Upper Eyelid Retraction After Blowout Fractures Allen M.
Putterman, MD, Martin J. Urist, MD
\s=b\ Two patients developed upper eyelid retraction secondary to a blowout fracture of the orbital floor. Posttraumatic overaction of M\l=u"\llermuscle is a possible cause of the eyelid retraction.
(Arch Ophthalmol 94:112-116, 1976)
of the upper eyelid result from thyroid disease, glaucoma surgery, or mis¬ direction of the third cranial nerve (pseudo-Graefe phenomenon), or it may be a congenital anomaly.14 We encountered two cases of upper eyelid retraction secondary to a blowout fracture of the orbital floor.5 To the best of our knowledge, this complica¬ tion of blowout fractures has not been
Retractionfiltration can
previously reported. REPORT OF CASES Case 1.—Several weeks after a first blow to the left eye, a 26-year-old man noted that his left eye was "down" and "back"
and that his left upper eyelid was elevated, but he received no treatment for this in¬ jury. At his first examination, six months after trauma, he had a 4-mm retraction of the left upper eyelid in primary position with the left eyelid 2 mm above the supe¬ rior limbus and the right eyelid 2 mm be¬ low (Fig 1). As a result, in primary posi¬ tion, there was a 3-mm difference in the width of the palpebrai fissures, 9 mm OD and 12 mm OS. A left upper eyelid lag on downgaze was demonstrated by the 5-mm difference in width of the palpebrai fissures-2 mm OD and 7 mm OS. The left eye was 4 mm below the horizontal level of the right eye, and there was a 4-mm left Submitted for publication May 29, 1974. From the Oculoplastic and Motility Services, University of Illinois Eye and Ear Infirmary,
Chicago. Reprint requests to 111 N Wabash Ave, Chicago, IL 60612 (Dr Putterman).
Fig
1 .—Left upper
(case 1).
eyelid
retraction and
lag following blowout fracture of left orbital
Downloaded From: http://archopht.jamanetwork.com/ by a New York University User on 06/05/2015
floor
enophthalmos. Visual acuity was 20/20 OU with no diplopia. The eyes were orthotropic and there was limitation in elevation of the left eye in extreme upgaze. A complete physi¬ cal examination disclosed no systemic ill¬ Conventional and tomographic orbit¬ al roentgenograms demonstrated an old left blowout fracture of the orbital floor and cloudiness of the left frontal, ethmoid, and maxillary sinuses. In September 1971, surgical exploration of the orbital floor showed a blowout frac¬ ture with entrapped orbital fat. The fibrotic orbital fat was released from the fracture site and a 3-mm thick 20 x 20-mm silastic implant was secured to the orbital floor. This surgery reduced the enoph¬ thalmos and inferior depression of the eye, but it did not change the upper eyelid re¬ traction and lag (Fig 2). Six months after surgery, the left enophthalmos was 2 mm and the left eye was 2 mm below the hori¬ zontal level of the right, an improvement of 2 mm. The palpebrai fissure width was still 9 mm OD and 12 mm OS with the right upper eyelid remaining 2 mm below and the left 2 mm above the superior limbus. On downgaze, the palpebrai fissure width was 2 mm OD and 6.5 mm OS. Levator function was 14 mm OU; the eye showed full ocular motility with improvement in elevation of the left eye in extreme up¬ gaze. In September 1972, we operated on the eyelid retraction using local anesthesia and a previously reported procedure.1 The Mül¬ ler muscle was excised. Then the patient sat up on the operating table to allow ob¬ servation of the effect on the height of the operated eyelid. Since the upper eyelids were symmetrical after excision of the Müller muscle, it was unnecessary to per¬ form an additional graded levator tenotomy until the upper eyelid levels were the same when the patient sat up. One year postoperatively, the palpebrai fissure ness.
