Complications from Eyelid Surgery

Andrzej J. Burkat, MD

Nicholas Ramey, MD

INTRODUCTION

Identification and management of potential complications begin before surgery. During the presurgical evaluation, a thorough discussion and easy-to-read informed consent will help prepare patients and surgeons for unexpected results.

Although complications are important to discuss preoperatively, surgeons must also set appropriate expectations for the range of normal experiences during and after surgery. The prepared patient understands that some intraoperative discomfort and awareness is possible. Typical postoperative bleeding, bruising, swelling, foreign body sensation, chemosis, epiphora, and even transient blurry vision are also expected. Every incision will scar, and no two lids are alike. Bilateral eyelid surgery will yield some degree of unevenness, which often reflects preoperative asymmetries. Imperfection is normal and expected.

The following outline of potential eyelid surgery complications focuses on “local” events. But patients should always be made aware of the systemic risks of surgery. Even procedures performed under local anesthetic can result in serious morbidity and death.

INTRAOPERATIVE COMPLICATIONS AND MANAGEMENT

Injuries to globe or adnexa
- Laceration or penetration of the conjunctiva, cornea, or sclera
  - Use scleral shield.
- Corneal abrasion
  - Use vaulted scleral shield lubricated with ophthalmic ointment.
- Chemical burn from surgical prep
  - Minimize contact with ocular surface and use dilute (5%) Betadine.
  - Avoid chlorhexidine as a facial antiseptic as it can be toxic to the cornea.
  - Baby shampoo may be used on patients allergic to Betadine.
- Disinsertion of levator aponeurosis during upper lid surgery or inferior oblique muscle during lower lid surgery
  - Dissect carefully and identify relevant anatomy.
Nerve injury
- Reduce axonal injury by lowering monopolar energy to minimum effective level, and use bipolar cautery when possible.
- Sensory denervation (supraorbital, supratrochlear, infratrochlear, infraorbital)
  - Sometimes unavoidable during transorbicularis and septal dissection
  - Anesthesia/hypesthesia/paresthesia usually resolves 3 to 6 months postoperatively.
- Motor denervation (temporal, zygomatic, buccal branches of facial nerve)
  - Respect boundary zones and planes of dissection.
  - Subcutaneous and subperiosteal planes are safe throughout the face and forehead.
  - Recovery (partial or complete) takes up to 12 months postoperatively or even longer in some cases.
Hemorrhage
- Preseptal
  - May occur from injection of local anesthetic or during dissection
  - Avoid by injecting subcutaneously and avoiding orbicularis or deeper injections unless necessary
- Orbital
  - May occur during any portion of the surgery
    - Injection of local or retrobulbar anesthetic
    - Orbital fat removal
    - Dissection of levator aponeurosis from the tarsus and Müller muscle
  - Vision loss may occur from compressive optic neuropathy/orbital compartment syndrome
    - Use meticulous blunt dissection techniques.
    - Achieve and maintain hemostasis incrementally.
    - Clamp and cauterize for fat excision.
    - Maintain systolic blood pressure <130 mm Hg.
  - Manage intraoperatively by exploring hemorrhages immediately
    - Lateral canthotomy and inferior cantholysis may be appropriate for hemorrhages occurring inferiorly or laterally.
    - Full orbital septum release may provide access to superior hemorrhages and yield necessary decompression without need for lateral canthotomy and cantholysis.

Over- and undercorrection

Overcorrection in upper blepharoplasty or ptosis repair

May result from many factors
- Removal of too much skin
- Incorporation of septum into the closure
- Overtightening the levator during levator repair (Figure 19.1)
- Resulting lagophthalmos may be well tolerated (usually <0.5 mm) or can yield ocular surface issues (Figure 19.2).