Eyelid Retraction

Tethered or pulled-down lower eyelid – eyelid retraction

The problem

The lower eyelid is pulled downward. There is resistance or tethering when attempting to push the eyelid upward to its normal position. The malpositioned eyelid is often associated with eye dryness and irritation, and possibly blurry vision as the surface of the eye has more exposure to the air and has less natural lubrication.

What causes eyelid retraction?

Lower eyelid retraction can occur after lower blepharoplasty. There are two main types of lower eyelid retraction:

1. Anterior lamellar retraction (known as cicatricial ectropion, not a true retraction)- this is due to a shortage of skin. This can be caused by over-removal of skin during lower blepharoplasty or other facial surgery, laser-resurfacing, chemical peels, severe sun damage, scars from an injury (see photo below), connective tissue disorders, and skin cancers.
2. Middle or posterior lamellar retraction- this is due to scarring, fibrosis, or tethering of the middle or back layer of the eyelid, including the orbital septum, eyelid retractors, and conjunctiva. This can be caused by abnormal healing after blepharoplasty, orbital surgery, or other eyelid surgery, diseases that affect the mucus membranes, thyroid eye disease, chemical burns, and traumatic eyelid injuries. It has been postulated that excessive manipulation or violation of the orbital septum during eyelid surgery can increase the risk of eyelid retraction.

Often seen with

Dry or irritated eye, blurred vision, corneal epithelial defects, watery eye or excessive tearing.

Not to be confused with

Loose lower eyelid or ectropion that is not cicacricial or tethered, meaning that the lower eyelid turns outward due to looseness of the eyelid or its supporting tendons (lateral and medial canthal tendons). A loose lower eyelid can predispose one to experience eyelid retraction after lower eyelid surgery if the eyelid is not supported with canthopexy or canthoplasty.

What you see in the mirror

The lower eyelid is pulled down, and it is difficult to gently push it back into place with your finger.