Causes, Prevention, and Treatment
E xcessive scleral show, also known as the scleral show, is an anatomical condition that can be hard to treat. The condition is characterized by a visibly exaggerated scleral area. The condition should be differentiated from ectropion, which is the outward turn of the eyelid.
Figure 1 – A weak lower eyelid contour can cause it to sag and reveal more of the sclera (white of the eyeball) than necessary for aesthetic, making the face seem permanently weary and tired.
Why Does Excessive Scleral Show Affect Facial Aesthetic?
The visibly exaggerated scleral area happens due to aging or hormonal, traumatic, and hereditary causes. It is a sign that there is something wrong with the eyes, especially if the condition is associated with inversion of both corners of the eyes. According to a study on the Italian people, the excessive scleral show is not considered aesthetically perfect. Too apparent sclera gives the entire face an ugly effect. (1)
What Causes Excessive Scleral Show?
If the excessive scleral show runs in your family, you will probably develop it over time. Some people have bigger eyes than others and, in this case, it is not considered a defect.
The only problem in this condition is that the excessive scleral show can put more pressure on the eyeballs and subsequently on the eyelids. The eyelids may appear too short to contain the entire eyeballs. Other people consider the too visible sclera abnormal and ugly. (2)
The orbicularis oculi muscle is the one responsible for closing the eyelids. Excessive scleral show due to evolution happens due to hypotonicity (constant relaxation) of this muscle. This appears significantly in the elderly due to the malfunction of nearly all facial muscles including orbicularis oculi, upper lid, and other muscles surrounding the eyes.
Ageing also causes a loss of elasticity in the skin surrounding the eyes, which contributes to the condition and makes it more prominent. (3)
Hyperthyroidism (Abnormal increase in the activity of the thyroid gland) leads to a condition called thyrotoxicosis. One of the most common signs of hyperthyroidism and thyrotoxicosis is the protrusion of the eyeball frontward. The muscles keeping the eyeball in its place contract all the time with contact upward pull on the upper eyelid lead to exaggerating the scleral show.
Both hypothyroidism and hyperthyroidism can lead to edema behind the eyeball, which leads to protrusion of the eyeball and excessive scleral show. (4)
Sometimes, excessive scleral show occurs as a complication to aesthetic blepharoplasty, especially in older patients who have hypotonic orbicularis oculi muscles. The condition appears immediately once the patient’s position becomes supine.
In some cases, the condition is caused by post-operative edema. In these cases, the condition resolves spontaneously after the edema disappears. The patient should either stay for a few days after the surgery until every part of the eye returns at its normal position and the tension is relieved or follow up regularly.
In other cases, the condition persists and even worsens depending on the main cause of the scleral show, the technique of the operation, and any other factors that may contribute to the condition. (5)
Surgeons try their best to avoid exaggerated resections of muscles, skin, or fat. The man goal of being careful here is to allow every part of the eye and its surroundings to return naturally to their normal positions.
The surgeon should be highly qualified because eye surgeries can go wrong easily since they are full of traps from skin correction, fat correction, to muscle correction. For example, exaggerated fat resection can make the scleral show more apparent over time, even if the patient sounded normal when the surgery was over.
Another example is when the septum between the eyes disappear over time after exaggerated skin and fat resections, which leads to deepening the area under the eyes and making the scleral show more evident.
How To Prevent Excessive Scleral Show?
Treatment of the Underlying Endocrinal Cause
Hypothyroidism & Hyperthyroidism
Treating hypothyroidism will prevent the formation of edema behind the eyeball, which prevents the occurrence of excessive scleral show.
Treating hyperthyroidism will lead to the return of the eyeball to its normal position.
Testing Orbicularis Oculi Muscle
Before performing aesthetic blepharoplasty on elderly persons, the orbicularis oculi muscle should be tested to make sure of its tonicity. If the muscle is too hypotonic, the surgery should be avoided.
Skin and Muscle Resections
The surgeon should be professional and experienced enough to avoid exaggerated shortening of skin and muscle. Suturing the fascia surrounding the eyes should be done correctly to allow the corners of the eye to return to their normal positions.
Too much fat resection will make the septal region between the eyes to swell. The surgeon should remove the right amount of fat to prevent any pulling to the eye structures.
Figure 2 – The intercantal line before and after in pacient with constitutional scleral show
How to Treat Excessive Scleral Show?
