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Young Woman Referred for a Drooping Eyelid

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.
1 Credit CME

A 38-year-old woman with a history of hypothyroidism and allergic conjunctivitis was referred for evaluation of her left upper eyelid after she noticed drooping for 2 months, which was confirmed on review of old photographs. On physical examination, the patient showed a margin-to-reflex distance 1 (MRD1) of 6 mm on the right and 4 mm on the left, but no evidence of lower eyelid asymmetry. Her levator function (LF) was 20 mm bilaterally. The right eye showed eyelid lag, lateral flare, and mild resistance to retropulsion (Figure).

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Thyroid eye disease (TED) with retraction of the right upper eyelid

C. Send for a thyroid panel

Ptosis of the upper eyelid is a common complaint among patients referred for plastic surgical management. However, a discerning examination prior to treatment can be crucial because other causes of eyelid asymmetry can present as ptosis. What may first appear to be ptosis of an upper eyelid may actually be relative asymmetry due to a contralateral upper eyelid retraction, dermatochalasis, or globe dystopia.1

Several measurements are necessary for evaluation of a drooping eyelid, including bilateral MRD1, LF, and assessment of the Hering effect.2 In the present case, evaluation of the eyelid measurements demonstrated an elevated MRD1 of the contralateral eyelid consistent with retraction. The Hering effect was negative, indicating that the right upper eyelid retraction was likely not due to a ptotic left upper eyelid. Additional observations of eyelid position, movement, and orbital resistance were suggestive of TED, which was confirmed by a follow-up thyroid panel demonstrating antithyroid peroxidase and thyroglobulin antibodies. Because examination pointed toward asymmetry due to right upper eyelid retraction, offering ptosis surgery for the left upper eyelid was not appropriate.

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Article Information

Corresponding Author: Lora R. Dagi Glass, MD, Department of Ophthalmology, Columbia University Medical Center, New York–Presbyterian Hospital, 635 W 165th St, PO Box 77, New York, NY 10032 (ld2514@cumc.columbia.edu).

Published Online: August 16, 2018. doi:10.1001/jamafacial.2018.0740

Conflict of Interest Disclosures: None reported.

Funding/Support: This study was supported in part by a departmental grant from Research to Prevent Blindness, New York, New York.

Role of the Funder/Sponsor: The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Additional Contributions: We thank the patient for granting permission to publish this information.

References
1.
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2.
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Gould  DJ, Roth  FS, Soparkar  CN.  The diagnosis and treatment of thyroid-associated ophthalmopathy.  Aesthetic Plast Surg. 2012;36(3):638-648. doi:10.1007/s00266-011-9843-4PubMedGoogle ScholarCrossref
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