
==== Front
Ophthalmic Plast Reconstr Surg
Ophthalmic Plast Reconstr Surg
IOP
Ophthalmic Plastic and Reconstructive Surgery
0740-9303
1537-2677
Lippincott Williams & Wilkins Hagerstown, MD

38346435
OPRS-D-23-00672
00006
10.1097/IOP.0000000000002632
3
Original Investigations
Blepharotomy Versus Levator Recession With Adjustable Sutures for Correction of Upper Eyelid Retraction in Thyroid Eye Disease
Ueland Hans Olav M.D., Ph.D. *
Halsøy Kathrine M.D. *
Rødahl Eyvind M.D., Ph.D. eyvind.rodahl@uib.no
*†
* Department of Ophthalmology, Haukeland University Hospital, Bergen, Norway
† Department of Clinical Medicine, University of Bergen, Bergen, Norway
Address correspondence and reprint requests to Hans Olav Ueland, M.D., Ph.D., Department of Ophthalmology, Haukeland University Hospital, N-5021 Bergen, Norway. E-mail: hans.olav.ueland@helse-bergen.no
15 4 2024
Sep-Oct 2024
40 5 516522
17 1 2024
Copyright © 2024 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.

Purpose:

To compare outcome, complications and surgical time of blepharotomy versus levator recession with adjustable sutures (LRWAS) for correction of upper eyelid retraction in thyroid eye disease.

Methods:

In the period 2019–2023, we performed a prospective randomized comparative study between blepharotomy and LRWAS. We examined patients, recorded time consumption, and obtained photographs preoperatively, 1 day, 1 week, 3 months, and 6 months after surgery. Outcome was categorized according to Mourits and Sasim`s classification from 1999 (perfect–acceptable–unacceptable).

Results:

A total of 30 patients (25 women) with a median (range) age of 51.5 (34–74) years at surgery were included. A significant different (p < 0.01) median operation time was found between blepharotomy (41.5 (17–105) minutes) and LRWAS (68 (35–101) minutes). Median time from operation to last examination was 6 (6–18) months. Fifteen patients (24 eyelids) were operated with blepharotomy and 15 patients (25 eyelids) with LRWAS. Preoperative median margin reflex distance 1 was 6.5 (5–8) mm, and at final visit, median margin reflex distance 1 was 3.5 (3–4) mm after blepharotomy and 3.5 (2–5.5) mm after LRWAS. Reoperation was performed in 11 eyelids, 10 due to overcorrection and 1 because of a residual retraction. Significantly more eyelids needed reoperation after LRWAS (n = 9) compared with blepharotomy (n = 2). At final examination, a perfect or acceptable result was found in 14 (93%) patients after both procedures. Significantly shorter total duration of all visits was observed after treatment with blepharotomy (50 (35–70) minutes) compared with LRWAS (65 (40–115) minutes). Wound dehiscence occurred in 1 patient after blepharotomy, and 1 postoperative infection was observed after LRWAS.

Conclusion:

We demonstrate equally high success rates after blepharotomy and LRWAS for correcting upper eyelid retraction in thyroid eye disease, but blepharotomy is less time-consuming and implies fewer reoperations.

This prospective randomized study suggests blepharotomy as the surgical choice over levator recession with adjustable sutures, for correction of upper eyelid retraction in thyroid eye disease, due to shorter surgical time and fewer reoperations.

Helse Vest 10.13039/501100004257 F-12130 Hans Olav UelandOPEN-ACCESSTRUE
==== Body
pmcThyroid eye disease (TED) is an autoimmune disorder of the orbit affecting approximately 30% of patients with Graves disease.1 TED consists of 2 phases. First, there is an active inflammation with an increasing volume of orbital fat and muscles. The inflammatory phase then gradually resolves into an inactive fibrotic phase, where reconstructive surgery may be needed.2 Patients have significantly reduced quality of life.3

The normal position of the upper eyelid is 1–1.5 mm below the limbus. When the upper eyelid margin is positioned at or above the limbus it is considered retracted.4,5 Upper eyelid retraction is the most common clinical finding in patients with TED and is observed in more than 90% of the patients.6 A characteristic feature is “lateral flare,” meaning that the lateral part of the upper eyelid is more retracted than the medial part. In addition to the aesthetic changes with a staring expression, patients frequently experience symptoms like foreign body sensation, tearing, pain, and reduced vision. Common complications due to eyelid retraction are lagophthalmos, corneal dryness, exposure keratitis, corneal ulcers, and bacterial infections of the cornea and conjunctiva.

