Scheimpflug Imaging in Dermatochalasis Patients Before and After Upper Eyelid Blepharoplasty

Evaluation of visual field and ocular surface parameters by clinical comparison after blepharoplasty for dermatochalasis

PURPOSE

To evaluate the effect of upper eyelid blepharoplasty surgery on corneal topography, visual field, ocular surface, meibography, corneal biomechanics and dry eye parameters.

METHODS

This prospective study included a total 80 eyes of 40 patients. Following a detailed ophthalmological examination, standardized patient satisfaction questions were posed to patients before and after upper eyelid blepharoplasty surgery. Visual field test, non-invasive break up time (NIBUT), meibography, and corneal topography parameters were analyzed and evaluated.

RESULTS

The mean (+) visible areas in the visual field were found to be 46.20±24.96 preoperatively, 56.73±21.98 at the 1st postoperative month and 65.96±18.5 at the 3rd month, which were statistically significant. NIBUT values preoperatively, at 1 month and at 3 months were 11.26±4.48, 11.16±4.5 and 10.14±4.0, respectively, which were statistically significant. Meibomian gland loss rates on meibography preoperatively and postoperatively at 1 and 3 months were found to be 30.24±8.3, 29.36±8.2 and 28.22±7.7 respectively and were statistically significant. With the scoring system after blepharoplasty, patients reported improvement in their symptoms.

CONCLUSION

Upper eyelid blepharoplasty surgery is predicted to increase the quality of vision. It was observed that there was a functional and cosmetic improvement in the complaints of the patients after blepharoplasty. However, blepharoplasty may cause changes in eyelid dynamics and cause dry eye syndrome.

Evaluation of early period changes in intraocular pressure, ocular biometry and anterior segment after upper eyelid blepharoplasty

PURPOSE

To investigate the acute effects of upper eyelid blepharoplasty on intraocular pressure (IOP) and ocular biometric parameters.

METHOD

This prospective cross sectional study examined the eyes of 49 patients with dermatochalasis. Following a detailed ophthalmological examination, corneal topography was used to evaluate the eyes mesopic and photopic pupil diameter, anterior chamber depth, and corneal astigmatism on the day of surgery and on days first and seventh postoperatively. Ocular biometry was used to assess axial length and intraocular lens power. Goldmann applanation tonometry was used to measure intraocular pressure.

RESULTS

Forty-nine eyes (26 males and 23 females) of 49 patients aged between 44 and 76 years (mean 61 ± 7.9) were included in our study. The mean anterior chamber depth (ACD) was 2.90 ± 0.37 mm preoperatively, 3.00 ± 0.29 mm at postoperative day first, and 3.04 ± 0.29 mm at postoperative day seventh, and the increase in anterior chamber depth was statistically significant (p < 0.001). The mean astigmatism values were measured as preoperative 0.73 ± 0.69 D, postoperative first day 0.93 ± 0.81 D, and postoperative seventh day 1.26 ± 0.90 D. The increase in astigmatism values was statistically significant (p < 0.001). The mean pupil diameter measurements in the mesopic environment were 4.20 ± 0.61 mm preoperatively, 4.40 ± 0.59 mm on the first postoperative day, and 4.39 ± 0.57 mm on the seventh postoperative day, and there was a statistically significant difference between the three measurements (p = 0.03). The mean IOP measurements of the patients were 15.91 ± 3.51 mmHg preoperatively, 16.81 ± 3.36 mmHg on the first postoperative day, and 16.97 ± 3.13 mmHg on the seventh postoperative day. The increase between these three measurements was statistically significant (p = 0.013).

CONCLUSION

This study includes important insights into the potential acute phase impact of blepharoplasty surgery on ocular findings. Patients undergoing upper eyelid surgery should be informed about the possible change in ocular biometric parameters, intraocular pressure, and pupil diameter.

Deep Transfer Learning for Ethnically Distinct Populations: Prediction of Refractive Error Using Optical Coherence Tomography

INTRODUCTION

The mismatch between training and testing data distribution causes significant degradation in the deep learning model performance in multi-ethnic scenarios. To reduce the performance differences between ethnic groups and image domains, we built a deep transfer learning model with adaptation training to predict uncorrected refractive errors using posterior segment optical coherence tomography (OCT) images of the macula and optic nerve.