Fig 2—Persistence of left upper eyelid retraction and thalmos and left eye depression with an orbital floor
lag following reduction implant (case 1).
of
enoph-
Downloaded From: http://archopht.jamanetwork.com/ by a New York University User on 06/05/2015
width in primary position was 9 mm OD and 10 mm OS (Fig 3). The right upper eyelid was 3 mm below the superior limbus and the left upper eyelid was 2 mm below the superior limbus. The palpebrai fissure width on downgaze was 2 mm OD and 4 mm OS, a decrease of 2.5 mm in left upper
eyelid lag. Fig 3.—Improvement of left upper eyelid retraction and Müller muscle from left upper eyelid (case 1).
lag
one
year after excision of
Case 2.—A 26-year-old man was hit over the right eye with a baseball bat. His eye¬ lids were swollen for about one to two weeks after which he noted that his right eyelids opened wider than his left, produc¬ ing a noticeable cosmetic defect. He was first examined four weeks after trauma. At that time, he had a 4-mm right upper eyelid retraction with the right upper eye¬ lid 2 mm above the superior limbus (Fig 4). In primary position, there was a 3-mm dif¬ ference in the width of the palpebrai fis¬ sures, 12 mm OD and 9 mm OS. The right upper eyelid had a 3-mm lag on downgaze, the palpebrai fissure width being 6 mm OD and 3 mm OS. A 1.5 mm enophthalmos of the right eye was present, and the eyes were at the same horizontal level. Visual acuity was 20/20 OU. The patient had a full range of ocular motility and no diplopia. He had no infraorbital anesthe¬ sia. A complete physical examination dem¬ onstrated no systemic illness. Conventional and tomographic orbital roentgenograms demonstrated a right blowout fracture of the orbital floor. In August 1973, the Müller muscle was completely excised from the right upper eyelid, resulting in symmetrical upper eye¬ lid levels at surgery.1 Examination three months postoperatively (Fig 5) showed only 1 mm of right upper eyelid retraction in primary position with the right upper eyelid 1 mm below and the left upper eye¬ lid 2 mm below the superior limbus. The palpebrai fissure width on downgaze was 4 mm OD and 3 mm OS, a 2-mm improve¬ ment in right eyelid lag.
COMMENT In all the other cases we have seen of palpebrai fissure changes following blowout fractures of the orbital floor, there was a narrowing of the palpabral fissure width on the side of the injury. This can be easily explained. Normally, the width of the palpebrai fissure depends on the position of the globe in the orbit since the eyelids rest against the globe. When the globe is forward, the eyelids are sepa¬
rated more and the palpebrai fissure is wider; when the globe is further back, as in deep-set eyes, the palpe¬ brai fissure is narrower. Thus, in
Downloaded From: http://archopht.jamanetwork.com/ by a New York University User on 06/05/2015
exophthalmos, as in thyroid disease, there is widening of the palpebrai fis¬ sure, while in enophthalmos following blowout fractures, there is narrowing. The pathologic physiology of upper eyelid retraction following blowout fractures of the orbital floor is un¬ known; we have considered the fol¬ lowing possible mechanisms: In case 1, with roentgenographic evidence of cloudiness of the frontal sinus, there could have been a concur¬ rent blowout fracture of the orbital roof that caused entrapment of the levator palpebrae superioris muscle into the frontal sinus and resulted in retraction of the upper eyelid. How¬ ever, this mechanism would not ex¬ plain the retraction of the upper eye¬ lid in case 2 in which there was no abnormality of the frontal sinus and orbital roof. Another possible explanation for the eyelid retraction is related to re¬ striction in movement of the inferior rectus muscle secondary to orbital fat trapped in the maxillary sinus." Re¬ striction of the inferior rectus muscle causes limitation of the eye on look¬ ing up. When this occurs in thyroid disease, holding the eyes straight in primary position requires increased innervation to the superior rectus muscle with resultant increased innervational input to the levator pal¬ pebrae superioris muscle and second¬ ary upper eyelid retraction. However, thyroid patients have a hypotropia in primary position, and the retraction improves on downgaze. In our cases of upper eyelid retraction following blowout fractures, the eyes were orthotropic in primary position with eyelid lag on downgaze. There was limitation only in extreme upward gaze in case 1 and no limitation in case 2. Also, in case 1, the limitation in upgaze decreased after an orbital floor implant, but the eyelid retrac¬ tion and lag remained essentially the same. These findings are evidence against inferior rectus restriction pro¬ ducing eyelid retraction in blowout fractures. We also ruled out retraction of the upper eyelid due to the eye being 4 mm lower in case 1; raising the eye by an orbital floor implant produced no effect on the retraction.
