Upper Eyelid Retraction After Glaucoma Filtering Surgery and Topical Application of Mitomycin C

Abstract

Upper eyelid retraction after filtering surgery is a rarely reported entity. Müller muscle overaction, independent of Graves disease, is a likely cause and has been pointed out as a possible factor in one previous report. Müller muscle fibrosis, euthyroid Graves disease, and mechanical hindrance to an elevated bleb are other possible factors.

A Vector Force Model of Upper Eyelid Position in the Setting of a Trabeculectomy Bleb

“…Also, all blebs in this series were Seidel negative. Worsening of eyelid height asymmetry in downgaze, which would be expected in the setting of Mueller's muscle fibrosis, was not seen in the 3 cases presented by Awwad et al, 3 the proponents of this theory. The median patient age of 64 years is also less consistent with the fibrosis theory as the inflammatory response of older individuals is generally less robust.…”

“…Two patients described in the literature developed bleb-induced retraction in the absence of mitomycin C, 6 the agent thought to be responsible for the presumed Mueller's muscle fibrosis by the proponents of this theory. 3 In 3 cases, Mueller's muscle was specifically evaluated and reported as nonfibrotic. 6 The vector force model is based on physical forces acting on the eyelid to cause mechanical displacement as shown in Figure 1B.…”

“…S ince 1975, 16 cases of upper eyelid retraction following the creation of glaucoma filtration blebs have been reported. [1][2][3][4][5][6] Trabeculectomy bleb-induced upper eyelid retraction is an accepted diagnosis, but the mechanism remains unclear. Leading pathophysiologic hypotheses center on chemical, mechanical, and myogenic factors.…”

“…2,5,6 The myogenic theory postulates that inflammation leads to Mueller's muscle fibrosis and subsequent eyelid retraction. 3 An array of treatment options has been described that focus on the eyelid, such as levator recession or disinsertion, Mueller's muscle recession or Müllerectomy, fullthickness blepharotomy with placement of adjustable sutures, and hyaluronic acid gel injection for tissue expansion and weight effect. 1,3-6 Additional modalities focusing on the bleb include the placement of bleb compression sutures, posterior needling of the bleb, and cautery-induced scleral fibrosis.…”

“…Leading pathophysiologic hypotheses center on chemical, mechanical, and myogenic factors. [1][2][3][4][5][6] The chemical hypothesis theorizes that an unknown sympathomimetic chemical in the aqueous stimulates Mueller's muscle, resulting in eyelid retraction. 1 The mechanical model states that the eyelid is physically elevated by a prominent underlying bleb.…”