Objective: To review the presentation of eyelid abnormalities in Graves- orbitopathy (GO). To review the surgical options for addressing eyelid retraction, with a detailed focus on the mullerectomy procedure. Study Design: Case report and review of the literature. Methods: We describe a case of a 36 year old woman with Graves- disease who presents with exophthalmos and upper eyelid retraction. She was bothered by the appearance of her "bulging eyes" and complained of dryness and irritation. She had no keratitis, diplopia, or evidence of optic neuropathy. Results: Patient underwent mullerectomy, or excision of Muller's muscle. Hypertrophy of the muscle was noted. Mullerectomy was performed via a posterior conjunctival approach. It involved delicate separation of Muller's muscle from the underlying conjunctiva and the overlying levator aponeurosis. Post-operative analysis showed improvement of upper eyelid position and patient comfort. Conclusions: Muller's muscle is a sympathetically innervated muscle that inserts upon the upper border of the superior tarsal plate and provides 2 mm of lift. Eyelid retraction is the most common eyelid abnormality in GO. Upper eyelid surgery involves lengthening or weakening of Muller's muscle and/or the levator aponeurosis. The mullerectomy procedure has received little attention in the otolaryngology literature. Mullerectomy is a safe and effective procedure that has been shown to improve upper eyelid position, lagophthalmos, exposure keratopathy, and patient comfort. The failure rate is low and is most often due to undercorrection. Otolaryngologists should consider mullerectomy as an option for addressing upper eyelid retraction in GO.
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