Cutaneous Lower Eyelid Retractor Release Averts Lower Lid Malposition After Inferior Rectus Muscle Recession

Introduction

The lower eyelid is anatomically coupled to the inferior rectus (IR) muscle, so that IR recession alone causes lower lid retraction often symptomatic due to corneal exposure. Although procedures within the conjunctival incision reduce retraction slightly, cutaneous lower eyelid retractor release (CLERR) eliminates this problem.

Design

Retrospective comparative interventional case series.

Methods

We reviewed 89 consecutive IR recessions performed by one surgeon between September 2019 and May 2024, of which 71 included CLERR performed after local anesthetic infiltration in 2-3 minutes by dissection of the retractors from the inferior margin of the tarsus via skin incision over the lateral orbital rim, using scissors blades visualized through the intact inferior tarsal conjunctiva. Inferior scleral show was measured an average of 116 days postoperatively.

Results

Although mean IR recession was greater at 4.6 ± 1.8 mm (standard deviation, range 2-8 mm) with CLERR than 3.2 ± 1.2 mm (range 2-6 mm) without it (P = .003), inferior scleral show averaged less with CLERR at 0.2 ± 0.9 mm than 0.7 ± 1.0 mm without it (P = .043). The procedure was also effective in thyroid ophthalmopathy. Lower lid ecchymosis occurred in 22 (31%) cases with CLERR, but resolved within one week without patient complaints. The skin incision healed without visible scar in 5-7 days. There was one complication of severing an IR hangback suture that was repaired during suture adjustment.

Conclusion/Relevance

CLERR is a quick and simple procedure that virtually eliminates lower eyelid retraction following IR recession of any amount, avoiding inferior scleral show and new dry eye symptoms without additional conjunctival dissection. It is a quick oculoplastic procedure readily performed by any strabismus surgeon.