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Mullerectomy for Upper Eyelid Retraction in Graves’ Orbitopathy
Jonathan Liang, MD1; Laura T. Hetzler, MD2; Travis T. Tollefson, MD1; Brian S. Orisek, MD1
1Department of Otolaryngology, University of California Davis (Sacramento, CA)
2Department of Otolaryngology, Louisiana State University (New Orleans, LA)
ABSTRACT
INTRODUCTION
Objective: To review the presentation of
eyelid abnormalities in Graves’
orbitopathy (GO). To review the surgical
options for addressing eyelid retraction,
with a detailed focus on the mullerectomy
procedure.
Graves’ orbitopathy (GO) is the most common orbital
inflammatory disorder in adults. It affects 10-15% of
patients with thyroid disease. The incidence is 0.4% in
the United States, with a female to male ratio of 4:1.
Study Design: Case report and review of
the literature.
Methods: We describe a case of a 36
year old woman with Graves’ disease who
presents with exophthalmos and upper
eyelid retraction. She was bothered by
the appearance of her “bulging eyes” and
complained of dryness and irritation. She
had no keratitis, diplopia, or evidence of
optic neuropathy.
Results: Patient underwent
mullerectomy, or excision of Muller’s
muscle. Hypertrophy of the muscle was
noted. Mullerectomy was performed via a
posterior conjunctival approach. It
involved delicate separation of Muller’s
muscle from the underlying conjunctiva
and the overlying levator aponeurosis.
Post-operative analysis showed
improvement of upper eyelid position and
patient comfort.
Conclusions: Muller’s muscle is a
sympathetically innervated muscle that
inserts upon the upper border of the
superior tarsal plate and provides 2 mm of
lift. Eyelid retraction is the most common
eyelid abnormality in GO. Upper eyelid
surgery involves lengthening or
weakening of Muller’s muscle and/or the
levator aponeurosis. The mullerectomy
procedure has received little attention in
the otolaryngology literature.
Mullerectomy is a safe and effective
procedure that has been shown to
improve upper eyelid position,
lagophthalmos, exposure keratopathy,
and patient comfort. The failure rate is
low and is most often due to undercorrection. Otolaryngologists should
consider mullerectomy as an option for
addressing upper eyelid retraction in GO.
Orbital manifestations include:
•Soft tissue features: chemosis, conjunctival
hyperemia, periorbital edema, orbital fat prolapse
•Myopathy: diplopia, extraocular muscle limitation,
exophthalmos, increased intraocular pressure
•Eyelid abnormalities: eyelid retraction, lagophthalmos,
scleral show, lid lag, lateral lid or temporal flare
•Orbital apex compression: optic neuropathy
Werner’s Classification:
•Class 0: No signs or symptoms
•Class 1: Only signs (retraction & stare)
•Class 2: Soft tissue involvement
•Class 3: Proptosis (3 mm or more)
•Class 4: Extraocular muscle involvement
•Class 5: Corneal involvement
•Class 6: Sight loss (optic nerve involvement)
Surgical management for GO follows a staged
approach: (1) orbital decompression, (2) strabismus
surgery, and (3) eyelid surgery. Eyelid surgery options
include lateral tarsorrhaphy, lengthening or weakening
of Muller’s muscle and/or the levator aponeurosis,
lower lid elevation, and blepharoplasty.
Mullerectomy was first described by Putterman and
Urist in 1975. Muller’s muscle (Figure 1) is a
sympathetically innervated smooth muscle. It arises
from the levator palpebrae superioris muscle
approximately 15 mm above the superior tarsal plate.
It inserts onto the superior tarsal plate, and provides 2
mm of lift.
RESULTS
Mullerectomy was performed via a posterior conjunctival
approach. Operative steps include:
•Evert the upper eyelid to expose the superior palpebral
conjunctiva (Figure 2).
•Incise the conjunctiva at the superior tarsal border.
•Dissect the conjunctiva from Muller’s muscle by raising a
conjunctival flap (Figure 3).
•Incise Muller’s muscle above the superior tarsal border.
•Dissect Muller’s muscle from the levator aponeurosis
(Figure 4).
•Excise Muller’s muscle.
•Close the conjunctival incision with absorbing sutures.
Figure 2.
The upper eyelid is everted.
The conjunctiva is incised just
above the upper border of the
superior tarsal plate.
Figure 3.
A conjunctival flap is raised via
careful blunt dissection.
