Ptosis after laser in situ keratomileusis

Periorbital aesthetic concerns in patients seeking corneal refractive surgery

Purpose:

To report the frequency of periorbital aesthetic abnormalities in patients undergoing refractive surgery and to report the ability of the patient and the refractive surgeon in picking up these findings compared to the oculoplastic surgeon.

Methods:

Single-center, prospective observational case series. All patients underwent standard pre-operative work-up for refractive surgery, answered a study questionnaire, and underwent face photographs (with and without glasses). The patient, the refractive, and the oculoplastic surgeons evaluated the photographs to categorize the concerns as none, presence of ptosis, tear trough deformity, scleral show, and others. The findings of the oculoplastic surgeon were taken as the standard of reference.

Results:

The photographs of 121 patients were analyzed. The mean age was 25.76 ± 3.75 years and 72% were males. The main indication for surgery was to eliminate dependency on glasses in a majority (76%) followed by cosmesis in 23%. The oculoplastic surgeon noted tear trough deformity in 14 (11.5%) cases, scleral show in 51 (42.1%), ptosis in 35 (28.9%), and other findings in 45 (37.1%). When the symmetrical scleral show was excluded, the patient picked up aesthetic concerns in only 8.26%, the refractive surgeon in 14% as compared to 39% by the oculoplastic surgeon (P < 0.01).

Conclusion:

Periorbital aesthetic significant findings were noted in 39% of the patients undergoing corneal refractive surgery when assessed by an oculoplastic surgeon. The refractive surgeon was able to pick up less than 50% of these. We recommend a basic aesthetic initial evaluation prior to refractive surgery and photographic documentation, especially in cosmetically aware patients.

Incidence and risk of ptosis following ocular surgery: a systematic review and meta-analysis

OBJECTIVE

We conducted a systematic review and meta-analysis to evaluate the incidence and risk factors of ptosis following ocular surgery.

METHODS

PubMed, Embase, and Cochrane Library were searched for articles that assessed the incidence or risk factors of ptosis following ocular surgery up to October 2017. We used a fixed effects model to calculate a pooled estimate of incidence, with subgroup analyses to evaluate the effect of different variables. The relative risks (RRs) or odds ratios (ORs) and 95% confidence intervals (CIs) for all available factors were calculated using the fixed effects models.

RESULTS

A total of 16 studies on 2856 eyes were analyzed, including 3 randomized controlled trials (RCTs) and 13 cohort studies. The overall incidence of ptosis following ocular surgery was 11.4% (95% CI 10.1-12.8%). Subgroup analyses showed that the region and the surgery type were significantly associated with the incidence of postoperative ptosis. Men were less likely to get postoperative ptosis than women (OR 0.62; 95% CI 0.43-0.89). However, age (OR 0.77; 95% CI 0.48-1.23), side (OR 1.37; 95% CI 0.84-2.25), type of anesthesia (OR 0.57; 95% CI 0.16-2.05), prior surgery (OR 1.09; 95% CI 0.64-1.83), bridle suture (OR 2.04; 95% CI 0.94-4.42), or combined surgery (OR 0.95; 95% CI 0.58-1.57) did not significantly change the risk of ptosis following ocular surgery.

CONCLUSION

More than one in ten patients who undergo ocular surgery will develop ptosis. Different regions and surgery types may influence the occurrence of this abnormality. Female gender is a risk factor for development of postoperative ptosis.

Influence of upper and temporal transconjunctival sclerocorneal incision on marginal reflex distance after cataract surgery

Background

Ptosis incidence following cataract surgery is reduced with a recently developed phacoemulsification technique using a small incision. However, it remains uncertain whether an upper transconjunctival sclerocorneal incision can cause minor blepharoptosis. In the present prospective study, patients underwent cataract surgery with either an upper or temporal 2.4-mm transconjunctival sclerocorneal incision. We measured the marginal reflex distance 1 (MRD1) preoperatively and postoperatively, and compared these measurements between the two different incision types. Further we explored the risk factors of the postoperative MRD1 reduction.

Methods

The study population included patients who underwent cataract surgery on both eyes at Aichi Medical University between October 2013 and September 2015. In each patient, one eye was operated using an upper 2.4-mm transconjunctival sclerocorneal incision, and the other with a temporal incision. We prespecified that an MRD1 difference of ≥0.5 mm between the pre- and post-surgical measurements indicated postoperative ptosis, which was a strict criterion. MRD1 was measured using digital photography, and we calculated the difference between the preoperative and postoperative MRD1 values. This change in MRD1 was compared between the groups with different incision locations. The change in MRD1 was analyzed by using the multivariate regression model including incision position (temporal or upper), preoperative MRD1, and preoperative distance between medial and lateral canthi.

