The human eye is a complex and fascinating organ. From focusing light to perceiving color, it allows us to experience the world in rich detail. However, certain anatomical variations and conditions can affect its appearance, sometimes causing concern. One such variation is “white without pressure,” more commonly known as scleral show. This refers to the visible white portion of the eye, the sclera, located either above or below the iris (the colored part of the eye) when the eye is in a relaxed, forward-facing position.
Understanding the Anatomy of the Eye
Before diving into the specifics of scleral show, it’s important to understand the basic anatomy of the eye. The eye is comprised of several key components, each playing a crucial role in vision.
The sclera, often referred to as the “white of the eye,” is a tough, fibrous outer layer that provides protection and support to the delicate inner structures. It extends from the cornea (the clear front part of the eye) to the optic nerve at the back. The cornea is responsible for refracting light as it enters the eye, playing a vital role in focusing.
The iris, the colored part of the eye, controls the amount of light that enters the pupil, the black circular opening in the center. The iris muscles contract or relax to adjust the pupil size, adapting to varying light conditions.
Within the eye, the lens further focuses the light onto the retina, a light-sensitive layer at the back of the eye. The retina contains photoreceptor cells (rods and cones) that convert light into electrical signals. These signals are then transmitted to the brain via the optic nerve, allowing us to perceive images.
Finally, the eyelids and surrounding tissues protect the eye from injury and dryness. They also play a role in the aesthetic appearance of the eye area.
What is Scleral Show?
Scleral show is characterized by the visibility of the sclera above or below the iris. While it’s often considered a cosmetic concern, it can sometimes be associated with underlying medical conditions. The location of the scleral show is important.
Inferior Scleral Show refers to the visibility of the white of the eye below the iris. This is often more common and can be a natural variation, particularly in younger individuals. However, it can also be associated with certain facial features and aging.
Superior Scleral Show, where the sclera is visible above the iris, is generally less common and more often raises concern. It’s more likely to be associated with underlying medical conditions, trauma, or surgical complications.
Causes of Scleral Show
Numerous factors can contribute to the development of scleral show. These can range from natural anatomical variations to more serious medical conditions.
Anatomical Variations
Some individuals are simply born with a slightly larger distance between the lower eyelid margin and the iris, resulting in inferior scleral show. Similarly, variations in the positioning of the eyeball within the eye socket can also contribute. In some cases, the position of the eye is naturally further back in the socket (relative to the eyelid margin), or the angle of the orbital bone gives the appearance of scleral show.
Aging
As we age, the skin and tissues around the eyes lose elasticity, leading to sagging and drooping. This can cause the lower eyelid to descend, exposing more of the sclera. The loss of volume in the midface can also contribute to this effect by reducing support for the lower eyelid.
Thyroid Eye Disease (Graves’ Disease)
Thyroid eye disease, often associated with Graves’ disease (an autoimmune disorder affecting the thyroid gland), can cause inflammation and swelling of the tissues around the eyes. This can lead to proptosis (bulging of the eyeballs) and retraction of the eyelids, resulting in both superior and inferior scleral show. This condition is a significant cause of noticeable scleral show and often requires medical intervention.
Eyelid Retraction
Eyelid retraction occurs when the eyelids are pulled back, exposing more of the sclera than normal. This can be caused by thyroid eye disease, but also by other conditions such as:
- Nerve damage: Damage to the nerves that control eyelid movement can lead to retraction.
- Surgical complications: Previous eyelid surgery (such as blepharoplasty) can sometimes result in eyelid retraction.
- Scarring: Scarring around the eyelids can cause them to pull back.
Trauma
Trauma to the eye or surrounding tissues can cause damage to the muscles and ligaments that support the eyelids, leading to scleral show. This can occur as a result of blunt force injuries, cuts, or burns.
Proptosis
Proptosis refers to the abnormal protrusion of the eyeball from the eye socket. In addition to thyroid eye disease, proptosis can be caused by tumors, infections, or other conditions that increase pressure behind the eye.
Facial Asymmetry
In some cases, subtle facial asymmetry can make scleral show more noticeable on one side of the face than the other.
Diagnosis of Scleral Show
Diagnosing the cause of scleral show involves a thorough examination by an ophthalmologist or oculoplastic surgeon. The examination typically includes:
- Medical history: The doctor will ask about your medical history, including any underlying conditions, previous surgeries, and medications you are taking.
- Visual acuity testing: This test measures your ability to see clearly at different distances.
