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*DNB (Oph); **Hon. and Head of Ophthalmology, MGM Hospital, Parel, Mumbai 400 012.

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.[1] 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 limits.

Fig.1 Pre-operative : Left eye showing upper lid
retraction with 2 mm scleral show above superior limbus.

Surgical approach

Since our patient was adult and co-operative, we planned to do the surgery under local anaesthesia.

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.[4]

Surgical technique

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 [5] (Fig. 2). The orbicularis and the skin were closed in layers. The skin bites included the spacer so as to form the lid crease.

Fig.2 Intra-operative : 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).

Fig.3 Post-operative : 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 and guidance.

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; 195.

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.

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