The Art of Upper Eyelid Retraction Repair.

The upper eyelid usually sets 1 to 2 mm below the upper corneal limbus. Upper eyelid retraction (UER) is defined as an abnormally elevated eyelid exposing the upper sclera in the resting position. This definition requires statistical knowledge of the normal population’s upper lid position distribution.1 Multiple causes can lead to UER with thyroid eye disease (TED) especially Graves’ ophthalmopathy being the most common causative disorder.2 Other causes include myogenic etiologies such as congenital UER and poststrabismus/ptosis surgeries, neurogenic causes such as Parinaud syndrome and Collier’s sign, and mechanistic factors such as cutaneous or conjunctival scaring, proptosis, and axial myopia.3,4 Proper patient assessment including comprehensive medical history and physical examination is crucial to deliver the most appropriate management plan and exclude causes of pseudo eyelid retraction such as proptosis and contralateral upper eyelid ptosis. Hence, accurate preoperative understanding and controlling the causative factors are of great value before proceeding to the operating theater. In the clinical settings, patients should be assessed for syndromic features, signs of previous trauma, cranial palsies, TED, conjunctival scaring, or neurological insults. The upper eyelid assessment is typically done using various methods as marginal reflex distance 1 (MRD1) which is normally 4 to 5 mm, palpebral fissure height, levator function, and the mid-pupil to upper lid margin distance.2 Moreover, other assessment tools such as Hertel exophthalmometer, orbicularis oculi function, lagophthalmos, bells phenomenon, corneal sensation, and preoperative