What Is Scleral Show?

Scleral show is the band of white you can see between the iris and the lower eyelid when your eyes are open and looking straight ahead. Doctors call the lower version inferior scleral show. You may also hear the same look called sanpaku eyes, from a Japanese term meaning three whites, because the sclera shows on three sides of the iris.

The lid sits lower than it should, the lash line pulls away from the iris, and the eye opening looks taller and rounder than usual. It is not the same as ectropion, where the edge of the lid actually turns outward.

Why does scleral show affect how a face looks?

A clearly exaggerated band of white usually traces back to aging, hormones, an injury, or your genes. Sometimes it is a sign that something is off with the eye itself, especially when both corners turn down with it. One study of Italian faces found that a lot of visible sclera was not read as attractive, and that too much white tended to throw the whole face off. (1)

What causes scleral show?

Genetics

If scleral show runs in your family, there is a good chance you will pick it up over time. Some people simply have bigger eyes than others, and on its own that is nothing to fix.

The catch is that a lot of visible white can put extra pressure on the eyeball and the lids around it, until the lids start to look too short to hold the whole eye. Other people may read the extra white as unusual or unattractive. (2)

Aging

The orbicularis oculi is the muscle that closes your eyelids. Age-related scleral show sets in when this muscle stays too slack, which is common in older faces as the muscles around the eyes lose their tone.

Aging also thins the skin around the eyes and drains its elasticity, so the look only gets more obvious with time. (3)

Hormonal causes

An overactive thyroid, or hyperthyroidism, can tip into a state called thyrotoxicosis. One of its common signs is the eyeball pushing forward: the muscles that hold the eye in place stay contracted and pull up on the upper lid, which exaggerates the scleral show.

Both an underactive and an overactive thyroid can also cause swelling behind the eyeball. That swelling pushes the eye forward and brings out more white. (4)

After surgery

Scleral show sometimes turns up as a complication of cosmetic eyelid surgery, especially in older patients whose orbicularis muscle is already weak. It can appear the moment the patient lies back.

When the cause is just post-surgical swelling, the look settles on its own once the swelling goes down. The patient might stay a few days after surgery until the eye returns to its normal position and the tension eases, or come back for regular follow-ups.

In other cases it sticks around or even worsens, depending on the underlying cause, the surgical technique, and anything else feeding into it. (5)

Over-aggressive resections

Surgeons work hard not to remove too much muscle, skin, or fat. The whole point of that caution is to let every part of the eye and the area around it settle back into place on its own.

Eyelid surgery is unforgiving, so the surgeon has to be highly skilled. Skin, fat, and muscle each carry their own traps. Take too much fat, for example, and the scleral show can grow more obvious over the following months, even when everything looked fine on the table.

Another trap is the septum between the eyes thinning out over time after too much skin and fat comes off. That deepens the under-eye area and makes the scleral show stand out more.

How can you prevent scleral show?

Treat the underlying thyroid cause

Underactive thyroid

Treating an underactive thyroid stops the swelling forming behind the eyeball, which keeps the scleral show from showing up in the first place.

Overactive thyroid

Treating an overactive thyroid lets the eyeball move back to where it belongs.

Test the orbicularis oculi muscle

Before doing cosmetic eyelid surgery on an older patient, the surgeon should test the orbicularis oculi to check its tone. If the muscle is too weak, the surgery is best left alone.

Conservative resections

Skin and muscle

The surgeon needs the experience to avoid shortening skin and muscle too much. Closing the fascia around the eyes properly lets the corners of the eye return to where they belong.

Fat

Removing too much fat makes the septal region between the eyes swell, so the surgeon should take only what is needed and leave nothing pulling on the structures of the eye.

How is scleral show treated?

Surgeons are split on this. Some feel scleral show cannot really be fixed with surgery, and that people who have it are better off learning to live with it. Others say severe cases can be improved with the right procedure.

Skin graft

Placing a skin graft on the lid can correct scleral show to a degree. It is the same approach used to fix ectropion. (6)

Lifting techniques

Certain lifts help too. Raising the outer corner of the eye, for instance, takes tension off the lower lid and can correct the scleral show. The orbicularis muscle can be lifted as well, which is especially useful in older patients. (7)

Blepharocanthoplasty and brow lift

For the most complicated cases, blepharocanthoplasty paired with a brow lift can be the final answer. Both work by correcting the position of the eyelids, which in turn corrects the whole eye and leaves it looking healthier and younger. (8)

Hyaluronic acid fillers

People with scleral show from heredity or from a previous surgery can sometimes be helped with hyaluronic acid fillers. The filler lifts the outer corner of the eye to correct the look, and it is a reasonable option for people dealing with complications from earlier eyelid surgery too.

The main risk with fillers here is fibrosis in the area, so the whole thing should be done by an experienced surgeon after a proper read of the case. (9)