Is the thyroid always behind an eyelid retraction?

No, but often enough for us to think of it in every case. An inflammation of the tissue in the eye socket in the setting of a thyroid disease — thyroid eye disease — is the commonest explanation for an upper lid that sits too high. Alongside that there are scarring causes after injuries to the lid, to the eye or from accidents, an overcorrection after a ptosis operation, rare congenital and neurological causes — and the illusion in which the lid only looks too high because the lid on the other side is drooping. Which of them applies to you is decided by the examination and not by the statistics.

My eyes have changed — is an ophthalmologist enough, or do I also need my thyroid assessed?

The two belong together, and neither side can replace the other. At the eye we assess and document eyelid position, eyelid closure, the corneal surface, eye movements and, where the findings call for it, optic nerve function; we monitor the course and protect the surface. The thyroid itself — blood values, ultrasound, adjusting the treatment — belongs in the hands of your GP or an endocrinologist. We do not run an endocrinology service; we carry out the ophthalmic assessment, tell you specifically what is due now, and refer you to the right place.

Can a lid that sits too high lower itself again?

That does happen. With thyroid eye disease the eyelid position changes in both directions during the active phase, and some of the findings recede fully or in part once the inflammation has settled — that can take months to years, and nobody can tell you beforehand how much of it will remain. That is exactly why waiting here is not inactivity but part of the plan: during that time we protect the cornea, measure the course, and only then decide about a procedure. There is one exception, however: if the cornea takes damage and moistening and night-time protection are not enough, the waiting stops and the procedure comes earlier. Scarred retractions after operations or injuries, by contrast, as a rule do not recede on their own.

Why is there no operation straight away?

Because the result is right only for as long as the finding holds still. During an active inflammation in the eye socket the eyelid position goes on changing; a lid correctly lowered today can sit too low or too high again in six months — and then a second procedure follows the first. That is why no operation takes place until the underlying disease has settled and the finding has been stable for months. The cornea alone is an exception: if the surface takes damage and moistening and night-time protection are not enough, the procedure comes earlier. Then it is not about appearance but about the eye.

How do I protect the eye at night when the lid does not close completely?

With something thick and, if that is not enough, mechanically. An eye gel or an eye ointment before sleeping keeps the surface moist for hours — that vision is briefly blurred afterwards is part of it. If a gap still stays open, gently taping the upper lid shut with a skin-friendly plaster helps, or a pair of moisture-chamber goggles that keeps the area around the eye moist. Which of the two suits you, and how the taping is done properly, we show you at the appointment — this is no small matter: a plaster under which the lid nevertheless opens rubs across the cornea with every blink and does more harm than good. If the eye or the lid is painful, red or sensitive to light in the morning despite gel and plaster, do not tape more tightly but call us. On top of that, anything that makes the air moister helps: turn the heating down, do not direct fans and air conditioning at your face.

Does the health insurer pay for correcting a lid that sits too high?

Where there is a functional indication the correction is treatment of an illness and goes through basic health insurance — that includes incomplete eyelid closure, a damaged or threatened corneal surface, and symptoms that cannot be controlled with moistening alone. We put the findings, the measurements and the photographic documentation together for the application for cost approval and submit them before the procedure; the decision is made by your insurer, not by us. The deductible and co-payment apply as with any other procedure. If, on the other hand, it is only about an asymmetry that troubles nobody but the mirror, the correction is an aesthetic service and therefore self-pay — with a cost estimate and with VAT added.

Eyelid malpositions

Eyelid retraction: when the upper lid sits too high and the eyes look astonished

'My eyes look startled, and yet I am perfectly calm.' Or: 'At night one eye does not quite close.' If a strip of the white of the eye becomes visible above the iris, the upper lid is sitting too high — an eyelid retraction. That is rarely only a question of appearance: a lid that sits too high no longer protects the cornea. And behind it there is often the thyroid.

Call now — have your eyelid findings assessed book an appointment online

What an eyelid retraction is

Looking straight ahead and relaxed, the upper lid normally covers the upper edge of the cornea by one to two millimetres. If it sits higher, a strip of the white of the eye becomes visible between the eyelid margin and the iris, which does not belong there. That is exactly what is called an eyelid retraction — in the medical report, where the upper lid is meant, also upper eyelid retraction, and in conversation often simply a high-standing lid.

What has been noticed is usually not the millimetre but the impression: the eyes look fixed, astonished or startled; they seem larger, sometimes only on one side. Many people hear it first from others — 'your eyes look so wide open' — and then recognise it in older photographs, where it still looked different.