METHODS

Observational, cross-sectional, multicenter study design. We pre-trained a deep learning model on OCT images from the B&VIIT Eye Center (Seoul, South Korea) (N = 2602 eyes of 1301 patients). OCT images from Poona Eye Care (Pune, India) were chronologically sorted into adaptation training data (N = 60 eyes of 30 patients) for transfer learning and test data (N = 142 eyes of 71 patients) for validation. Deep learning models were trained to predict spherical equivalent (SE) and mean keratometry (K) values via transfer learning for domain adaptation.

RESULTS

Both adaptation models for SE and K were significantly better than those without adaptation (P < 0.001). In myopia/hyperopia classification, the model trained on circular optic disc OCT images yielded the best performance (accuracy = 74.7%). It also performed best in estimating SE with the lowest mean absolute error (MAE) of 1.58 D. For classifying the degree of corneal curvature, the optic nerve vertical algorithm performed best (accuracy = 65.7%). The optic nerve horizontal model achieved the lowest MAE (1.85 D) when predicting the K value. Saliency maps frequently highlighted the retinal nerve fiber layers.

CONCLUSIONS

Adaptation training via transfer learning is an effective technique for estimating refractive errors and K values using macular and optic nerve OCT images from ethnically heterogeneous populations. Further studies with larger sample sizes and various data sources are needed to confirm the feasibility of the proposed algorithm.

Effect of Upper Lid Blepharoplasty Surgery on Corneal Topography and Corneal High-Order Aberrations

The objective of this study was to prospectively investigate the effect of upper eyelid blepharoplasty surgery for dermatochalasis on corneal topographic data and high-order aberrations (HOAs). Fifty eyelids of 50 patients with dermatochalasis who underwent upper lid blepharoplasty surgery were prospectively studied. A Pentacam (Scheimpflug camera, Oculus) device was used to measure corneal topographic values, astigmatism degree, and HOAs before and at 2 months after upper eyelid blepharoplasty. The mean age of the patients included in the study was 55.96 ± 12.4 years, 40 (80%) were female and 10 (20%) were male. We found no statistically significant difference in the pre-and postoperative values of corneal topographic parameters (p > 0.05 for all). In addition, we observed no significant postoperative change in the root mean square values of low, high, and total aberration values. In HOAs, we detected no significant change in spherical aberration, horizontal and vertical coma, and vertical trefoil; we only found a statistically significant increase in horizontal trefoil values after surgery (p < 0.05). In our study, we found that upper eyelid blepharoplasty did not cause significant changes in corneal topography, astigmatism, and ocular HOAs. However, studies are reporting different results in the literature. For this reason, it is important for patients considering upper eyelid surgery to be warned about visual changes that may occur after surgery.

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 .

Corneal biophysical changes after upper eyelid blepharoplasty and ptosis surgery: a review

Upper eyelid surgeries, such as blepharoplasty and ptosis correction, are commonly performed procedures worldwide. This review examines the effects of these surgeries on ocular properties and visual function. A search of the PubMed and Google Scholar databases was conducted to identify relevant articles published after 2000. The results demonstrate that the ocular and adnexal organs function as a unified visual system, with changes in one component affecting the functions of others. Eyelid surgery can alter ocular properties and functions by modifying retinal lighting and ocular optics. These alterations can affect intraocular pressure estimation, corneal curvature, corneal epithelial thickness, refractive power of the cornea, and intraocular lens calculation. Additionally, eyelid surgery can exacerbate dry eye symptoms and impact contrast sensitivity, which is a significant factor in visual quality. Therefore, understanding these interactions is crucial before performing eyelid surgery and during follow-up. This review summarizes recent literature on the effects of upper eyelid surgery on corneal properties and visual function, emphasizing the importance of considering these factors when planning or undergoing such procedures.

Dioptric power and refractive behaviour: a review of methods and applications

Myopia is a global healthcare concern and effective analyses of dioptric power are important in evaluating potential treatments involving surgery, orthokeratology, drugs such as low-dose (0.05%) atropine and gene therapy. This paper considers issues of concern when analysing refractive state such as data normality, transformations, outliers and anisometropia. A brief review of methods for analysing and representing dioptric power is included but the emphasis is on the optimal approach to understanding refractive state (and its variation) in addressing pertinent clinical and research questions.

Although there have been significant improvements in the analysis of refractive state, areas for critical consideration remain and the use of power matrices as opposed to power vectors is one such area. Another is effective identification of outliers in refractive data. The type of multivariate distribution present with samples of dioptric power is often not considered. Similarly, transformations of samples (of dioptric power) towards normality and the effects of such transformations are not thoroughly explored. These areas (outliers, normality and transformations) need further investigation for greater efficacy and proper inferences regarding refractive error. Although power vectors are better known, power matrices are accentuated herein due to potential advantages for statistical analyses of dioptric power such as greater simplicity, completeness, and improved facility for quantitative and graphical representation of refractive state.

