Squirrel over the iris
The upper eyelid is raised, and between it and the iris a strip of white is visible; the eyes seem wide open.
CONDITION / FACE
Retraction of the upper and lower eyelid.
Eyelid retraction is a condition in which the upper eyelid is raised higher than it should be, or the lower eyelid is lowered lower, and a streak of protein is visible above or below the iris. Most often, it is caused by endocrine ophthalmopathy, less often by operations on the eyelids, scars or other reasons. The eye closes worse and dries up; the eyelid is returned to its place by injections or surgery.
CONCEPTUAL VISUALIZATION- What it is
- The upper eyelid is raised too high or the lower eyelid is lowered too low.
- Most often
- With endocrine ophthalmopathy: in a cohort of 120 such patients, retraction was in 108.
- What threatens
- The eye closes worse and dries up; the cornea may be damaged.
- Who treats it
- A surgeon who operates on the eyelids, together with an endocrinologist and an ophthalmologist.
01 / WHAT IS ITWhat is
What is
eyelid retraction.
Normally, the upper eyelid slightly covers the upper edge of the iris, and the lower one passes along its lower edge. During retraction, the eyelid is displaced from this position: the upper one is raised, the lower one is lowered. Because of this, white is visible above or below the iris, the eyes seem wide open.
Retraction is not a separate disease, but a symptom. Most often, it is associated with endocrine ophthalmopathy, but there are many reasons. Doctors divide them into three groups: nervous, muscular and mechanical.
Retraction can be on the upper eyelid, on the lower or both, on one eye or on both. In addition to changing the appearance, it can threaten vision: the uncovered eye dries out, and the cornea can be damaged.
This page is general, about retraction for any reason. There are separate pages about endocrine ophthalmopathy itself and about retraction of the lower eyelid after blepharoplasty.
This is general information. The doctor will tell you what will suit you after the examination.
02 / SIGNSHow
How
retraction presents.
Changes are visible in a photo or in a mirror: the look has become different. But the sensation in the eye can also be disturbing.
Squirrel under the iris
The lower eyelid is lowered, a protein is visible under the iris.
The eyelid lags behind
When you look down, the upper eyelid does not keep up with the eye.
The eye does not close
It is difficult to close the eyelids completely, especially during sleep.
LagophthalmusDryness and irritation
Feeling of sand, redness, lacrimation, unpleasant sensations in bright light.
03 / REASONSWhy the eyelid?
Why the eyelid?
shifts
The order of treatment and who is treating the patient depend on the cause.
Endocrine ophthalmopathy
The most common reason. The disease affects the eyes of about one in four people with hyperthyroidism due to Graves' disease, and retraction is its most characteristic feature, usually in the upper eyelid.
Endocrine ophthalmopathyEyelid operations
Retraction is a well-known complication of aesthetic and reconstructive operations on the eyelids; of the lower eyelid is a frequent complication of blepharoplasty.
Retraction after blepharoplastyScars
A scar from an injury, burn, or previous surgery shortens the tissue and pulls the lower eyelid down.
Scars after facial injuriesWhat makes Graves' disease worse
Smoking, thyroid dysfunction, high levels of TSH receptor antibodies, radioactive iodine treatment, and high cholesterol.
Other reasons
Retraction can also be caused by disorders of the nerves or muscles that control the eyelid. Therefore, if the cause is not obvious, the doctor looks for it separately.
04 / SEEK MEDICAL ADVICE
When to seek medical advice?
Retraction usually develops gradually and does not require emergency care. But the open eye is less protected, severe endocrine ophthalmopathy can threaten vision, and after surgery or trauma to the eyelids, some signs require immediate help.
103 immediately if:
- suddenly stopped seeing in one or both eyes;
- sudden severe pain in or around the eye;
- after an operation or an injury to the eyelids, the pain in or around the eye increases;
- after surgery or trauma to the eyelids, the eye protrudes or became tense;
- after surgery or trauma to the eyelids, the eyelids do not open;
- after surgery or trauma to the eyelids, diplopia appeared or vision worsened.
To the doctor without delay:
On the same day: vision has changed - blurriness, double vision, flashes; the eye is red and painful; it is painful to look at the light. If you have recently had an operation on your eyelids and something unexpected has appeared, immediately contact the clinic where you were operated on; with severe pain, bulging of the eye or deterioration of vision - 103. In the coming days: the eyes began to protrude, the eyelids rose or swelled, dryness and sand appeared in the eyes - consult a doctor: with endocrine ophthalmopathy, it is important to get to specialized specialists early. Planned: longstanding retraction that does not change — surgeon consultation for correction.
05 / DIAGNOSTICSAs defined,
As defined,
that pulls the eyelid.
