Surgical Approach to the Treatment of Upper Eyelid Retraction Caused by Prominent Filtration Bleb

Abstract

Objective: To report on the technique of upper eyelid lengthening in patients with upper eyelid retraction not associated with Graves' disease but associated with bleb exposure and exposure keratitis. Case series: We present three patients (four eyes) with a history of glaucoma who underwent trabeculectomy with an active bleb with symptoms associated with bleb and corneal exposure due to retraction of the upper eyelid not associated with Graves' disease. All patients underwent surgical treatment to lengthen the upper eyelid by percutaneous complete blepharotomy with complete dissection of the orbicularis muscle, aponeurosis of levator palpebral muscle, Muller’s muscle and dissection of nasal and temporal conjunctiva reaching the superior border of the tarsus. In addition, the lateral horns of the levator muscle were resected, while preserving a strip of intact conjunctiva directly above the bulging bleb. Before and after surgery, the following measurements were made: including, visual acuity, retraction measurement, presence symptoms of dry cornea and bleb, MRD, and upper eyelid contour. Results: Preoperative upper lid marginal reflex distance (MRD) was measured. In addition, conjunctival staining of the bleb and cornea was recorded. Visual acuity ranged from 6/12 to 6/36. Upper eyelid retraction ranged from 3mm to 7.5mm, this was measured by calculating the marginal reflex distance (MRD) of the upper retracted eyelid minus 4.5 mm, representing the normal MRD. Amounts of lubricating drops used by patients per day was also recorded and quantified. The following postoperative measurements were recorded: MRD of upper eyelid; specifically including upper eyelid contour and position, present or absence of upper eyelid ptosis. Visual acuity improved by one line in the first postoperative week and maximum up to three lines after a month. A good cosmetic result was achieved. Conclusion: Blepharotomy is a surgical procedure suitable for the treatment of severe eyelid retraction. Preservation of the bridge of the intact conjunctiva over the bleb protects the bleb from traumatization in the postoperative period. This makes possible to use the blepharotomy in cases of eyelid retraction with exposure of the filtration bleb, and also maintain the correct contour of the upper eyelid.