Correction of lower eyelid retraction in thyroid eye disease: a randomised controlled trial of retractor tenotomy with adjuvant antimetabolite versus scleral graft

Abstract

Background/aims-Lower eyelid retraction in thyroid eye disease contributes to ocular discomfort and an unsightly appearance, especially if asymmetrical. The use of donor scleral grafts is eVective in lengthening the lower eyelids but carries a risk of virus transmission. Other techniques, including those which do not use grafts, need to be compared with scleral grafts. Recurrent retraction is a recognised complication of thyroid eyelid surgery; therefore, the authors investigated the use of antimetabolites to reduce postoperative fibrosis. Methods-In this prospective randomised controlled trial of 25 patients (35 eyelids), the use of donor sclera in 20 lower eyelids (13 patients) was compared with partial tenotomy of the anterior part of the lower eyelid retractors (ALER) with adjuvant peroperative antimetabolite in 15 lower eyelids (12 patients). A 5 minute peroperative application of either 5-fluorouracil (25 mg/ml) in nine lower eyelids (eight patients) or mitomycin C (0.2 mg/ml) in six lower eyelids (four patients) was used to focally inhibit fibroblasts. Follow up ranged from 3 to 18 months (mean 7.8). Results-One month after surgery the results of both groups were similar. However, at 3 months after surgery the results of scleral grafting were better than tenotomy with antimetabolites: 3/12 patients (25%) treated with tenotomy and adjuvant antimetabolite required subsequent surgery using grafts for correction of recurrent retraction. There were no significant complications associated with the use of antimetabolites in the eyelid in the doses used in this study. Conclusions-This randomised prospective trial shows that donor scleral grafts were more eVective in the long term than partial tenotomy with adjuvant antimetabolite in the correction of lower eyelid retraction associated with thyroid eye disease. The use of peroperative antimetabolites in the lower eyelid was safe. (Br J Ophthalmol 1998;82:174-180)

A review of combined orbital decompression and lower eyelid recession surgery for lower eyelid retraction in thyroid orbitopathy

“…Spacer material includes autogenous free tarsal graft,13 hard palate mucosal graft,14 dermis fat graft,15 homologous donor sclera16 17 and synthetic material (including Mersilene mesh,18 porous polyethylene19 and Alloderm15) with reported improvements ranging from 1.0 mm15 to 2.38 mm 16. Complications are wide ranging and involve the donor or recipient site, with rates varying from 17.5%14 to 49%19 depending on the material used.…”

How to Repair the Lower Eyelid Retraction, Resulting from the Primary Surgery for Epiblepharon?

“…The posterior layer, which is comprised of dense fibers of the capsulopalpebral fascia with scattered smooth muscle fibers and attached to the tarsus, is the main pulling structure of the lower eyelid retractors. We utilised the surgical concept of cleft of the lower eyelid retractors, in which scar rigidity or fibrous contracture are the main causes of retractions [21,22].…”

Korrektur von Unterlidretraktion mittels eines porösen Polyethylen (Medpor®) Unterlidimplantats

“…Vorteile gegenüber Biomaterialien wie Sklera, Ohrknorpel, harter Gaumen, azelluläre Dermis oder Tarsus sind bessere Verfügbar-keit, keine möglichen Komplikationen an der Entnahmestelle, keine Spendermaterialrisiken wie z. B. Infektiosität, sowie kosten-, operationstechnische und anästhesiologische Erwägungen [7,15,19,21,29]. Nachteile wie Behinderung und Gesichtsfeldeinschrän-kung beim Blick nach unten, Extrusion und höhere Revisionsraten lassen sich in einem gewissen Maße durch Operationstechnik und sorgfältige Indikationsstellung beeinflussen.…”

“…Alle bisher verwendeten Unterlidimplantate haben jedoch potenzielle Nachteile: Sklera birgt ein Infektionsrisiko [3,17]. Wie auch bei allogenen azellulären Hauttransplantaten werden bei Skleraimplantaten Rezidive aufgrund von Absorption und Fibrosierung des Spendermaterials beobachtet [4,19,23,26]. Autogene Transplantate wie Mucosa des harten Gaumens, Tarsus oder Ohrknorpel bedeuten operativen Mehraufwand und es kann zu Komplikationen an der Entnahmestelle kommen [6,7,13,15,21,29].…”