- Conversation
Is there a disease of the thyroid gland, have there been operations on the eyelids, injuries, burns; when changes were noticed and whether they are increasing.
- Analyzes and endocrinologist
Blood test for thyroid hormones; with endocrine ophthalmopathy — assessment of whether the disease is active and how severe it is.
- Examination of the eyelids
They measure the distance from the pupil to the edge of the eyelid and the white strip, evaluate how the eyelids close and whether the scar is pulling.
- Eye examination
An ophthalmologist checks the cornea and vision; photo in standard angles — for plan and comparison.
06 / TREATMENTHow we treat
How we treat
retraction
First, the cause is treated and the eye is protected, then, if the eyelid has not returned to its place, it is corrected. The method is chosen according to the reason, which eyelid is displaced, and to what extent.
01
The reason and protection of the eye
- Endocrine ophthalmopathy
- It is treated by an endocrinologist and an ophthalmologist: the method is chosen according to how active and severe the disease is. For many, mild eye symptoms are relieved when the thyroid gland is treated.
- Eye protection
- Moisturizing drops and ointment to prevent the cornea from drying out.
- Do not smoke
- Smoking is one of the factors that worsen endocrine ophthalmopathy.
02
Without surgery
Temporarily - in the acute phase or when it is not possible to operate.
- Botulinum toxin
- An injection into the upper eyelid lowers it. According to a meta-analysis of 19 studies (299 patients), the success rate was 84%, the eyelid dropped an average of 2.42 mm, the effect lasted 1–6 months. Side effects — excessive drooping of the eyelid (13%) and diplopia (2%).
- Hyaluronic acid and steroids
- Eyelid injections can also reduce retraction. Everyone's response is different and repeated injections may be necessary.
03
Surgery on the upper eyelid
When the disease has subsided or the retraction is persistent.
- Eyelid extension
- The muscles that lift the eyelid are lengthened, if necessary, a spacer is sewn. According to a meta-analysis of 39 studies (2064 patients), the eyelid was in the correct position in 85%, reoperation was required in 12%.
- Own fabrics
- Autologous tissue spacers in this analysis resulted in 88% success and 5% reoperations versus 76% and 25% with nonautologous materials.
- Procedure for endocrine ophthalmopathy
- Restorative operations are performed when the disease is inactive, usually in three stages: orbital decompression, strabismus correction, eyelid surgery. The decompression itself barely lowers the upper eyelid, so eyelid surgery is usually required separately.
04
Surgery on the lower eyelid
- Spacer
- To raise the eyelid, a spacer graft is sewn under it; there are many materials, and on systematic review none has a clear advantage.
- Scar retraction
- Transplants, spacers, tightening of the middle area of the face and fixation of the outer corner of the eye are combined. If more than 2 mm of protein is visible under the iris, a combination of methods may be needed.
07 / AT THE VALIKHNOVSKYI INSTITUTE
How
How
we treat it.
Eyelid retraction at Dr. Valikhnovskyi's Institute of Surgery is treated in the direction of "New face" - together with scars that tighten the eyelids and the consequences of orbital injuries. The clinic is responsible for eyelid surgery; endocrine ophthalmopathy is treated by an endocrinologist and an ophthalmologist, and eyelid surgery is planned when the disease has subsided.
CLINIC SERVICE
A new face
Form, symmetry, facial expressions and functions after injuries, wounds, burns, removal of tumors and congenital changes.
View service
What we do for this condition
- Extension of the upper eyelid — the muscles that lift the eyelid are lengthened so that it descends to the correct height.
- Spacers and grafts — the patient's own cartilage or other graft under the eyelid lengthens it and keeps it in place.
- Canthopexy and canthoplasty - strengthen or restore the outer corner of the eye so that the lower eyelid fits tightly to the eye.
- Scar correction - a scar that tightens the eyelid is cut out and closed with local fabrics.
- Repeat blepharoplasty — correction of the eyelids, if retraction is a consequence of the previous operation.
Rostislav Valikhnovskyi
Plastic surgeon, candidate of medical sciences, founder of Dr. Valikhnovskyi Institute of Surgery.
How treatment works with us
- Photo onlineSend photos of the eyes directly and from the side and, if available, the results of an endocrinologist or ophthalmologist.
- ConsultationExamination of the eyelids and eye, measurements; clarification of the cause, if necessary — referral to an endocrinologist or ophthalmologist.
- PlanWhat to do now, and what to do when the disease subsides; what eyelid and how to adjust.
- SurgeryEyelid lengthening, spacer, fixation of the corner of the eye — techniques are selected according to the cause.
- RecoveryThe first weeks — swelling and bruises; the doctor will explain how to care for the eye and when to come for an examination.
08 / QUESTIONS AND ANSWERSCommon
Common
questions
Short answers. What is right for you, the doctor will tell you during the consultation.
