Lynda Charters

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Reviewed by JosÃ© Luis Tovilla-Canales, MD


	
	Upper eyelid blepharoplasty (UEB) is the most frequently performed invasive facial esthetic procedure, according to

. The procedure can remove excess skin, muscle and sometimes fat from the upper or lower eyelids. It is performed for either functional or cosmetic indications. UEB may be performed in a traditional fashion, using stainless steel instruments, or may be modified with radiosurgery incisional techniques or laser incisional techniques.
	
	Following UEB, the visual fields can improve by as much as 26.2%. Dr. Tovilla-Canales, director, 

Orbit and Oculoplastics Department, Instituto de Oftalmologia, Mexico City, Mexico

, enumerated his pearls for performing a successful UEB. “The surgery is usually considered a simple procedure, but there are key points that must be adhered to before surgery to avoid adverse events,” he said. Dr. Tovilla-Canales offered several key points to consider for successful UEB procedures:

The procedure is not a recipe. Each patient will have different anatomic landmarks, and, therefore, have different surgical needs.

The brows and the different amounts of skin to be excised must be considered.

Understand the anatomy. Knowledge of the anatomy is essential to perform an appropriate technique for each patient.

The preoperative assessment is one of the most important steps before surgery is even undertaken. The physician must obtain a history and perform a complete examination, discuss expectations with the patient, select the appropriate technique, and discuss potential complications.

Patients must be instructed to stop taking aspirin and anticoagulants before surgery.

 Physicians also should obtain preoperative photographs in the event that patients question the postoperative outcome.

Another consideration in the preoperative assessment is determining whether just skin or skin and fat are to be removed.

“Watch the eyebrow,” Dr. Tovilla-Canales said, pointing out that the eyebrows are always considerations when performing UEB. He demonstrated cases with the preoperative presence of upper lid ptosis, a droopy eyebrow, fat pads in the lateral aspect upper lids disguised as upper lid ptosis and bulging of the upper lids caused by supraobicularis fat, indicating that these must be addressed to achieve an appropriate UEB.

Perhaps the most important surgical factor is marking the incisions, according to Dr. Tovilla-Canales.
	
	“With the patient supine, I create the crease in the patient’s natural crease, usually 10 millimeters from the lid margin in women and a little lower in men,” he explained, demonstrating the pinch test, performed using forceps with the patient sitting and with eyes closed, to determine the amount of skin to remove.
	Dr. Tovilla-Canales said he uses a guideline of 20 millimeters from below the incision to above the incision as a safe amount. When it comes to anesthesia, Dr. Tovilla-Canales advises administering intravenous sedation preoperatively and a small amount of local anesthesia.
	
	The incision, skin and fat removal also are important, and Dr. Tovilla-Canales said his preference is to create incisions using a blade rather than a CO2 laser because of the possibility of wound dehiscence related to the laser. Once the incision is created, Dr. Tovilla-Canales performs electrocautery. When removing the orbicularis, he said he prefers to remove only skin and preserve as much orbicularis as possible.
	
	When removing fat, he extracts the least amount possible to avoid hollowing of the eye. Typically, he removes only the medial fat pad. Dr. Tovilla-Canales also emphasized the importance of identifying lacrimal gland prolapse, which also can mimic the appearance of fat pads; his procedure of choice in such cases is to reposition the lacrimal gland with sutures.
	
	The procedure is not simply one of removing skin and/or fat, but recognition of structural issues such as ptosis. “Surgeons must be very conservative with the amount of skin, fat, and orbicularis muscle that is left postoperatively,” he said.
	
	During wound closure and crease formation, the wounds can be closed with interrupted 6-0 or 7-0 nylon or Prolene sutures. In some cases, a crease may need to be created. Dr. Tovilla-Canales said he takes a small bite of the orbicularis muscles, a bite of the aponeurosis where it joins the tarsus and finally another bite of the orbicularis muscle in the upper incision.
	
	While UEB appears to be a simple procedure, complications can occur. This can include asymmetry, ptosis, lagophthalmos, ocular motility disorders, scarring, hematoma, retrobulbar hemorrhage, and lymphedema.
	
	“UEB is usually a safe and effective procedure,” Dr. Tovilla-Canales concluded. “Complications can be prevented by performing an adequate preoperative assessment, understanding the patient’s expectations, obtaining meticulous measurements for skin markings, and proper surgical technique.”

Dr. Tovilla-Canales has no financial interest in any aspect of this report.

Articles

No cookie-cutter procedure, UEB can improve patients’ visual fields by more than 25%

Pearls for upper eye lid blepharoplasty

Preventing and treating vitamin A deficiency is the first step in preventing systemic and ocular complications, including xerophthalmia.

, a form of dry eye that results from vitamin A deficiency, was recognized medically as far back as 1520 BC. A treatment was devised that involved cooking beef liver, and then squeezing the “juice” of the liver on the affected eyes, according to 

theorized that the juice from the liver trickled down through the lacrimal sac and was absorbed, entered the blood stream, and ultimately reached the back of the eye.
	