Fig 4.—Right upper eyelid (case 2).
floor
retraction and
lag following blowout fracture of right orbital
Downloaded From: http://archopht.jamanetwork.com/ by a New York University User on 06/05/2015
overaction of Müller muscle may have been due to an edematous infiltration of Müller muscle by aqueous humor with secondary contracture or may have been caused by some aqueous chemical stimulating Müller muscle.2 Subsequent excision of Müller muscle in one of these cases relieved the eye¬ lid retraction and lag. 4. Increasing the action of Müller muscle with a Fasanella-Servat oper¬ ation or a Müller muscle-conjunctival resection can retract the upper eyelid in cases of blepharoptosis.8-10 It therefore seems that the most likely cause for the retraction of the upper eyelid and eyelid lag in our two cases of blowout fractures was overaction of Müller muscle. Overaction could have been due to traumatic edema, hemorrhagic infiltration, or fibrosis with shortening. The relief of the retraction of the upper eyelid with improvement of the eyelid lag afforded by removal of Müller muscle supports this speculation.
Jerry Sewell and Norbert Jednock provided photographs.
the
References
AM, Urist MJ: Surgical treateyelid retraction. Arch Ophthal-
1. Putterman ment of upper
Fig 5.—Improvement of right upper eyelid retraction and of Müller muscle from the right upper eyelid (case 2).
Upper eyelid retraction can also oc¬ secondary to misdirection of the
cur
third cranial nerve, in which the up¬ per eyelid retracts as the patient looks downward (pseudo-Graefe phe¬ nomenon).3 Our patients did not ex¬ hibit this phenomenon since they had retraction in primary position, and their upper eyelids lowered as they looked down. Retraction of the upper eyelid with eyelid lag on downgaze, similar to that described in the cases of blowout fracture, is produced by overaction of Müller muscle in the following in¬ stances:
lag three months after excision
1. Stimulation of the sympathetic innervation to Müller muscle can be caused by instilling 10% phenylephrine into the upper fornix of normal
subjects.
2. In thyroid patients known to have overaction of Müller muscle, sympathetic deinnervation with guanethidine sulfate drops will relieve the eyelid retraction and eyelid lag.7 Sur¬ gical removal of Müller muscle in these cases will also relieve the eyelid retraction and lag.1 3. In our two cases, each of which developed a large filtering bleb fol¬
lowing glaucoma filtering operations,
Downloaded From: http://archopht.jamanetwork.com/ by a New York University User on 06/05/2015
mol 87:401-405, 1972. 2. Putterman AM, Urist MJ: Upper eyelid retraction after filtering procedures. Ann Ophthalmol 7:263, 1975. 3. Cogan DG: Neurology of the Ocular Muscles, ed 2. Springfield, Ill, Charles C Thomas, 1956, pp 71-72. 4. Mustarde JC, Jones LT, Callahan A: Ophthalmic Plastic Surgery Up-to-Date. Birmingham, Ala, Aesculapias, 1970, pp 73-75. 5. Smith B, Regan WF Jr. Blow-out fracture of the orbit: Mechanism and correction of internal orbital fracture. Am J Ophthalmol 44:733\x=req-\ 739, 1957. 6. Putterman AM, Stevens T, Urist MJ: Nonsurgical management of blow-out fractures of the orbital floor. Am J Ophthalmol 77:232-239, 1974. 7. Gay AJ, Salmon ML, Wolkstein MA: Topical sympatholytic therapy for pathologic lid retraction. Arch Ophthalmol 77:341-344, 1967. 8. Fasanella RM, Servat J: Levator resection for minimal ptosis: Another simplified operation. Arch Ophthalmol 65:493-496, 1961. 9. Putterman AM: A clamp for strengthening M\l=u"\ller'smuscle in the treatment of ptosis: Modification, theory, and clamp for the Fasanella-Servat ptosis operation. Arch Ophthalmol 87:665\x=req-\
667, 1972.
10. Putterman AM, Urist MJ: M\l=u"\llermuscleconjunctival resection: Technique for treatment of blepharoptosis. Arch Ophthalmol 93:619-623, 1975.
