Eyelid surgeries and dry eye

[Rebecca Petris]

If you have dry eye and you want to get elective eyelid surgery, IMO your best bet is (1) find a good oculoplastic surgeon - NEVER simply a plastic surgeon; and (2) get them in conversation with your cornea specialist.. Why?

• "Close interaction of the eyelids, tear film and ocular surface makes effective lubrication susceptible to surgery-related changes "
• "As a result, a thorough knowledge of the eyelids' complex anatomical structure and function is mandatory to prevent inadvertent injury and to ensure effective tear film function post-surgery"

Dry eye after lid surgery is overlooked: "Lid surgery causing DED onset or worsening preoperative dry eye is common but underdiagnosed"

We don't necessarily even have reliable numbers: A large study showed 26.5% of blepharoplasty patients had dry eye. Another study showed only 8% who already had dry eye got worse after surgery.

It's not just about the danger of "short lids" where they don't fully meet afterwards. Any impact on the blinking function can mess with your tear film in multiple ways, so if you already have dry eye, you want to be really careful going into a lid surgery.

Previous LASIK and current HRT are some of the specific risk factors for dry eye after lid surgery.


TFOS DEW II Iatrogenic Dry Eye Report

4.4.3 Lid surgeries

4.4.3.1 Incidence and prevalence

Lid surgery causing DED onset or worsening preoperative dry eye [265–269], is common but underdiagnosed [270]. Prischmann et al. documented DED in 26.5% of 892 patients following blepharoplasty (the excision of skin, orbicularis oculi muscle and/or orbital fat) [271]. In a retrospective study by Saadat et al., only 5 of 60 patients (8.0%) with preoperative DED worsened following blepharoplasty [267]. Risk factors for dry eye symptoms following blepharoplasty include Bell's phenomenon, previous LASIK surgery, concurrent upper and lower blepharoplasty, skin-muscle flap blepharoplasty, hormone replacement therapy use, preoperative scleral show and postoperative lagophthalmos [271,272]. After ptosis surgery, both normal tear function [273–279] and dry eye [280–286] have been reported. 4.4.3.2 Mechanism


Close interaction of the eyelids, tear film and ocular surface makes effective lubrication susceptible to surgery-related changes [266,270,287–289]. As a result, a thorough knowledge of the eyelids' complex anatomical structure and function is mandatory to prevent inadvertent injury and to ensure effective tear film function post-surgery [269,290,291]. Lid surgery can seriously affect eyelid closure or position [288,292,293]. Symptoms occur secondary to exposure, leading to an increased tear evaporation rate and drying of the ocular surface, especially in poor Bell's phenomenon [291,294]. The cause of dysfunctional eyelid closure may be readily diagnosed in the presence of lagophthalmos, scleral show or ectropion [290,295]. Poor postoperative eyelid closure results from skin and/or muscle deficiency (anterior lamella) or intrinsic eyelid stiffness secondary to cicatricial changes within the middle and posterior lamella (orbital septum, lid retractors, conjunctiva) [290,291]. Eyelid dysfunction may also relate to the onset and persistence of chemosis and thus increase the risk of corneal and conjunctival exposure [288,296,297]. Dysfunction and/or dehiscence of the lateral canthus is another source of symptomatic eyelid closure disorder and an overlooked postblepharoplasty complication [288,295].

Although one study of 16 patients showed no significant compromise of eyelid kinematics following blepharoplasty [298], other authors have reported sluggish lid closure [299], incomplete reflex blink [269] and decreased blink rate [268] following partial resection of the orbicularis oculi with injury to the innervation. Blink alteration might account for reduced outflow of lipid secretion from the meibomian glands [41,300,301], for poor mechanical tear film distribution and for reduced tear drainage with impaired debris removal from the ocular surface [272,302]. After ptosis surgery, a widened palpebral fissure with a greater ocular surface exposure, increased efficacy of the lacrimal pump due to greater lid excursion, and altered ocular surface sensation influencing the blink reflex may predispose patients to, or intensify, dry eye [281,282,285,303].

The Fasanella-Servat procedure for ptosis correction involves tarsal resection and thus a loss of meibomian glands [284,304]. Tumor resection and lid reconstruction using a modified Hughes tarsoconjunctival flap results in a complete loss of meibomian glands in the excision area of the lower eyelid and a loss of glands in the tarsoconjunctival flap of the upper eyelid, as confirmed by meibography [305]. Injury during surgery can occur, especially to a prolapsed lacrimal gland [290,291], a condition observed in about 60% of patients undergoing blepharoplasty [306] and mostly in those with multiple previous eyelid surgeries [307,308]. Cosmetic lateral canthoplasty may cause outward redirection of normal lacrimal ductule orifices by externalization of conjunctival tissue or a direct injury to the lacrimal ductules, leading to fistula formation and lacrimal dysfunction [307,309]. In ptosis procedures via conjunctival incisions, damage to goblet cells and accessory lacrimal glands may affect tear quality or quantity; other mechanisms in ptosis surgery conducted via the skin include kinking of lacrimal ductules, especially those originating from the palpebral lobe [280,285]. 4.4.3.3 Recommendations for management

Any signs of ocular surface problems, such as DED and blepharitis should be addressed preoperatively [269,310]; after surgery, a curative treatment typically comprises two steps: the first conservative step involves medical treatment and the second step includes surgery.

Medical management of DED following lid surgery utilizes artificial tears and lubrication during the night [268,270,272,297,311]. Nonpreserved products are recommended [269]. Medical options also include topical steroids and cyclosporine A [268,272,310]. Punctal occlusion could be considered in case of treatment failure [272]. A perioperative intravenous dose of systemic corticosteroids may also curtail the inflammatory response after surgery [268,288]. Chemosis can be treated with cold compresses, head elevation, massage, extra lubrication and eye patching [296,312]. Prolonged chemosis requires the prescription of steroid eye drops, topical phenylephrine and a tapering dose of systemic corticosteroids [288,290,311,312]. Conservative treatment of lagophthalmos and mild lower eyelid retraction involves massage with a topical steroid ointment as well as vertical eyelid traction, muscular re-education and taping [269,272,296,313].

More persistent symptoms may require surgical intervention such as tarsorrhaphy and lower lid repositioning including firm canthal tendon anchoring and lateral canthal reconstruction [268,269,295,309,312]. Surgical treatment also includes eyelid scar release and interpositional skin grafting [269,296,297,313].

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