The same thing exists at the lower lid. If the lower eyelid margin sits too low, a strip of the white of the eye becomes visible below the iris as well; this is called a lower eyelid retraction. It stands out less than the upper one, but it enlarges the exposed area just as much — which is why both eyelid margins are measured at the examination and not only the upper one.

An eyelid retraction is not a disease in its own right but a finding: a visible sign that has a cause. The first question is therefore never 'how do we get the lid lower' but 'why is it up there'. Everything else follows from the answer.

What a lid that sits too high does in everyday life

With every blink the upper lid spreads the tear film and covers the eye. If it sits too high, more surface is left exposed, the tear film breaks up faster — and the eye makes itself heard:

A feeling of dryness, burning, a gritty feeling, worse in the evening than in the morning
Watering, precisely because the eye is dry — the irritation sets off a surge of tears that holds nothing
Glare and light sensitivity; draughts, air conditioning and heated air become unpleasant
Blurred vision, which improves for a moment after a blink
Lids that do not close completely at night. Those affected notice nothing of it; what stands out is the red, rough eye in the morning — and often the person next to you knows it first
Slowly increasing double vision or a feeling of pressure behind the eye, where the tissue of the eye socket is involved as well. If the pressure behind the eye increases, it does not belong in this list but in the red box alongside

The last point but one is medically the most important, even though it feels the most harmless. What stays open at night is not moistened, and what is not moistened dries out — first in the lower third of the cornea. An irritated surface can become superficial damage, and out of that, in an unfavourable case, an inflammation of the cornea with pain and worsening vision. That is why with an eyelid retraction we treat the surface early and not only once it hurts.

Two things on this list tolerate no waiting, even though they feel harmless. Double vision that has appeared suddenly is something different from the slowly increasing kind above: it needs examining the same day, and you do not get behind the wheel with it. And if the eye does not close because the facial muscles are weak — the corner of the mouth droops, the forehead can no longer be furrowed on one side — then the lid is not sitting too high; eyelid closure is failing. A newly appeared facial palsy needs assessing the same day; if symptoms affecting speech, vision, or one side of the body join it, call the ambulance (144). What happens with the lower lid in that case and how the eye is protected in the meantime is set out on Ectropion — when the eyelid margin tips outward.

What you must not wait with. If vision gets worse, if colours — red in particular — look paler and washed out, if a dull pressure behind the eye increases or if the eye protrudes rapidly further, call us the same day: +41 44 500 69 00. Where the eye socket is involved the optic nerve can come under pressure, and then days count. The same applies to severe pain with light sensitivity or a whitish spot on the cornea. Outside consulting hours the ophthalmic emergency service applies, or the emergency department of an eye hospital directly — do not wait with that until the next consultation.

Our rule on advice

A lid is not lowered while the cause is still moving. With thyroid disease the finding changes over months — upwards as well as downwards. Anyone who operates during that phase corrects a state that will no longer exist in that form in six months. We say this to you even when you would rather have the procedure sooner.

The commonest cause: the thyroid

When an upper lid sits too high, the commonest explanation is a disease that does not begin at the lid at all: an inflammation of the tissue in the eye socket in the setting of a thyroid disease. The technical term for it is thyroid eye disease; it occurs most often with Graves' disease, occasionally with an underactive thyroid as well, and in individual cases with entirely normal thyroid values.

And here comes the piece of information that surprises many: eyelid retraction is often the first visible sign of this disease — at times before the thyroid itself causes any symptoms and before anyone has measured blood values. Anyone who comes to us because 'the eyes look different' therefore not infrequently leaves again with a recommendation for an assessment in internal medicine — and that is not a detour but the shortest way to the cause.

Why the lid slips upwards in the process

Three things work together. A fine, involuntarily controlled lid muscle works harder and pulls the lid upwards. The lid-lifting muscle and the tissue behind it stiffen and scar over time, so that the lid no longer gives. And if the tissue in the eye socket increases, the eyeball comes forward and pushes the lid along with it. That explains why such a lid cannot simply be 'put back' and why it goes on changing during the active phase.

What that means for the assessment

This disease has two sides, and neither can treat the other on its own. At the eye we assess and document eyelid position, eyelid closure, the corneal surface, eye movements and, where the findings call for it, optic nerve function; we protect the surface and monitor the course. The thyroid itself belongs in the hands of your GP or an endocrinologist: blood values, ultrasound and adjusting the treatment. We do not run an endocrinology service — we carry out the ophthalmic assessment, tell you specifically what is due now, refer you to the right place and stay in contact with those treating you.

