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Show Journal of Neuro- Ophthalmology 19( 2): 122- 124, 1999. © 1999 Lippincott Williams & Wilkins, Inc., Philadelphia Spontaneous Resolution of Upper Eyelid Retraction in Thyroid Orbitopathy Douglas K. von Brauchitsch, M. D., James Egbert, M. D., Robert C. Kersten, M. D., and Dwight R. Kulwin, M. D. This study was conducted to document in the literature case reports of spontaneous resolution of eyelid retraction in patients with thyroid orbitopathy. Two cases of thyroid orbitopathy associated with eyelid retraction were observed without surgical treatment. Spontaneous resolution of upper eyelid retraction occurred during an 8- to 12- month period. Key Words: Eyelid retraction- Thyroid orbitopathy. Upper eyelid retraction is a common feature of thyroid orbitopathy. Such retraction may be unilateral or bilateral, and according to Duke- Elder ( 1) may resolve after the patient becomes euthyroid. Many authors have stated, without references, that eyelid retraction surgery should be delayed to ensure stability of the lid height. We have been unable to find case reports in the English literature supporting this practice. We document two patients who had spontaneous resolution of upper eyelid retraction over an 8- to 12- month period. The following case reports are from the practice of one of the authors ( DRK). CASE REPORTS Case 1 An 18- year- old woman had bilateral upper eyelid swelling and right upper eyelid retraction 6 months before our examination. Autoimmune thyroiditis with hypothyroidism was diagnosed. The patient had a low T4 level of 3.8 | xg/ dl ( normal, 5- 13 | xg/ dl) and a high thyroid- stimulating hormone ( TSH) level of 194 IU/ ml ( normal, 20- 50 IU/ ml). With replacement therapy, the patient was in a euthyroid state at the time of our initial evaluation. Visual acuity, optic nerve function, ocular Manuscript received January 29, 1998; accepted December 2, 1998. From the Department of Ophthalmology, University of Cincinnati, College of Medicine, Ohio, U. S. A. Address correspondence and reprint requests to James E. Egbert, M. D. University of Minnesota, Department of Ophthalmology, UMHC 493, 516 Delaware Street, SE, Minneapolis, MN 55455, U. S. A. motility, and the cornea were normal. A positive von Graefe's sign was present. Exophthalmometry measurements were 19 mm right eye and 18 mm left eye. The right upper eyelid rested 3 mm above the superior limbus in primary gaze ( Fig. 1A) and no lagophthalmos was present. The left upper eyelid level was normal. Eight months later the right upper eyelid retraction had spontaneously resolved ( Fig. IB), and there continued to be no lagophthalmos. The Hertel measurements were unchanged. Computed tomographic scans were clinically unnecessary. Case 2 A 52- year- old woman experienced tachycardia, weight loss, right upper eyelid swelling, and proptosis 6 months before our examination. A diagnosis of hyperthyroidism related to Grave's disease was made. After tapazole administration the patient was in a euthyroid state at the time of our initial evaluation with a normal T4 ( 6.8 ( xg/ dl) and TSH ( 1.5 mlU/ ml) for that testing facility. Visual acuity, optic nerve function, ocular motility, and the cornea were normal. A positive von Graefe's sign was present. Exophthalmometry measurements were 19 mm right eye and 17 mm left eye. The right upper eyelid rested 3 mm above the superior limbus in primary gaze ( Fig. 2A), and no lagophthalmos was present. The left upper eyelid level was normal. Twelve months later, the right upper eyelid retraction had spontaneously resolved ( Fig. 2B), and there continued to be no lagophthalmos. Hertel measurements remained unchanged. Computed tomographic scans were clinically unnecessary. DISCUSSION The upper lid retraction found in thyroid orbitopathy is seen most commonly in hyperthyroidism, but also may be seen in patients in hypothyroid or euthyroid states. Various theories have been put forth to explain the retraction, from levator or Miiller's muscle hyperactivity, hypertrophy, fatty infiltration, or scarring and restriction, to increased sensitivity of Miiller's muscle, to circulating 722 SPONTANEOUS RESOLUTION OF UPPER EYELID RETRACTION 123 • * * iW-: & ® FIG. 1. ( A) Case 1. Unilateral right upper eyelid retraction with superior scleral show. ( B) Case 1. Eight months later, showing resolution of superior scleral show and improvement of right upper eyelid retraction without surgical intervention. catecholamines ( 2- 6). It is a common clinical practice to document a period of stable eyelid height before surgical correction of eyelid retraction caused by thyroid orbit-opathy ( 7,8). Documentation supporting this practice of observation has not been published. Although possibly rare ( occurrence is an estimated 2% of cases in our practice), these two case reports demonstrate that unilateral upper eyelid retraction can spontaneously resolve during an 8- to 12- month period. Spontaneous resolution may occur in patients who have hypothyroidism ( case 1) or hyperthyroidism ( case 2). Explanations for this phenomenon include the possibility that hyperactivity or contraction of Mtiller's muscle without significant scarring or thickening could release spontaneously, or that spontaneous levator dehiscence might occur, causing lowering of the upper lid height. In these two cases, both patients were clinically euthyroid during the period of observation, thus the resolution was probably not related to the resolution of the hyperthyroid state. Because the possibility of spontaneous improvement exists in these cases, we observe eyelid height for 12 months before treating eyelid retraction. FIG. 2. ( A) Unilateral right upper eyelid retraction at initial presentation. ( B) One year later, eyelid retraction has resolved without surgical intervention. J Neuro- Ophthalmol, Vol. 19, No. 2, 1999 124 D. K. VONBRAUCHITSCH ET AL. REFERENCES 1. Duke- Elder. The ocular adnexa. Part I: Diseases of the eyelids. System of Ophthalmology. Vol. 13. St. Louis, MO: C. V. Mosby, 1974. 2. Putterman AM, Urist M. Surgical treatment of upper eyelid retraction. Arch Ophthalmol 1972; 87: 401- 5. 3. Small RG. Enlargement of levator palpebrae superioris muscle fibers in Graves' ophthalmopathy. Ophthalmology 1989; 96: 424- 30. 4. Ohnishi T, et al. Levator palpebrae superioris muscle: MR evaluation of enlargement as a cause of upper eyelid retraction in Graves' disease. Radiology 1993; 188: 115- 8. 5. Grove AS Jr. Upper eyelid retraction and Graves' disease. Ophthalmology 1981; 88: 499- 506. 6. Eden KC, Trotter WR. Lid- retraction in toxic diffuse goiter. Lancet 1942; 2: 385- 7. 7. Liu D. Surgical correction of upper eyelid retraction. Ophthalmic Surg 1993; 24: 232- 7. 8. Ceisler EJ, Bilyk JR, Rubin PAD, Burks WR, Shore JW. Results of mullerotomy and levator aponeurosis transposition for the correction of upper eyelid retraction in Graves' disease. Ophthalmology 1995; 102: 483- 92. J Neuro- Ophthalmol, Vol. 19, No. 2, 1999 |
