23.1 Patient History Leading to the Specific Problem

The patient is a 60-year-old white woman who underwent four-lid blepharoplasty and returns 1 month after the surgery complaining of severe irritation and burning of both eyes (Fig. 23-1). This is accompanied by fluctuation of vision and intermittent tearing from both eyes. She has been using cold compresses and over-the-counter artificial tears several times a day with no relief. Her past eye history is negative for ophthalmologic problems other than wearing bifocals. Her past medical history reveals no systemic or ocular allergies. She is otherwise completely healthy.

23.2 Anatomic Description of the Patient’s Current Status

This patient’s complaints are common after blepharoplasty surgery. The etiology of postblepharoplasty “dry eye” is multifactorial. From an ophthalmic standpoint, dry eye is due to either reduced tear production or increased tear evaporation. The patient typically complains of irritated, red eyes and intermittent blurred vision. When severe, dry eye can significantly affect the quality of life.

The tear film can be conceptualized as a three-layered sandwich (Fig. 23-2). The inner mucin layer is produced by conjunctival goblet cells. It functions to protect the ocular surface and provide a smooth surface for the adherence of the overlying aqueous layer. The middle aqueous layer is produced by the basic secretory glands of Wolfring and Krause scattered throughout the palpebral conjunctiva and the main and accessory lacrimal glands. The outer lipid layer is mainly produced by the meibomian glands of the eyelids and prevents evaporation of the aqueous layer. Disruption in any of these three layers leads to dry eye symptoms.

Reduced tear production (aqueous layer deficiency) is the most common cause of dry eye. It is more common in women older than 40 years and the incidence increases with age. It is worsened by diuretics, antihistamines, anticholinergics, antidepressants, connective tissue disorders, previous LASIK surgery, low-humidity environments, and other causes. About 10% of patients with aqueous tear deficiency will have Sjögren’s syndrome. There is no evidence that blepharoplasty itself causes a change in the basic secretion of the aqueous component of tears, but it is very common for symptoms to manifest after surgery. It is typically managed by supplementation with over-the-counter artificial tear drops and ointments. Frequent use of tear supplements will suffice for most patients. Severe cases may require placement of silicone punctal plugs (to slow the removal of tears from the ocular surface), cyclosporine ophthalmic drops (Restasis) to increase aqueous tear production, and sometimes topical ophthalmic steroid drops (which can cause cataract and elevate intraocular pressure) to reduce inflammation.

Evaporative dry eye (lipid layer instability) is typically caused by meibomian gland dysfunction, which is especially common in patients with rosacea. Redness of the lid margins, midface telangiectasis, rhinophyma, a history of chalazia, and northern European ancestry are suggestive of underlying rosacea. This author’s clinical impression from over 33 years of practice is that eyelid surgery may worsen the symptoms of rosacea and increase meibomian gland dysfunction in those patients so predisposed. Meibomian gland dysfunction is typically managed by warm compresses and eyelid hygiene with baby shampoo lid scrubs or over-the-counter eyelid scrub preparations. More recalcitrant cases will usually respond to a 2-month course of oral tetracycline, 50 mg daily, to normalize meibomian secretion.

Evaporative dry eye is also due to mechanical disorders of the eyelids such as lagophthalmos, lid retraction, and ectropion. Even a minimal amount of corneal exposure will lead to significant symptoms with findings of exposure keratitis on microscopic exam of the eyes. Likewise, exposure of the palpebral conjunctiva in ectropion will cause enough discomfort to generate complaints from affected patients. Mild degrees of ectropion, lid retraction, and lagophthalmos will usually resolve with time and conservative therapy such as eyelid massage. Persistent and severe lid position abnormalities will require additional surgery and in worst cases may need skin grafting.