Two points you can influence yourself, and we say them plainly. Smoking worsens the course of thyroid eye disease; stopping smoking here is not a general health recommendation but part of the treatment. And a well-controlled thyroid function is the basis on which the eye can settle at all.

The inflammatory active phase later passes into a quiet, scarred one. How long that takes differs from person to person — months to years, and nobody can give you a date for it in good faith. Treatments that slow the inflammation itself belong at a centre specialising in it, as does a decompression operation on the eye socket or a correction of persisting double vision. Our part is the ophthalmic assessment, protecting the cornea, monitoring the course — and the question of when each step is due.

Other causes: after operations, after injuries

Not every eyelid retraction has to do with the thyroid. The second most common group is the scarring one: tissue that is missing or has contracted holds the lid up.

After upper eyelid surgery, where too much skin was removed. How much has to be left so that the eye closes completely is described on the page Upper eyelid surgery — the procedure, its limits and aftercare.
After an operation on the lid-lifting muscle, where the lid was overcorrected and now sits too high instead of too low.
After injuries, burns or skin grafts and with skin conditions that make the tissue shrink.
After procedures on the eye itself, where scar traction develops on the structures of the lid.

A group of its own is formed by weakness of the muscle that closes the eyelid. If the facial nerve fails, the ring muscle around the eye loses its tension: the lids look further apart, the eye seems larger — and yet no lid here sits too high; eyelid closure is failing. The difference is not academic, because the treatment is an entirely different one and the assessment is urgent. It is recognisable from the fact that half the face is involved as well: a drooping corner of the mouth, a forehead that can no longer be furrowed on one side. Details on that are on the page about ectropion.

Rarer are a congenital malformation of the lid-lifting muscle, neurological diseases involving the brainstem and, in individual cases, medicines. With the brainstem group, typically both upper lids sit too high, and looking upwards is restricted — a newly appeared bilateral eyelid retraction with disturbed upward movement is therefore a finding that needs assessing promptly and not at some point. Rare does not mean trivial: this group is exactly the reason why a newly appeared high-standing lid is examined and not disguised.

Eyelid retraction, ptosis or hooded eyelid — what you can tell apart

Three findings in the same place, three entirely different answers. From the outside they are regularly mixed up; surgically they have almost nothing to do with one another.

Eyelid retraction. The eyelid margin sits too high, the white of the eye becomes visible above the iris, and the eyes look wide open. What is treated first is the cause, then — where necessary — the lid.
Ptosis. The eyelid margin sits too low and covers part of the iris; the eyes look tired. What lies behind it and how it is treated is set out on Ptosis — causes of the drooping upper lid.
Hooded eyelid. The eyelid margin sits where it should, but excess skin lies over it. The difference, and the self-check for it: Hooded eyelid — too much skin with the eyelid margin in the right place.

Combinations exist as well: with thyroid eye disease the lid can sit too high and skin can be in excess at the same time. Anyone who then removes only the skin has a lid that still sits too high — and an eye that closes even less well than before. That is why things are measured here and not decided from a photograph.

A drooping lid on one side can make the other look too high. Both upper lids are controlled together. If the brain lifts harder to hold a drooping lid up, the healthy one goes up with it. That is why we always examine both eyes — even when only one of them bothers you.

If the other lid has newly begun to droop, that is something else. If double vision and a wide pupil on the same side join a newly drooping upper lid, go straight away to an emergency department — do not wait for an appointment and do not wait until morning. The same applies to a drooping lid with a strikingly narrow pupil on the same side and pain in the throat or neck. If a disturbance of language, speech or swallowing, weakness in one half of the body, a drooping corner of the mouth, or a sudden severe headache joins them, call the ambulance (144). If instead the lid drops on its own and painlessly within days, call us the same day: +41 44 500 69 00. What lies behind it is set out on Ptosis — causes of the drooping upper lid.

How we examine

At this appointment 'it looks different' becomes a figure that can be compared in six months' time. With a finding that changes over months, that is not formalism but the basis of every later decision.

Measurement of the eyelid position. Distance from the light reflex on the cornea to the upper eyelid margin, the width of the palpebral aperture, the height of the visible white of the eye above and below, the excursion of the lid-lifting muscle — all of it separately for each side and in millimetres.
Eyelid closure and the situation at night. Whether the lids close completely on gentle closure and at rest, and how large any remaining gap is.
The corneal surface at the slit lamp, with staining. This is where it first shows whether the dryness is already doing damage — usually in the lower third.
The position and movement of the eye. Whether the eyeball protrudes, whether the eye movements are free and whether double vision occurs.
Optic nerve function where involvement of the eye socket is suspected: visual acuity, colour vision, visual field.
Photographic documentation in a standardised head position and lighting — the only fair comparison across months.