Putterman, MD, Martin J. Urist, MD
\s=b\ Two patients developed upper eyelid retraction secondary to a blowout fracture of the orbital floor. Posttraumatic overaction of M\l=u"\llermuscle is a possible cause of the eyelid retraction.
(Arch Ophthalmol 94:112-116, 1976)
of the upper eyelid result from thyroid disease, glaucoma surgery, or mis¬ direction of the third cranial nerve (pseudo-Graefe phenomenon), or it may be a congenital anomaly.14 We encountered two cases of upper eyelid retraction secondary to a blowout fracture of the orbital floor.5 To the best of our knowledge, this complica¬ tion of blowout fractures has not been
Retractionfiltration can
previously reported. REPORT OF CASES Case 1.—Several weeks after a first blow to the left eye, a 26-year-old man noted that his left eye was "down" and "back"
and that his left upper eyelid was elevated, but he received no treatment for this in¬ jury. At his first examination, six months after trauma, he had a 4-mm retraction of the left upper eyelid in primary position with the left eyelid 2 mm above the supe¬ rior limbus and the right eyelid 2 mm be¬ low (Fig 1). As a result, in primary posi¬ tion, there was a 3-mm difference in the width of the palpebrai fissures, 9 mm OD and 12 mm OS. A left upper eyelid lag on downgaze was demonstrated by the 5-mm difference in width of the palpebrai fissures-2 mm OD and 7 mm OS. The left eye was 4 mm below the horizontal level of the right eye, and there was a 4-mm left Submitted for publication May 29, 1974. From the Oculoplastic and Motility Services, University of Illinois Eye and Ear Infirmary,
Chicago. Reprint requests to 111 N Wabash Ave, Chicago, IL 60612 (Dr Putterman).
Fig
1 .—Left upper
(case 1).
eyelid
retraction and
lag following blowout fracture of left orbital
Downloaded From: http://archopht.jamanetwork.com/ by a New York University User on 06/05/2015
floor
enophthalmos. Visual acuity was 20/20 OU with no diplopia. The eyes were orthotropic and there was limitation in elevation of the left eye in extreme upgaze. A complete physi¬ cal examination disclosed no systemic ill¬ Conventional and tomographic orbit¬ al roentgenograms demonstrated an old left blowout fracture of the orbital floor and cloudiness of the left frontal, ethmoid, and maxillary sinuses. In September 1971, surgical exploration of the orbital floor showed a blowout frac¬ ture with entrapped orbital fat. The fibrotic orbital fat was released from the fracture site and a 3-mm thick 20 x 20-mm silastic implant was secured to the orbital floor. This surgery reduced the enoph¬ thalmos and inferior depression of the eye, but it did not change the upper eyelid re¬ traction and lag (Fig 2). Six months after surgery, the left enophthalmos was 2 mm and the left eye was 2 mm below the hori¬ zontal level of the right, an improvement of 2 mm. The palpebrai fissure width was still 9 mm OD and 12 mm OS with the right upper eyelid remaining 2 mm below and the left 2 mm above the superior limbus. On downgaze, the palpebrai fissure width was 2 mm OD and 6.5 mm OS. Levator function was 14 mm OU; the eye showed full ocular motility with improvement in elevation of the left eye in extreme up¬ gaze. In September 1972, we operated on the eyelid retraction using local anesthesia and a previously reported procedure.1 The Mül¬ ler muscle was excised. Then the patient sat up on the operating table to allow ob¬ servation of the effect on the height of the operated eyelid. Since the upper eyelids were symmetrical after excision of the Müller muscle, it was unnecessary to per¬ form an additional graded levator tenotomy until the upper eyelid levels were the same when the patient sat up. One year postoperatively, the palpebrai fissure ness.
