Article

DRY EYE DX AND TX

FROM BLEPHAROPLASTY TO OCULAR SURFACE TRAVESTY

In a world driven by instant gratification, a “quick fix” surgery can sometimes seem like the right answer. Upper and lower blepharoplasties are routinely performed to restore cosmesis and overall lid function. With such a small margin of error, these delicate surgeries can be the difference between normal lid apposition and chronic ocular surface disease. This is a case of a 66-year-old Caucasian female who presented to us in tears, complaining of severe pain and photophobia in her right eye that had progressively worsened over time.

Our patient’s surgical history was positive for an upper lid blepharoplasty OD and OS, performed five to six years ago by a general facial plastic surgeon. Her visual acuity was reduced, and gross observation revealed obvious incomplete lid closure OD > OS, with little to no lower lid movement even after forceful closure. In the right eye, biomicroscopy revealed a large, 4mm x 1mm ulcerative lesion in the inferior cornea, with stromal edema but no infiltrates; the left eye exhibited 1+ inferior superficial punctate keratitis (SPK). All other exam findings were normal.

Healing the Ocular Surface

This patient was treated with a therapeutic bandage lens in the right eye combined with a topical antibiotic-steroid every hour for the first day, followed by four times per day for one week. Additionally, preservative-free artificial tears were used every one to two hours OD and OS, and 2,000mg of vitamin C was taken daily by mouth.

At her three-day follow-up visit, she demonstrated 50% improvement in wound closure (Figure 1), and the bandage lens was replaced. At her one-week follow-up visit, she reported significant improvement in signs, symptoms, and vision, and there was only trace inferior SPK with resolving stromal edema. The bandage lens was removed, and the patient was prescribed topical ophthalmic ointment OD and OS every night for one week, with a taper of every other day for two weeks.

Figure 1. Three days post-bandage lens wear. There is significant diffuse corneal staining and an inferior linear epithelial lesion consistent with exposure keratopathy.

Long-term therapy options were discussed, including gels, ointments, moisture chamber goggles, ophthalmic immunomodulators, and autologous serum drops; but ultimately, a second blepharoplasty repair with lateral canthoplasty was required to restore her lid mechanics.

Patient Education Is Key

Blepharoplasty can certainly do wonders to restore the eyes to a more youthful and natural appearance. However, complications such as lid malposition can occur, resulting in chronic exposure keratopathy, stromal scarring, and neurotrophic ulcerative keratitis. Although both patient and eyecare provider may be hesitant to undergo yet another surgery, a thorough discussion including a risk/benefit analysis, consequences of noncompliance, and cost of long-term treatment should help in making the best decision for each case.

As primary eyecare providers, we can educate our patients regarding the benefits of working with an oculoplastic specialist for this type of surgery as well as inform them of our ability to co-manage any post-operative ocular surface complications that may occur. CLS