Eyelid Surgery in Patients with Thyroid Eye Disease (TED): Systematic Review and Meta-Analysis

Eyelid surgery remains the cornerstone of rehabilitative treatment in patients with thyroid eye disease (TED), addressing both corneal exposure and facial disfigurement that accompany this autoimmune orbital disorder.Over the past five decades, rapid advancements in oculoplastic techniques, surgical sequencing, and biologic therapies have transformed the management of eyelid malpositions in TED.This systematic review and meta-analysis comprehensively evaluated literature from 1975 to 2025, integrating data from 28 studies encompassing 6,745 patients and 12,928 eyelids.The pooled mean improvement in upper eyelid position as margin reflex distance (MRD1) was -3.12 mm (95% CI, -3.48 to -2.77), while lower eyelid correction (ΔMRD2) averaged -1.89 mm (95% CI, -2.24 to -1.56).The overall patient satisfaction rate was 88.4%, with a recurrence rate of 13.7% and complication rate of 9.6%.Levator aponeurosis recession produced the greatest eyelid lowering, whereas spacer grafts and Müller's muscle recession offered superior aesthetic contouring with lower recurrence.Surgeries performed during the inactive phase of TED, particularly following orbital decompression, demonstrated significantly improved outcomes (p < 0.05).The evidence underscores a paradigm shift toward precision-based, patient-centered surgery integrating AI-assisted symmetry mapping, 3D-printed grafts, and biologic modulation (e.g.teprotumumab) to optimize outcomes.Modern eyelid reconstruction in TED now balances functional ocular protection and aesthetic restoration, achieving long-term stability and high patient satisfaction.Despite moderate heterogeneity among studies, this meta-analysis confirms that surgical timing, technique selection, and multidisciplinary coordination remain decisive factors for success.Eyelid surgery in TED is thus reaffirmed as a safe, effective, and evolving therapeutic strategy, where art meets evidence to restore both vision and confidence.