Several pathogenic mechanisms contribute to the development of eyelid retraction. Initially, eyelid retraction may arise due to a transient increase in sympathetic activity during hyperthyroidism.7 After the thyroid hormone levels have been restored, a decrease in the sympathetic impact on the eyelid often results in normalization of the position. However, several studies support that inflammation of the levator palpebra muscle is the main cause of eyelid retraction,8,9 and that after the active inflammatory phase, the levator palpebra muscle and Mueller`s muscle may undergo fibrosis, resulting in an irreversible upper lid retraction.

The surgical reconstruction in TED should be performed after the patient has become euthyroid, and the inflammatory phase has subsided. The treatment often involves more than 1 procedure, and if required, orbital decompression and strabismus surgery should be completed before eyelid surgery is carried out.

Correction of upper eyelid retraction is challenging, and different surgical techniques have been developed.10 The techniques are all variants of weakening or increasing the length of the upper eyelid retractors, and both anterior approaches through the skin and posterior through the conjunctiva have been used. Procedures include recession or excision of Mueller`s muscle11,12 and recession of the levator muscle with or without adjustable sutures.13–15 Other techniques are the utilization of spacer grafts,16 elongation of the levator muscle through marginal myotomy17 or z-myotomy.18 In addition, implementation of an orbital septal flap,19 repositioning the lateral horn of the levator aponeurosis towards the medial aspect20 and full-thickness blepharotomy21,22 are in current use. The technique used is often based on the surgeon`s experience and confined traditions. Currently, most published reports are of retrospective design and only investigate a single procedure.

Graded full-thickness blepharotomy to correct upper eyelid retraction was developed in the 1990s by Leo Koornneef. The first description of the procedure with data on outcome was presented by Elner et al.21 The procedure addresses postinflammatory fibrosis by an incision through all eyelid structures. Reproducible results in follow-up studies have been obtained for this relatively simple procedure and it has become a popular procedure for correcting upper eyelid retraction in TED.23

Levator recession with adjustable sutures (LRWAS) is a 2-step procedure, where the eyelid margin is positioned on the first postoperative day without the use of sedatives and local anesthetics with adrenaline.15 This procedure addresses several of the known challenges in the correction of upper eyelid retraction, like cutting the lateral horn to correct “lateral flare”, adjustment of contour and symmetry postoperatively, and restoration of the eyelid crease. We have previously reported our experience with LRWAS in TED patients.24

To date, there are no prospective studies comparing blepharotomy and LRWAS. In this study, we compare outcomes, complications, and surgical time of the 2 procedures for correcting upper eyelid retraction in TED.

MATERIALS AND METHODS

Study Population

From 2019 to 2023, all TED patients selected for correction of upper eyelid retraction at the Department of Ophthalmology, Haukeland University Hospital were included in a 2-armed prospective randomized interventional study. At inclusion, patients agreed to attend the study and signed an informed consent. The study adhered to the tenets of the Declaration of Helsinki and was approved by the Regional Committee for Medical and Health Research Ethics, Western Norway (IRB# 00001872, ref. 2019/753). Consent to publish identifiable photographs was obtained.

Clinical Data

Before operation and at follow-up (1 day, 1 week, 3 months, and 6 months postoperatively) patients underwent a general clinical examination and photographs were obtained. Previous treatment of TED (medical and surgical), smoking status, history of diabetes, and use of anticoagulants and platelet inhibitors were recorded. The following clinical characteristics were registered: vertical eyelid aperture (mm), margin reflex distance 1 (MRD1) (mm), exophthalmos, upper eyelid fissure (mm), vertical movement of upper eyelid (mm), keratopathy, lagophthalmos (mm), symmetry, “lateral flare”, duration (minutes) of the surgical procedure and peri- and postoperative complications. In addition, the duration (minutes) of each study visit was recorded.

