A conservative blepharoplasty may be a means of alleviating dry eye symptoms

Is Blepharoplasty Cost-effective? Utility Analysis of Dermatochalasis and Cost-effectiveness Analysis of Upper Eyelid Blepharoplasty

PURPOSE

This cross-sectional prospective study measured utility values of upper eyelid dermatochalasis to quantify its impact on quality of life and assess cost-effectiveness of upper blepharoplasty.

METHODS

Utility of dermatochalasis was assessed using the standard reference gamble and time trade-off methods, with dual anchor points of perfect eye function and perfect health. The utility value obtained was used to create a Markov model and run a cost-effectiveness analysis of blepharoplasty as a treatment for dermatochalasis while utilizing the societal perspective.

RESULTS

One hundred three patients with dermatochalasis recruited from an urban outpatient ophthalmology clinic completed the utility survey. The authors determined utility values for dermatochalasis ranging from 0.74 to 0.92 depending on the measurement method (standard reference gamble/time trade-off) and anchor points. The cost-effectiveness analysis yielded an incremental cost-effectiveness ratio of $3,146 per quality-adjusted life year, well under the conventional willingness-to-pay threshold of $50,000 per quality-adjusted life year. Probabilistic sensitivity analysis with Monte Carlo simulation demonstrated that blepharoplasty would be cost-effective in 88.1% of cases at this willingness-to-pay threshold.

CONCLUSIONS

Dermatochalasis has an impact on quality of life that is significantly associated with level of perceived functional impairment. Rising health care costs have underscored the importance of providing value-based treatment to patients, and the results of this study suggest that blepharoplasty is a cost-effective treatment option for symptomatic bilateral upper eyelid dermatochalasis.

The Effect of Upper Eyelid Blepharoplasty on Corneal Tomography and Epithelial Profile

Introduction

Upper tarsal mechanical forces influence corneal epithelial thickness profile, which could modulate corneal astigmatism. Upper eyelid blepharoplasty reduces upper tarsal strength and may have an impact on ocular surface. The aim of this study is to evaluate the effect of upper eyelid blepharoplasty on corneal epithelial thickness profile, astigmatism and aberrations.

Methods

Patients with dermatochalasis underwent bilateral upper eyelid blepharoplasty. Anterior segment optical coherence tomography (AS-OCT) (Zeiss Cirrus 5000 HD-OCT) and Pentacam (Oculus, Wetzlar Germany) were performed before surgery and in the 8th postoperative week. Corneal epithelial thickness, keratometry, aberrations and asphericity were considered for statistical purposes. Only right eyes were considered. A p-value lower than 0.05 was considered significant.

Results

Thirty eyes of 30 patients were included. The degree of astigmatism did not change after surgery (0.95D vs 0.83D, p=0.23). The difference between preoperative and postoperative steepest axis was 3.1° (p=0.04) with a tendency to change toward the vertical meridian. Mean epithelial thickness was higher in the inferior region both pre- and postoperatively and did not change. ET in the superior octant was lower (42 µm vs 45 µm, p<0.01) and the difference between inferior and superior octants (I-S) was higher (7 µm vs 3 µm, p<0.001) before surgery. There were no statistically significant changes in corneal aberrations (p=0.52) and asphericity (p=0.41) after surgery.

Conclusion

Our results support that upper tarsus pressure influences epithelial thickness profile and, consequently, the corneal steepest keratometry. These results lead us to postulate that upper eyelid blepharoplasty may influence biometric and keratometric measurements.

Dry eye in the upper blepharoplasty patient: a study comparing orbicularis-sparing versus orbicularis-excising techniques

PURPOSE

To compare subjective and objective dry eye syndrome (DES) metrics preoperatively and postoperatively in patients undergoing bilateral upper eyelid blepharoplasty (ULB) using orbicularis-sparing versus orbicularis-excising techniques.

METHODS

A double-blind, randomized clinical trial was conducted on patients without prior DES or other severe conditions who presented to our institution between 2017 and 2019 for routine functional ULB. Patients were randomized into two treatment arms: bilateral ULB using the orbicularis-sparing technique or bilateral ULB using the orbicularis-excising technique. One subjective and seven objective DES assessments were performed on all patients preoperatively and 1 month and 1 year after surgery.