Fig 2—Persistence of left upper eyelid retraction and thalmos and left eye depression with an orbital floor
lag following reduction implant (case 1).
of
enoph-
Downloaded From: http://archopht.jamanetwork.com/ by a New York University User on 06/05/2015
width in primary position was 9 mm OD and 10 mm OS (Fig 3). The right upper eyelid was 3 mm below the superior limbus and the left upper eyelid was 2 mm below the superior limbus. The palpebrai fissure width on downgaze was 2 mm OD and 4 mm OS, a decrease of 2.5 mm in left upper
eyelid lag. Fig 3.—Improvement of left upper eyelid retraction and Müller muscle from left upper eyelid (case 1).
lag
one
year after excision of
Case 2.—A 26-year-old man was hit over the right eye with a baseball bat. His eye¬ lids were swollen for about one to two weeks after which he noted that his right eyelids opened wider than his left, produc¬ ing a noticeable cosmetic defect. He was first examined four weeks after trauma. At that time, he had a 4-mm right upper eyelid retraction with the right upper eye¬ lid 2 mm above the superior limbus (Fig 4). In primary position, there was a 3-mm dif¬ ference in the width of the palpebrai fis¬ sures, 12 mm OD and 9 mm OS. The right upper eyelid had a 3-mm lag on downgaze, the palpebrai fissure width being 6 mm OD and 3 mm OS. A 1.5 mm enophthalmos of the right eye was present, and the eyes were at the same horizontal level. Visual acuity was 20/20 OU. The patient had a full range of ocular motility and no diplopia. He had no infraorbital anesthe¬ sia. A complete physical examination dem¬ onstrated no systemic illness. Conventional and tomographic orbital roentgenograms demonstrated a right blowout fracture of the orbital floor. In August 1973, the Müller muscle was completely excised from the right upper eyelid, resulting in symmetrical upper eye¬ lid levels at surgery.1 Examination three months postoperatively (Fig 5) showed only 1 mm of right upper eyelid retraction in primary position with the right upper eyelid 1 mm below and the left upper eye¬ lid 2 mm below the superior limbus. The palpebrai fissure width on downgaze was 4 mm OD and 3 mm OS, a 2-mm improve¬ ment in right eyelid lag.
COMMENT In all the other cases we have seen of palpebrai fissure changes following blowout fractures of the orbital floor, there was a narrowing of the palpabral fissure width on the side of the injury. This can be easily explained. Normally, the width of the palpebrai fissure depends on the position of the globe in the orbit since the eyelids rest against the globe. When the globe is forward, the eyelids are sepa¬
rated more and the palpebrai fissure is wider; when the globe is further back, as in deep-set eyes, the palpe¬ brai fissure is narrower. Thus, in
Downloaded From: http://archopht.jamanetwork.com/ by a New York University User on 06/05/2015
exophthalmos, as in thyroid disease, there is widening of the palpebrai fis¬ sure, while in enophthalmos following blowout fractures, there is narrowing. The pathologic physiology of upper eyelid retraction following blowout fractures of the orbital floor is un¬ known; we have considered the fol¬ lowing possible mechanisms: In case 1, with roentgenographic evidence of cloudiness of the frontal sinus, there could have been a concur¬ rent blowout fracture of the orbital roof that caused entrapment of the levator palpebrae superioris muscle into the frontal sinus and resulted in retraction of the upper eyelid. How¬ ever, this mechanism would not ex¬ plain the retraction of the upper eye¬ lid in case 2 in which there was no abnormality of the frontal sinus and orbital roof. Another possible explanation for the eyelid retraction is related to re¬ striction in movement of the inferior rectus muscle secondary to orbital fat trapped in the maxillary sinus." Re¬ striction of the inferior rectus muscle causes limitation of the eye on look¬ ing up. When this occurs in thyroid disease, holding the eyes straight in primary position requires increased innervation to the superior rectus muscle with resultant increased innervational input to the levator pal¬ pebrae superioris muscle and second¬ ary upper eyelid retraction. However, thyroid patients have a hypotropia in primary position, and the retraction improves on downgaze. In our cases of upper eyelid retraction following blowout fractures, the eyes were orthotropic in primary position with eyelid lag on downgaze. There was limitation only in extreme upward gaze in case 1 and no limitation in case 2. Also, in case 1, the limitation in upgaze decreased after an orbital floor implant, but the eyelid retrac¬ tion and lag remained essentially the same. These findings are evidence against inferior rectus restriction pro¬ ducing eyelid retraction in blowout fractures. We also ruled out retraction of the upper eyelid due to the eye being 4 mm lower in case 1; raising the eye by an orbital floor implant produced no effect on the retraction.