Can retraction go away by itself?
Sometimes it is reduced: in many people with endocrine ophthalmopathy, mild eye symptoms are relieved when the thyroid gland is treated. If the eyelid remains displaced, it is corrected.
When is it possible to operate an eyelid with endocrine ophthalmopathy?
When the disease is inactive. If multiple operations are required, orbital decompression is usually performed first, then strabismus correction, and only then the eyelids.
Will botulinum toxin injections help?
Botulinum toxin injection can temporarily lower the upper eyelid: according to a meta-analysis, the effect lasts 1–6 months. Excessive drooping of the eyelid is possible in 13% of patients.
Can retraction be corrected after blepharoplasty?
Yes. Retraction is a known complication of eyelid surgery; it is corrected with spacers, fixation of the corner of the eye and other methods. How exactly - the doctor will tell after the examination.
How does retraction threaten the eye?
The eye closes worse and dries up, the cornea may be damaged. Therefore, even while waiting for treatment, it is important to protect the eye with drops and ointment.
Could a repeat operation be necessary?
This is possible: according to a meta-analysis of operations on the upper eyelid, 12% of patients needed a repeat operation. The result depends mostly on how strong the retraction was before the operation.
Who should I contact first?
If there is a disease of the thyroid gland or the eyes have started to protrude, see an endocrinologist and an ophthalmologist. The surgeon corrects the position of the eyelids when the cause is under control.
Sources
17 sources · EUGOGO guideline, systematic reviews, meta-analyses and NHSshowCollapse
- The differential diagnosis and classification of eyelid retractionOphthalmology, 1996doi:10.1016/s0161-6420(96)30744-6 ↗
- Clinical features of Graves' ophthalmopathy in an incidence cohortAmerican Journal of Ophthalmology, 1996doi:10.1016/s0002-9394(14)70276-4 ↗
- The 2021 European Group on Graves' orbitopathy (EUGOGO) clinical practice guidelines for the medical management of Graves' orbitopathyEuropean Journal of Endocrinology, 2021doi:10.1530/EJE-21-0479 ↗
- Management of eyelid retraction related to thyroid eye diseaseTaiwan Journal of Ophthalmology, 2022doi:10.4103/tjo.tjo_57_21 ↗
- Graves upper eyelid retractionSurvey of Ophthalmology, 2013doi:10.1016/j.survophthal.2012.02.007 ↗
- Non-surgical treatment for eyelid retraction in thyroid eye disease (TED)British Journal of Ophthalmology, 2017doi:10.1136/bjophthalmol-2017-310695 ↗
- Nonsurgical management of upper eyelid retraction in thyroid eye diseaseTaiwan Journal of Ophthalmology, 2024doi:10.4103/tjo.TJO-D-23-00043 ↗
- Botulinum Toxin Treatment in Thyroid Eye Disease: A Systematic Review and Meta-analysisOphthalmic Plastic and Reconstructive Surgery, 2025doi:10.1097/IOP.0000000000002852 ↗
- Exploring successful treatments for upper eyelid retraction in thyroid eye disease: A scoping reviewSurvey of Ophthalmology, 2026doi:10.1016/j.survophthal.2026.01.003 ↗
- Upper eyelid retraction: meta-analysis & systematic review of surgical outcomesJPRAS Open, 2026doi:10.1016/j.jpra.2026.09.018 ↗
- Influence of orbital decompression on upper eyelid retraction in Graves' orbitopathy: a systematic review and meta-analysisOrbit, 2024doi:10.1080/01676830.2023.2248621 ↗
- Surgical Correction of Cicatricial Lower Eyelid Retraction: A Systematic ReviewSeminars in Ophthalmology, 2024doi:10.1080/08820538.2023.2273850 ↗
- Comparison of Efficacy and Complications Among Various Spacer Grafts in the Treatment of Lower Eyelid Retraction: A Systematic ReviewAesthetic Surgery Journal, 2017doi:10.1093/asj/sjx003 ↗
- Graves Lower Eyelid RetractionOphthalmic Plastic and Reconstructive Surgery, 2016doi:10.1097/IOP.0000000000000613 ↗
- Overactive thyroid (hyperthyroidism): complicationsNHS, 2023nhs.uk/conditions/overactive-thyroid-hyperthyroidism/complications ↗
- Vision lossNHS, 2025nhs.uk/conditions/vision-loss ↗
- Eyelid surgeryNHS, 2023nhs.uk/tests-and-treatments/cosmetic-procedures/cosmetic-surgery/eyelid-surgery ↗
The figures on the page are from these sources.
The eyes became "wider"
is the eyelid displaced?
Send a photo of the eyes and, if available, the results of an endocrinologist or ophthalmologist. The doctor will tell you what is displacing the eyelid and how it can be put back in place.