Ocular Surface Effects of Blepharoplasty Can be a Real Eye-Opener

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By Danielle Kalberer, OD FAAO, and Natalia Dobrer, OD

Blepharoplasty, also known as an “eyelid lift,” is becoming increasingly popular among aging patients. As the incidence of periorbital plastic surgery continues to increase, so to do questions regarding the impact of these procedures on ocular health. Since the eyelid is responsible for protecting, rewetting, and the cycling of nutrients to the cornea, we need to pay particular attention to the ocular surface implications of anatomical changes. As optometrists, we should have an active role in the preoperative evaluation, patient education, and follow-up care for patients undergoing oculoplastic procedures.

Functional v. Cosmetic Blepharoplasty

It is best to consider blepharoplasty as having two separate components, functional and cosmetic. Functional blepharoplasty is indicated when ptosis or dermatochalasis impairs visual function in some way. Most commonly, peripheral vision is impaired; however, central vision can also be impacted if the ptosis or dermatochalasis is significant. Such an impairment can be detected and quantified by performing a visual field test with and without taping the eyelid(s). Though no standardized visual field test is required, studies have shown that static fields (Humphrey) and kinetic fields (Goldmann) are equally effective in ptosis evaluation.1 If the lid encroaches the pupillary border, this should be noted, and the lid apertures should be measured.2 If ptosis is new or asymmetric, neurologic and neuromuscular ptosis evaluation needs to be performed. (The details of such is outside the scope of this article.)

According to Matthew DelMauro, MD, a Manhattan-based aesthetic plastic surgeon, functional blepharoplasty must address the cause(s) of the patient’s visual impairment: either by excision of excess skin (if dermatochalasis is present) or by repair of the lid-lifting mechanism (if ptosis is present). Ptosis surgery entails correction of the levator or mueller muscle mechanism with or without additional correction of excess skin. In contrast, dermatochalasis correction does not involve manipulation of muscles and is thus less invasive and generally has a faster recovery time.

Cosmetic procedures are analogous to the aforementioned but without the pretext of visual disturbance. In cosmetic blepharoplasty the goals are to redrape skin and redistribute orbital fat in order to improve tired-looking eyes and restore a more youthful facial appearance.

Preoperative

Prior to blepharoplasty, it is important that both the surgeon and the patient have an understanding of the current ocular surface status. Eyecare providers are commonly consulted to work-up prospective surgical patients and provide an assessment, especially if the surgeon is an aesthetic plastic surgeon not an oculoplastic specialist. As optometrists, we generally have access to current and historical ocular health information and thus play a role in transferring this knowledge. This allows for all parties to form appropriate treatment plans and have appropriate expectations.

At the very least, ocular surface integrity and general corneal health should be assessed. Dry eye syndrome (DES) evaluation should include Shirmer testing and tear break-up time (TBUT). Tear osmolarity testing is also appropriate if available. To reduce the likelihood of infection, meibomian gland dysfunction needs to be treated and controlled preoperatively. Be sure to note any impending lower lid ectropion, lid laxity, and inferior scleral show—as patients with these findings are at greater risk for postsurgical ectropion.3,4

If the patient is already being treated for DES, inform the surgeon of previous treatments to better demonstrate the severity. Punctal plug use does not preclude a patient from blepharoplasty, however, plug insertion should be avoided for at least 1-2 weeks preoperatively. This minimizes the risk of plugs dislodging and causing surgical complications since they are at greatest risk of extrusion during the first week after insertion.5

Patients at highest risk for dry eye after blepharoplasty are those with pre-existing corneal conditions, thyroid disease, previous lid surgery, and those with advanced age. Patients with a history of refractive surgery may also be at greater risk. This is attributed to alteration of tear dispersion on the corneal surface which can be exacerbated with additional surgery.6 Contact lens wearers are not at increased risk of complications but should discontinue lens use several days before surgery to ensure maximum corneal health.