MRD1 is the distance (mm) from the corneal light reflex to the center of the upper eyelid margin in the primary position of gaze. Exophthalmos was estimated by Hertel`s exophthalmometry, and severe exophthalmos was defined as proptosis above 21 mm. Vertical movement of the upper eyelid was defined as the distance (mm) between the upper eyelid position in up and down gaze. A restricted vertical movement of the upper eyelid was defined as less than 12 mm.

The eyelid position was measured in relation to the limbus, with the normal position being situated 1–1.5 mm below the limbus. Retraction was defined as an eyelid position at or above the limbus. Retraction was categorized as mild when the eyelid margin was less than 1 mm above the limbus, moderate when the eyelid was situated between 1 and 2 mm above the limbus, and severe if the eyelid`s position exceeded 2 mm above the limbus.

The outcome after surgery was categorized from clinical examination and photographs as perfect, acceptable, and unacceptable according to Mourits and Sasim`s classification (Table 1).25 Level of orbital inflammation was assessed according to clinical activity score.26 Active TED was defined as a clinical activity score of 3 out of 7 or higher.

TABLE 1. Grading of results after surgical treatment of upper eyelid retraction*

Classification	Description	
Perfect	Upper eyelid covering 0.5 to 1.5 mm of the cornea	
	A smooth eyelid contour	
	Symmetry of lid position equivalent or less than 1 mm	
	A satisfied patient	
Acceptable	Upper eyelid margin is within 0.5 mm of the limbus or covers no more than 2 mm of the cornea	
	Symmetry of the lid position is equivalent or less than 2 mm	
	Otherwise as in perfect results	
Unacceptable	One or more of the “acceptable” criteria are not fulfilled	
* According to Mourits and Sasim`s criteria.25

Surgical Procedures

Surgery was performed on a day-care basis by a single surgeon (HOU) having 15 years of experience as an oculoplastic surgeon. Patients received sedation (2.5 mg diazepam tablet) and local anesthesia (5 mg/ml bupivacaine hydrochloride with 5 µg/ml epinephrine). Bilateral retractions were operated upon in 1 procedure.

Blepharotomy (Fig. 1A) was performed through an anterior approach with an incision in the upper eyelid skin crease, followed by division of the orbicularis muscle, levator aponeurosis, and Muller`s muscle just above the upper edge of the tarsus. Splitting of the conjunctiva from the tarsal plate was adjusted perioperatively to achieve the desired eyelid position. A central conjunctival bridge was preserved in all cases to maintain the contour of the eyelid margin. Apart from the central conjunctival bridge, we followed the procedure described by Elner et al.21 If a lateral “flare” was present, the lateral horn was cut. Care was taken not to transect the lacrimal gland ducts. The skin incision was closed in 1 layer by nonabsorbable sutures (Prolene 6-0). Skin sutures were removed 10 days postoperatively.

FIG. 1. A, Illustration of blepharotomy. B, Illustration of LRWAS. LRWAS, levator recession with adjustable sutures.

LRWAS was performed as a 2-step procedure (Fig. 1B). This technique was carried out as described by Tucker and Collin.15 Initially, a traction suture to stretch the eyelid structures was placed. After an upper eyelid skin crease incision, the levator aponeurosis and Müller`s muscle were detached from the tarsus and conjunctiva. The lateral horn was cut if necessary. The levator aponeurosis was reattached to the tarsus with 3 loose Vicryl 6-0 sutures and passed through the skin (Fig. 1B). Interrupted nonabsorbable sutures (Prolene 6-0) was used to close the skin incision. The upper eyelid was positioned the following day by adjusting the Vicryl sutures without the use of local anesthesia.

If overcorrection was noticed after 1 week, the Vicryl (adjustable) sutures were removed, and the patient was instructed to stretch the eyelid for 2–4 minutes each day the following week.

