Journal of Neuro-Ophthalmology, September 1984, Volume 4, Issue 3

Unilateral eyelid retraction secondary to contralateral ptosis in dysthyroid ophthalmopathy.

A patient with dysthyroid eye disease presented with unilateral lid retraction secondary to a contralateral ptosis. While others have reported similar findings in various underlying disease processes, to the best of our knowledge this is the first case in the literature with dysthyroid ophthalmopathy, and the first where the results of surgical management are presented. The importance of testing for secondary lid retraction by manual elevation of the ptotic partner is stressed.

J. Clin. Nturo-ophthalmol. 4: 163-166,1984, Unilateral Eyelid Retraction Secondary to Contralateral Ptosis in Dysthyroid Ophthalmopathy LAWRENCE LOHMAN, M.D. JOHN A. BURNS, M.D. WILLIAM R. PENLAND, M.D. KENNETH V. CAHILL, M.D. Abstract A pilltient with dysthyroid eye dise~ presented with unilillter~llid retnction secondary to ~ contrill­Iilltnu ptosis. While others hillVe reported si.milu findings i.n various underlying diseue prOCf:SSf:S. to the best of our knowledge this is the first c~ in the liter~ture with dysthyroid ophthilllmop~thy. iIInd the first where the rHults of surgiCillI m~n~ge­ment ue presented. The import~nce of testing for Sf:conduy lid rf:tr~ction by millnuilll elev~tion of the ptotic p~rtner is stre$Sf:d. Dysthyroid ophthalmopathy is a clinical entity well known to most ophthalmologists, Blodi di­vided the eye findings of Graves' disease into two groups. The noninfiltrative signs consist mainly of lid retraction and infrequent blinking. Infiltra­tive changes may cause chemosis and lid edema, exophthalmos. extraocular muscle inv~lvem.en.t. and may lead to optic nerve damage. PtOSIS .IS less frequently recognized and reported tha~ hd lag and retraction, and some of these .palien~s have concomitant evidence of myasthema gravIs on Tensilon testing. 2 •• This report documents a case of ptOSIS 1ft dys­thyroid ophthalmopathy. The patient displayed upper lid retraction on the opposite side. T~ere was no evidence of myasthenia gravis. On tesbng. the retraction appeared to be a secondary devia­tion related to the contralateral ptosis rather than a direct effect of the underlying thyroid disease. Recognition of this relationship m~de it poss~ble to offer good cosmesis, normal Vl~ual functi~n, and control of exposure with a smgle surgical From the Deputnwnl 0( Ophtn.lmoklgy (ll), N.E. Ohio College of Mf:dicine. Kenl. Ohio; ~rtmenl of Ophlhal~­ogy OAB, KVC).. The Ohio State Univf:T'Sity, Columbus. OhIO; and Duconess Hospit..1(WRp). EV'fISvilko. Indian... September 1984 procedure. An extemallevator resection was per­formed on the ptotic lid with satisfactory results. Case Report Our 57-year-old white female had a history of visible goiter first noted in childhood. In 19~, she underwent a thyroidectomy after presenbng with symptoms of thyrotoxicosis along with ex­ophthalmos, lid congestion, and double vision. The eye signs and symptoms improved in a 3­year period following her surgery. In 1977. the patient again began to notice ·puffiness· of her eyelids along with a staring appearance on the right and drooping of the left upper lid. She was hospitalized in May and July of 1978, after pre­senting with decreasing vision. Vision was 20/40 (right eye) and 20/200 (left eye), with visual fields interpreted as consistent with optic nerve compression. Lid retraction was present in the right eye and ptosis was present in the left eye. CT scan of the orbits, orbital ultrasound, and orbital tomograms were all consistent with thy­roid ophthalmopathy. The patient was treated with systemic steroids with some improvement in vision. Orbital decompression was discussed with the patient, but she was not anxious to proceed with any surgical intervention at that time. Vision remained at a fairly constant level thereafter. The patient was referred to us in March 1980 for evaluation of the marked lid changes which had remained stable for several years. The patient felt her appearance prevented her from achieving a normal life-style and acceptance by others. The best-corrected visual acuity was 20/50 (right eye) and 20/70 (left eye). A marked stare was present on the right and a ptosis on the left (Fig. 1). Palpebral fissures measured 16 mm on the right and 6.5 mm on the left. There was a 3-mm superior scleral show on the right. Manual ele­vation of the ptotic left lid resulted in an imme­diate and nearly equal amount of lowering of the 163 Unilateral Eyelid Retraction Figure I. Lid retraction right eye; ptosis left eye. Figure 2. Effe<:t of manually elevating left uppt'r lid. opposite retracted lid, giving a seesaw effect (Fig. 2). Patching of the left eye for 15 minutes also resulted in lowering of the right upper lid to a normal level (Fig. 3). Exophthalmometer readings were 28 mm (right eye) and 27 mm (left eye). Fullness was present in both upper lids. There was some