5 Things all plastic surgeons should know about operating around the eyes
by Dr Chris Thiagarajah on 05/23/13
There are many types of plastic surgeons who perform eyelid surgery. These may include facial plastic surgeons, general plastic surgeons, maxillofacial surgeons and even some dermatologists. Oculoplastic surgeons train extensively in eyelid surgery. Most perform over 1000 in their training. I myself performed closer to 2000 surgeries on the eyelid during my fellowship. When performing a blepharoplasty or eyelid lift, there are five key points that are important to remember. As an oculoplastic surgeon, I am mindful of these five points every time I operate and most surgeons who work around the eye should be mindful of these five points.
1. Stitches that rub against the cornea can cause permanent damage.
When we operate on the lower eyelid and perform a blepharoplasty some surgeons place a stitch to close the conjunctiva. The conjunctiva is the pink tissue that is the top layer of the “skin” of the inside of the eyelid. Commonly surgeons will place a dissolvable suture such as a chromic or fast absorbing gut suture to close the entry point on the inside of the eyelid to the fat that was accessed during surgery. If the knot ends are not cut down or even buried, these can rub against the cornea. The cornea is the clear glasslike surface of the eye that we see through. Symptoms of having a stitch against the cornea include scratching feeling, pain, decreased vision. Most often the stitch can be cut or released for relief of symptoms. The cornea usually heals well within a couple days.
2. If the tear duct system is damaged, it needs to be repaired immediately
The tear duct system is at the corner of the eyelid at the side of the nose. There is a punctum or entrance to the tear duct in the upper and lower eyelid. The eyelid skin there is weak and can easily tear. In fact when patients have eyelid trauma, that is the most common part of the eyelid to tear. In lower eyelid surgery, sometimes when the eyelid is retracted, the same part of the eyelid can tear as well. When it does tear, the canaliculus or tear duct tubing also inevitably tears. The treatment is to fix the tear immediately (within 24-48 hours). Fixing it means placing a silicone tube in the tear duct system so the tubing heals in place. Otherwise the tear duct tubing can scar down and tears cannot pass into the tear duct system. In 70% of patients if a tear duct system in one of the eyelids is patent, the patient will not tear as long as the other system in the other eyelid is functional. However, 30% of the patients will tear and the treatment includes a glass tube (aka Jones tube) to be placed in the tear duct system. That does not work as well as the normal natural system and we like to avoid it whenever possible. Waiting to fix the tear duct system will most likely result in the system scarring down. I like to repair the tear duct system within 48 hours ideally.
3. 3. Any decrease in vision after surgery should be investigated
After surgery, patients can have decreased vision. This is commonly from ointment in the eye that blurs the vision like Vaseline on a window pane. Also the eye can be dry or irritated resulting in distortion of vision. However, there can be more serious causes of decreased vision after eyelid surgery. Along with eye surfaces problems such as a scratch on the eye surface or tear or cut on the eye surface, there can be more serious problems. I had a patient sent to me after eyelid lifting surgery with decreased vision who had a retinal detachment after eyelid surgery. Though he informed his plastic surgeon, the decreased vision was thought to be due to dry eye,eye irritation, or even the ointment being placed in the eye. The patient was sent to me after two weeks. At that point I sent him immediately to a retinal specialist to have his retinal detachment repaired but the vision was poor after surgey. Strokes to the eye also can occur. Though nothing can be done in that situation, it is important to determine the cause of the vision loss when it occurs. Decreased vision tha can be blinked out of are more reassuring and tend to be surface problems. Even a surface problem such as a scratch or abrasion on the eye surface needs to be treated appropriately with antibiotic drops so a secondary infection does not occur.
4. Long term steroid ointment to the eye may cause damage
Steroid antibiotic drops or ointment may be given after surgery on the eyelids to promote healing, decrease the chance of infection and reduce scarring. That being said, the steroids can have untoward effects on the eye. The eye pressure can increase in certain individuals after 6 weeks of steroid drops or ointment. Why is that bad? Because increased eye pressure can lead to glaucoma and damage to the optic nerve. When this nerve is damaged it cannot be reversed or fixed. Usually the pressure can increased after 6 weeks of steroid exposure. As a result I have patients use ointment or drops for 1-2 weeks at the most. If they are taking the medication any longer, I will check their eye pressure to make sure that it is not elevating at that point. In order to check the pressure, one needs to have a tonometer, the instrument that checks eye pressure.
5. .5. Having corneal shields on the eye does not eliminate the risk of damage to the eye
During blepharoplasty or eyelid surgery, some surgeons place corneal shields on the eye. This is a metal or plastic disc that covers the cornea. This reduces the chance that the laser being used or the electrocautery needle being used does not accidentally nick or cut the eye surface. However having the shield in the eye does not eliminate the chance of having damage to the surface of the eye. How is that possible? There are several ways. First, sometimes the shield can migrate on the surface of the eye during surgery and expose parts of the eye surface. As a result, the surgeon has a false sense of confidence with his or her cutting instrument and may accidentally damage part of the eye thinking the shield was protect the surface when it was not. Second, placing or removing the eye shield itself can cause a scratch to the eye surface or cornea. Third, ointment is necessary to lubricate the eye underneath the eye shield. When this is not placed in enough quantity the corneal surface of the eye can dry out or be damaged from the shield sitting on it. Finally, some of the cutting instruments can cut through the shield. Any decreased vision to the eye such as a bleed behind the eye that puts pressure on the optic nerve can cause vision loss and has nothing to do with the corneal shields.