Statistical Analyses

Data were analyzed using the Statistical Package for the Social Sciences (SPSS Version 26.0; IBM Corporation, Armonk, NY, U.S.A.). Descriptive statistics was used to describe the subgroups. Students t test or Mann–Whitney U test was used as appropriate to detect differences between groups. Differences in categorical variables between groups were analyzed by χ2 test. Linear regression was used to adjust outcome variables (MRD1 and vertical eyelid aperture) for smoking habits. The level of statistical significance was set to p < 0.05.

RESULTS

Study Population

A total of 30 patients (25 women) with a median (range) age of 51.5 (34–74) years at surgery were included. Basic characteristics and previous treatment of hyperthyroidism and orbitopathy are presented in Table 2. Surgical procedures were performed bilaterally in 19 and unilaterally in 11 individuals. Fifteen patients (24 eyelids) were treated with blepharotomy, and 15 individuals (25 eyelids) with LRWAS. Median time from operation to last examination was 6 (6–18) months. There was no difference in follow-up time between the 2 treatment groups.

TABLE 2. Basic characteristics and treatment of 30 TED patients surgical treated for upper eyelid retraction

Parameter	All patients	Blepharotomy patients	LRWAS patients	p	
Basic characteristics	
Patients, n	30	15	15	1.00	
Age, year (range)	51.5 (34–74)	51 (34–71)	52 (36–74)	0.69	
Female, n (%)	25 (83.3)	14 (93.3)	11 (73.3)	0.55	
Smoking habits	
 Daily smoker, n (%)	9 (30)	1 (6.7)	8 (53.3)	0.02	
 No-smoker, n (%)	13 (43.3)	10 (66.7)	3 (20)	0.52	
 Ex-smoker, n (%)	8 (26.7)	4 (26.7)	4 (26.7)	1.00	
Diabetes mellitus, n (%)	1 (3.3)	0 (0)	1 (6.7)		
Antiplatelet agents, n (%)	2 (6.7)	2 (13.3)	0 (0)		
Duration of GD, month (range)	56 (18–468)	45 (18–468)	75 (18–240)	0.33	
Duration of TED, month (range)	44.5 (14–468)	40 (14–468)	50 (18–192)	0.32	
Severe UER (>2 mm), n = 49 (%)	7 (14.3)	5 (20.1)	2 (8)	0.26	
Restricted eyelid movement (<12 mm), n = 49 (%)	4 (8.2)	1 (4.2)	3 (12)	0.32	
Severe exophthalmos (>21 mm), n = 49 (%)	7 (14.3)	2 (8.3)	5 (20)	0.26	
Treatment	
Treatment of hyperthyroidism, n (%)	
 No treatment	2 (6.7)	0 (0)	2 (13.2)		
 Antithyroid drugs	10 (33.3)	6 (40)	4 (26.7)	0.53	
 Radioiodine ablation	3 (10)	1 (6.7)	2(13.3)	0.56	
 Total thyroidectomy	12 (40)	8 (53.3)	4 (26.7)	0.25	
 Total thyroidectomy + radioiodine ablation	3 (10)	0 (0)	3 (20)		
Anti-inflammatory treatment of TED, n (%)	
 No treatment	14 (46.7)	9 (60)	5 (33.3)	0.29	
 Corticosteroids	11 (36.7)	4 (26.7)	7 (46.7)	0.37	
 Corticosteroids + irradiation	3 (10)	2 (13.3)	1 (6.7)	0.56	
 Corticosteroids + irradiation+ rituximab	2 (6.7)	0 (0)	2 (13.3)		
Previous surgical treatment of TED, n (%)	
 Lateral orbitotomy	8 (26.7)	4 (26.7)	4 (26.7)	1.00	
 Lateral + medial orbitotomy	4 (13.3)	2 (13.3)	2 (13.3)	1.00	
 Medial orbitotomy	3 (10)	0 (0)	3 (20)		
 Strabismus surgery	6 (20)	2 (13.3)	4 (26.7)	0.41	
 Blepharoplasty	4 (13.3)	1 (6.7)	3 (20)	0.32	
 Correction of LER	2 (6.7)	1 (6.7)	1 (6.7)	1.00	
Categorical data are given as n (%); continuous data are given as median (range).

GD, Graves disease; LER, lower eyelid retraction; LRWAS, levator recession with adjustable sutures; TED, thyroid eye disease; UER, upper eyelid retraction.

