Thyroid Eyelid Retraction & Double-Vision Surgery

Thyroid Eyelid Retraction & Double-Vision Surgery | Paul Riske, M.D., F.A.C.S., P.C. | EyePlastics

Part of our complete guide to Thyroid Eye Disease (TED) — this page covers TED eyelid and strabismus surgery in depth.

Once thyroid eye disease has stabilized, two of its most disabling effects — a retracted, staring eyelid and double vision from tight eye muscles — are corrected surgically. These are the rehabilitative steps that follow orbital decompression.

Eyelid Retraction

Eyelid retraction is among the most common and distressing features of TED. The upper lid normally covers 1–2 mm of the superior limbus; in TED it may sit above the limbus entirely, exposing the sclera and giving the characteristic staring appearance.

Lower-eyelid retraction in thyroid eye disease, sclera visible below the iris — Clinical appearance of eyelid retraction in thyroid eye disease — the upper and/or lower lids pull back, exposing sclera and producing the characteristic “staring” look.

Causes of Upper Lid Retraction in TED

Overactive sympathetic tone (Müller muscle stimulation from hyperthyroidism) — often partially reversible with thyroid control
Levator muscle fibrosis — the levator becomes adherent to surrounding tissues; responds only to surgery
Inferior rectus restriction with compensatory upgaze effort — increased levator drive to elevate the globe worsens lid retraction; strabismus surgery may reduce this component

Consequences

Corneal exposure: dryness, punctate keratitis, corneal ulceration in severe cases
Lagophthalmos (inability to close lids fully during sleep)
Significant cosmetic distress

Surgical Correction

Eyelid surgery is the last step in the sequential rehabilitation of TED (after decompression and strabismus if needed), performed once disease is stable for ≥ 6 months.

Upper lid lowering: Müller muscle recession (müllerectomy), levator recession, or eyelid spacer graft (using donor sclera, hard palate mucosa, or synthetic spacer) to lengthen the posterior lamella. Can lower the upper lid by 2–8 mm depending on technique
Lower lid raising: Recession of the lower lid retractors with or without a spacer graft. Lateral tarsal strip canthoplasty to improve lower lid position and support
Tarsorrhaphy: Partial closure of the lateral eyelids as a temporary or permanent measure for severe corneal exposure when definitive surgery is not yet possible

The animation below steps through the surgical correction of lower-eyelid retraction — recession of the lower-lid retractors, with or without a spacer graft — via both the external (transcutaneous) and internal (transconjunctival) approaches.

Lower-Eyelid Retraction CorrectionStep-by-Step

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Front-view anatomical illustration highlighting the relevant anatomy of the lower eyelid.

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Eyelid Retraction — Before & After

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Before Graves Disease / Eyelid Recession — case Lower-lid recession with TarSys spacer graft — Case Lower-lid recession with TarSys spacer graft

Case Lower-lid recession with TarSys spacer graft

Strabismus & Double Vision

Thyroid eye disease with strabismus and double vision

Diplopia (double vision) in TED results from restrictive strabismus — the inflamed, fibrotic extraocular muscles tether the eye and prevent full movement, causing misalignment. Unlike paralytic strabismus, TED strabismus features a positive forced duction test (the eye cannot be passively moved through full range).

Patterns

Inferior rectus restriction (most common): hypotropia (eye deviated down) with limited upgaze. Patient cannot look up and sees double in primary or downgaze positions
Medial rectus restriction: esotropia (eye deviated in) with limited abduction. Double vision on lateral gaze
Restrictive strabismus is variable in active disease — surgery is deferred until disease is stable (≥ 6 months without change)

Treatment

Prism glasses: fresnel prisms adhered to spectacle lenses can neutralize small deviations; useful during active disease while waiting for stability
Strabismus surgery: recession (lengthening) of the tight, overacting muscle — the muscle is detached from the globe and reattached further back. Goals are single vision in primary gaze and reading position; some double vision may remain in extreme gaze directions, and additional surgery or prisms may be required. More than one procedure is sometimes needed
Strabismus surgery is performed before eyelid surgery in the sequence: orbital decompression → strabismus → eyelid

Frequently Asked Questions

Why does thyroid eye disease cause double vision?: Inflammation makes the eye muscles fibrotic and tight, restricting movement. The eyes no longer move together, producing double vision — most often on up-gaze or side-gaze.
How is eyelid retraction corrected?: The retracted lid is lowered by lengthening or recessing the muscles and spacers that hold it up, restoring normal lid position, protecting the cornea, and softening the staring appearance.
In what order are these surgeries done?: After the disease is stable: orbital decompression first, then strabismus (eye-muscle) surgery, and eyelid surgery last — because each step can change what the next one needs to correct.

Your Surgeon

Paul Riske, M.D., F.A.C.S., P.C.

🏅 ASOPRS Fellowship Trained

Book Appointment 📞 (919) 782-5400

Eyelid Retraction

Causes of Upper Lid Retraction in TED

Consequences

Surgical Correction

Lower-Eyelid Retraction CorrectionStep-by-Step

Lower-Eyelid Retraction CorrectionStep-by-Step

Eyelid Retraction — Before & After

Strabismus & Double Vision

Patterns

Treatment

Frequently Asked Questions

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