RESULTS

A total of 63 patients were recruited for the study. Standard Patient Evaluation of Eye Dryness (SPEED) scores decreased in both treatment groups at 1 month and 1 year postoperatively. This change did not significantly vary based on surgical technique. Objective DES assessments were not significantly changed at both postoperative time points for either group. There was a correlation between the severity of preoperative DES symptoms and the subjective improvement of DES symptoms postoperatively in both groups.

CONCLUSIONS

ULB with an orbicularis-sparing or orbicularis-excising technique does not worsen subjective or objective DES metrics and so, surgeons may confidently use either surgical technique. These findings may impact postoperative expectations for surgeons and patients alike.

Upper Eyelid Blepharoplasty: Surgical Techniques and Results-Systematic Review and Meta-analysis

BACKGROUND

Upper eyelid blepharoplasty is a surgical procedure that aims to correct the typical changes that occur with aging to the periorbital area. The outcomes of this surgery are aesthetic, as well as functional. Many studies have described an impact on the cornea, intraocular pressure, dry eye syndrome, and visual quality. The aim of this systematic review is to compare the different surgical techniques and their outcomes.

METHODS

The authors performed a literature review through online databases PubMed, Web of Science, Clinicaltrials.gov, and CENTRAL libraries. Information was collected about the surgery techniques and the functional and aesthetic outcomes as well as complications of the interventions. Six types of upper blepharoplasty surgery were studied. Data were analyzed using Cochrane RevMan.

RESULTS

Twenty studies were included in our systematic review and nine in our meta-analysis. We presented results about intraocular pressure, central corneal thickness, flattest keratometry, steepest keratometry, corneal astigmatism, visual acuity, Schirmer test 1 and 2, tear film break-up time and the ocular surface disease index questionnaire, according to type of surgery. Our meta-analysis showed no significant results.

CONCLUSIONS

No significant results were found; however, many studies reported an impact of upper blepharoplasty surgery in the outcomes studied. Only a small number of complications were reported, and patients were satisfied with the aesthetic outcomes.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors https://www.springer.com/00266 .

Study to the Effect of Involutional Blepharoptosis Surgery Using Objective and Subjective Parameters

Background  We investigate the effect of involutional blepharoptosis (IB) surgery based on dry eye symptoms by analysis using objective and subjective measures.

Methods  We recorded various parameters from patients that underwent levator advancement surgery for IB, totaling 125 eyes (total 65 patients, 5 unilateral, 60 bilateral). Subjective assessment comprised a questionnaire on dry eye-related quality of life score (DEQS), a summary score calculated from DEQS, and six-grade evaluation, the patient's own measure of eye comfort. Objective assessment comprised marginal-reflex distance-1 (MRD-1), measurement of tear film breakup time, and superficial keratopathy (SPK) existence by slit lamp microscope.

Results  Subjective assessments showed that IB patients had improvement of dry eye symptoms and eye comfort when surgery increased MRD-1. On the other hand, objective assessments showed that the presence of SPK is suspected when the postoperative MRD-1 level is 3 mm or higher.

Conclusion  IB surgery must not only increase MRD-1 value, but also to perform maintenance of the appropriate ocular surface condition. From our parameters, we suggest postoperative MRD-1 value should be maintained at < 3 mm to safe and effective of IB surgery.

Impact of upper blepharoplasty, with or without orbicularis oculi muscle removal, on tear film dynamics and dry eye symptoms: A randomized controlled trial

PURPOSE

Upper blepharoplasty may be related to dry eye symptoms since the function of the orbicularis oculi muscle may affect the tear film. We aimed to assess the effect of blepharoplasty with or without the removal of a strip of orbicularis oculi muscle on tear film dynamics and dry eye symptoms.

METHODS

A double-blind, randomized, controlled trial comparing upper blepharoplasty without (group A) or with (group B) orbicularis oculi muscle excision was performed on 54 healthy Caucasian patients. Tear film dynamics and dry eye symptoms were evaluated using multiple dry eye parameters, i.e. tear osmolarity, Schirmer test I, corneal/conjunctival staining, tear break-up time (TBUT), Oxford Scheme, Sicca Ocular Staining Score and Ocular Surface Disease Index questionnaire. All the parameters were assessed preoperatively and 6 and 12 months after upper blepharoplasty. All the groups' outcomes were compared.