Preoperative Examination

Preoperative eyelid retraction was defined as mild in 7 patients (9 eyelids), moderate in 19 patients (33 eyelids), and severe in 4 patients (7 eyelids). Severe exophthalmos (>21 mm) and impaired vertical motility of the lid (<12 mm) were observed preoperatively in 7 eyes and 5 eyelids, respectively. There was no significant difference in the number of eyes with severe retraction, exophthalmos, or impaired eyelid motility between the blepharotomy and LRWAS group (Table 2). There were more smokers in the LRWAS (n = 8) than in the blepharotomy (n = 1) group (p = 0.02). All patients had thyroid hormone levels in the normal range for at least 12 months before surgery. For a minimum of 6 months preoperatively, no patients had signs of active orbital inflammation (clinical activity score ≥3) or used anti-inflammatory treatment, and none experienced reactivation of their orbital inflammation from surgery to last follow-up.

Outcome

The median preoperative lid aperture was 12 (10.5–16) mm and median MRD1 was 6.5 (5–8) mm. Three months after the primary surgery (before secondary corrections were performed), the median (range) eyelid aperture was 10 (6–11) mm after blepharotomy and 9.5 (7–13) mm after LRWAS. At the same time point, median MRD1 was 3.5 (1–4.5) mm after blepharotomy and 3.5 (2–7) mm after LRWAS. There was no significant difference in postoperative eyelid aperture (p = 0.54) or MRD1 (p = 0.74) between patients operated with LRWAS or blepharotomy after the primary operation. After a single procedure, we observed no significant difference (p = 0.53) in the number of patients with perfect or acceptable results after blepharotomy (n = 13, 86.7%) compared with after LRWAS (n = 10, 66.7%). Reoperation was performed in 11 (37%) eyelids, 10 due to overcorrection (Fig. 2), and 1 because of residual retraction. We observed a significant difference (p = 0.04) in reoperations after the 2 different procedures. Two reoperations were performed after blepharotomy and 9 after LRWAS.

FIG. 2. Photographs of a patient treated with LRWAS for upper eyelid retraction (left side). Photos are taken before treatment, and then at follow-ups, as indicated. The photographs illustrate delayed development of overcorrection and show the final result after the patient received additional surgery for secondary ptosis 6 months after LRWAS. LRWAS, levator recession with adjustable sutures.

At the final examination, postoperative median eyelid aperture was 10 (7.5–11) mm after blepharotomy and 10 (8–11) after LRWAS (Table 3). Further, the median MRD1 was 3.5 (3–4) mm after blepharotomy and 3.5 (2–5.5) mm after LRWAS. We observed no significant difference in postoperative eyelid aperture or MRD1 between patients operated with blepharotomy and LRWAS after all necessary secondary corrections had been completed. Further, we observed no differences in position of the upper eyelid fissure after blepharotomy (10 (8–13)) compared with after LRWAS (11 (9–12)). According to Mourtis and Sashimi`s classification, treatment outcomes were identical after the 2 different procedures, and a perfect or acceptable result was found in 14 (93%) patients in each group (Table 3). Out of all patients, 28 (93%) were satisfied with the outcome, 14 (93%) after both blepharotomy and LRWAS.

TABLE 3. Clinical characteristics of 49 eyelids in 30 TED patients before and after operation (including reoperations if necessary) for upper eyelid retraction