Results

We assessed data from a total of 34 patients. The mean change in MRD1 from pre-operation to post-operation measurements was −0.26 ± 0.93 with the temporal incision and −0.24 ± 0.86 with the upper incision. The mean difference in the change in MRD1 between the different two incision types was −0.02, with a 95 % CI of −0.24 to 0.20, establishing equivalence between these incision types. The multivariate regression analysis showed that the preoperative MRD1 was significantly associated with the reduction of MRD1 after surgery (p = 0.034).

Conclusions

Cataract surgery using upper and temporal 2.4-mm transconjunctival sclerocorneal incisions are clinically equivalent with regards to change in MRD1, and neither incision type caused critical postoperative ptosis. The longer preoperative MRD1 was significantly associated with the reduction of MRD1 after surgery.

Trial registration

Current Controlled Trials UMIN000022310. Retrospectively registered 14 May 2016.

Electronic supplementary material

The online version of this article (doi:10.1186/s12886-016-0286-1) contains supplementary material, which is available to authorized users.

Timing of eyelid surgery in the setting of refractive surgery: preoperative and postoperative considerations

PURPOSE OF REVIEW

With any operation, the surgeon should be aware of predisposing factors that may lead to postoperative complications. Here we review the major factors due for consideration in both eyelid and refractive eye surgery, preoperatively and postoperatively, and consider the importance of timing to lessen the inherent risks of each procedure.

RECENT FINDINGS

Refractive surgery can affect corneal sensation by ablating the corneal nerves and can cause serious corneal complications if followed by eyelid surgery. Studies find that patients undergoing eyelid surgery have a change in astigmatic error of as much as 1.0 D during the first 3 postoperative months. The longest reported follow-up period of astigmatic changes in adult patients following eyelid ptosis surgery is 1 year and a considerable number of patients had a change in cylinder of up to 0.3 D postoperatively. Blepharoplastic surgery is also reported to cause astigmatic changes postoperatively, significantly more if entire fat pads are removed.

SUMMARY

To prevent corneal exposure, postrefractive eyelid surgery should be performed at least 6 months after lamellar ablative procedures and at least 3 months after surface ablative procedures. Refractive surgery revision may be necessary when astigmatic error occurs and should be carried out no earlier than 6 months postoperatively to allow for stabilization. Cosmetic blepharoplasty with fat pad debulking should be performed at least 6 months prior to refractive surgery to allow for any potential corneal astigmatic change to stabilize, for regained strength in the orbicularis, and for improved tear film distribution.

The incidence of ptosis following extracapsular and phacoemulsification surgery: comparison of two prospective studies and review of the literature

We prospectively compared 120 patients who underwent either phacoemulsification or extracapsular cataract (ECCE) surgery to establish the incidence of postoperative ptosis between the two techniques. Of the 120 patients, 60 underwent ECCE (unpublished data 1989) and 60 had phacoemulsification. Data was collected prospectively on upper and lower margin reflex distance, upper lid skin crease and levator function, preoperatively and 6 weeks postoperatively. Photographs were taken pre and postoperatively and examined by a blinded observer. At 6 weeks, ptosis was present in 18% of ECCE patients compared with 0% in the phacoemulsification group. By changing from ECCE to phacoemulsification the incidence of postoperative ptosis has reduced. The possibility to induce postoperative ptosis remains, potential mechanisms are discussed.

Prospective Randomized Double-Masked Trial to Evaluate Perioperative Pain Profile in Different Stages of Simultaneous Bilateral LASIK

PURPOSE

To evaluate the perioperative pain profile in simultaneous bilateral LASIK.

METHODS

Fifty consecutive Chinese patients undergoing simultaneous bilateral LASIK were randomly allocated to have either the right or left eye operated first. The pain scores for each eye at speculum placement, microkeratome cut, laser ablation, and at 15, 30, and 45 minutes after the procedure were recorded. In addition, an overall score for the whole operation was evaluated immediately after the procedure for each eye. Comparisons between eyes and among different stages of the procedures were analyzed.

RESULTS

The second eye was significantly more painful than the first eye at the stage of speculum placement and microkeratome pass (P < 0.001). Laser ablation was the least painful stage for both eyes. There were no statistical differences in pain scores for the postoperative period.

CONCLUSION

Higher pain scores were associated with the stages involving eyelid manipulation. In patients with small palpebral fissures where stretching of the eyelid structures are anticipated, supplementary anesthesia for the lid region should be considered when required.