Best Procedure to Correct my Slightly Scleral Show? (photo)

Question

I have a slightly scleral show in my eyes. I just want my lower eyelid to be less droopy and be more horizontal. Thanks in advance.

Sirius K. Yoo, MD · Answer

Thank you for your question and photo. There have been several interesting posts already, so I won't repeat what has already been said. It’s always difficult to evaluate a two-dimensional photo unless the views are standardized (which is difficult to accomplish without training). The one thing that immediately strikes me is that the photo appears to have been taken with a camera angle from above, with you looking slightly upward. The reflection of the camera flash is only a couple millimeters from your upper lid and your lateral and medial limbi (sides of the circles formed by your iris or colored portion of your eye) are nearly touching your upper lid. Taking that into consideration, it seems unlikely that you need any corrective surgery. But, I would advise you to see a board-certified cosmetic surgeon who can take photos with standardized views and evaluate you in person. Best of luck.

Evan Ransom, MD, FACS · Answer

Thank you for the question and your picture. Without examining your eyelids to determine the degree of laxity, it is not possible to say whether or not you need a canthal repositioning procedure. There are many reasons for scleral show: 1) in some people, this is "normal" (i.e., not a result of surgery or any sort of trauma); 2) there could be scar tissue in the lower eyelid, which is limiting its movement or causing the lid to rotate outward; 3) the lower eyelid may be too loose, and it hangs down. There are some important tests that will be done during your evaluation, including distracting the lid away from the eye and checking how quickly and easily it returns to its normal position. Procedures available will depend in part on this information, and include a lower eyelid lift with canthopexy, canthoplasty alone, or midface lift. Please have a detailed conversation with your qualified surgeon regarding your options and aesthetic goals.

Kenneth Hughes, MD · Answer

Filler in the lower eyelid is sometimes effective. I will tell you that canthal laxity cannot be determined from a photo, and you will have to be examined. Based upon the exam, further recommendations can be made. Kenneth Hughes, MD Los Angeles, CA

Mehryar (Ray) Taban, MD, FACS · Answer

Lower eyelid retraction causing scleral show can be improved using surgical (lower eyelid retraction surgery) or nonsurgical techniques (filler injection into the lower eyelids to lift them). See an oculoplastic surgeon for evaluation.

Kenneth D. Steinsapir, MD · Answer

Not all inferior scleral show is abnormal. Not all inferior scleral show needs to be fixed. An obvious questions is why do you think it needs to be fixed? It is a problem when there is chronic corneal drying with symptoms that can not be addressed with simple medical treatment. "Repairing" cosmetic inferior scleral show needs to be done thoughtfully recognizing that it is possible to do harm with even the best intentioned surgical procedure. Students of topology should be able to understand why canthal tightening procedures (canthoplasty and canththopexy) are not appropriate for improving inferior scleral show. These procedures are used for addressing lower eyelid laxity. The reason why they are not effective for addressing inferior scleral show is related to the geometry of curved surfaces. On a plane, the shortest distance between to points is a straight line. On a curved surface, however, it is not a straight line but a curved line. Think about a polar route in flying from Los Angeles to London. The shortest path follows and arc described on a sphere known as a geodesic. Surgeons who attempt to pull a lid to a higher position on the globe by shortening the eyelid are surprised when the result is that the eyelid follows an arc that is even lower on the globe than it was before surgery. This is because the lid is following the shortest arc on the eye which is under the curve of the eye. For this reason shortening procedures are the wrong approach to fixing this issue and doomed to fail. The solution is lengthening the lower eyelid in both a horizontal and vertical dimension. I would be very careful what you look for. Good luck.

A.J. Amadi, MD · Answer

I would NOT recommend a midface or SOOF lift, nor a canthoplasty/canthopexy.

	Your scleral show is a sign of lower eyelid retraction. This can be repaired using a graft on the inside of the eyelid. There are many different areas the graft can be harvested from, such as the inside of the upper eyelid, the roof of the mouth, or even some "off the shelf" products.

	Seek a consultation with an ASOPRS trained oculoplastics surgeon.

	See link below to find one near you.

Sachin S. Parikh, MD · Answer

Thanks for your question. There are a few options to fix scleral show. To reposition the lid it sometimes requires a lateral canthopexy or lateral canthoplasty. This surgery removes the current attachments of the lower eyelid and places them a bit higher improve the scleral show. Some physicians advocate a SOOF lift or midface lift to reposition the lower eyelid but this has variable results. 

	 

	A lateral canthopexy or canthoplasty usually is a secondary procedure and not something done primarily. I would seek the opinion of a board certified surgeon before making any major decisions.

	Good luck,

	Sachin Parikh MD

Michael Sundine, MD, FACS · Answer

If you really feel that you need improvement of your scleral show this is probably best performed with a lateral canthopexy procedure since you do not appear to have any previous eyelid surgery.

Darryl J. Blinski, MD · Answer

NONE is the best option in your case. Seems like an issue of unrealistic expectations. and no understanding of the risks involved.

Gregory Sexton, MD · Answer

First, I would recommend no surgery. Your eyes look fine. If you insist on doing something, then, removing a small triangle of your lower lid and pulling the lid tighter should correct what you are seeing.

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