Parameter	Preoperative all eyelids	After blepharotomy	After LRWAS	p *	
Eyelid aperture, mm (range)	12 (11–16)	10 (7.5–11)	9.8 (8–13)	0.92	
MRD, mm (range)	6.5 (5–8)	3.5 (3–4)	3.5 (2.5–4.5)	0.37	
Position of upper eyelid margin, mm (range)	1 ((−2)−3)	−1.5 ((−2)–(−0.5))	−1.5 ((−2.5)–0.5)	0.53	
Vertical motility upper eyelid, mm (range)	13 (10–16)	13 (10–16)	14 (5–15)	0.53	
Normal upper eyelid contour, n = 49 (%)	42 (85.7)	22 (91.7)	20 (80)	0.76	
Lateral flare, n = 49 (%)	31 (63.3)	1 (4.2)	1 (4.0)	1.00	
Symmetry, n = 30 (%)	11 (36.7)	11 (73.3)	9 (60)	0.66	
Lagophthalmos, n = 49 (%)	10 (20.4)	0 (0)	1 (4)		
Keratopathy, n = 49 (%)	23 (49.9)	3 (12.5)	1 (4)	0.32	
Exophthalmos†, mm (range)	19 (12–25)	17 (12–24)	20 (10–22)	0.08	
Position of upper eyelid fissure, mm (range)	10 (8–13)	9.5 (8–13)	10 (8–13)	0.19	
Satisfied patient, n=30 (%)		14 (93.3%)	13 (86.7%)	0.70	
Categorization of final outcome‡, n = 30 (%)	
 Perfect		9 (60)	9 (60)	1.00	
 Acceptable		5 (33.3)	5 (33.3)	1.00	
 Unacceptable		1 (6.7)	1 (6.7)	1.00	
* p values at final examination between eyelids operated with blepharotomy and levator recession with adjustable sutures.

† Measured by Hertels` exophthalmometer.

‡ Outcome categorized according to Mourits and Sasim criteria.25

LRWAS, levator recession with adjustable sutures; MRD, medial reflex distance; TED, thyroid eye disease.

Regardless of the procedure used, the 4 patients with severe retraction (above 2 mm) exhibited a similar postoperative outcome compared with the remaining cases, as 2 had a perfect and 2 showed an acceptable result at the final examination. Severe preoperative exophthalmos (above 21 mm) or impaired vertical motility of the lid (less than 12 mm) did not significantly influence the postoperative outcome. Further, we observed no difference in the surgical outcome between unilateral and bilateral procedures. In addition, we did not find smoking habits to affect outcomes when adjusting for smoking habits by linear regression.

A significant difference (p < 0.01) in median operation time was found between patients treated with blepharotomy (41.5 (17–105) minutes) and LRWAS (68 (35–101) minutes) (Fig. 3). First-day postoperatively, the upper eyelid position was adjusted after LRWAS. Median time (range) used at the first-day visit was 10 (5–10) minutes after blepharotomy and 15 (7–30) minutes after LRWAS (p = 0.29). Significant shorter (p = 0.02) total duration of all visits was observed in patients treated with blepharotomy (50 (35–70) minutes) compared with LRWAS (65 (40–115) minutes).

FIG. 3. Duration of surgery in minutes. LRWAS, levator recession with adjustable sutures.

Wound dehiscence occurred in 1 patient 6 weeks after blepharotomy, and 1 case of postoperative infection was observed 10 days after LRWAS. No other complications were observed.

DISCUSSION

This randomized prospective interventional study is the first to compare blepharotomy and LRWAS for correcting upper eyelid retraction in TED. We found equivalent results with an acceptable or perfect final outcome in 93% after both procedures. To achieve this, a higher number of reoperations had to be performed after LRWAS than after blepharotomy. No differences in postoperative vertical eyelid aperture or MRD1 were observed between the 2 techniques, but a significantly longer operation time was required in LRWAS. Few complications were observed with both procedures.

Our observation of a success rate of 93% is in line with the results reported by other authors. By using blepharotomy to correct upper eyelid retraction secondary to TED, Elner et al.21 reported a desired upper eyelid height in 88% of their patients. Hintschich observed a good result in 97% after a full-thickness blepharotomy that was extended nasally and temporally until the desired lid height and contour were achieved.22 After LRWAS, Tucker and Collin reported good results in 75% of the patients in a cohort with mixed eyelid malpositions.15 Using the same procedure Woog et al.27 observed acceptable results in 86% of eyelids in a small group of 10 patients.

More patients needed secondary correction of ptosis after LRWAS than after blepharotomy. This could be explained by the resolution of the absorbable sutures (Vicryl 6-0). After 2–3 weeks the sutures resolve, and if the levator muscle has not been attached to the tarsus by then, the upper eyelid could descend, leading to secondary ptosis. A moderate dissection of the upper eyelid structure may be favorable. The medial part of the levator aponeurosis is less developed and weaker than the lateral part,28 and is less important for the development of eyelid retraction. Therefore, complete disinsertion of the medial aspect of the levator should be avoided except for in severe retraction.

