SURGICAL CORRECTION IN CASE OFCONGENITAL
ANAMIKA K KELSHILKAR*, JAYESH R NISAR**
*DNB (Oph); **Hon. and Head of Ophthalmology, MGM Hospital, Parel, Mumbai
A case of congenital lid retraction
without any shortage of skin or conjunctiva is reported here. It was surgically
managed by the use of a spacer to achieve cosmetic correction.
Lid retraction is a disorder of eyelid position that can affect the upper lid,
the lower lid, or both. The condition is characterized by the appearance of
a band of white sclera between the limbus and the eyelid margin when the eyes
are in primary position. Surgery is indicated if there is
corneal exposure due to poor lid closure or else if cosmetic asymmetry exists.
A 20-year old college going student presented to us with a history of retraction
of his left upper lid since birth. It was conspicuous and bothering him cosmetically.
There was no significant family history, no associated systemic illness, and
no history of trauma (Fig. 1).
On examination, the left eye vision was 6/6 on Snellens chart. He had upper
lid retraction of his left eye with approximately 3 mm scleral show at the superior
limbus, with good levator action, normal extraocular movements, and no Marcus
- Gunn phenomenon. The anterior and posterior segments were normal. Examinations
of other cranial nerves were found to be normal. The right eye was within normal
|Fig.1 Pre-operative : Left eye showing
retraction with 2 mm scleral show above superior limbus.
Since our patient was adult and co-operative, we planned to do the surgery under
The patient had a lid retraction of about 5 mm. There was no shortage of either
skin or conjunctiva. So, it was decided to perform upper lid retractor recession
with a spacer through the anterior approach.[2,3] The use of
a spacer would give predictable results. The dimensions of the spacer selected
were as follows: horizontal 15 mm and vertical 7 mm (degree of retraction to
be corrected + 2 mm). The material selected was donor sclera.
The lid crease was marked with methylene blue and then infiltrated with lignocaine
(2%) with adrenaline. After cleaning and draping an incision was taken at the
lid crease. The pretarsal orbicularis was exposed. After dissecting the orbicularis,
the levator insertion on the tarsus was exposed. The levator muscle was dissected
upwards till the orbital septum. The upper lid retractor complex was cut from
the tarsus and separated from the conjunctiva. Next, the spacer was cut to the
desired dimensions and was placed between the upper border of the tarsus and
the lower border of upper lid retractors, where it was secured with 6-0 vicryl
suture  (Fig. 2). The orbicularis and the skin were closed
in layers. The skin bites included the spacer so as to form the lid crease.
: Donor sclera used as a spacer
material which is placed between upper border of
tarsus and lower border of upper lid retractors.
The present case demonstrates a cosmetically acceptable correction of retraction
of upper lid with spacer. This patient did not have any associated shortage
of skin or conjunctiva. The upper lid retractor recession along with the use
of spacer achieves correction of more than 4 mm. In our case, donor sclera was
used as a spacer. Other materials that may be used include : nasal cartilage,
hard palate mucous membrane. The advantage of using donor sclera are : the ease
of availability from an eye bank and good rigid tissue characteristics mimicking
tarsal plate consistency. During surgery, care should be taken while dissecting
laterally to avoid damage to the lacrimal gland, and also while separating upper
lid retractors from conjunctiva to avoid button holing of the conjunctiva. Intra-operative
over-correction is desired. Post-operatively within a few days as the lid oedema
resolves the desired lid level is achieved (Fig. 3).
: Over correction is desirable.
As the lid oedema resolves, cosmetically
acceptable correction is achieved in few days.
I take great pleasure in presenting
this case managed by our team at MGM Hospital under the guidance of our ever-enthusiastic
and most encouraging Honorary - Dr. Jayesh Nisar.
I am most grateful to my dearest teacher Dr. Anjali D Nicholson - a great ophthalmologist,
who has helped me in each and every step of preparation of this case report.
The virtue of this kind was not possible for me without her generous support
I am thankful to Dr. Faisal Khan, Dr. Ruvit Nikam, Dr. Renu for their help.
My special thanks to Mr. Vaidya (Photography Department - MGM Hospital). Above
all, I dedicate this to my dear parents and lovely sisters - Santoshi and Rupali
who encouraged me a lot.
1.Frederick T, Fraunfelder F, Hampton Roy, et al. Current Ocular
Therapy, 4th edition, WB Saunders Company. 1995; 583-84.
2.Dryden RM, Soll DB. The use of scleral transplantation in
cicatricial entropion and eyelid retraction. Trans Am : Acad Ophthalmol Otolaryngol
1971; 86 : 669.
3.Tyers AG, Collin JRO. Colour Atlas of Ophthalmic Plastic Surgery.
1st edition, Churchill Livingstone and Longman Group Limited. 1995; 183.
4.Tyers AG, Collin JRO. Colour Atlas of Ophthalmic Plastic surgery.
1st edition, Churchill Livingstone and Longman Group Limited. 1995; 194.
5.Tyers AG, Collin JRO. Colour Atlas of Ophthalmic Plastic
surgery. 1st edition, Churchill Livingstone and Longman Group Limited. 1995;
6.Yoshida K, Suzuki J, Suzuki S, Kume K, Suzuki H, Hujiki T.
A case of IgA nephropathy in three sisters with thin basement membrane disease.
Am J Nephrol 1998; 18 : 422-24.