Some surgeons believe that excessive scleral show cannot be corrected surgically and that people with the excessive scleral show should learn how to live with it.
However, other authors believe that severe cases can be improved by surgical intervention.
Application of a skin graft to the lid can correct excessive scleral show somehow. It is the same procedure done to correct ectropion. (6)
Certain lifting techniques can be useful in correcting excessive scleral show. For example, lifting the lateral corner of the eye can reduce the tension of the lower eyelid, which can correct the scleral show. In addition, the orbicularis muscle can be lifted too, especially in elderly persons. (7)
Blepharocanthoplasty & Browlift
Blepharocanthoplasty combined with browlift can be the ultimate solution for the most complicated cases of excessive scleral show. They depend on correcting the position of the eyelids, which subsequently corrects the whole eye and makes it look healthier and younger. (8)
Hyaluronic Acid Fillers
People who have scleral show due to hereditary and post-operative causes can be treated with hyaluronic acid fillers. The procedure depends on elevating the lateral corner of the eye to correct the scleral show. It is also recommended for people who suffer from complications of blepharoplasty.
The main problem of using hyaluronic acid fillers in correcting scleral show is the risk of developing fibrosis locally. The whole procedure should be done by a professional surgeon after assessing the case. (9)
Figure 3 – Changes of lower scleral show in eight patients. In the left column are pre-operative photos. In the central column are pre-operative photos with temporary aponeurotic advancement by vascular clips. In the right column are post-operative photos of the primary gaze position. The vertical level and size of the photos of each patient in the left, central, and right columns were adjusted based on the intercanthal line and the square scale. (A, B) Unilateral lower scleral show in patients with unilateral decompensated aponeurotic blepharoptosis. (C, D) Bilateral lower scleral show in patients with bilateral decompensated aponeurotic blepharoptosis. (E, F) Bilateral scleral show in patients with bilateral compensated aponeurotic blepharoptosis and the features of Mongoloid eye. (G, H) Bilateral scleral show in patients with bilateral compensated aponeurotic blepharoptosis (the goggled eye).
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1. Prendergast PM. Facial proportions. In: Erian A, Shiffman MA, editors. Advanced Surgical Facial Rejuvenation. Berlin, Germany: Springer-Verlag; 2012. pp. 15–22.
2. Young TL, Guo XD, King RA, Johnson JM, Rada JA. Identification of genes expressed in a human scleral cDNA library. Mol Vis. 2003;9:508-514. Published 2003 Oct 7.
3. Bernardi C, Dura S, Amata PL. Treatment of orbicularis oculi muscle hypertrophy in lower lid blepharoplasty. Aesthetic Plast Surg. 1998;22(5):349-351. doi:10.1007/s002669900215
4. Litwin, A. S., & Malhotra, R. (2014). Comment on ‘Acute thyroid eye disease (TED): principles of medical and surgical management’. Eye (London, England), 28(5), 632. https://doi.org/10.1038/eye.2013.292
5. Matsuo K, Kondoh S, Kitazawa T, Ishigaki Y, Kikuchi N. Pathogenesis and surgical correction of dynamic lower scleral show as a sign of disinsertion of the levator aponeurosis from the tarsus. Br J Plast Surg. 2005;58(5):668-675. doi:10.1016/j.bjps.2004.12.032
6. Kim HJ, Hayek B, Nasser Q, Esmaeli B. Viability of full-thickness skin grafts used for correction of cicatricial ectropion of lower eyelid in previously irradiated field in the periocular region. Head Neck. 2013;35(1):103-108. doi:10.1002/hed.22934
7. Di Stadio A. Eyelid lifting for ectropion and scleral show in facial palsy disease. ORL J Otorhinolaryngol Relat Spec. 2014;76(6):329-335. doi:10.1159/000369623
8. Seckel BR, Kovanda CJ, Cetrulo CL Jr, Passmore AK, Meneses PG, White T. Laser blepharoplasty with transconjunctival orbicularis muscle/septum tightening and periocular skin resurfacing: a safe and advantageous technique. Plast Reconstr Surg. 2000;106(5):1127-1145. doi:10.1097/00006534-200010000-00024
9. Bravo, B., Totti, J., Gelpi, B., Bianco de Souza, S., & Bravo, L. G. (2018). Use of Hyaluronic Acid Fillers to Correct Scleral Show: A Review of Technique. The Journal of clinical and aesthetic dermatology, 11(6), 38–40.