RESULTS

The differences were not significant between the two upper blepharoplasty techniques regarding most of the above-mentioned outcomes. Subjective symptoms of ocular irritation, consistent with dry eye disease and vision-related impairment, were reduced after upper blepharoplasty independent of the type of the technique applied, while the pre and postoperative outcomes of the objective tear dynamics did not differ 12 months after surgery. However, group B demonstrated a significant increase in tear osmolarity and TBUT at the 6-month follow-up visit.

CONCLUSION

An upper blepharoplasty alleviates subjective dry eye complaints in the long term, while not changing the tear dynamics. The improvement was independent of the blepharoplasty technique used.

Epiphora before and after upper eyelid functional blepharoplasty: A retrospective cohort study

Epiphora and dermatochalasis are common presentations in the ophthalmology clinic. To evaluate the change of epiphora before and after functional blepharoplasty, this retrospective cohort study reviewed 39 medical records of epiphora patients who underwent upper blepharoplasty. Severity of epiphora using MUNK score was collected and compared between before and at 6 months after blepharoplasty. The analysis model was performed to measure tear breakup time (TBUT) and frequency of artificial tears use. Subgroups of subjects before blepharoplasty to short baseline TBUT (≤ 10 seconds) and long TBUT (≥ 10 seconds) were also evaluated for the MUNK score change. From the analysis of 39 patients, the results showed a statistically significant decrease in post blepharoplasty MUNK score compared to the baseline (all P < 0.001). There was no significant difference between baseline and post-operative TBUT (P > 0.05). Twenty patients were in the short TBUT group and 19 in the long TBUT group. The reduction of MUNK score after blepharoplasty in the short TBUT group was not different to the long TBUT group (P = 0.50, 95% CI -0.84 to 0.41). However, in short TBUT group, frequency of artificial tears use after surgery was less than pre-operation. From the study, upper eyelid blepharoplasty might be one technique reducing the bothersome epiphora in dermatochalasis patients.

Impact of Full-Incision Double-Eyelid Blepharoplasty on Tear Film Dynamics and Dry Eye Symptoms in Young Asian Females

BACKGROUND

Dry eye symptoms as a complication of double-eyelid blepharoplasty are controversial. This article evaluates tear film dynamics and changes in dry eye symptoms after cosmetic double-eyelid blepharoplasty in young Asian female.

METHODS

One hundred and twenty patients underwent full-incisional double-eyelid blepharoplasty. Subjective and objective parameters were documented before surgery, at 1 week, 1 month and 3 months post-surgery, which included Ocular Surface Disease Index questionnaire (OSDI), tear meniscus height (TMH), noninvasive breakup time (NIBUT), Schirmer I test, corneal and conjunctival fluorescein staining scores, and palpebral fissure height. Dry eyes were defined based on the DEWS II criteria: OSDI ≥ 13 points and NIBUT < 10 s. Patients were divided into two groups, group A included patients with redundant skin, while group B included patients with absence of redundant skin.

RESULTS

The incident rate of dry eyes preoperatively, and at 1 week, 1 month and 3 months were 12.5%, 12.5%, 32.5%, and 16.67%. OSDI scores were significantly increased at 1 week (9.71 ± 10.07, P < 0.001) and 1 month (11.35 ± 12.28, P < 0.001) postoperatively. A significant increase in TMH, NIBUT and Schirmer's test I values were observed at 1 week post-surgery (P < 0.001). Patients in group A showed higher OSDI scores compared to group B at 1 week and 1 month (P = 0.051) post-surgery, and the other variables showed no difference between the groups.

CONCLUSIONS

Cosmetic double-eyelid blepharoplasty may temporarily affect tear film dynamics and aggravate dry eye symptoms in young females. However, these changes generally recover 3 months postoperatively.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Functional outcomes of upper eyelid blepharoplasty: A systematic review

OBJECTIVE

Various functional outcomes after upper blepharoplasty are reported in the literature. We systematically reviewed the literature to assess the objective and subjective functional effects of upper blepharoplasty.