Postoperative

Early

Immediately after the procedure, it is normal for patients to experience eyelid edema and bruising. Patients generally apply ice or cold compresses for the first 24-48 hours after surgery (although the exact protocol varies between surgeons). Recovery takes several weeks. Glasses can be worn during this period, but contact lenses should not be used until the swelling has completely resolved (approximately 2-4 weeks). Dailies may be indicated if ocular surface status has changed.3 The exception to this rule is if excessive corneal disruption or abrasion is present postoperatively—temporarily necessitating a bandage contact lens.4

While lid edema exists, it can cause lagophthalmos or other types of irregular eyelid closure. During this period, copious lubrication with artificial tears and ointments should be used to prevent excessive corneal disruption. If lagophthalmos is present, the most common finding is superficial punctate keratitis (SPK) in a linear pattern at the lid margin. The associated symptoms include photophobia, foreign body sensation, blurred vision, and tearing.6

Late

Blepharoplasty permanently alters eyelid anatomy which may or may not cause persistent functional changes. Chronic dry eye symptoms or exacerbation of pre-existing symptoms in the postoperative period are usually caused by “aggressive” surgery in which too much skin was removed or the orbicularis muscle was partially de-innervated. The former leads to lagophthalmos and lid retraction; while the latter interferes with normality and intensity of the blink.6,7

If significant lagophthalmos from overcorrection or lid malposition is still present after several months, a surgical revision may be indicated. For patients with mild incomplete closure is mild, surgical revision may not be necessary, but ocular surface protection practices should be continued. The surgeon may also recommend regular gentle lid massage to assist with loosening overcorrection.4

Management of chronic ocular surface exposure due to surgery does not need to differ from your routine protocol. For an incomplete blink, consider a sleep mask or gentle taping of the lids at night with lubricant gel drops or ointment. For patients who do need further interventions (such as Restasis, punctal plugs, or low dose steroids), no contraindications to using these therapies have been found. It is, however, recommended to wait 4-6 weeks until lid edema has completely subsided to use punctal plugs.6

Surgical Modification for the At-Risk Patient

Since blepharoplasty procedures can be performed by oculoplastic surgeons, plastic surgeons or even dermatologists, the surgeon’s level of knowledge and consideration of the ocular surface can vary. Recommend that the patient sees a reputable surgeon that they feel comfortable working and one who, especially for those at-risk patients, will consider the relevant clinical information you are providing when planning surgery.

According to Dr. DelMauro, both ocular surface disease and pre-existing lid issues should play a role in the surgeon’s decision making. When patients at risk for postoperative dry eye or ectropion undergo cosmetic blepharoplasty, technical modifications must be employed to mitigate the risk. When these techniques were employed in a 2004 study in the Journal of Facial Plastic Surgery, 83% of patients with dry eye symptoms preoperatively had no change after surgery; about 8% had improvement in symptoms; and about 8% had worsening of symptoms.7

In Summary

Patients are constantly searching for ways to restore a more youthful appearance. Blepharoplasty is one route that should be of interest to us as primary eyecare providers. The benefits of cosmetic blepharoplasty include correction of drooping lids and improvement in under-eye “bags.” If a functional repair is performed concurrently, blepharoplasty also results in correction of visual field deficits. For the right patient, this type of procedure can successfully restore a youthful appearance of the eyes and improve quality of life.

All patients (especially those with preexisting ocular surface disease or dry eye syndrome) should be made aware of the potential short- and long-term outcomes in order to manage expectations. Optometrists have the unique opportunity to guide patients and inform surgeons so that surgery achieves the desired look without compromising ocular health integrity.

References:
1. Riemann, Christopher D. “A Comparison of Manual Kinetic and Automated Static Perimetry in Obtaining Ptosis Fields.” Archives of Ophthalmology, American Medical Association, 1 Jan. 2000.
2. Boname, Mary E. “Open Your Eyes to Functional Blepharoplasty.” Review of Optometry, 10 Nov. 2010.
3. Bhattacharjee, Kasturi, et al. “Updates on Upper Eyelid Blepharoplasty.” Indian Journal of Ophthalmology, Medknow Publications & Media Pvt Ltd, July 2017.
4. Oestreicher, James, and Sonul Mehta. “Complications of Blepharoplasty: Prevention and Management.” Plastic Surgery International, Hindawi Publishing Corporation, 2012.
5. Burling-Phillips, Leslie. “Considerations for Lacrimal Occlusion in the Moderate Dry Eye Patient.” American Academy of Ophthalmology, 30 June 2016.
6. Fagien, Steven. “Reducing the Incidence of Dry Eye Symptoms After Blepharoplasty.” Aesthetic Surgery Journal, Oct. 2004, pp. 464–468.
7. Saadat, Daryoush. “Safety of Blepharoplasty in Patients With Preoperative Dry Eyes.” Archives of Facial Plastic Surgery, American Medical Association, 1 Mar. 2004.