	Dr. Sommer, professor of ophthalmology,

, recounted his experience in 1978 in an Indonesian village during which he witnessed a similar ceremony performed on a child with nightblindness who was treated with goat’s liver and then given the liver to eat, which may be how the vitamin A entered the child’s circulation in the first place.
	
	


	
	A 19th-century treatment that was less humane advised keeping the affected person in a dark room for at least a month, which works temporarily because the retinal pigments have a chance to build up, Dr. Sommer explained. 

 is diagnosed currently by observing a patient’s response to various levels of light, a method that grew out of an observation in malnourished Confederate soldiers during the 

.
	
	The soldiers refused to take night watch because they could not see in the dark, which was confirmed by the lack of a pupillary response when a candle was waved in front of their eyes, Dr. Sommer noted. Another manifestation of xerophthalmia is the presence of Bitot’s spots on conjunctiva, which are comprised of keratin.
	
	“Vitamin A is necessary for development of normal, mucous-secreting conjunctival epithelium,” he explained.
	
	The spots usually develop temporally, but severe cases involve the entire conjunctiva. In the late 19th century, cod liver oil, which is rich in vitamins A and D, was determined to be an effective cure for night blindness and Bitot’s spots.


	
	Dr. Sommer described the case of a child who was vitamin A-deficient and had an unusual form of local necrosis.

“This manifestation often begins with a small ulcerative area that is hard to differentiate from an infection until the clinician realizes that nothing can be cultured from it and it is refractory to antibiotic treatment,” Dr. Sommer said.

 revealed the presence of liquefied corneal stroma over an intact epithelium.
	
	The 

n recommended treatment of the necrosis with water-miscible vitamin A, which was unavailable and required formulation. Dr. Sommer instead administered an oily preparation of vitamin A orally (it was known that it did not work when injected, as had long been taught) until the water-miscible formulation became available.
	
	The new formulation worked well when given intra-muscularly, but no better than the less expensive oily preparation given by mouth. Studies of locally necrotic corneal ulcers in children who died showed them to be strictly demarcated, absent of inflammatory cells, under an intact epithelium, and bordered by normal tissue.
	
	“It did not fit any of the suggestions we had about the mechanism by which sterile corneal melting would develop,” Dr. Sommer said.
	
	Because of the good results Dr. Sommer achieved with the cheap, available orally administered oily vitamin A, he compared it with the more expensive, less readily available water-miscible form administered intramuscularly.
	
	“The rates at which corneal healing occurred were very similar in the two groups,” he said. “We confirmed in 1980 that both the clinical and the biochemical responses were identical in the two groups.”
	
	At six to eight days after administration, the improved/cure rates were 94% and 97%. Early treatment of xerophthalmia is essential before the cornea is completely necrotic. The disease is associated with a mortality rate of about 25% despite hospital care.

Nutrition a priority for dry eye patients


	
	Keratomalacia is the most severe form of xerophthalmia. The association between the corneal deterioration and Bitot’s spot was not recognized until the early 1900s, about the same time as the discovery of vitamin A.
	
	This was a period when it was found that the so-called 

, i.e., fat, carbohydrates, and protein, were insufficient by themselves to sustain life, but, according to Dr. Sommer, life required “accessory factors,” as they were called by Hopkins, or “vital amines” by Funk, and fat-soluble A by McCollum and Davis.
	
	It was not until 1917, that McCollum reported, “We feel confident that these cases of xerophthalmia … should be looked upon as a deficiency disease not hitherto recognized in its true relationship to diet.”
	
	Dr. Sommer described a rat study in which pregnant rats were made vitamin A deficient and the pups were born severely deficient, to facilitate development of xerophthalmia and other manifestations of vitamin A deficiency. The deaths among the pups were charted. The results showed that xerophthalmia developed much later, after a number had died.
	
	This death rate was evident when Dr. Sommer and colleagues studied xerophthalmia in Indonesia and found that children with mild vitamin A deficiency, but with normal looking eyes, died at a third of the rate of those with nightblindness, which was one-sixth the rate of the children with 

.
	
	Further studies, and randomized trials, showed that by giving vitamin A by mouth twice a year to children in the developing world, would reduce childhood mortality by one-third.
	
	“This changed the paradigm,” he noted. “Instead of vitamin A deficiency equaling xerophthalmia, as the vitamin A status declines other systemic functions are seriously impacted.”
	
	The ocular manifestations, which had been considered the primary outcomes of vitamin A deficiency, develop relatively late. This recognition led to a program in 50 countries in which large-dose vitamin A capsules are distributed twice annually to all children younger than 5 years. This has been estimated to save about 350,000 lives annually.
	
	

Dr. Sommer has no financial interest in any aspect of this report.

