What is eyelid retraction?
Eyelid retraction is a condition in which the upper eyelid sits too high, the lower eyelid sits too low, or both, exposing more of the eye's surface than normal. In a healthy eye, the upper eyelid rests just below the top edge of the iris and the lower eyelid sits at or just above the bottom edge, keeping the white of the eye largely covered. When retraction is present, this relationship is disrupted and the exposed surface of the eye becomes vulnerable to dryness, irritation, and corneal damage.
Eyelid retraction can affect one or both eyes and may involve the upper eyelid, lower eyelid, or both simultaneously. It is one of the most common findings in thyroid eye disease but can also develop as a result of previous surgery, scarring, or neurological conditions.
Types of eyelid retraction
Eyelid retraction is classified by which eyelid is affected and the underlying mechanism driving the abnormal position:
- Upper eyelid retraction – Occurs when the upper eyelid sits higher than its normal position, exposing the white of the eye above the iris. This is the most common form of retraction and is frequently associated with thyroid eye disease.
- Lower eyelid retraction – Occurs when the lower eyelid sits lower than its normal position, exposing the white of the eye below the iris. Lower eyelid retraction can occur in isolation or alongside upper eyelid retraction.
- Combined upper and lower eyelid retraction – Occurs when both eyelids are affected simultaneously, significantly increasing the amount of exposed ocular surface. Most commonly seen in moderate to severe thyroid eye disease.
What are the symptoms of eyelid retraction?
Because the eyelids are no longer able to adequately cover and protect the eye's surface, patients with eyelid retraction commonly experience:
- A wide-eyed or startled appearance
- Visible white of the eye above the iris, below the iris, or both
- Dry eye symptoms including burning, stinging, and foreign body sensation
- Excessive tearing as the eye attempts to compensate for dryness
- Redness and chronic irritation of the eye
- Difficulty closing the eyes fully, particularly during sleep
- Light sensitivity
- Blurred vision due to an unstable tear film
- Eye fatigue or discomfort with prolonged visual tasks
In more advanced cases, inadequate eyelid closure can lead to corneal exposure, abrasion, ulceration, and vision loss if left untreated.
What causes eyelid retraction?
Eyelid retraction develops when the muscles, tendons, or surrounding tissue that control eyelid position are affected by inflammation, scarring, or structural changes. Common causes include:
- Thyroid eye disease (TED) - An autoimmune condition associated with Graves' disease that causes inflammation and enlargement of the muscles and fat within the eye socket. This inflammation can tighten the muscles that elevate the upper eyelid and pull down the lower eyelid, resulting in retraction of one or both lids.
- Previous eyelid surgery - Overcorrection following ptosis repair or blepharoplasty can result in an eyelid that sits too high or too low. Surgical scarring can also tether the eyelid in a retracted position over time.
- Scarring from injury or inflammation - Trauma, burns, or chronic inflammatory conditions affecting the eyelid or surrounding tissue can cause scar tissue to form, pulling the eyelid away from its normal resting position.
- Neurological causes - Conditions affecting the nerves that control eyelid position can result in eyelid retraction.
- Proptosis - When the eyeball is pushed forward out of the orbit, the eyelids stretch around the displaced eye, creating the appearance and functional consequences of retraction.
How is eyelid retraction diagnosed?
Eyelid retraction is diagnosed through a comprehensive clinical examination. A provider will measure the position of the upper and lower eyelids relative to the iris and assess the degree of scleral show — the amount of white visible above or below the colored portion of the eye. Additional evaluation includes:
How is eyelid retraction treated?
Treatment depends on the underlying cause, the severity of retraction, and the degree to which the cornea is affected.
In mild cases or during the active phase of thyroid eye disease when surgery must be delayed, conservative measures are used to protect the eye, including:
- Lubricating eye drops and ointments to reduce corneal dryness and irritation
- Moisture chamber glasses or moisture goggles to maintain humidity around the eye
- Taping the eyelids closed at night when lagophthalmos is present
- Botulinum toxin injections into the upper eyelid retractor muscles as a temporary measure to lower the upper eyelid and provide corneal protection
For patients with significant or persistent eyelid retraction, surgical intervention may be recommended. The approach differs depending on whether the upper or lower eyelid is involved:
- Upper eyelid retraction repair involves lengthening the retractor muscles of the upper eyelid to allow the lid to descend to a more normal position.
- Lower eyelid retraction repair involves supporting and elevating the lower eyelid through spacer grafts, typically harvested from donor tissue, and placed between the lower eyelid retractors and the tarsal plate to push the lid upward into a more normal position. In some cases, a canthoplasty or canthopexy is performed in combination to provide additional support to the lower lid.
- Combined upper and lower eyelid retraction repair addresses both lids during the same procedure when retraction is present in both. The sequence and combination of techniques are planned based on the individual anatomy and the degree of retraction in each lid.
When eyelid retraction is associated with thyroid eye disease, orbital decompression surgery is typically performed before eyelid surgery, as correcting the forward displacement of the eye often improves eyelid position on its own.
Recovery following eyelid retraction surgery varies depending on the extent of the procedure. Swelling and temporary changes in eyelid position are expected in the weeks following surgery. Most patients achieve stable, functional results within several weeks to months, with continued refinement of eyelid position as healing progresses.
Whether retraction is related to thyroid eye disease, prior surgery, or another cause, the oculofacial plastic surgeons at The Iowa Clinic will evaluate your eyelids and develop a treatment plan appropriate for your situation. Call 515.875.9480 to schedule an appointment.