Reply Re: “Blepharotomy Versus Levator Recession With Adjustable Sutures for Correction of Upper Eyelid Retraction in Thyroid Eye Disease”

To the Editor: We appreciate Ravikumar and coworker’s interest in our article “Blepharotomy Versus Levator Recession With Adjustable Sutures for Correction of Upper Eyelid Retraction in Thyroid Eye Disease”1 and for highlighting important aspects of these surgical procedures. Below, we address the raised queries: 1. Vertical strabismus and inferior rectus involvement We acknowledge that vertical strabismus due to a restricted inferior rectus muscle can influence eyelid position and that strabismus surgery often is required in such cases.2 In our patients, correction of strabismus was performed before eyelid surgery. Nine patients had undergone strabismus surgery, including 7 who received inferior rectus recession (either isolated or combined with correction of horizontal strabismus). None of the patients required strabismus surgery after correction of the upper eyelid retraction, indicating adequate preoperative management. 2. Comparable outcomes despite procedural differences Blepharotomy and levator recession with adjustable sutures (LRWAS) are both lid-lengthening procedures. Our initial assumption before commencing the study was that LRWAS would result in a superior outcome compared to blepharotomy. However, our findings indicated that blepharotomy, in addition to being faster to perform (41.5 vs. 68 minutes operative time), yielded comparable results to LRWAS (93% acceptable outcomes in both groups). Both procedures have their pros and cons. When correctly performed, blepharotomy is less invasive and preserves a central strip (and in some cases an additional medial strip) of conjunctiva that maintains the curvature of the lid margin.3 Conversely, LRWAS involves a more extensive dissection of the levator and Müller muscles, potentially interrupting normal tissue architecture. Also, the outcome in LRWAS is dependent on the development of a new attachment for the levator aponeurosis to the tarsal plate as the adjustable sutures absorbs. However, our findings are limited by a small sample size (30 patients) that includes few patients with severe eyelid retraction. A larger study with more severe cases could potentially yield results more favorable to LRWAS. 3. Incidence of postoperative ptosis Within the follow-up period of 6 months, ptosis was observed in 2 eyelid (8%) after blepharotomy and 8 eyelids (32%) after LRWAS. All received additional ptosis surgery. Information on later development of ptosis is missing for this cohort due to lack of extended follow-up time. As mentioned earlier, a central and sometimes a medial strip of tissue is preserved in blepharotomy, which supports the position of the tarsal plate and helps in maintaining the contour of the eyelid. This could explain why fewer cases of ptosis were observed in this group. Several factors may contribute to the occurrence of postoperative ptosis in LRWAS. Postoperative ptosis was observed in 3 eyelids 1 week after surgery, suggesting either inadequate suture tightening or extensive muscle detachment. This underscores the importance of appropriate suture adjustments and precise detachment of the Müller and levator muscles from the tarsus. In mild cases, achieving a normal curvature of the lid margin could be facilitated by preserving the medial part of the attachments of the levator and Müller muscles to the tarsus.4 In most eyelids, we observed that ptosis occurred around 3 weeks after surgery, indicating that the sutures had started to dissolve before a new attachment for the levator aponeurosis had developed. 4. Recurrent retraction In this study, one patient who underwent LRWAS surgery experienced a recurrence of upper eyelid retraction. The retraction was visible at the first control 2 weeks postoperatively, possibly caused by excessive tightening of the sutures. A new LRWAS procedure was performed 2 months later with a successful outcome. No recurrences were observed in the blepharotomy group during the 6-month follow-up. Long-term data are needed to assess late relapse. Finally, our findings support blepharotomy as first-line therapy for moderate TED-related upper eyelid retraction, given its efficacy and lower reoperation rate. LRWAS might be preferable for severe or recurrent cases that require precise titration. We echo the need for extended follow-up in future studies. Thank you for the opportunity to respond to the comments on our article.