Changes in Intraocular Pressure and Ocular Biometry After Blepharoplasty

PURPOSE

To investigate the effects of blepharoplasty on intraocular pressure (IOP) and ocular biometric parameters.

METHODS

A total of 112 eyelids of 56 patients undergoing bilateral blepharoplasty due to upper eyelid dermatochalasis was included. The patients were classified into three groups according to margin reflex distance (MRD) (Group 1 >4 mm MRD, Group 2 2-4 mm MRD, and Group 3 <2 mm MRD). The IOP and ocular biometric parameters obtained baseline and postoperative 3^rd month were compared.

RESULTS

The demographic characteristics of the groups were similar (p > 0.05, for all). IOP (p = 0.002) and central corneal thickness (p = 0.038) increased in Group 3. The mean amount of the increase in IOP was 0.95mmHg. The keratometric values increased in all groups and corneal astigmatism was also increased in Group 2 and Group 3 (p < 0.001, for all). The mean amount of the increase in corneal astigmatism was 0.54D in Group 3. Anterior chamber depth and axial length did not change (p > 0.05, for all). The intraocular lens powers calculated by six different formulas decreased in Group 3 (p < 0.001, for all), and the mean amount of the decrease was 0.40D.

CONCLUSIONS

Clinicians should be aware of the potential change in IOP and ocular biometric parameters in patients who underwent blepharoplasty. If a patient has glaucoma risk factors, close follow-up is needed after blepharoplasty. Change in strategy or timing may also be needed for dermatochalasis patients when planning corneal refractive surgery or cataract surgery.

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 .

Effect of upper eyelid blepharoplasty on corneal biomechanical, topographic and tomographic parameters 4 weeks after surgery

Purpose

To investigate the effect of “skin-only” upper eyelid blepharoplasty on corneal biomechanics and central as well as peripheral topographic/tomographic parameters before and 4 weeks after surgery.

Methods

In a prospective study, the corneal hysteresis (CH) and corneal resistance factor (CRF) were evaluated before and after blepharoplasty. Corneal topographic (maximum simulated keratometry value, inferior-superior value, index of surface variance, index of vertical asymmetry, index of height asymmetry, index of height decentration) and tomographic parameters (corneal thickness, corneal astigmatism and mean 5-mm- and 7-mm-zone keratometry value) were measured by the Pentacam HR. Statistical analysis was performed using a linear mixed model considering correlated data of both eyes.

Results

This study included 42 eyes of 35 patients (mean age: 64.5 years, range 52–82 years). Four weeks after surgery CH and CRF increased (9.4 ± 2.3 to 10.2 ± 2.2 mmHg and 9.7 ± 2.1 to 10.5 ± 2.2 mmHg) but did not reach statistical significance (P = 0.100 and P = 0.072). A significant increase in central maximum simulated keratometry value (Kmax) from 45.0 ± 2.3 to 45.4 ± 2.2 diopters (D) was observed (P = 0.004). Inferior-superior value (I-S) and index of surface variance (ISV) showed significant changes from 0.32 ± 0.98 to 0.10 ± 0.98 D (P = 0.02) and from 19.98 ± 9.84 to 22.93 ± 11.23 (P = 0.009), respectively. These alterations did not affect the subjective spherical equivalent (-0.09 ± 4.71 to -0.04 ± 4.51 D; P = 0.437) and the best-corrected distance visual acuity of patients (0.11 ± 0.14 to 0.15 ± 0.15 logMAR; P = 0.142). Age, gender and corneal thickness were not correlated with pre and postoperative differences of CH, CRF, corneal compensated IOP, Kmax, corneal astigmatism or I-S.

Conclusion

The trend of increasing CH and CRF values might indicate a rise of corneal damping capacity. Despite statistically significant differences of Kmax, I-S and ISV, all other tomographical and topographical parameters did not change 4 weeks after surgery. The corneal steepening with a mean change of 0.4 diopters and the decrease of I-S with a mean of 0.22 diopters do not seem to have a clinically relevant effect for blepharoplasty patients in daily practice.

Long-term changes in contrast-sensitivity, corneal topography and higher-order aberrations after upper eyelid blepharoplasty: A prospective interventional study

Purpose

The aim of this study was to analyze the long-term changes in visual parameters, that is, contrast sensitivity (CS) and higher-order aberrations (HOAs), and corneal topography in the patients undergoing upper eyelid blepharoplasty (UEB) for dermatochalasis.