Muller’s muscle is identified
and incised at the upper
border of the superior tarsal
plate.
Figure 4.
Muller’s muscle is carefully
dissected from the levator
aponeurosis. Subtotal
mullerectomy is performed
leaving a short 2-3 mm stump.
Pre-operative (Figure 5) and post-operative (Figures 6 & 7)
photos of the patient. Note the improvement of the upper
eyelid position.
Figure 1. Sagittal cross section of the upper eyelid.
CASE PRESENTATION
We describe a case of a 36 year old woman with
Graves’ disease who presented to a tertiary care
medical center. Her chief complaints are dry eyes and
irritation. She was previously treated with I131, and is
currently euthyroid (TSH 0.62 ng/dl, free T4 1.09 ng/dl)
on thyroid replacement medication. She is bothered by
the appearance of her “bulging eyes” and complains of
dryness and irritation. She denies any history of
keratitis, diplopia, loss of vision, or orbital pain.
CONTACT
Jonathan Liang, MD
Department of Otolaryngology
University of California Davis Med Center
2521 Stockton Blvd, Suite 7200
Sacramento, CA 95817
[email protected]
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Physical examination showed (Figure 5):
•Pupils equally round and reactive to light
•Extraocular muscles intact, no entrapment
•MRD1 of 5 mm on L, and 6 mm on R
•No inferior scleral show, R superior scleral show
•No diplopia
•Complete eye closure
•Minimal injection, no chemosis
•No evidence of keratitis
Figure 5. Pre-Operative.
DISCUSSION
Eyelid retraction is the most common eyelid
abnormality in patients with GO. This is due to
sympathetic overaction of Muller’s muscle, increased
sensitivity to circulating catecholamines, and fibrosis
and functional shortening of the lid retractor muscles.
In some patients, the upper eyelid can peak more
laterally (temporal flare sign). This phenomenon has
been attributed to levator aponeurosis dominance in
the lateral horn and histological evidence of far lateral
extension of Muller’s muscle.
Surgery for upper eyelid retraction has focused on
lengthening or weakening of Muller’s muscle and/or the
levator aponeurosis. Techniques include marginal
myotomies, recession with and without use of a spacer,
and resection. Up to 2 mm of upper eyelid retraction
can be ameliorated with Muller’s muscle excision.
Lateral levator aponeurosis tenotomy can help
decrease temporal flare.
Simon et al. presented the largest series of patients
who underwent transconjunctival mullerectomy. His
study included 78 patients and 108 eyelids, with a
mean follow-up of 16.7 months. He showed a mean
MRD1 decrease of 2.6 mm and a mean lagophthalmos
decrease of 0.6 mm. There was improvement in upper
eyelid position, lagophthalmos, exposure keratopathy,
and patient comfort. Failure was noted in 8.4% and
mostly due to under-correction, which can be
addressed with a second surgery. Less common
complications include overcorrection, scar formation,
eyelid crease asymmetry, contour abnormalities, eyelid
perforation, and injury to the lacrimal apparatus.
CONCLUSIONS
The mullerectomy procedure has received little
attention in the otolaryngology literature. Mullerectomy
can be performed via a posterior conjunctival
approach. It involves delicate separation of Muller’s
muscle from the underlying conjunctiva and overlying
levator aponeurosis. Mullerectomy is a safe and
effective procedure that has been shown to improve
upper eyelid position, lagophthalmos, exposure
keratopathy, and patient comfort. The failure rate is
low and is most often due to under-correction.
Otolaryngologists should consider mullerectomy as an
option for addressing upper eyelid retraction in GO.
REFERENCES
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resection for the correction of blepharoptosis. Eye 22:
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Management of Graves’ Orbitopathy. Otolaryngol Clin N Am
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Figure 6. Post-operative day #1.
4. Meyer DR. Surgical management of Graves orbitopathy.
Curr Opin Ophthalmology 10: 343-351, 1999.
5. Putterman AM, Fett DR. Muller’s Muscle in the Treatment of
Upper Eyelid Retraction: A 12-Year Study. Ophthalmic
Surgery 17: 361-367, 1986.
6. Rose Jr JG, Burkat CN, Boxrud CA. Diagnosis and
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Figure 7. Post-operative day #8.
7. Simon GJB, et al. Transconjunctival Muller Muscle
Recession with Levator Disinsertion for Correction of Eyelid
Retraction Associated with Thyroid-Related Orbitopathy. Am
J Ophthalmology 140: 94e1-94e6, 2005.