Centuries of research show treating deficiencies can have dramatic impact

Focusing on xerophthalmia, vitamin A deficiency

-A trifocal diffractive lens (FineVision IOL, PhysIOL) reduces spectacle dependence after cataract  surgery and provides good patient satisfaction with uncorrected visual  capabilities for near, intermediate, and distance tasks. Sunil Shah, FRCS(Ed), FRCOphth, reported the results of a pilot study at the annual meeting of the American Society of Cataract and  Refractive Surgery.

This intraocular lens (IOL) is composed of two diffractive structures, according to Prof. Shah. The first diffractive  structure adds about 3.5 D for near vision and the second 1.75 D for intermediate vision.

Prof. Shah, who is a visiting professor, University of Aston, Birmingham, UK, and colleagues conducted a study that included 20 patients who underwent bilateral implantation of the IOL. Prof. Shah performed all of the surgical procedures. The primary goal of the study was to examine  visual outcomes following bilateral implantation of the IOL.

At 3 months postoperatively, the mean uncorrected postoperative monocular distance logarithm of the minimum angle of resolution (logMAR) visual acuity (VA) was 0.24 (20/20 = 0.0), the mean spherical equivalent 0.02, the mean logMAR best-corrected distance monocular (BCDVA) 0.12, and the mean logMAR binocular BCDVA 0.09, Prof. Shah said.

Following surgery, the patients were asked to complete a questionnaire to measure satisfaction. The questionnaire was specifically validated for use with  patients with accommodative and multifocal IOLs to assess their level of visual  independence. The responses to the quality of the VA could range from 0 to 4,  with 0 indicating complete satisfaction and 4 indicating completely unsatisfied.

“The  overall patient satisfaction at 3 months after implantation was 0.9 ± 0.9, a  result that is very similar to all the new multifocal IOLs being introduced,”  according to Prof. Shah.

Regarding  the defocus curve, the investigators found that the IOL maintained a moderate  level of VA 3 months postoperatively, which was better than that at all levels  of defocus, he explained.

“This  intraocular lens provides a clear area of intermediate VA not seen with other multifocal  IOLs,” he said.

“The  Fine Vision trifocal IOL works extremely well at three levels of VA and  provides good patient satisfaction with uncorrected vision,” Prof. Shah  concluded.

Prof. Shah has no financial interest in this  subject matter.

A trifocal diffractive intraocular lens (FineVision IOL, PhysIOL) reduces spectacle dependence after cataract surgery and provides patient satisfaction.

Trifocal diffractive intraocular lens reduces spectacle dependency

-Fibrin glue might be a potential cause of toxic anterior segment syndrome (TASS). During the American Society of Cataract and Refractive Surgery annual meeting, Selcuk Sizmaz, MD, reported four cases of TASS that developed after uneventful phacoemulsification and IOL implantation.

The four cases (two men, two women) were the initial consecutive two cases that developed on two different surgical days. All patients underwent uneventful surgery for age-related cataract. At presentation, the patients had severe corneal edema that extended from limbus to limbus. The IOP was elevated in three cases. Two patients reported pain, according to Dr. Sizmaz, who is from Baskent University School of Medicine, Ankara, Turkey.

All of the patients were treated with prednisolone acetate drops hourly, 5% sodium chloride three times a day, ofloxacin four times a day, oral acetazolamide three times a day for high IOP, and subconjunctival dexamethasone (0.2 ml, 4 mg/ml) from the second to the sixth treatment days, Dr. Sizmaz recounted.

In the three affected patients, the IOP returned to normal. The steroid therapy was tapered over 6 weeks in two patients. The other two patients had persistent cornea edema and underwent penetrating keratoplasty. In two patients the pupils were fixed and dilated, and they were unresponsive to light.

Dr. Sizmaz and colleagues experienced two outbreaks of TASS 5 months apart. The cases were the first two cases treated on two different surgical days. The rest of the patients who underwent surgery on those two days were not affected. The investigators reviewed all preoperative, intraoperative, and postoperative procedures to determine the cause of the TASS.

“The two outbreaks were not distinguished by means of preoperative or intraoperative procedures,” he commented. “Both outbreaks were preceded by pterygium excisions during which fibrin glue was used; those [procedures] were performed at the end of the two preceding days.”

Fibrin glue has been thought to be a relatively benign product. In one experimental study, there was no evidence of toxicity in cultured bovine endothelial cells; another study in rabbits also reported no damage to the corneal endothelial cells.

The investigators concluded that remnants of fibrin glue on the surgical equipment that was denatured by sterilization might have caused the TASS outbreaks.

“TASS is a sight-threatening condition that requires thorough investigation to prevent development of new cases,” Dr. Sizmaz said.

Dr. Sizmaz has no financial interest in this subject matter.

"AAO provides cataract tips for patients"

Fibrin glue might be a potential cause of toxic anterior segment syndrome (TASS).

Author | Lynda Charters

Articles

Pearls for upper eye lid blepharoplasty

Focusing on xerophthalmia, vitamin A deficiency

Trifocal diffractive intraocular lens reduces spectacle dependency

Fibrin glue may cause TASS