Methods

This was a prospective, single surgeon, intervention study including patients (≥40 years age) having severe dermatochalasis with a minimum post-UEB follow-up of 12 months. The preoperative readings of CS (using Pelli-Robson chart), HOAs (using WaveLight ALLEGRO analyzer), and corneal topography (using topographic modeling system-4, Tomey corporation) were noted and compared at 3, 6, and 12 postoperative months.

Results

We studied 30 patients (60 eyes) who underwent bilateral UEB. The majority of patients were females (n = 21,70%), and the mean age of patients was 56.53 ± 9.06 years. The preoperative and postoperative values of LogMAR visual acuity, log CS value, corneal topography measurements (K1, K2, cylinder value, and the axis), optical aberrations (total HOAs; third-order--trefoil & coma; four-order--spherical aberrations and secondary astigmatism, and tetrafoil) were compared. At 12 months, the mean CS value, the majority of HOAs, and corneal topography (only cylinder values) showed a stable, statistically significant difference in the postoperative period.

Conclusion

The UEB may produce long-term, visually-beneficial, optical, and corneal changes. The patients undergoing cataract surgery aiming for spectacle independence may gain additional visual benefits with UEB.

Effects of Upper Eyelid Blepharoplasty on Contrast Sensitivity in Dermatochalasis Patients

Objectives

To evaluate the impact of upper eyelid blepharoplasty on contrast sensitivity in dermatochalasis patients.

Materials and Methods

Best corrected visual acuity, ophthalmologic examination, eyelid examination, lash ptosis, contrast sensitivity using sine-wave contrast sensitivity chart, keratometric parameters, and corneal aberrations of 34 eyes of 34 patients who underwent upper eyelid blepharoplasty due to dermatochalasis in our clinic between the years 2014 and 2018 were evaluated preoperatively and at postoperative 3 months.

Results

Twenty-three (68%) of the patients were females and 11 (32%) were males. Mean age was 63.1±7 (52-81) years. Mean best corrected visual acuity was 0.036±0.06 (0-0.15) logMAR preoperatively and postoperatively (p>0.05). Contrast sensitivity values of the patients at the frequencies of 1.5, 3, 6, 12, and 18 cycles per degree were 44.38±19.5, 59.03±27.2, 41.44±34.1, 15.15±19.3, and 5.15±4.26 preoperatively and 44.80±20.9, 76.85±33.4, 63.21±46.4, 28.21±31.1, and 10.5±9.5 postoperatively, respectively. The difference between contrast sensitivity values was statistically significant at the frequencies of 3, 6, 12, and 18 cpd (p=0.005, =0.001, <0.001, and <0.001, respectively). Although lash ptosis of the patients improved significantly after the surgery, there was no correlation between lash ptosis improvement and change in contrast sensitivity (p>0.05). Keratometric values and corneal high order aberrations did not change significantly after the surgery (p>0.05).

Conclusion

Contrast sensitivity significantly increases after upper eyelid blepharoplasty, especially at higher spatial frequencies which are known to deteriorate due to age-related changes in the lens and retina in older adults. Our results show that blepharoplasty may have additional functional indications for elderly dermatochalasis patients in terms of improving the functions such as performing daily tasks and reading.

Prospective analysis of visual function changes in patients with dermatochalasis after upper eyelid blepharoplasty

OBJECTIVE

To evaluate the changes of visual acuity, contrast sensitivity, astigmatism, and higher order aberrations after blepharoplasty in patients with dermatochalasis.

METHODS

Two hundred six eyelids of 103 patients with dermatochalasis were prospectively studied. Visual acuity, contrast sensitivity, corneal topography, astigmatism degree, and higher order aberrations were examined and recorded before and at 1 month after upper eyelid blepharoplasty. Change in contrast sensitivity and astigmatism values were determined according to margin reflex distance of patients, which were classified into three following groups: <2 mm, 2-3 mm, and ⩾ 4 mm. A Wilcoxon signed rank test was performed to compare the difference.

