When the white part of your eye, known as the sclera, becomes noticeably visible beneath the iris, it can be a source of concern or curiosity. While sometimes an anatomical variation, increased visibility of the lower sclera can also indicate underlying changes within or around the eye. Exploring this observation helps to clarify its meaning and potential significance.
Understanding Scleral Show
The term for seeing the white of the eye below the colored part, or iris, is commonly known as “scleral show.” In medical contexts, this condition is often referred to as “lower eyelid retraction.” Scleral show describes the visible space between the lower edge of the iris and the margin of the lower eyelid. While a slight amount of scleral show can be a natural feature in some individuals, particularly those with larger eyeballs or certain genetic predispositions, an increased or newly developed visibility can signal a change in eyelid position. This appearance can make the eyes look more rounded or open than their natural almond shape.
What Causes Lower Eyelid Retraction
Various factors can lead to lower eyelid retraction, ranging from typical aging processes to specific medical conditions or previous procedures. Some individuals naturally exhibit more scleral show due to their inherent facial structure or genetics. As people age, the supporting tendons of the lower eyelid can stretch, and the midface tissues may sag, causing the eyelid to lose its tautness and contribute to a downward pull.
A significant medical cause is Thyroid Eye Disease, also known as Graves’ Ophthalmopathy. In this autoimmune condition, inflammation and swelling of tissues behind the eye can push the eyeball forward, a process called proptosis, and simultaneously cause the eyelids to retract. This combination leads to increased scleral exposure. Post-surgical changes are also a frequent cause, particularly after cosmetic lower eyelid procedures like blepharoplasty. Excessive skin or fat removal, scar tissue formation, or weakened eyelid support structures during surgery can pull the eyelid down.
Facial nerve palsy, which involves weakness or paralysis of facial muscles, can also result in lower eyelid sagging because the affected muscles lose their tone. Trauma to the eye area, such as a direct injury or orbital fractures, can lead to scarring and contracture of tissues, pulling the eyelid downward. Less common factors contributing to lower eyelid retraction include chronic inflammation, severe dry eye, or certain congenital conditions.
Related Symptoms and Complications
When scleral show results from an underlying condition, it can lead to various accompanying symptoms and complications beyond its visible appearance. Increased exposure of the eye’s surface to air can cause significant ocular irritation and dry eye symptoms, including grittiness, burning, and redness. This happens because the eyelid cannot adequately protect and spread tears across the eye.
The constant exposure can also make the eyes more sensitive to light, a condition known as photophobia. Paradoxically, despite dry eye, individuals may experience excessive tearing, or epiphora. This occurs because the malpositioned eyelid can disrupt the normal drainage of tears, leading to overflow. If the underlying cause affects eye movement or the health of the cornea, blurred vision or even double vision might occur. The altered appearance of the eyes can also lead to cosmetic concerns.
When to Consult a Professional
While some degree of scleral show can be a harmless anatomical variation, certain indicators suggest that consulting a healthcare professional is advisable. Seek evaluation if:
A sudden onset or rapid worsening of scleral show occurs.
The condition is accompanied by significant eye discomfort, such as severe dryness, persistent pain, or noticeable redness.
You experience changes in vision, including blurriness or double vision, or the sensation of the eye bulging forward (proptosis).
You have difficulty closing your eye completely, especially during sleep.
There is any suspicion of an underlying systemic condition, such as thyroid disease.
The scleral show causes significant cosmetic distress or impacts daily life.
Addressing Scleral Show
Addressing scleral show depends largely on its underlying cause and the severity of symptoms. For mild cases, particularly those primarily causing dry eye, conservative management often begins with lubricating eye drops or gels to provide comfort and protect the eye surface. In more severe instances where the eye cannot close completely, taping the eyelids shut at night might be recommended to prevent corneal exposure.
If a medical condition like Thyroid Eye Disease is determined to be the cause, managing that specific condition is a primary focus, which may involve medication or other interventions to stabilize the disease activity. For cases where conservative measures are insufficient or when the condition is caused by structural issues, surgical options may be considered. Surgical procedures aim to reposition the lower eyelid and restore its natural contour.
Common surgical techniques include canthoplasty, which tightens the outer corner of the eyelid, or other procedures that lift and support the lower eyelid, sometimes involving grafts of tissue to lengthen the eyelid internally. These interventions strive to improve both eye function, by enhancing protection and comfort, and cosmetic appearance. However, if the scleral show is mild, stable, and causes no discomfort, treatment may not be necessary. Non-surgical approaches like hyaluronic acid fillers can also be used in some cases to add volume and elevate the eyelid.