Unexpected outcomes associated with laser in situ keratomileusis: ptosis, anisocoria, and "curing" of exotropia

Refractive surgery as a treatment tool for strabismus: systematic review

The impact refractive surgery has on preoperative horizontal strabismus is rapidly evolving, and this knowledge can provide valuable clinical context when considering refractive surgery as a treatment for strabismus. 515 studies were identified, of which 26 met the inclusion criteria. Analysis indicated that refractive surgery resulted in an overall decrease in the mean uncorrected postoperative angle of deviation caused partially or fully due to refractive error and highlighted the varied outcome of refractive surgery on nonaccommodative horizontal strabismus with limited evidence to suggest refractive surgery for this type of strabismus. Efficacy of refractive surgery in reducing concomitant horizontal strabismus depends on several factors: type of horizontal ocular deviation, patient age, and extent of refractive error. Refractive surgery can be an effective treatment for refractive accommodative horizontal strabismus in patients with stable, mild to moderate myopia or hyperopia and should be considered with careful patient selection for optimum outcome.

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.

Strabismus following implantable anterior intraocular lens surgery

Strabismus in adults is increasing and has recently become an important focus of attention due to the development of refractive surgery techniques. In this case, permanent strabismus developed in a woman with previous high myopia after implantable anterior intraocular lens surgery. An ophthalmologic examination revealed the presence of a lens which was placed slightly downward in relation to the center of visual axis in the anterior chambers and up-drawn pupils in both eyes. The prismatic effect due to lens decentration may be the main cause of strabismus. Therefore, we suggest precise intraocular lens insertion and placement technique during surgery as well as careful ophthalmologic assessment including cover/uncover tests in all candidates for refractive surgery and full ocular motility evaluation if there is any doubt about binocular issues.

Diplopia after laser in situ keratomileusis (LASIK) in a patient with a history of strabismus

In patients with a history of strabismus, refractive surgery can result in decompensation of ocular alignment, with subsequent diplopia. Refractive surgery in the management of strabismus has been described, although it remains controversial. We present a young adult with past history of strabismus surgery and new-onset diplopia after refractive surgery. Binocular diplopia was treated surgically with laser in situ keratomileusis.

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.

Refractive surgery in children

PURPOSE OF REVIEW

To evaluate recent literature regarding indications and outcomes for refractive surgery in children, including laser in-situ keratomileusis, laser epithelial keratomileusis, photorefractive keratectomy, and refractive intraocular lens placement.

RECENT FINDINGS

Refractive surgery in children is controversial. Recent publications have reported refractive surgery to treat strabismus and both ametropic and anisometropic amblyopia. Questions remain as to the age at which to perform the surgery, and which specific procedure to perform. Choice of technique depends on the clinical situation.

SUMMARY

Refractive surgery is an option for children with amblyopia and strabismus who fail treatment with spectacles or contact lenses. Prospective controlled studies are needed, and longer follow-up will answer questions about the utility and safety of refractive surgery in children.

Advances in the diagnosis and treatment of ptosis

PURPOSE OF REVIEW

The surgical correction of blepharoptosis, both congenital and acquired, has been intensively examined and reported on for many years. This paper reviews recent publications on basic science, evaluation, technique modifications, and innovative materials in the care of ptosis patients.

RECENT FINDINGS

The frontalis suspension technique is a commonly performed surgical correction of congenital blepharoptosis, used widely in the repair of ptosis with poor levator function. The repair typically includes using either tissue such as autologous or banked fascia lata or permanent suture material. The procedure involves connecting the motor unit (frontalis muscle) and the upper eyelid. Authors have recently reintroduced the technique of a dynamic frontalis muscle flap tunneled into the eyelid that directly attaches to the tarsal plate.Patients presenting with symptomatic blepharoptosis due to disinsertion or thinning of the levator aponeurosis require surgical repair. Multiple groups have tended toward a minimally invasive approach directed specifically at the levator aponeurotic defect. Proposed advantages of a small eyelid incision (8-13 mm) include less local anesthetic and tissue distortion, less ecchymosis and edema, decreased operative times, a shortened recovery period, and improved surgical results.

SUMMARY

Surgical correction of congenital blepharoptosis may be performed with autologous fascia lata, cadaveric allograft, or permanent suture material. The use of a frontalis muscle advancement flap is elegantly designed; however, its role in clinical practice remains to be defined. Advancement of the levator aponeurosis for senile blepharoptosis may be preformed via a minimally invasive small incision approach. Patients benefit with decreased operative time, edema, ecchymosis, and recovery times.