RESULTS

No significant differences were observed for visual acuity (p = 0.157). The contrast sensitivity of patients significantly increased at all spatial frequencies both under glare and nonglare conditions (p < 0.05). The mean refractive astigmatism significantly decreased from ‒1.01 ± 1.3 to ‒0.79 ± 0.71, postoperatively (p = 0.029). In patients with marginal reflex distance < 2 mm, mean contrast sensitivity was increased (p < 0.001) and mean astigmatism was decreased significantly (p < 0.001) compared with those with ⩾ 2 mm. Higher order aberrations decreased significantly from 0.62 ± 0.41 µm to 0.55 ± 0.38 µm (p = 0.038) after blepharoplasty. Root mean square of the vertical trefoil (p = 0.038), vertical coma (p = 0.002), horizontal trefoil (p = 0.027), third-order aberration (p = 0.005), secondary vertical stigmatism (p = 0.001), spherical aberration (p = 0.023), secondary horizontal astigmatism (p = 0.002), fourth-order aberration (p = 0.024), vertical pentafoil (p = 0.015), secondary horizontal coma (p = 0.035), secondary horizontal trefoil (p = 0.030), and horizontal pentafoil (p = 0.048) were decreased significantly.

CONCLUSION

Upper eyelid blepharoplasty in patients with dermatochalasis has a significant improvement in visual function in terms of contrast sensitivity, astigmatism, and higher order aberrations.

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).

Functional benefits and patient satisfaction with upper blepharoplasty - evaluated by objective and subjective outcome measures

PURPOSE

To investigate the functional benefits and patient satisfaction with upper blepharoplasty in patients meeting the Danish visitation guidelines for upper blepharoplasty from the Danish Health and Medicines Authority (Sundhedsstyrelsen).

METHODS

Before and 3 months after upper blepharoplasty, the following investigations were made: (i) a standard eye examination, (ii) photographic documentation with a normal camera and the infrared camera of a Spectralis Optical Coherence Tomograph and (iii) measurements of the upper visual fields using the blepharoptosis test of Octopus 900. Along with the pre- and postoperative examinations, the patients completed a questionnaire concerning the functional and psychosocial impact of their eyelids.

RESULTS

Ninety eyelids of 45 patients were studied, 34 females and 11 males. The mean age was 56.9 years (SD: 12.8). The mean change in the distance between the upper eyelid skin fold and the visual axis or the marginal reflex distance (MRD), depending on which was lowest, was 1.6 mm (SD: 0.8 mm) for the right eyelids and 1.2 (SD: 0.9 mm) for the left eyelids. The mean improvement in the upper visual field was 31.3% points for the right eyelids (SD: 21.4% points) and 28.3% points for the left eyelids (SD: 24.9% points). A statistically significant correlation between the preoperative distance from skin fold to visual axis/MRD and the pre- and postoperative visual field was found. The patients reported an improvement in their symptoms postoperatively. All subjects were satisfied with the postoperative result and would undergo the surgery again if they had to make the choice again.

CONCLUSION

Patients meeting the Danish visitation guidelines for upper blepharoplasty experience a measurable improvement in function and alleviation of symptoms after blepharoplasty.

Effect of Upper Eyelid Blepharoplasty on Vision and Corneal Tomographic Changes Measured By Pentacam

PURPOSE

The aim of this study is to determine whether any change occurs in corneal astigmatic values measured by a pentacam and any subjective visual acuity changes occurs following the upper eyelid blepharoplasty.

METHODS

This is a prospective study; 43 eyes of 23 patients with dermatochalasis underwent pentacam and surveyed for blurred vision before, 1 and 3 months after blepharoplasty surgery. In the course of those 3 measurements, both refractive and keratometric data were recorded and analyzed. The changes in refractive sphere, cylinder and cylindrical axis from both preoperative and postoperative readings were compared statistically.

RESULTS

Compared to preoperative measurements, 26 eyes (60%) had a measurable increase in corneal astigmatism after the surgery. Increased astigmatism observed by pentacam in the first and the third month after surgery, showed statistically significant results according to Wilcoxon test with (p = 0.028 < 0.05) and (p = 0.048 < 0.05) values, respectively. The mean change in astigmatism was reported as 0.15D. Regarding the astigmatism axis, no significant change was detected; in the 1 month (p = 0.435 > 0.05) and 3 months (p = 0.560 > 0.05) postoperative measurements compared to preoperative values. Two patients (4.34%) reported visual acuity change 3 months after the surgery.

CONCLUSION

We discovered statistically significant astigmatic changes; however, these were clinically insignificant visual acuity changes in compatibility with prior studies. Patients undergoing blepharoplasty surgery should be advised that this procedure may potentially alter vision. It is also very important to advise the patients to undergo cataract and/or refractive surgery after having upper eyelid surgery that this procedure may induce vision changes.