Monday, April 13, 2009

Preventing & Managing Dry Eye Syndrome after Periorbital Surgery– an Article Review

Updated 3/2017-- all links (except to my own posts) removed as many no longer active. and it was easier than checking each one. 

Dry eye syndrome is a source of discomfort to many.   An estimated 3.23 million women and 1.68 million men in the U.S. aged 50 years and older are affected by this common disorder.  That’s an estimated 10-30% of the population.
The article to which the post title refers is the first one listed in the reference section below.  It is a retrospective review of charts for 202 consecutive patients (180 women and 22 men) who underwent upper and/or lower blepharoplasty (eyelid surgery).  Dry eye syndrome is a well-recognized problem  that every surgeon performing blepharoplasties will encounter, but try to minimize or avoid.  The article does a nice job of discussing key elements of perioperative care.  It outlines algorithms for detection, prevention, and management.
Simply put dry eye syndrome is caused by reduced tear production or excessive tear evaporation.  Symptoms can include mild irritation and itching and foreign body sensation. Other complaints may suggest a vague soreness or awareness of my eyes (not previously noted), ocular fatigue, and changes in visual function (blurred vision).
The article focuses on four areas:
Successful surgery and prevention of persistent dry eyes entails
(1) proper understanding of tear film anatomy physiology
(2) preoperative recognition of risk factors through the history and physical examination
(3) intraoperative maneuvers to maximize prevention
(4) immediate and aggressive postoperative management.

Understanding tear formation and the anatomy is important in the prevention.  Any surgical modification of the periocular anatomy can alter the eyelid closure and blinking mechanism which are so important in the “lubrication” of the ocular surface of the eye. 
Risk factors can be divided into systemic, pharmacologic, environmental, and anatomical.  The article has a nice list of all four categories.
A thorough history and physical examination is essential.  The patient should be asked about signs and symptoms of dry eyes and their successful (or not) use of contact lenses.  Questions covering the risk factors (ie Rheumatoid arthritis, Sjogrens, use of anticholinergics, allergies).
Physical examination should include visual acuity measurements, document signs of dry eyes (ie erythema, epiphora, frequent blinking), and note any anatomical risk factors (ie  proptosis, lower lid laxity, scleral show, negative vector orbit, and lateral canthal dystopia).
They make the point that if any of these risk factors are present then one should consider delaying the operation or possibly not proceeding with surgery, depending on the degree of symptoms and risk. 
Their next section is on the surgical approaches in these patients.  It is a nice overview and if you do many blephroplasties you may want to read the entire review article, but here are a few of their tips and cautions:
Staging the upper and lower blepharoplasties in two separate operations may be considered.
Corneal protection is an obvious, often overlooked aspect of blepharoplasty.
Trauma or, more importantly, prolonged exposure can lead to corneal abrasion or ulceration.
Conservative excision is critical. This entails accurate measurement with a caliper and leaving 8 to 9 mm in the pretarsal fold when performing an upper blepharoplasty.
Skin resection in the lower blepharoplasty should be more conservative, taking into account that even if there is no lower lid retraction after resection, postoperative healing and scarring may eventually pull a lax lid down.
The orbicularis oculi muscle should be preserved in both upper and lower blepharoplasty. Special attention is paid to not injure the innervation as well. Disruption may lead to a decreased blink rate and is a setup for evaporative tear loss.
Canthopexy to correct lateral canthal depression and protect against ectropion is a safe measure that may be performed.

Postsurgical prevention of dry eyes is also very important.  It should be aimed at 1) limiting swelling, 2) maintaining hydration and lubrication, 3) controlling inflammation,  and 4) preventing infection. 
Edema may be controlled with head elevation and periorbital cool compresses.
Immediately after surgery, normal tear film production is disrupted and may take several days to recover.  Liberal use of artificial tears during the day and lubrication at night protect the eyes during this period.
Topical antibiotic and steroid (TobraDex; Alcon Labs, Fort Worth, Texas) drops help in reducing the inflammatory response and preventing conjunctivitis.
The systemic steroids are also continued by tapering oral corticosteroids over 5 days (Medrol Dosepak; Upjohn Co., Kalamazoo, Mich
Overall, an article well worth the time it takes to read and study it.

Preventing and Managing Dry Eyes after Periorbital Surgery: A Retrospective Review; Plastic and Reconstructive Surgery:Volume 123(1)January 2009pp 353-359; Hamawy, Adam H. M.D.; Farkas, Jordan P. M.D.; Fagien, Steven M.D.; Rohrich, Rod J. M.D.
Dry Eye Syndrome; eMedicine Article, Sept 26, 2008; C Stephen Foster MD, Erdem Yuksel MD, Fahd Anzaar MD, and Anthony S Ekong MD

1 comment:

hdhindsa said...

Just read the article--I agree it is a nice overview. The role of environment is very important. Here, in Reno, which is high desert environment, this problem is quite apparent. Even though I am a retina specialist, a significant portion of my patients ask me what I can do about their dry eye problem. This problem even prevents me from wearing contact lenses --due both to the climate and my "incomplete blink," (as pointed out to me some years ago by one of my corneal colleagues during a tennis game in Riyadh).