By the end you know whether there is an eyelid retraction, how pronounced it is, whether the cornea is already suffering, what needs assessing outside the eye — and what makes sense in which order.

First step: protecting the cornea

Before any procedure is discussed, it is the surface that matters. That sounds unspectacular, and it is the part that takes away the most symptoms in the short term.

Moisten during the day, regularly and not only once it burns. Preservative-free preparations are better tolerated with frequent use.
Protect at night — with a thick gel or an eye ointment. If the lids still do not close completely, gently taping the upper lid shut helps, or a pair of moisture-chamber goggles. What suits you is something we show you at the appointment.
Avoid irritants. Do not direct fans and air conditioning at your face, damp down dry heated air, sunglasses outdoors, and a deliberate blink during screen work.
Put contact lenses aside, for as long as the surface is irritated — they aggravate the dryness instead of easing it.

How a permanently dry eye is treated more generally is set out in detail on dry eyes — causes, diagnosis and treatment. With an eyelid retraction there is one particular point on top of that: here the dryness is the consequence of an eyelid position. For as long as the lid sits too high, moistening is protection — it does not remove the cause.

If you notice a lid on yourself that sits too high, have it assessed before the cornea causes trouble: by phone on +41 44 500 69 00, Mon–Fri 08:00–12:00 / 13:00–17:30, or book an appointment online for the eyelid consultation.

When surgery comes into question — and why the timing counts

A lid that sits too high can be lowered surgically: at the upper lid the lid-lifting muscle and the fine lid muscle behind it are released or set back, and at the lower lid a piece of graft tissue is often inserted to support the lid. What is decisive, though, is not the technique but the timing.

No operation takes place until the underlying disease has settled and the finding has been stable for months. During active thyroid eye disease the eyelid position goes on changing; a result that is right today can be too low or too high again in six months. The cornea alone is an exception: if the surface is at risk of taking damage and moistening and night-time protection are not enough, the procedure comes earlier. Then it is not about appearance but about the eye.

The order is not arbitrary either. If decompression of the eye socket is due, it comes first; then, if necessary, the correction of persisting double vision; the lid last, because every preceding step changes the eyelid position again. Anyone who operates on the lid first often operates on it twice.

Which steps are due for you, in which order and where they are carried out, we discuss after the examination — procedures on the eye socket and on the eye muscles belong at a centre specialising in them, and we tell you openly what of that takes place here and what does not. An overview of the other findings on the lid that we treat is given by the page Eyelid malpositions — findings on the eyelid and their treatment.

Costs & health insurance

What does the insurer pay for — and what not?

With an eyelid retraction the answer hangs on whether a functional impairment is documented — incomplete eyelid closure, a damaged or threatened cornea, symptoms that cannot be controlled with moistening alone. Everything else follows from that.

Service	Coverage	What this means for you
Ophthalmic assessment of the eyelid findings	Basic health insurance, where symptoms are the reason	If you come with symptoms — dry eyes, glare, a changed lid — the assessment is treatment of an illness; the deductible and co-payment apply as at any doctor's appointment.
Measurement of eyelid position, testing of eyelid closure, corneal staining, photographic documentation	Same as for the assessment	The measurements serve at once as a follow-up check and as the basis of a later application. They are reimbursed even when they show that no procedure is needed — they are not tied to a particular result.
Assessment of the thyroid (blood values, endocrinological review)	Basic health insurance, but not with us	These examinations run through your GP or an endocrinology practice and are billed there. We put the ophthalmic findings together for the referral.
Lubricating drops, gels and eye ointment	Depending on the preparation	Whether a preparation is carried by basic health insurance (OKP) depends on whether it is on the Federal Specialities List. Many artificial tears you buy yourself — we tell you which product serves the purpose before you go and get it.
Surgical lowering of the lid where there is a functional indication	Basic health insurance, after cost approval	We put the findings, the measurements and the photographs together for the application and submit them to your insurer. The decision is made there. No operation takes place before the written approval — so that you do not receive a bill you had not counted on.
Correction without functional impairment	Self-pay	If it is only about an asymmetry that troubles nobody but the mirror, the correction is an aesthetic service. You receive a written cost estimate beforehand; supplementary insurance as a rule does not cover such procedures.
Combined procedure — functional part plus aesthetic additional service	split billing	If the lid sits too high and excess skin lies over it as well, those are two different questions with two different answers. The medically justified part goes through basic health insurance, the part beyond that through you. What belongs to which is set down in writing before the procedure, not after it.
Follow-up checks and aftercare	Same as for the procedure itself	Aftercare follows how the operation is classified and where it takes place. With a functional procedure it goes through basic health insurance; with an aesthetic one it is included in the cost estimate.

