Surgical Science, 2011, 2, 376-378
doi:10.4236/ss.2011.27082 Published Online September 2011 (http://www.SciRP.org/journal/ss)
Copyright © 2011 SciRes. SS
Eyelid Fissure Narrowing after Recession of the Medial
Hirohiko Kakizaki1*, Yasuhiro Takahashi1, Akihiro Ichinose2, Masayoshi Iwaki1
1Department of Ophthalmolog y, Aichi Medical University, Nagakute, Aichi, Japan
2Department of Plastic Surgery, Kobe University, Chuo, Kobe, Japan
Received January 13, 2011; revised February 5, 2011; accepted March 12, 2011
A 67-year-old male had suffered from eye movement disturbance from Graves’ orbitopathy. His right eye
was fixed in an esotropic position. Examination by synoptophore showed that his right eye deviation was 22
degrees medially. The upper eyelid margin reflex distance (MRD) was 3.5 mm OD and 5.6 mm OS, and the
lower eyelid MRD was 5.1 mm OU. Six mm medial rectus muscle recession with tenotomy was performed
in the patient. The next day after the surgery, his eye position did not change and the right eyelid fissure
demonstrated narrowing with upper eyelid lowering and lower eyelid elevation. The right upper eyelid MRD
was decreased to 1.9 mm and the right lower eyelid MRD was similarly decreased to 4.3 mm. On the same
day, 4 mm resection of the ipsilateral lateral rectus muscle was performed, but the same MRDs were ob-
served postoperatively. Patients undergoing medial rectus muscle recession in Graves’ orbitopathy need to
be informed of this potential complication.
Keywords: Graves’ Orbitopathy, Lower Eyelid Elevation, Margin Reflex Distance, Medial Rectus Muscle,
Upper Eyelid Lowering
Surgery on the medial rectus muscle is known to have
the complication of a change in eyelid fissure heigh t .
Recession tends to show widening of the eyelid fissure
height, and then narrowing which is mostly caused by
resection . Although these results are mainly due to
changes in the lower eyelid position, upper eyelid low-
ering by recession is a rare response .
We report a case with eyelid fissure height narrowing
with upper eyelid lowering and lower eyelid elevation
after medial rectus muscle recession in Graves’ orbito-
2. Case Report
A 67-year-old male had suffered from eye movement
disturbance from Graves’ orbitopathy. At first admission,
his thyroid hormone level was normal and his clinical
activity score  was 0 points. He was administered two
times steroid pulse therapy more than 1 year prior to the
admission. His visual acuity was 0.6 OD and 0.9 OS, the
loss of which was caused by a cataract. Hertel exoph-
thalmometry showed 15 mm OU. His right eye was fixed
in an esotrop ic position with a Hirschberg angle of more
than 15 degrees (Figure 1(a)). A binocular single vision
field  showed no single vision area at the time, but he
suppressed his right eye under the unconscious. A forced
duction test demonstrated lateral restriction but it did not
show any medial resistance. According to a synopto-
phore, his right eye deviation was 22 degrees medially.
The upper eyelid margin reflex distance (MRD) was 3.5
mm OD and 5.6 mm OS, and the lower eyelid MRD was
5.1 mm OU (Figure 1(a)).
Six mm medial rectus muscle recession with tenotomy
was initially performed in the patient. The nex t day after
surgery, his eye position did not change, but the right
eyelid fissure height demonstrated narrowing with upper
eyelid lowering and lower eyelid elevation. The right
upper eyelid MRD was decreased to 1.9 mm, but the left
upper eyelid MRD remained at 5.6 mm. In addition, the
right lower eyelid MRD was decreased to 4.3 mm but the
left lower eyelid MRD remained at 5.1 mm. On the same
day, 4 mm advancement of the ipsilateral lateral rectus
muscle was performed, but unfortunately, the same
MRDs were observed postoperatively (Figure 1(b)). Six
H. KAKIZAKI ET AL.
months later, the right upper and lower eyelid MRDs had
slightly improved (upper: 2.3 mm, lower 4.7 mm). The
left upper eyelid MRD was still 5.6 mm and that of the
lower eyelid was 5.1 mm, which had consistently been at
e same levels (Figure 1(c)). th
We report a rare case with eyelid fissure narrowing after
medial rectus muscle recession in Graves’ orbitopathy
. Although medial rectus muscle recession tends to
show widening of the eyelid fissure height, mostly with
lower eyelid lowering , our patient showed a para-
doxical response by the same procedure.