- Eye movement assessment: This evaluates the movement of your eyes in all directions to identify any muscle imbalances or nerve damage.
- Eyelid measurements: The doctor will measure the position of your eyelids and the amount of sclera that is visible.
- Slit-lamp examination: This allows the doctor to examine the structures of the eye under high magnification.
- Exophthalmometry: This measures the degree of proptosis (if present).
- Imaging studies: In some cases, imaging studies such as CT scans or MRI scans may be necessary to evaluate the underlying cause of the scleral show.
Treatment Options for Scleral Show
The treatment for scleral show depends on the underlying cause. In cases where the scleral show is mild and not causing any functional problems, treatment may not be necessary. However, if the scleral show is causing discomfort, dryness, or cosmetic concerns, several treatment options are available.
Artificial Tears and Lubricants
Artificial tears and lubricating ointments can help to relieve dryness and irritation caused by scleral show. These products are available over-the-counter and can be used as needed.
Eyelid Surgery
Eyelid surgery, also known as blepharoplasty, can be used to correct eyelid retraction and reposition the eyelids to reduce the amount of visible sclera. There are different types of blepharoplasty procedures, depending on the specific cause of the scleral show. For example:
- Lower eyelid retraction repair: This procedure involves releasing the lower eyelid retractors and repositioning the eyelid margin to a more normal position. This may involve the use of a spacer graft to support the eyelid.
- Upper eyelid retraction repair: This procedure involves lengthening the upper eyelid retractors to lower the eyelid margin.
Thyroid Eye Disease Treatment
If the scleral show is caused by thyroid eye disease, treatment will focus on managing the underlying thyroid condition. This may involve medications, radiation therapy, or surgery. In addition, specific treatments for the eye disease may include:
- Steroids: Steroids can help to reduce inflammation and swelling around the eyes.
- Orbital decompression surgery: This procedure involves removing bone from the eye socket to create more space for the swollen tissues.
- Eyelid surgery: Eyelid surgery can be used to correct eyelid retraction and proptosis.
Botulinum Toxin Injections (Botox)
In some cases, botulinum toxin injections can be used to temporarily relax the muscles that retract the eyelids, reducing the amount of sclera that is visible. However, this is a temporary solution and the effects typically last for several months.
Spacer Grafts
In cases of significant lower eyelid retraction, a spacer graft may be required to support the eyelid and prevent it from drooping. Spacer grafts are typically made from cartilage, skin, or synthetic materials.
Living with Scleral Show
For some individuals, scleral show is a minor cosmetic concern that does not significantly impact their quality of life. However, for others, it can lead to self-consciousness and anxiety. In addition to seeking medical treatment, there are several things you can do to cope with scleral show:
- Makeup: Makeup can be used to camouflage the scleral show and make it less noticeable. Using a light-colored eyeliner on the waterline of the lower eyelid can help to create the illusion of a smaller scleral show.
- Sunglasses: Sunglasses can help to protect the eyes from the sun and reduce glare, which can make the scleral show less noticeable.
- Counseling: If the scleral show is causing significant emotional distress, counseling can help you to cope with your feelings and improve your self-esteem.
In conclusion, while the presence of white showing beneath the iris can be a normal variation, it is important to understand the potential underlying causes. Scleral show can be a result of aging, facial structure, or more serious conditions like thyroid eye disease. If you are concerned about scleral show, consult with an eye care professional for proper diagnosis and management.
What exactly is “white without pressure” or scleral show in the eye?
Scleral show refers to the visible white part of the eye (sclera) that appears below the iris (the colored part of the eye) when the eyes are in a neutral, relaxed position. Ideally, the lower eyelid margin should rest just at or slightly above the lower edge of the iris. When it’s positioned lower, exposing the sclera underneath, that’s considered scleral show or, informally, “white without pressure,” suggesting the lower lid isn’t naturally positioned high enough to cover the sclera without needing to be actively raised.
It’s important to note that a small amount of scleral show can be normal and not necessarily a cause for concern, especially if it has always been present. However, a noticeable increase in scleral show or its presence in one eye but not the other might indicate an underlying medical or cosmetic issue requiring evaluation. The amount of scleral show considered aesthetically pleasing varies culturally and individually.
What are the common causes of scleral show?
Several factors can contribute to the development of scleral show. One of the most common is age-related changes, as the tissues supporting the lower eyelid weaken over time. This weakening can cause the lower eyelid to droop downwards, leading to increased visibility of the sclera beneath the iris. Furthermore, certain surgical procedures, such as lower blepharoplasty (eyelid surgery), can sometimes inadvertently cause or worsen scleral show if too much skin or muscle is removed.
