Cutaneous Lower Eyelid Retractor Release Averts Lower Lid Malposition After Inferior Rectus Muscle Recession

Introduction: The lower eyelid is anatomically coupled to the inferior rectus (IR) muscle, so that IR recession alone causes lower lid retraction often symptomatic due to inferior scleral show and corneal exposure. Although procedures within the conjunctival incision reduce retraction slightly, release of the lower lid retractor muscles via cutaneous incision (CLERR) eliminates this problem. Methods: We reviewed 89 consecutive IR recessions performed by one surgeon between September 2019 and May 2024, of which 71 included CLERR. CLERR was performed after local anesthetic infiltration in 2-3 minutes by blunt dissection of the retractors from the inferior margin of the tarsus via a small skin incision over the lateral orbital rim, using scissors blades visualized through the intact inferior tarsal conjunctiva. Inferior scleral show was measured an average of 116 days post-operatively. Results: Although mean IR recession was significantly greater at 4.6±1.8 mm (standard deviation, range 2-8mm) with CLERR than 3.2±1.2mm (range 2-6mm) without it (P=0.003), inferior scleral show averaged less with CLERR at 0.2±0.9mm than 0.7±1.0mm without it (P=0.043). The procedure was also effective in thyroid ophthalmopathy. Lower lid ecchymosis occurred in 22 cases with CLERR, but resolved within one week without patient complaints. The skin incision healed without visible scar in 5-7 days. Conclusion/Relevance: CLERR is a quick and simple procedure that virtually eliminates lower eyelid retraction following IR recession of any amount, avoiding inferior scleral show and new dry eye symptoms without additional conjunctival dissection. It is a quick oculoplastic procedure readily performed by any strabismus surgeon.