Blepharotomy was less time-consuming compared with LRWAS, reflecting that blepharotomy is a simpler surgical technique and may be easier to learn.23 Between 2 equally effective techniques, the quickest and easiest procedure should be the first choice, while the more time-consuming procedure could be used in selected cases. Thus, LRWAS could be the primary surgical choice in severe retraction as variable final postoperative height in severe retraction has been reported after blepharotomy.21 We further propose that LRWAS could be used to correct secondary retractions after blepharotomy.

A rise in the upper eyelid skin crease position is of concern after blepharotomy.29 In LRWAS, the connection between the skin and the levator muscle by the adjustable sutures is expected to counteract descent of the crease.24 In our patients, we did not observe a difference in position of the crease after blepharotomy compared with LRWAS.

There are very few studies where different lid-lowering procedures have been compared. A retrospective study comparing 3 different techniques, reported LRWAS to give better results than levator recession without sutures and levator recession with nonadjustable sutures.15 In a prospective comparative study, Gonçalves et al.30 observed blepharotomy and transconjunctival eyelid lengthening to be equally effective in treatment of upper eyelid retraction in patients with TED. In contrast to our findings, they observed poorer results in severe retraction regardless of the procedure used.

One of the key strengths of this study is the study design where 2 surgical procedures are compared prospectively. Further, the bias related to evaluation of surgical performance is limited as only a single surgeon has performed all procedures. A difference in number of smokers between the 2 groups is a limitation of the study. Smoking is a known risk factor for development of more severe manifestations of TED.31 However, we did not observe smoking to affect the postoperative outcome. An additional study weakness is a short median follow-up time of 6 months because the long-time results could be of interest.

In conclusion, our study demonstrates that blepharotomy and LRWAS are both safe and effective methods for correcting upper eyelid retraction in patients with TED. Blepharotomy is the fastest procedure to perform, requires less follow-up and implies fewer reoperations due to overcorrection. We therefore propose blepharotomy to be the primary surgical procedure in this group of patients.

ACKNOWLEDGMENTS

The professional assistance of medical photographer Bård Kjersem is greatly appreciated, and we thank cand. med. Sara T. Nøland for illustration of Figure 1.

This work was supported by grants from the Regional Health Authorities of Western Norway.

