21 Chemosis in the Aesthetic Surgery Setting
Summary
Chemosis can occur after aesthetic eyelid surgery, especially the more invasive lower eyelid procedures. Being able to recognize and treat this condition is very important for patient safety and satisfaction. Chemosis can arise from local trauma, temporary lymphatic blockage, and scleral exposure. Should conservative measures not suffice to treat chemosis, procedural intervention may be necessary. This chapter presents such an example and how it was treated.
21.1 Patient History Leading to the Specific Problem
This patient is a 67-year-old woman who initially presented to the clinic with an interest in facial rejuvenation (Fig. 21-1). She had prior cataract surgery in 2006 and smokes a pack of cigarettes per week. She does not report any symptoms of dry eye. On exam, she demonstrates moderate to severe signs of panfacial aging including dermatochalasis of the upper and lower eyelids. Her eyelid tone was normal. After consultation, a face and neck lift with upper and lower lid blepharoplasty and periorbital and perioral croton oil peel was recommended.
She had an uneventful procedure that included a transpalpebral midface lift, canthopexy, and croton oil peel of the crow’s feet (in addition to the face and neck lift and upper lid blepharoplasty). A temporary lateral tarsorrhaphy suture was placed on both sides during the case. After surgery, TobraDex ophthalmic ointment was prescribed. At 1 week postoperation, the temporary tarsorrhaphy suture was removed and the ointment was stopped. At that time, she had no evidence of chemosis.
21.2 Anatomic Description of the Patient’s Current Status
At 3 weeks postoperation, delayed chemosis in the right eye was noted on the exam (Fig. 21-2a). Her eyelid closure was normal. The chemosis is evident in the right eye predominantly in the lateral scleral triangle. Chemosis represents fluid collection/edema that appears in the sclera, typically in the lateral triangle, but it can appear medially as well in more severe cases. Anatomically, the edema occurs within the space between the outermost layer of the eye (the reflexion of the conjunctiva from the eyelid) and the underlying bulbar sheath (a.k.a. Tenon’s capsule) Fig. 20.1. It is important to note that the sclera can be as thin as 0.4 mm at the insertion of the rectus muscle about 6 mm behind the corneoscleral junction. The conjunctiva is firmly adherent to the sclera along the entire circumference of the cornea representing a stop point in chemosis formation (Fig. 21-2a, see the right eye between 7 and 8 o’clock positions in the photo).
21.2.1 Recommended Solution to the Problem
Wetting eye drops.
Steroid-containing ophthalmic solution or ointment.
Temporary lateral tarsorrhaphy suture.
Eye patching at night with or without compression.
Conjunctivectomy with 24-hour patching.
This case was initially treated with FML (fluorometholone ophthalmic suspension, USP 0.1% sterile) drops. After a week, there was no improvement, so a conjunctivectomy was performed.
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