Eyelid retraction is a condition where the upper or lower eyelid is positioned abnormally high or low, exposing more of the eye than normal. This can lead to functional and cosmetic issues, as well as potential damage to the eye due to inadequate protection. Eyelid retraction is often associated with underlying medical conditions and requires prompt diagnosis and treatment.
The upper lid normally covers the top edge of the iris by 1 to 2 millimetres. When it sits higher than that, a strip of white sclera becomes visible above the coloured part of the eye. Other people usually read this look as startled, surprised or angry, and it is one of the things patients mind most. In lower lid retraction the lid slips downward and a similar gap opens beneath the eye.
The real problem is not appearance. As the lid aperture widens the tear film evaporates faster, the ocular surface dries and the cornea is left unprotected. I therefore treat retraction not as a cosmetic finding but as a threat to the ocular surface.
In the short video below I explain why eyelid retraction is not only a matter of appearance.
At the examination I measure the distance from the lid margin to the corneal light reflex in millimetres, separately for the upper and lower lid; this grades the retraction. I record the total height of the lid aperture, how far the eye protrudes and how completely the lids close. Whether the lid stays open during sleep tells me whether the ocular surface is protected overnight.
Staining the ocular surface shows exposure damage, and tear production is measured. When I suspect thyroid eye disease, thyroid function tests and the relevant antibodies are requested and the patient is followed together with an endocrinologist. Restricted eye movements, double vision or reduced visual acuity call for orbital imaging. Establishing whether the disease is in its active inflammatory phase or has become quiet is decisive for the timing of surgery.
In adults I mostly operate under local anaesthesia; being able to ask the patient to open and close the eye lets me set lid height on the table. Cold compresses and keeping the head elevated reduce swelling in the first 48 hours. Sutures come out during the first week and bruising settles noticeably in the second.
Lid height fluctuates in the early weeks and takes a few months to reach its final position as swelling resolves and the tissues settle, so I do not judge the result early. Risks include undercorrection or overcorrection, asymmetry between the two sides, irregularity of the lid margin and the need for a further adjustment. Recurrence is more likely when surgery is carried out while thyroid eye disease is still active, which is why I wait for the disease to become quiet whenever possible.
The two are opposites and are sometimes confused. In ptosis the lid sits lower than normal and the eye looks small and tired. In retraction the lid sits higher and the eye looks large and startled. One eye may have ptosis while the other has retraction; in fact a drooping lid on one side commonly produces pseudoretraction on the other. Both lids must therefore be assessed together to work out which side carries the real problem.
An eye that has looked larger or more prominent over recent months, lids that do not close fully during sleep, surface pain on waking, double vision or reduced vision all deserve prompt assessment. A drop in visual acuity may mean pressure on the nerve within the orbit and is treated as urgent.
Eyelid retraction affects both eye health and quality of life. With early diagnosis and appropriate treatment, eyelid function can be restored. If you notice excessive opening of the eyelid or similar findings, consult an ophthalmologist without delay.
Ayşe Dolar Bilge MD, FEBOphth.
Ophthalmologist — Oculoplastic Surgery
As an Ophthalmologist, Dr. Ayşe Dolar Bilge, I provide diagnosis and treatment services with my experienced team.
Eyelid retraction means the upper lid sits higher, or the lower lid lower, than it should. The upper lid normally covers the top edge of the iris by 1 to 2 millimetres; when it sits higher, a strip of white sclera appears above the iris and the gaze takes on a startled look.
A widened lid aperture produces this look. Thyroid eye disease is the commonest cause: when the muscles and tissues around the eye swell, the lid is pulled up and the eye may be pushed forward. Previous lid surgery, scar tissue, neurological causes and drooping of the opposite lid can create a similar appearance.
The problem is not appearance. As the lid aperture widens, the tear film evaporates faster, the surface dries and the cornea is left unprotected. If the lids do not close fully during sleep, the surface hurts on waking, and over time the risk of corneal ulceration and infection rises.
Retraction can settle to some degree once thyroid function is regulated and the active inflammatory phase has passed. Stopping smoking is among the most important steps in improving the course of the eye findings. Any remaining difference in lid height is corrected surgically after the disease becomes quiet.
In thyroid eye disease I plan surgery, where possible, after the active phase has passed; corrections made during the active phase are more likely to recur. The order also matters: orbital decompression first, then strabismus surgery, and lid surgery last. If the cornea is at risk, that timing may be brought forward.
They are opposites. In ptosis the lid sits lower than normal and the eye looks small and tired; in retraction the lid sits higher and the eye looks large and startled. A drooping lid on one side commonly produces pseudoretraction on the other, so both lids must be assessed together.
Protecting the ocular surface comes first: frequent artificial tears during the day and a thicker ointment or moisture-chamber goggles at night. Sleeping with the head elevated reduces morning swelling. If you have surface pain on waking, redness or blurred vision, you should be assessed without delay.
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