The most feared complication of blepharoplasty is permanent visual loss. The most common cause is retrobulbar hemorrhage, although other causes such as globe perforation, ischemic optic neuropathy, and angle closure glaucoma have been reported.
- Incidence is 0.05%; associated permanent visual loss was diagnosed in 0.0045%. This corresponds to a one in 2000 risk of hemorrhage and a one in 10,000 risk of permanent visual loss.
- Most occur within the first 24 hours after surgery (96%), and of these, more than half occur intraoperatively or within the first 6 postoperative hours.
- The most common presenting symptoms are pain and pressure.
- Treatment should be aggressive for the first 24 to 48 hours postoperatively, as vision has been reported to return in patients with “no light perception” that was present for 24 hours. (photo credit)
- Ptosis can be seen following upper eyelid blepharoplasty. No statistics are available regarding frequency. Mechanical ptosis can result from postoperative edema or ecchymosis and should resolve with conservative treatment, including cool compresses.
- Lagophthalmos occurs frequently in the postoperative period. Reasons include excessive skin removal, trauma to the orbicularis muscle or peripheral seventh cranial nerve, tethering of the eyelids by sutures or Steri-Strips, and postoperative pain, leading to guarding and incomplete closure. It is usually temporary. Lubrication and lid massage are advisable in the intermediate postoperative period.
As in the early postoperative period, keratopathy may persist or become evident during the intermediate period. First-line treatment is expectant, with frequent ocular lubrication and taping. One condition worth mentioning is the patient with undiagnosed thyroid ophthalmopathy who undergoes blepharoplasty that unmasks lid retraction and keratopathy.
Signs that make diplopia less worrisome are preoperative history of strabismus, monocular diplopia that clears with blinking (suggestive of precorneal tear film abnormality), and intermittence.Persistent binocular diplopia requires additional consideration. In a review of over 900 blepharoplasty procedures, the risk of persistent strabismus was approximately 0.2 percent.
Lagophthalmos in the late postoperative period is the result of excessive skin excision or incorporation of the orbital septum in skin closure resulting in eyelid retraction. If conservative therapy fails or severe exposure keratopathy warrants, surgical correction should be considered.
Malar Festoons are more likely to occur in patients who are predisposed to fluid accumulations (ie history of thyroid disease, renal failure, sinusitis, allergies). (photo credit)Late lower eyelid malposition is complex and requires careful consideration based on anatomical concepts. Identification of the affected lamella (anterior, middle, or posterior), usually the result of deficient tissue or cicatrization, is the key to successful reconstruction. In addition, horizontal laxity must be considered as a potential component of malposition. …………..
Patients who are at higher risk should be treated intraoperatively with intravenous steroids. Postoperative oral steroids are useful. Furosemide (Lasix, 20 to 40 mg daily) early in the postoperative course is helpful. Although persistent malar festoons can be excised, the success rate is low. If the underlying condition is systemic, eyelid surgery cannot locally correct the problem.
REFERENCESTrue dry eye disease in a postblepharoplasty patient can only be diagnosed after ample time has been allowed for resolution of common early and intermediate sicca symptoms. …...Initial treatment of dry eye consists of ocular lubrication. Treatment failure should prompt ophthalmologic examination, with consideration of antiinflammatory eyedrops (such as topical cyclosporine) or punctal occlusion.