Fig 4.—Right upper eyelid (case 2).
floor
retraction and
lag following blowout fracture of right orbital
Downloaded From: http://archopht.jamanetwork.com/ by a New York University User on 06/05/2015
overaction of Müller muscle may have been due to an edematous infiltration of Müller muscle by aqueous humor with secondary contracture or may have been caused by some aqueous chemical stimulating Müller muscle.2 Subsequent excision of Müller muscle in one of these cases relieved the eye¬ lid retraction and lag. 4. Increasing the action of Müller muscle with a Fasanella-Servat oper¬ ation or a Müller muscle-conjunctival resection can retract the upper eyelid in cases of blepharoptosis.8-10 It therefore seems that the most likely cause for the retraction of the upper eyelid and eyelid lag in our two cases of blowout fractures was overaction of Müller muscle. Overaction could have been due to traumatic edema, hemorrhagic infiltration, or fibrosis with shortening. The relief of the retraction of the upper eyelid with improvement of the eyelid lag afforded by removal of Müller muscle supports this speculation.
Jerry Sewell and Norbert Jednock provided photographs.
the
References
AM, Urist MJ: Surgical treateyelid retraction. Arch Ophthal-
1. Putterman ment of upper
Fig 5.—Improvement of right upper eyelid retraction and of Müller muscle from the right upper eyelid (case 2).
Upper eyelid retraction can also oc¬ secondary to misdirection of the
cur
third cranial nerve, in which the up¬ per eyelid retracts as the patient looks downward (pseudo-Graefe phe¬ nomenon).3 Our patients did not ex¬ hibit this phenomenon since they had retraction in primary position, and their upper eyelids lowered as they looked down. Retraction of the upper eyelid with eyelid lag on downgaze, similar to that described in the cases of blowout fracture, is produced by overaction of Müller muscle in the following in¬ stances:
lag three months after excision
1. Stimulation of the sympathetic innervation to Müller muscle can be caused by instilling 10% phenylephrine into the upper fornix of normal
subjects.
2. In thyroid patients known to have overaction of Müller muscle, sympathetic deinnervation with guanethidine sulfate drops will relieve the eyelid retraction and eyelid lag.7 Sur¬ gical removal of Müller muscle in these cases will also relieve the eyelid retraction and lag.1 3. In our two cases, each of which developed a large filtering bleb fol¬
lowing glaucoma filtering operations,
Downloaded From: http://archopht.jamanetwork.com/ by a New York University User on 06/05/2015
mol 87:401-405, 1972. 2. Putterman AM, Urist MJ: Upper eyelid retraction after filtering procedures. Ann Ophthalmol 7:263, 1975. 3. Cogan DG: Neurology of the Ocular Muscles, ed 2. Springfield, Ill, Charles C Thomas, 1956, pp 71-72. 4. Mustarde JC, Jones LT, Callahan A: Ophthalmic Plastic Surgery Up-to-Date. Birmingham, Ala, Aesculapias, 1970, pp 73-75. 5. Smith B, Regan WF Jr. Blow-out fracture of the orbit: Mechanism and correction of internal orbital fracture. Am J Ophthalmol 44:733\x=req-\ 739, 1957. 6. Putterman AM, Stevens T, Urist MJ: Nonsurgical management of blow-out fractures of the orbital floor. Am J Ophthalmol 77:232-239, 1974. 7. Gay AJ, Salmon ML, Wolkstein MA: Topical sympatholytic therapy for pathologic lid retraction. Arch Ophthalmol 77:341-344, 1967. 8. Fasanella RM, Servat J: Levator resection for minimal ptosis: Another simplified operation. Arch Ophthalmol 65:493-496, 1961. 9. Putterman AM: A clamp for strengthening M\l=u"\ller'smuscle in the treatment of ptosis: Modification, theory, and clamp for the Fasanella-Servat ptosis operation. Arch Ophthalmol 87:665\x=req-\
667, 1972.
10. Putterman AM, Urist MJ: M\l=u"\llermuscleconjunctival resection: Technique for treatment of blepharoptosis. Arch Ophthalmol 93:619-623, 1975.
