EC Ophthalmology

Eyelid surgery remains the cornerstone of rehabilitative treatment in patients with thyroid eye disease (TED), addressing both corneal exposure and facial disfigurement that accompany this autoimmune orbital disorder. Over the past five decades, rapid advancements in oculoplastic techniques, surgical sequencing, and biologic therapies have transformed the management of eyelid malpositions in TED. This systematic review and meta-analysis comprehensively evaluated literature from 1975 to 2025, integrating data from 28 studies encompassing 6,745 patients and 12,928 eyelids. The pooled mean improvement in upper eyelid position as margin reflex distance (MRD1) was -3.12 mm (95% CI, -3.48 to -2.77), while lower eyelid correction (ΔMRD2) averaged -1.89 mm (95% CI, -2.24 to -1.56). The overall patient satisfaction rate was 88.4%, with a recurrence rate of 13.7% and complication rate of 9.6%. Levator aponeurosis recession produced the greatest eyelid lowering, whereas spacer grafts and Müller’s muscle recession offered superior aesthetic contouring with lower recurrence. Surgeries performed during the inactive phase of TED, particularly following orbital decompression, demonstrated significantly improved outcomes (p < 0.05). The evidence underscores a paradigm shift toward precision-based, patient-centered surgery integrating AI-assisted symmetry mapping, 3D-printed grafts, and biologic modulation (e.g. teprotumumab) to optimize outcomes. Modern eyelid reconstruction in TED now balances functional ocular protection and aesthetic restoration, achieving long-term stability and high patient satisfaction. Despite moderate heterogeneity among studies, this meta-analysis confirms that surgical timing, technique selection, and multidisciplinary coordination remain decisive factors for success. Eyelid surgery in TED is thus reaffirmed as a safe, effective, and evolving therapeutic strategy, where art meets evidence to restore both vision and confidence.

 Keywords: Thyroid Eye Disease (TED); Graves’ Orbitopathy; Eyelid Retraction Surgery; Oculoplastic Reconstruction; Levator Recession; Müller’s Muscle Recession; Spacer Graft; Orbital Decompression; Botulinum Toxin; Teprotumumab; Aesthetic and Functional Outcome

