title: Graves Lower Eyelid Retraction.
abstract: OBJECTIVE
  Graves lower eyelid retraction (GLLR) is a common and controversial sign of Graves orbitopathy. The authors reviewed the mechanisms and surgical techniques currently used to correct this Graves orbitopathy-related eyelid malposition.
  
  
  METHODS
  A literature search was performed on the MEDLINE database using the keywords "lower eyelid retraction," "Graves orbitopathy," "thyroid ophthalmopathy," "thyroid eye disease," "spacers," and "eyelid surgery." Only articles in English were included. The level of evidence of publications regarding surgical correction of GLLR was evaluated and graded from I to IV, using a rating system adapted from a validated scientific evidence classification method.
  
  
  RESULTS
  The mechanisms responsible for GLLR are not fully understood and no subtypes of GLLR have been distinguished. The surgical literature of GLLR encompasses mainly descriptions of surgical techniques without objective measurements of the results, and uncontrolled studies. Only 1 randomized controlled trial was identified. To lengthen the lower retractors, a large variety of different materials have been used as spacers.
  
  
  CONCLUSIONS
  The scientific literature on GLLR is vast, however controlled and randomized studies comparing different surgical techniques are lacking. At the present moment it is not clear if bioengineered materials are superior to conventional autogeneous tissue as lower eyelid spacers. The effects of GLLR on lower eyelid movements and contour have not been studied.
authors.affiliation: *Department of Ophthalmology, Hospital Lusíadas Porto, Porto, Portugal; †Department of Ophthalmology, Hospital de Braga, School of Health Sciences, University of Minho, Braga, Portugal; ‡School of Medicine of Porto, University of Porto, Porto, Portugal; and §Department of Ophthalmology, Otorhinolaryngology and Head and Neck Surgery, Hospital das Clínicas-Campus, School of Medicine of Ribeirão Preto, University of São Paulo, Ribeirão Preto, São Paulo, Brazil.
authors.forename: Sara Filipa Teixeira
authors.initials: SF
authors.lastname: Ribeiro
authors.forename: Maria
authors.initials: M
authors.lastname: Shekhovtsova
authors.forename: Ana Filipa
authors.initials: AF
authors.lastname: Duarte
authors.forename: Antonio Augusto
authors.initials: AA
authors.lastname: Velasco Cruz
mesh_terms: D019882:Blepharoplasty / Q000379:methods*; D019299:Decompression, Surgical / Q000379:methods*; D005143:Eyelids / Q000601:surgery*; D049970:Graves Ophthalmopathy / Q000601:surgery*; D006801:Humans