The authors have no conflicts of interest to disclose.
==== Refs
REFERENCES

1 Bartalena L Tanda ML . Current concepts regarding Graves’ orbitopathy. J Intern Med. 2022;292 :692–716.35604323
2 Bartalena L Kahaly GJ Baldeschi L ; EUGOGO †. The 2021 European group on Graves’ orbitopathy (EUGOGO) clinical practice guidelines for the medical management of Graves’ orbitopathy. Eur J Endocrinol. 2021;185 :G43–G67.34297684
3 Park J Sullivan T Mortimer R . Assessing quality of life in Australian patients with Graves’ ophthalmopathy. Br J Ophthalmol. 2004;88 :75–78.14693779
4 Bartley GB Gorman CA . Diagnostic criteria for Graves’ ophthalmopathy. Am J Ophthalmol. 1995;119 :792–795.7785696
5 Cruz AAV Ribeiro SF Garcia DM . Graves upper eyelid retraction. Surv Ophthalmol. 2013;58 :63–76.23217588
6 Bartley GB Fatourechi V Kadrmas EF . Clinical features of Graves’ ophthalmopathy in an incidence cohort. Am J Ophthalmol. 1996;121 :284–290.8597271
7 Feldon SE Levin L . Graves’ ophthalmopathy: V. Aetiology of upper eyelid retraction in Graves’ ophthalmopathy. Br J Ophthalmol. 1990;74 :484–485.2390525
8 Rootman J Patel S Berry K . Pathological and clinical study of Müller’s muscle in Graves’ ophthalmopathy. Can J Ophthalmol. 1987;22 :32–36.3815153
9 Davies MJ Dolman PJ . Levator muscle enlargement in thyroid eye disease-related upper eyelid retraction. Ophthalmic Plast Reconstr Surg. 2017;33 :35–39.26808176
10 Schaefer DP . The graded levator hinge procedure for the correction of upper eyelid retraction (an American ophthalmological society thesis). Trans Am Ophthalmol Soc. 2007;105 :481–512.18427627
11 Henderson JW . Relief of eyelid retraction: a surgical procedure. Arch Ophthalmol. 1965;74 :205–216.14318497
12 Putterman AM Urist M . Surgical treatment of upper eyelid retraction. Arch Ophthalmol. 1972;87 :401–405.5018244
13 Harvey JT Anderson RL . The aponeurotic approach to eyelid retraction. Ophthalmology. 1981;88 :513–524.6894973
14 Levine MR Chu A . Surgical Treatment of Thyroid Related Lid Retraction: A New Variation. NJ: SLACK Incorporated Thorofare, 1991:90–94.
15 Tucker SM Collin R . Repair of upper eyelid retraction: a comparison between adjustable and non-adjustable sutures. Br J Ophthalmol. 1995;79 :658–660.7662630
16 Doxanas MT Dryden RM . The use of sclera in the treatment of dysthyroid eyelid retraction. Ophthalmology. 1981;88 :887–894.7301305
17 Grove AS Jr . Eyelid retraction treated by levator marginal myotomy. Ophthalmology. 1980;87 :1013–1018.7017523
18 Thaller V Kaden K Lane C . Thyroid lid surgery. Eye. 1987;1 :609–614.3446542
19 Lai C-S Lin T-M Tsai C-C . A new technique for levator lengthening to treat upper eyelid retraction: the orbital septal flap. Aesthetic Plast Surg. 2002;26 :31–34.11891595
20 Ceisler EJ Bilyk JR Rubin PA . Results of Müllerotomy and levator aponeurosis transposition for the correction of upper eyelid retraction in Graves disease. Ophthalmology. 1995;102 :483–492.7891989
21 Elner VM Hassan AS Frueh BR . Graded full-thickness anterior blepharotomy for upper eyelid retraction. Arch Ophthalmol. 2004;122 :55–60.14718295
22 Hintschich C Haritoglou C . Full thickness eyelid transsection (blepharotomy) for upper eyelid lengthening in lid retraction associated with Graves’ disease. Br J Ophthalmol. 2005;89 :413–416.15774915
23 Kazim M Gold KG . A review of surgical techniques to correct upper eyelid retraction associated with thyroid eye disease. Curr Opin Ophthalmol. 2011;22 :391–393.21730842
24 Ueland HO Uchermann A Rødahl E . Levator recession with adjustable sutures for correction of upper eyelid retraction in thyroid eye disease. Acta Ophthalmol. 2014;92 :793–797.24697978
25 Mourits MP Sasim IV . A single technique to correct various degrees of upper lid retraction in patients with Graves’ orbitopathy. Br J Ophthalmol. 1999;83 :81–84.10209441
26 Mourits MP Prummel MF Wiersinga WM . Clinical activity score as a guide in the management of patients with Graves’ ophthalmopathy. Clin Endocrinol (Oxf). 1997;47 :9–14.9302365
27 Woog JJ Hartstein ME Hoenig J . Adjustable suture technique for levator recession. Arch Ophthalmol. 1996;114 :620–624.8619780
28 Older JJ . Surgical treatment of eyelid retraction associated with thyroid eye disease. Ophthalmic Surg. 1991;22 :318–22; discussion 322.1896167
29 Tyers AG Collin JRO . Colour Atlas of Ophthalmic Plastic Surgery. Elsevier Health Sciences; 2008.
30 Gonçalves ACP Nogueira T Gonçalves ACA . A comparative study of full-thickness blepharotomy versus transconjunctival eyelid lengthening in the correction of upper eyelid retraction in Graves’ orbitopathy. Aesthetic Plast Surg. 2018;42 :215–223.29026936
31 Cawood TJ Moriarty P O’Farrelly C . Smoking and thyroid-associated ophthalmopathy: a novel explanation of the biological link. J Clin Endocrinol Metab. 2007;92 :59–64.17047020
