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Lids -  LID RETRACTION Lecture 11 of 47  NEXT»

Lid retraction is defined normally as more than 85% of vertical palpebral fissures and 10 mm or less with the eyelids just concealing the corneoscleral limbus at the 12 and 6 o' clock meridians.

1. Lid retraction with upward movement of eye

 A. Congestive dysthyroid disease
 B. Deficiency in upward gaze-following rectus operation or weakness of superior  rectus
 C. Excessive stimulation of levator muscles in Bell phenomenon with seventh nerve  palsy
 D. Levator muscles receive excessive stimuli from nerve fiber of superior rectus
 E. Pretectal or periaqueductal lesion in midbrain

2. Lid retraction with downward movement of eye

 A. Aberrant regeneration of third nerve of inferior rectus to levator (pseudo-Graefe  phenomenon) - elevation of lid in downward gaze
 B. Brown syndrome (superior oblique tendon sheath syndrome)
 C. Extrapyramidal syndrome of postencephalic parkinsonism and progressive  supranuclear palsy
 D. Failure of levator to relax on downward movement of eye
  (1) Secondary neuromuscular
  *(2) Mechanical, such as from a scar
 E. Noncongestive type of dysthyroid exophthalmos (Graefe sign)-lid lag in downward gaze

3. Lid retraction with horizontal gaze

 A. Duane syndrome (retraction syndrome)
 B. Underaction of lateral rectus muscle and spillover to levator causing widening

4. Lid retraction because of supranuclear lesions-usually bilateral when due to lesion in or about posterior commissure (Collier sign, tucked lids, posterior fossa stare)

 A. Bulbar poliomyelitis
 B. Chorea (Huntington hereditary chorea)
 C. Closed head injury associated with defective adduction of eyes, coarse  nystagmus, nuclear palsy, pyramidal signs
 D. Coma due to disease of ventral midbrain and pons
 E. Craniostenosis
 F. Epidemic encephalitis
 G. Hydrocephalic infants
 H. Hydrophobia
 I. Hysteria
 J. Malingering
 K. Meningitis
 L. Multiple sclerosis (disseminated sclerosis)
 M. Parinaud syndrome (divergence paralysis)
 N. Parkinson disease (paralysis agitans)
 O. Russell syndrome
 P. Sylvian aqueduct syndrome (Koerber-Solus-Elschnig syndrome)
 Q. Syphilis (tabes)
 R. Tumors of the midbrain; meningiomas of sphenoid wing; sellar, parasellar, and  suprasellar tumors; and frontal or temporal lobe tumors
 S. von Economo syndrome (encephalitis lethargic a)

5. Lid retraction because of neuromuscular disease-commonly asymmetric or unilateral

 A. Drugs
  (1) Phenylephrine and other sympathomimetics
  (2) Prostigmin and Tensilon, especially with myasthenic levator     involvement
  (3) Succinylcholine, subparalytic doses
  (4) Thyroid extract
 B. Fuch phenomenon-healing of injured third nerve, previously ptotic lid has  involuntarily spastic raising with movements of eyes
 C. Infant lid retraction-transient because of maternal hyperthyroidism
 D. Irritation of cervical sympathetic nerve (Homer syndrome)
 *E. Mechanical suspension of lid such as that due to scar, tumor, surgical  attachment to frontalis muscle, or shortening of levator muscle or following  glaucoma filtering procedures
 F. Peripheral seventh nerve paresis with loss of orbicularis oculi muscle tone

6. Lid retraction with myopathic disease

 A. Associated with hepatic cirrhosis
 B. Thyroid myopathy (Graves disease, Basedow syndrome)
  (1) Dalrymple sign-widening of palpebral fissure
  (2) Stellwag sign-retraction of upper lid associated with infrequent or incomplete blinking

7. Lid retraction following operations on vertical muscles, such as recession of superior rectus muscle or simultaneous recession and restriction of the levator by common fascial check ligament between the two muscles

8. Paradoxical lid retraction because of paradoxical levator innervation

 A. Defective ocular abduction with abducens palsy
 B. Lid retraction associated with ptosis of the opposite eyelid (levator denervation  supersensitivity)
 C. Misdirection of third nerve axons (following acquired or congenital lesions)-  occurs on attempt to adduct, elevate, or depress eye
 D. Movement of lower jaw
  (1) Contraction of external pterygoid muscle by opening mouth (Marcus Gunn)
  (2) Contraction of internal pterygoid muscle by closing the mouth

9. Physiologic

 A. Act of surprise
 B. Slow onset of blindness, such as that secondary to glaucoma and optic atrophy
 C. Time of attention

Collins JR, et al. Congenital eyelid retraction. Br J Ophthalmol 1990; 74:542-544.

Dixon R. The surgical management of thyroid-related upper eyelid retraction. Ophthalmology 1982; 89:52.

Roy FH. Ocular syndromes and systemic diseases, 3rd ed. Philadelphia: Lippincott Williams & Wilkins, 2002.

Walsh FB, Hoyt WF. Clinical neuro-ophthalmology, 4th ed. Baltimore: Williams & Wilkins, 1985.


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