There are deliberately no amounts here: what is involved and which technique is used depend on the findings, and a figure without an examination would be a guess. You receive the cost estimate in writing after the assessment, before you have to decide.

A tax point: with purely aesthetic procedures VAT is added; with medically indicated treatment it is not. That too is in the cost estimate.

Related conditions

Eyelid malpositions Dry eyes Hooded eyelids

Medically reviewed by PD Dr. med. Andrea von Rückmann

Your ophthalmologistPD Dr. med. Andrea von RückmannView profile

Frequently asked questions

: No, but often enough for us to think of it in every case. An inflammation of the tissue in the eye socket in the setting of a thyroid disease — thyroid eye disease — is the commonest explanation for an upper lid that sits too high. Alongside that there are scarring causes after injuries to the lid, to the eye or from accidents, an overcorrection after a ptosis operation, rare congenital and neurological causes — and the illusion in which the lid only looks too high because the lid on the other side is drooping. Which of them applies to you is decided by the examination and not by the statistics.
: The two belong together, and neither side can replace the other. At the eye we assess and document eyelid position, eyelid closure, the corneal surface, eye movements and, where the findings call for it, optic nerve function; we monitor the course and protect the surface. The thyroid itself — blood values, ultrasound, adjusting the treatment — belongs in the hands of your GP or an endocrinologist. We do not run an endocrinology service; we carry out the ophthalmic assessment, tell you specifically what is due now, and refer you to the right place.
: That does happen. With thyroid eye disease the eyelid position changes in both directions during the active phase, and some of the findings recede fully or in part once the inflammation has settled — that can take months to years, and nobody can tell you beforehand how much of it will remain. That is exactly why waiting here is not inactivity but part of the plan: during that time we protect the cornea, measure the course, and only then decide about a procedure. There is one exception, however: if the cornea takes damage and moistening and night-time protection are not enough, the waiting stops and the procedure comes earlier. Scarred retractions after operations or injuries, by contrast, as a rule do not recede on their own.
: Because the result is right only for as long as the finding holds still. During an active inflammation in the eye socket the eyelid position goes on changing; a lid correctly lowered today can sit too low or too high again in six months — and then a second procedure follows the first. That is why no operation takes place until the underlying disease has settled and the finding has been stable for months. The cornea alone is an exception: if the surface takes damage and moistening and night-time protection are not enough, the procedure comes earlier. Then it is not about appearance but about the eye.
: With something thick and, if that is not enough, mechanically. An eye gel or an eye ointment before sleeping keeps the surface moist for hours — that vision is briefly blurred afterwards is part of it. If a gap still stays open, gently taping the upper lid shut with a skin-friendly plaster helps, or a pair of moisture-chamber goggles that keeps the area around the eye moist. Which of the two suits you, and how the taping is done properly, we show you at the appointment — this is no small matter: a plaster under which the lid nevertheless opens rubs across the cornea with every blink and does more harm than good. If the eye or the lid is painful, red or sensitive to light in the morning despite gel and plaster, do not tape more tightly but call us. On top of that, anything that makes the air moister helps: turn the heating down, do not direct fans and air conditioning at your face.
: Where there is a functional indication the correction is treatment of an illness and goes through basic health insurance — that includes incomplete eyelid closure, a damaged or threatened corneal surface, and symptoms that cannot be controlled with moistening alone. We put the findings, the measurements and the photographic documentation together for the application for cost approval and submit them before the procedure; the decision is made by your insurer, not by us. The deductible and co-payment apply as with any other procedure. If, on the other hand, it is only about an asymmetry that troubles nobody but the mirror, the correction is an aesthetic service and therefore self-pay — with a cost estimate and with VAT added.

A lid that sits too high has a reason.

At the eyelid consultation we measure the eyelid position, check eyelid closure and the cornea — and tell you which assessment outside the eye is due now. That costs one appointment and may save you years.

Call now — appointment at the eyelid consultation

+41 44 500 69 00 — Mon–Fri 08:00–12:00 / 13:00–17:30. Or book an appointment online.