42.1 Patient History Leading to the Specific Problem

The patient is a 68-year-old white woman who had a four-eyelid blepharoplasty 1 month ago. She complains of bothersome tearing from both eyes since the surgery. She has tried over-the-counter artificial tear supplements and a prescription ophthalmic steroid eye drop with no relief. She says that her vision is blurry but does improve when she wipes her eyes. The swelling and discomfort from her surgery has mostly resolved. She is concerned that she has “pink eye” and wants to know if an antibiotic eye drop is needed (Fig. 42-1).

42.2 Anatomic Description of the Patient’s Current Status

On examination, the patient still has a slight amount of eyelid edema from her surgery. The eyelids are in good position with no ectropion. There is no sign of lagophthalmos on passive closure. A small amount of conjunctival edema is noted along the lower eyelid margins and the conjunctiva of both eyes is slightly injected. There is no obvious tearing on exam.

42.3 Recommended Solution to the Problem

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  Determine if there is any conjunctival discharge or conjunctival edema.

  
  
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  Look for evidence of eyelid malposition and lagophthalmos.

  
  
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  Check to see if the patient appears to be blinking normally.

42.4 Technique

Closely inspect the eyes to see if there is any evidence of conjunctival discharge. Increased tearing is common after any eye or eyelid surgery. The tear fluid is normally clear but is often thicker after surgery due to increased mucus secretion, a normal response to ocular irritation. Mucus in the tear film is typically white and stringy, while true bacterial conjunctivitis is characterized by a yellow discharge indicative of pus. If there is any doubt, a conjunctival culture will differentiate and suggest appropriate antibiotic therapy if indicated.

Determine if there is any conjunctival edema (chemosis) along the lower eyelid margin (Fig. 42-2). Chemosis is quite common after lower eyelid surgery and can disrupt the normal flow of tears across the surface of the eye to the punctum. This is most common in the lateral canthus. Such patients will also complain of a foreign body sensation generated by the swollen conjunctiva and often report that they see a “blister” or “water pocket” on the surface of the eye. Older patients may even have redundant conjunctiva across the entire lower lid margin (conjunctivochalasis) preoperatively and are even more likely to develop postoperative chemosis (Fig. 42-3).

Check for any evidence of ectropion of the lower eyelid. If the punctum is displaced outward from its position against the globe, it cannot drain the tears away from the eye and epiphora results. Even the slightest amount of punctual ectropion will lead to tearing (Fig. 42-4).

Ask the patient to gently close the eyes to determine if there is any lagophthalmos (Fig. 42-5). Even 1 mm of lagophthalmos can lead to significant corneal exposure and complaints of ocular irritation and tearing. It may be necessary to ask the patient’s spouse to observe for any signs of nocturnal lagophthalmos since subtle weakness of closure may not be obvious in the examination room. This entity is covered in another chapter in this book.

Evaluate the patient’s blinking ability. Is there any sign of the seventh cranial nerve weakness that could have resulted from the surgery? Do the lids appear to blink normally or do they appear to function slower than normal? The tear film is intimately related to and dependent on normal eyelid integrity and mechanics. The eyelids are the “pump” for pushing tears into the lacrimal sac and down the nasolacrimal duct. Any disruption of their ability to do so results in tearing.