Lower Eyelid Contour in Graves Orbitopathy.

Purpose: The aim of the present study was to analyze quantitively the lower lid contour of patients with Graves orbitopathy.Methods: Bézier curves were manually adjusted to the ciliated and nasal (or lacrimal) portions of the lower lid contour of 41 patients with Graves orbitopathy and 43 normal subjects using National Institute of Health (NIH) ImageJ software. Considering the main coordinates of the Bézier functions, the Matlab software was employed to express the lid contours with 1000 points. The first order numerical derivative of the curves was calculated in order to compare the curvature of the whole lid contour of patients and controls. The same comparison was made for the temporal and nasal contour segments. Other parameters measured included the location of the lowest point on the contours (contour peak); the position of the lateral and medial canthi, as well as the angle formed by the lower lacrimal punctum and the vertex of the inner canthus.Results: The curvature of the temporal portion of the lid contours of patients and controls correlated with both the height of the lateral canthus and the magnitude of the MRD2. Graves retraction affects the medial and lateral portion of the lid. Both segments were more curved in patients than in controls. The lower punctum was significantly lowered, increasing the angle between the lower punctum and the medial canthus.Conclusions: The increased lateral curvature of the lower lid seen in patients with Graves disease is a natural geometric effect of the increment of MRD2. The nasal portion of the lid is also significantly lowered by retraction.

An Unusual Differential Diagnosis of Orbital Cavernous Hemangioma: Ancient Schwannoma.

Schwannomas are rare lesions of the orbit that can be confused with cavernous hemangioma on imaging studies. We report the case of an 84-year-old woman with a 9-year history of a tumoral lesion in the inferolateral left orbit. The imaging studies did not reveal specific characteristics, only bone remodeling due to the long evolution of the tumor. The patient underwent complete excision of the tumor by anterior orbitotomy via the inferior conjunctival fornix. The histopathological examination revealed an ancient schwannoma, a variant of schwannoma with uncommon histological features. The follow-up was uneventful. The present case emphasizes the importance of considering neural tumors in the differential diagnosis of orbital masses with bone changes and degenerative alterations such as hemorrhagic areas, cysts, and/or calcifications.

Graves Lower Eyelid Retraction.

PURPOSE: Graves lower eyelid retraction (GLLR) is a common and controversial sign of Graves orbitopathy. The authors reviewed the mechanisms and surgical techniques currently used to correct this Graves orbitopathy-related eyelid malposition. METHODS: A literature search was performed on the MEDLINE database using the keywords "lower eyelid retraction," "Graves orbitopathy," "thyroid ophthalmopathy," "thyroid eye disease," "spacers," and "eyelid surgery." Only articles in English were included. The level of evidence of publications regarding surgical correction of GLLR was evaluated and graded from I to IV, using a rating system adapted from a validated scientific evidence classification method. RESULTS: The mechanisms responsible for GLLR are not fully understood and no subtypes of GLLR have been distinguished. The surgical literature of GLLR encompasses mainly descriptions of surgical techniques without objective measurements of the results, and uncontrolled studies. Only 1 randomized controlled trial was identified. To lengthen the lower retractors, a large variety of different materials have been used as spacers. CONCLUSIONS: The scientific literature on GLLR is vast, however controlled and randomized studies comparing different surgical techniques are lacking. At the present moment it is not clear if bioengineered materials are superior to conventional autogeneous tissue as lower eyelid spacers. The effects of GLLR on lower eyelid movements and contour have not been studied.

Graded müllerectomy for correction of graves upper eyelid retraction: effect on eyelid movements.

PURPOSE: To measure the effect of müllerectomy from posterior approach on the amplitudes of spontaneous blinking and downward eyelid saccades. METHODS: Spontaneous blinks and downward upper eyelid saccadic movements of 16 patients (23 eyelids) with Graves orbitopathy were measured before and after müllerectomy from posterior approach. A new video system was used to continuously register the blinking activity while subjects viewed a commercial movie for 5 minutes. Downward eyelid saccades (30° of downgaze) were also measured with the video system. RESULTS: Müllerectomy had no effect on the amplitude of the blink. However, as the eyelid margins were significantly lowered by the surgery, the amplitude of the blink movements relative to the pupil center increased substantially. The number of movements occluding the pupil center increased from 0% to 13%. Due to the increased efficiency of blinking, the blink rate decreased. Surgery induced a mean increase of 1.1 mm of downward saccades. CONCLUSIONS: The effects of müllerectomy on the blinks are indirect and related to correction of eyelid retraction. The relative amplitude of blink movements increases and blink rate decreases. Müllerectomy does affect the downward eyelid saccades increasing the ability of the upper eyelid to relax on downgaze.

Lateral and medial upper eyelid contour abnormalities in graves orbitopathy: the influence of the degree of retraction.

PURPOSE: To determine the location of contour abnormalities in Graves upper eyelid retraction. METHODS: Multiple midpupil angular eyelid distances of 75 upper eyelids of 55 patients (mean age = 41.7 ± 13.3 SD years) in the inactive phase of Graves orbitopathy were measured with a recently developed custom-made software. Sixty eyelids of 60 normal subjects were also measured as a control group. A contour peak was defined by the highest midpupil angular eyelid distance normalized (divided) by the superior limit of normality (mean + 2SD). RESULTS: In 45 eyelids (60%), the peaks were lateral between 120° and 150°. For high levels of retraction, the peaks tended to be centrally located with a substantial number of medial deformities (30 eyelids). Although the lateral and medial peaks were not affected by exophthalmometry, there was a statistically significant increase of medial peaks when midpupil eyelid distance was greater than 6.75 mm (χ = 5.20, p = 0.02). CONCLUSIONS: Lateral contour abnormalities are more frequent than medial deformities. With minor degrees of retraction, there is a predominance of lateral peaks. With higher degrees of retraction, the number of medial abnormalities is similar to the lateral ones.