Besides aging and surgery, other potential causes include thyroid eye disease (Graves’ ophthalmopathy), which can cause retraction of the eyelids. Additionally, trauma to the eye or surrounding area, certain neurological conditions, and even wearing contact lenses over a prolonged period can contribute to the development of scleral show. It’s important to consult with an ophthalmologist or oculoplastic surgeon to determine the specific cause in your individual case.
Is scleral show just a cosmetic concern, or can it indicate a medical problem?
While scleral show is often considered a cosmetic concern, as it can alter the overall appearance of the eyes and face, it can also be a sign of an underlying medical condition. If the scleral show is significant or rapidly developing, it’s crucial to rule out any medical causes, such as thyroid eye disease. In cases of thyroid eye disease, the eyelids can retract, leading to prominent scleral show and other symptoms like double vision and dry eyes.
Even if the scleral show is primarily a cosmetic concern, it can still impact an individual’s self-esteem and confidence. Furthermore, significant scleral show can sometimes contribute to dry eye symptoms, as the lower eyelid may not be able to properly support tear drainage and maintain adequate lubrication of the eye surface. Therefore, even if not directly indicative of a serious medical issue, addressing scleral show can improve both appearance and comfort.
How is scleral show diagnosed?
Diagnosis of scleral show typically begins with a thorough eye examination by an ophthalmologist or oculoplastic surgeon. The doctor will assess the position of the eyelids, the amount of visible sclera, and the overall health of the eyes. They will also inquire about your medical history, any previous eye surgeries, and any symptoms you may be experiencing, such as dry eyes, double vision, or eyelid discomfort.
In some cases, further diagnostic testing may be necessary to determine the underlying cause of the scleral show. This might include blood tests to check for thyroid abnormalities or imaging studies, such as CT scans or MRIs, to rule out other potential medical conditions affecting the eye and surrounding structures. Photographic documentation is also often used to track the progression of scleral show over time and to assess the effectiveness of any treatment.
What are the treatment options for scleral show?
Treatment options for scleral show vary depending on the severity of the condition and the underlying cause. Mild cases that are primarily cosmetic may not require any treatment at all. However, if the scleral show is causing discomfort or impacting vision, or if it is due to an underlying medical condition, treatment may be necessary. Nonsurgical options include lubricating eye drops or ointments to alleviate dry eye symptoms associated with increased scleral exposure.
For more significant scleral show, surgical correction is often the most effective treatment. Surgical options include procedures to reposition the lower eyelid, such as a canthoplasty or canthopexy, which tighten the lower eyelid and raise its position. Additionally, a midface lift can indirectly improve lower lid position. In cases where scleral show is caused by thyroid eye disease, treatment of the underlying thyroid condition is crucial, and surgery may be needed to address eyelid retraction after the thyroid condition is stabilized.
Is it possible to prevent scleral show?
While not all causes of scleral show are preventable, there are some measures you can take to reduce your risk. Maintaining healthy lifestyle habits, such as avoiding smoking and protecting your eyes from excessive sun exposure, can help to preserve the elasticity of the skin around your eyes and reduce the risk of age-related eyelid drooping. Additionally, using lubricating eye drops regularly, especially if you experience dry eyes, can help to keep your eyes comfortable and reduce irritation.
If you are considering any type of facial surgery, it’s important to choose a qualified and experienced surgeon who is knowledgeable about the potential complications associated with eyelid surgery, including scleral show. Discuss your concerns with your surgeon beforehand and ensure that they take appropriate measures to minimize the risk of developing scleral show as a result of the procedure. Promptly addressing any underlying medical conditions that could contribute to scleral show, such as thyroid eye disease, is also crucial.
What are the risks associated with surgical correction of scleral show?
As with any surgical procedure, there are potential risks associated with surgical correction of scleral show. These risks can include infection, bleeding, scarring, and asymmetry. It’s also possible that the surgery may not achieve the desired result, and further surgery may be necessary. In some cases, patients may experience temporary or permanent changes in sensation or vision after surgery.
Choosing a highly skilled and experienced oculoplastic surgeon can minimize the risks associated with scleral show surgery. It’s important to have a thorough discussion with your surgeon about the potential risks and benefits of the procedure before making a decision. Following your surgeon’s post-operative instructions carefully is also crucial for ensuring optimal healing and minimizing the risk of complications.