METHODS

After a systematic search of four search engines (Pubmed, Embase, Cinahl and Cochraine), any study on objective and subjective (patient reported) functional outcome after upper blepharoplasty was subjected to a quality assessment for possible inclusion in the review. The intervention was defined as a solitary surgical upper blepharoplasty containing the removal of skin, with or without the removal of a strip of orbicularis oculi muscle and/or upper orbital fat. Eligible studies were randomized controlled trials, controlled trials, cohort studies and case series (n ≥ 10).

RESULTS

A total of 3525 studies were assessed, of which 28 studies were included in this systematic review. Favorable outcomes after an upper blepharoplasty were reported and included enlarged visual field, enhanced quality of life related to fewer headaches and improved vision. Furthermore, sensitivity of the eyelids decreased, with differences in recovery. Outcomes for eyebrow height, astigmatism, contrast sensitivity and eyelid kinematics were not consistent between the studies. No meta-analysis could be performed due to the limited scope of included studies and the great variety in outcomes and blepharoplasty techniques.

CONCLUSIONS

Upper blepharoplasty is accompanied by a great variety of beneficial functional outcomes including an increased visual field and improvement in headache- and vision-related quality of life. Further research is needed, especially where results are conflicting (effects on eye dryness and eyebrow height) and/or the data are limited (contrast sensitivity, astigmatism).

Tear condition following unilateral ptosis surgery

PURPOSE

To evaluate changes in tear film condition following unilateral ptosis surgery.

METHODS

This interventional case series includes patients with unilateral blepharoptosis scheduled for ptosis surgery with no prior history of eye disease and surgery over a 2-year period. Tear film evaluation before surgery were performed, which included Schirmer test with and without anesthesia, and tear break up time (TBUT). Ptosis surgery included levator resection and frontalis sling. The previously mentioned tests were repeated 1, 3, and 6 months after surgery. Subjective symptoms related to dry eye also evaluated before and after surgery.

RESULTS

A total of 83 patients including 46 (55.4%) male subjects with mean age of 26.2 ± 16.2 years were enrolled in the study. The most common cause of ptosis was congenital in 77 (92.8%) patients. Surgical intervention included levator resection in 56 (67.5%) cases and frontalis sling procedure in 27 (32.5%) cases. The result of surgery was good in 47 (56.6%) patients while under- and overcorrection were observed in 32 (39.8%) and 3 (3.6%) patients, respectively. Schirmer's test with and without anesthesia and TBUT after surgery revealed a decrease in tear quantity and quality after surgery with time. Patients who had subjective complaints from dryness after surgery only had shorter TBUT among the objective signs.

CONCLUSIONS

Ptosis surgery can decrease the quantity and quality of tears in operated eyes. Since some of these patients may need other types of operations in future, such as refractive or cataract surgery, evaluation of the tear condition before further surgery is prudent.

Dynamic changes of tear fluid after cosmetic transcutaneous lower blepharoplasty measured by optical coherence tomography

PURPOSE

To investigate the dynamic changes of tear fluid after cosmetic transcutaneous lower blepharoplasty.

DESIGN

Prospective, observational case series study.

METHODS

A total of 60 eyes of 30 patients with transcutaneous lower blepharoplasty were involved in the study. All subjects completed the Ocular Surface Disease Index questionnaire and underwent tear film break-up time measurements and the Schirmer test before surgery and 1 week, 1 month, and 3 months after surgery. Tear meniscus parameters measured by optical coherence tomography were recorded. Lower lid margin reflex distance was also measured. At each time point after surgery, these parameters were compared with the baseline parameters. The incidence of dry eye and chemosis after surgery was assessed.

RESULTS

The Ocular Surface Disease Index score increased significantly 1 week after surgery (P < .01). The Schirmer test values were significantly decreased 1 week postoperatively (P < .01), and they returned to baseline by 3 months. There was no significant change in tear film break-up time before and after surgery. The tear meniscus height, depth, and cross section area values were significantly increased at 1 week postoperatively, decreased at 1 month (P < .01), and returned to baseline at 3 months (P > .05). The cornea-lower eyelid angle significantly decreased at 1 week postoperatively (P < .01), increased at 1 month (P < .01), and returned to baseline by 3 months (P > .05). The lower lid margin reflex distance was increased 1 week after surgery (P < .01), and gradually recovered but had not returned to the baseline 3 months after surgery (P < .01). The increased tear meniscus height had a positive correlation with lower lid margin reflex distance. The incidence of dry eye and chemosis at 1 week postoperatively was 16.7% and 15%, respectively.

