Eyelid retraction is an abnormal positioning of the upper or lower eyelid where the lid margin is pulled away from the surface of the eye, exposing more of the globe than is typical. This condition involves the upward elevation of the upper eyelid or the downward depression of the lower eyelid, preventing the lids from resting in their normal, protective positions. While often viewed as a cosmetic concern, it is frequently associated with underlying systemic health issues, such as autoimmune disorders. The condition can affect one or both eyes.
Defining Eyelid Retraction and Its Visual Indicators
Eyelid position is maintained by a complex interplay of muscles, primarily the levator palpebrae superioris and Müller’s muscle in the upper lid. Retraction occurs when these lifting muscles become overactive, fibrotic, or when the opposing muscles responsible for closing the eye are weakened. This abnormal height creates a characteristic “staring” or wide-eyed appearance.
A distinct sign is “scleral show,” describing the visible white part of the eye (sclera) positioned above or below the iris. Normally, the upper eyelid rests just above the iris, covering a small portion of the cornea. Upper eyelid retraction is the more frequent presentation, resulting from either hyperactivity of the lid-elevating muscles or a mechanical restriction.
Primary Causes of Eyelid Retraction
The most common cause of eyelid retraction, particularly in the upper eyelid, is Thyroid Eye Disease (TED), also known as Graves’ Ophthalmopathy. This autoimmune condition involves the immune system targeting tissues around the eye, leading to inflammation and swelling of the orbital fat and extraocular muscles. This inflammation causes shortening and fibrosis of the levator and Müller’s muscles, mechanically pulling the upper eyelid into a retracted position. Upper eyelid retraction is seen in approximately 90% of TED patients.
Previous eyelid surgery is a frequent cause of retraction, especially in the lower lid following a blepharoplasty procedure. Surgical complications can lead to scarring and contraction of the internal tissues, resulting in a shortage of vertical tissue that pulls the lid downward. Other causes include trauma, which creates scar-related contracture, and neurological disorders. For example, lesions in the dorsal midbrain can lead to over-stimulation of the eyelid-lifting muscles, resulting in Collier’s sign.
Associated Ocular Symptoms and Complications
The primary functional problem resulting from eyelid retraction is the increased exposure of the ocular surface, which directly impacts eye comfort and health. The inability of the eyelids to adequately cover the cornea during blinking or sleep leads to exposure keratopathy and chronic dry eye. Symptoms often include a gritty or foreign body sensation, excessive tearing (epiphora), light sensitivity (photophobia), and blurred vision due to corneal drying. The inability to fully close the eye, especially during sleep, significantly increases the risk of corneal abrasion and ulceration.
Management and Treatment Approaches
Initial management focuses on protecting the exposed corneal surface and alleviating dry eye symptoms. This involves the frequent use of lubricating artificial tear drops, gels, and preservative-free ointments, particularly at night. For retraction secondary to a systemic condition like TED, managing the underlying disease is important, though the retraction often persists even after thyroid hormone levels stabilize.
Definitive correction is typically achieved through surgical intervention performed by an oculoplastic surgeon. The goal of surgery is to lengthen the contracted structures by performing a recession of the eyelid retractors, such as the levator or Müller’s muscle. This allows the eyelid to drop to a lower, more natural position.
In severe cases of lower eyelid retraction or those with significant tissue shortage, a spacer graft may be inserted to provide structural support and length. Materials for spacer grafts include donor tissue (e.g., alloderm) or tissue harvested from the patient (e.g., hard palate mucosa or ear cartilage). For upper lid retraction, the degree of recession is carefully calibrated to ensure full eye opening and symmetry. Surgery is generally deferred until the underlying cause, especially inflammation associated with TED, has entered a stable phase to minimize recurrence risk.