The medial rectus muscle and the upper and lower
eyelids have a close relationship via the medial rectus
capsulopalpebral fascia (mrCPF) . The mrCPF con-
tains the medial rectus muscle pulley, the medial check
ligament and fibers to the lacrimal caruncle, and it
reaches the medial aspect of the upper and lower tarsal
plates . The mrCPF enables synchronous movement
of the eyeball, eyelids and carunc le . Various tensions
of the mrCPF may be reflected in the upper and lower
eyelid positions. This is supported by the fact that hori-
zontal eye muscle surgeries can change the position of
the eyelids .
The medial rectus muscle of our patient was very
hardened by fibrosis as shown by the restricted forced
duction test. However, the lateral rectus muscle did not
demonstrate any restriction during the fo rced duction test.
This finding may be the reason why lateral rectus muscle
advancement may not have influenced the postoperative
The clothes lining effect is occasionally demonstrated
in the lower eyelids . This is similar to lower eyelid
retraction, typically occurring with too much horizontal
tension during horizontal eyelid tightening surgery. In
this situation, the lower eyelid is no t elevated superiorly,
but it is more lowered. This phenomenon tends to occur
in a more proptotic eye. However, since our patient
showed 15 mm exophthalmos, which is a normal level,
lower eyelid elevation may have occurred instead of the
clothes lining phenomenon. The same mechanism may
be applied to the upper eyelid lowering in this patient.
A previous report  that investigated eyelid fissure
height change after horizontal rectus muscle surgeries
excluded orbital diseases, and it probably also excluded
Graves’ o rbitopathy. In g eneral, orbital tissues in Graves’
orbitopathy tend to be hardened by fibrosis . This may
be the reason why our patient showed a paradoxical out-
come compared with the previous report .
Our patient showed a large angle esotropia (22 de-
grees), which was caused by fibrosis of the right medial
Figure 1. (a) Preoperative photograph of the patient. The
right eye is fixed in an esotropic position with a Hirschberg
angle of more than 15 degrees. The upper eyelid margin
reflex distance (MRD) is 3.5 mm OD and 5.6 mm OS, and
the lower eyelid MRD is 5.1 mm OU. Subconjunctival
hemorrhage of the left eye is not related to any traumas or
surgeries; (b) Postoperative 1-month photograph of the
same patient. The right eyelid fissure height is narrowed
with upper eyelid lowering and lower eyelid elevation. The
right upper eyelid MRD is decreased to 1. 9 mm but the left
upper eyelid MRD remains at 5.6 mm. The right lower eye-
lid MRD is decreased to 4.3 mm but the left lower eyelid
MRD remains at 5.1 mm; (c) Postoperative 6-month pho-
tograph of the same patient. The right upper and lower
eyelid MRDs have slightly improved (upper: 2.3 mm, lower
4.7 mm). The left upper eyelid MRD is still 5.6 mm and that
of the lower eyelid is 5.1 mm.
Copyright © 2011 SciRes. SS
H. KAKIZAKI ET AL.
Copyright © 2011 SciRes. SS
rectus muscle. Although he ideally should have been
operated on with a bilateral medial rectus muscle reces-
sion, he hoped to only have an operation fo r the affected
eye. Therefore, we only operated on his right eye. Since
he had suppression of the right eye, he was hopeful that
he did not have to have a furt h e r operation.
In conclusion, patients undergoing medial rectus mus-
cle recession in Graves’ orbitopathy need to be informed
of this adverse complication.
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