CONCLUSIONS

Cosmetic transcutaneous lower blepharoplasty affects ocular surface and tear fluid, which leads to dryness, tearful eyes, and chemosis. However, this influence is temporary after surgery, and the symptoms resolve within 3 months. A positive correlation between tear meniscus height and lower lid margin reflex distance was observed. Assessment of the tear meniscus with optical coherence tomography provided a quick, noninvasive, and quantitative method to investigate the dynamic changes of the tear fluid after blepharoplasty.

Complications in periocular rejuvenation

Thorough preoperative evaluation with meticulous surgical planning to achieve facial aesthetic balance between the forehead, eyelids, and midface is imperative to avoid or decrease potential functional and/or cosmetic complications in cosmetic periocular surgery. Before performing surgery, the physician should be aware of the patient's history of dry eyes, previous facial trauma, previous injection of Botox Cosmetic, history of previous laser-assisted in situ keratomileusis, and past facial surgery. A full evaluation should be performed on the upper eyelid/brow region to assess for the presence of brow ptosis, brow/eyelid asymmetry, dermatochalasis/pseudodermatochalasis, eyelid ptosis, and deep superior sulcus. On the lower eyelid/cheek examination, special attention should be directed to the diagnosis of underlying negative vector, dry eyes, prominent eyes, lower lid retraction, ectropion, lateral canthal dystopia, lower eyelid laxity, scleral show, and lagophthalmos, with a rejuvenation goal that focuses on obtaining a youthful fullness through repositioning and reinforcing efforts to avoid the negative effects of hollowness. Intraoperative and postoperative medical and surgical management of cosmetic periocular surgery complications focus on decreasing the risk of postoperative ptosis, lagophthalmos, lid retraction, and lid asymmetry, with special attention to limiting the risk of visual loss secondary to orbital hemorrhage.

Impression cytology: recent advances and applications in dry eye disease

Impression cytology (IC) allows cells to be harvested from the ocular surface noninvasively. Superficial layers of the epithelium are removed by application of cellulose acetate filters or Biopore membranes, and the cells can be subsequently analyzed by various methods, depending on the objective of the investigation or pathology involved. IC techniques are easily learned, can be performed in an outpatient setting, and cause virtually no discomfort to the patient. IC facilitates the diagnosis of ocular surface disorders, including, among others, keratoconjunctivitis sicca, ocular surface squamous neoplasia, and ocular surface infections. During the past decade, IC has been used increasingly to assist in diagnosis of ocular surface disease, improve our understanding of the pathophysiology of ocular surface disease, and provide biomarkers to be used as outcome measures in clinical trials. Dry eye disease is one area in which IC has contributed to significant advances.

Blepharoplasty in the post-laser in situ keratomileusis patient: preoperative considerations to avoid dry eye syndrome

BACKGROUND

The authors used a retrospective case series to describe the increased frequency of dry eye syndrome in patients who have undergone both laser in situ keratomileusis and blepharoplasty.

METHODS

The authors reviewed records from six patients who required surgical correction for exposure keratopathy previously treated by both laser in situ keratomileusis and blepharoplasty.

RESULTS

All six patients developed significant exposure keratopathy postoperatively requiring surgical intervention. Four patients had blepharoplasty followed by laser in situ keratomileusis, and two patients had laser in situ keratomileusis followed by blepharoplasty. Symptomatic dry eye symptoms followed the second procedure 1 week to 4 months later. Surgical correction of eyelid malposition and lagophthalmos markedly improved symptoms.

CONCLUSIONS

Patients with a history of laser in situ keratomileusis contemplating blepharoplasty are at higher risk of developing postoperative dry eye syndrome. Surgeons performing these procedures should perform thorough preoperative evaluation and surgical planning to minimize this potential complication.