1. Bahn RS. “Graves’ ophthalmopathy”. New England Journal of Medicine8 (2010): 726-738.
2. Smith TJ and Hegedüs L. “Graves’ disease”. New England Journal of Medicine16 (2016): 1552-1565.
3. Bartley GB. “The epidemiologic characteristics and clinical course of ophthalmopathy associated with autoimmune thyroid disease”. American Journal of Ophthalmology 3 (1996): 284-290.
4. Perros P., et al. “Management of thyroid eye disease: a consensus statement by EUGOGO”. European Journal of Endocrinology 3 (2022): C1-C18.
5. Dolman PJ. “Evaluating Graves’ orbitopathy”. Best Practice and Research Clinical Endocrinology and Metabolism 3 (2012): 229-248.
6. Rootman DB., et al. “Modern concepts in eyelid surgery for thyroid eye disease”. Clinical Ophthalmology 14 (2020): 1661-1675.
7. Dutton JJ. “Comprehensive management of thyroid eye disease”. Survey of Ophthalmology 1 (2009): 29-46.
8. Saeed P., et al. “Long-term outcomes of eyelid surgery in thyroid eye disease: a meta-analysis”. British Journal of Ophthalmology 9 (2021): 1221-1228.
9. Nuzzi R and Aluffi Valletti P. “Management of upper and lower eyelid retraction in thyroid orbitopathy: a systematic review”. BMC Ophthalmology 22 (2022): 140.
10. Choi J., et al. “Eyelid surgery after orbital decompression in Graves’ orbitopathy: a meta-analysis of surgical sequence and outcomes”. Plastic and Reconstructive Surgery 5 (2023): 1009-1020.
11. Kossler AL., et al. “Advances in oculoplastic reconstruction in thyroid eye disease”. Current Opinion in Ophthalmology 5 (2019): 428-434.
12. Lee H and Rootman D. “Comparative outcomes of autologous vs alloplastic spacer grafts in lower eyelid retraction”. Ophthalmic Plastic and Reconstructive Surgery 5 (2015): 410-416.
13. Tran E., et al. “Incidence of alemtuzumab-induced thyroid-associated orbitopathy: a systematic review and meta-analysis”. Ophthalmic Plastic and Reconstructive Surgery (2025).
14. Zong AM., et al. “Botulinum toxin treatment in thyroid eye disease: a systematic review and meta-analysis”. Ophthalmic Plastic and Reconstructive Surgery 3 (2025): 250-257.
15. Wakelkamp IM., et al. “Clinical features and treatment outcomes in Graves’ ophthalmopathy”. Ophthalmology 2 (2003): 345-352.
16. Wiersinga WM., et al. “Graves’ orbitopathy: state of the art and perspectives”. Endocrine Reviews 6 (2021): 706-760.
17. Rimmer T., et al. “Three-dimensional analysis in eyelid surgery planning for TED”. Ophthalmic Plastic and Reconstructive Surgery 3 (2023): 213-221.
18. Teprotumumab Study Group. “Teprotumumab for thyroid-associated ophthalmopathy”. New England Journal of Medicine 4 (2020): 341-352.
19. Garrity JA., et al. “Complications of eyelid surgery in thyroid eye disease”. Ophthalmology 11 (2005): 2038-2046.
20. Dolman PJ. “Graded approaches to upper eyelid retraction”. Ophthalmic Plastic and Reconstructive Surgery 4 (2018): 315-322.
21. Saeed P., et al. “Surgical trends in TED: meta-analysis and practice recommendations”. Eye (London)2 (2024): 345-355.
22. Rootman DB., et al. “Long-term stability after eyelid surgery in Graves orbitopathy”. Ophthalmic Plastic and Reconstructive Surgery 6 (2019): 563-570.
23. Perros P., et al. “Predictors of recurrence after TED surgery”. Clinical Endocrinology (Oxford)2 (2023): 234-242.
24. Kahana A., et al. “Complications and revision rates in TED eyelid surgery: a meta-analysis”. Ophthalmic Plastic and Reconstructive Surgery 3 (2020): 247-254.
25. Nuzzi R., et al. “Surgical optimization and patient satisfaction in TED reconstruction”. BMC Surgery1 (2024): 88.
26. Guyatt GH., et al. “GRADE: an emerging consensus on rating quality of evidence and strength of recommendations”. British Medical Journal 7650 (2008): 924-926.
27. Smith TJ., et al. “Teprotumumab for thyroid-associated ophthalmopathy”. New England Journal of Medicine 4 (2020): 341-352.
28. Lai KKH., et al. “Low clinical activity score ‘progressive’ thyroid eye disease: presentations of 1,439 patients from a tertiary centre in Hong Kong”. British Journal of Ophthalmology 6 (2025): 715-722.
29. Zhao M., et al. “Three-dimensional orbital morphometry and artificial intelligence for surgical planning in thyroid-associated ophthalmopathy”. Ophthalmic Plastic and Reconstructive Surgery 2 (2024): 142-149.
30. Moriyama T., et al. “Intraoperative digital navigation for eyelid repositioning in Graves’ orbitopathy: a multicenter prospective study”. Plastic and Reconstructive Surgery 4 (2024): 890-900.
31. Zhang L., et al. “Teprotumumab pretreatment improves surgical outcomes and reduces fibrosis in thyroid eye disease: a randomized controlled trial”. New England Journal of Medicine Evidence 11 (2023): EVIDoa2300241.
32. Li X., et al. “Global consensus on combined upper and lower eyelid surgery in thyroid eye disease: an international multicenter survey”. Aesthetic Surgery Journal 8 (2024): NP612-NP622.
33. Wang T., et al. “Surgical sequencing and long-term stability of eyelid correction in thyroid-associated orbitopathy: a 10-year follow-up analysis”. Eye (London)4 (2025): 823-831.
34. Page M J., et al. “The PRISMA 2020 statement: an updated guideline for reporting systematic reviews”. British Medical Journal 372 (2021): n71.