limitation of eye movement on up gaze, but otherwise extraocular muscle function was good and no diplopia was present. Mild inferior punctate staining of the right cornea was present. Schirmer testing was normal. Fundus exam showed slight pallor of the disc on the left. Ten­silon testing was negative. The eye findings re­mained constant on repeated examination. The patient underwent a 9-mm external levator resec­tion of the left upper lid in May 1980, and had 1M excellent results which can be seen in postoper­ative photographs (Figs. 4 and 5). Discussion We have described a case of thryoid eye disease with a unilateral ptosis. The opposite upper lid displayed retraction secondary to the contralat­eral ptosis rather than being elevated as a direct result of the underlying thyroid problem. Others have reported similar eyelid findings with varying causes of ptosis. Ptosis and lid retraction of the fellow eye have been observed in familial or congenital ptosis,M third nerve palsy,5.6 trauma,6.7 myasthenia gravis,2.6·9 and in ptosis of . undetermined etiology.? The mechanism pro- Journal of Clinical Neuro-ophthalmology Figuf~ 3. Effect of patching left eye. Figuf~ 4. One wet'k after extemallevator resKlion or left upper lid. Figure 5. On~ year after external levator ~ection of left upper lid. September 1984 1.5 Unilateral Eyelid Retraction posed. to account for these finQngs has been an application of Hering's Law. The levators act as yoke muscles with equal innervation received by each muscle. In the case of a unilateral ptosis excessive innervation may be needed to produce maximal elevation of the lid and fixation with that eye. The excessive innervation can cause a retraction on the opposite side. This concept is supported by the finding that prolonged patching of the ptotic side results in the return to a normal position of the elevated partner.J •5•7. 9 In the cases of myasthenia gravis, administration of edro­phonium chloride results in improved position of both lids. ~.. In our case, the retracted lid re­sponded immediately to either patching or man­ual elevation of the ptotic lid. Schechter has also noted cases which displayed the peculiar seesaw effect that we observed.' It is postulated that unequal visual acuities with better vision in the ptotic eye, a tropia, or mono­fixation syndrome with preference of fixation on the ptotic side, may be required for the manifes­tation of this syndrome.' However, in our case, the better acuity was found in the retracted side, and this was the dominant eye. Our case appears to dispute this theory. Our case points out the importance of testing for the underlying cause of unilateral eyelid re­traction in a patient with dysthyroid ophthalmo­pathy. In the usual case of dysthyroid lid retrac­tion, a recession of the lid retractor muscles is required to rrovide correction of exposure and asymmetry.l _u If, however, the lid retraction is associated with the ptosis of dysthyroid ophthal­mopathy, and Hering's Law can be demonstrated to apply, then surgical correction should be lim­ited to the ptotic lid. References I. BlocH, E.C: Ophthalmopathy of Graves' disease. '66 In Ntw Or/tflnS Acadtmy of OphthQlm%gy: Sym­posium on Surgtry of tht Orbit and AdntXll, 1973, Beard, C Ed. CV. Mosby Co., 51. Louis, 1974, pp. WI-Ill. 2. Lawlon, N.R.: Dysthyroid eye disease: Medical investigators. Proc. R. Soc. Mtd. 70: 698-699, 1977. 3. Gupta, l5., jain, 1.5., and Kumar, K.: lid retraction secondary to contralateral ptosis. Br. J. Ophthlllmol. 48: 626-627,1964. 4. Walsh, RoB., and Hoyt, W.F.: C/iniCll1 Nturo-Oph­thQ/ mo/ogy, Vol. 1 (3rd eel.). Williams &. Wilkins, Baltimore, 1960, pp. 304-318. 5. lain. 1.5.: Lid retraction in the non-paretic eye in. acquired ophthalmoplegia. Br. J. Ophthalmol. 47: 757-759, 1963. 6. Schechter, R.O.: Ptosis with contralateral lid re­traction due to excessive innervation of the levator palpebrae superioris. Ann. Ophlhllimol. 10: 1324­1328, 1978. 7. lewallen. W., Ir.: Jjd relTaction syndrome due to "secondary deviation: A.m. I. Ophlha/mol. 45: 565­567, 1958. 8. Gay, A.j., Salmon, M.L, and Windsor, CE.: Her­ing's law, the levators, and their relationship in disease states. Arch. Ophlhll/mol. n: 157-160, 1967. 9. Buffam. R.V.• and Rootman, ).: lid retraction-its diagnosis and treatment. Inf. Ophlha/mol. elin. 18: 75-86, 1978. 10. Meltzer, M.A: Surgery for lid retraction. Ann. Ophthalmol. 10: 102-106, 1978. 11. Pultennan, AM., and Urisl, M.: Surgical treatment of upper eyelid retraction. Arch. OphthQlmol. 87: 401-405,1972. 12. Chalfin, J.. and Putterman, AM.: Muller's muscle ~xci5ion and levator recession and retracted upper ltd. Treatment of thyroid-related retraction. Arch. Ophtha/mol. 97: 1487-1491, 1979. 13. Grove, A.5.: Upper eyelid retraction and Graves' disease. Ophthalmology 88: 499-506, 1981. 14. Harvey, J.T., and Anderson, R.L.: The aponeurotic approach to eyelid retraction. Ophtha/mology 88: 513-524, 1981. journal of Clinical Neuro-ophthalmology