of the upper eyelid.
A normal \(\text{MRD}_{1}\) typically ranges from 4 to 5 millimeters; a greater measurement confirms and quantifies the degree of retraction. Assessing the eyelid’s position in downgaze is also important, as a delay in the upper eyelid following the globe downward—known as lid lag or von Graefe’s sign—is often associated with Thyroid Eye Disease. The doctor also measures the interpalpebral fissure height, which is the distance between the upper and lower eyelid margins, to note the overall widening of the eye opening.
To identify the underlying cause, the diagnostic process includes blood tests to check thyroid hormone levels and rule out systemic conditions. Imaging tests, such as computed tomography (CT) or magnetic resonance imaging (MRI) scans, may be ordered to visualize the orbital soft tissues. These scans look for enlarged or inflamed extraocular muscles and confirm the presence of orbital fat expansion, helping determine the most appropriate course of management.
Corrective Management and Procedures
Initial management for upper eyelid retraction often focuses on conservative, non-surgical methods to address exposure and dryness. Frequent application of lubricating eye drops, gels, or ointments is the first line of therapy. This lubrication protects the exposed ocular surface, alleviates irritation, and reduces the risk of corneal damage by maintaining the integrity of the tear film.
For mild retraction or as a temporary measure, injectables can relax the muscles responsible for the elevated eyelid position. Botulinum toxin injections (Botox) temporarily relax the hyperactive Müller’s muscle. The effect typically lasts about four to six months and can alleviate symptoms while patients await a more definitive surgical procedure.
Surgical correction is the definitive treatment for moderate to severe UER. The primary goal is to lower the eyelid by weakening or lengthening the retracting muscles. The surgical approach is tailored to the severity and specific cause of the retraction.
Surgical Techniques
A common technique is Müller’s muscle recession, which involves releasing or excising a portion of the muscle through a hidden incision on the inside of the eyelid. This procedure is suitable for mild retraction, such as cases caused primarily by sympathetic over-stimulation.
For more significant retraction, a levator aponeurosis recession is performed. This involves surgically releasing and repositioning the main eyelid-lifting muscle. Both recession procedures aim to reduce the muscle’s pulling effect, allowing the eyelid to rest at a more natural height.
In complex or severe cases, the surgeon may combine muscle recession with the use of spacer materials, such as tissue grafts. These materials mechanically lengthen the eyelid and help prevent the retraction from recurring. Success is typically defined by achieving a normal \(\text{MRD}_{1}\) of 2.5 to 4.5 millimeters with minimal asymmetry.