Visual loss

The most feared complication of blepharoplasty surgery is visual loss. The most common cause is retrobulbar hemorrhage, although other etiologies have been reported (globe perforation, central retinal artery occlusion, retrobulbar optic neuritis, angle closure glaucoma).

Retrobulbar hemorrhage

The incidence of retrobulbar hemorrhage was reported in the plastic surgery literature at 0.04%.¹ More recently, an epidemiologic study of greater than 250 000 blepharoplasty cases performed by oculoplastic specialists found the incidence of retrobulbar hemorrhage to be 0.05%; associated permanent visual loss was diagnosed in 0.0045%.² This corresponds to a 1/2000 risk of significant hemorrhage and a 1/10 000 risk of permanent visual loss. Most often clinical presentation is within the first 24 hours after surgery, although bleeding has been reported as late as 9 days after surgery.³ Patients may complain of pain, pressure, diplopia and visual loss. Examination shows decreased visual acuity, lid edema, proptosis, subconjunctival hemorrhage, extraocular motility disturbance, increased intraorbital (resistance to retropulsion) and intraocular (tonometry) pressure and an afferent pupillary defect (Fig. 34.2).

Fig. 34.2 Retrobulbar hemorrhage producing ecchymosis after a frontal nerve block during transcutaneous blepharoplasty (A) and retrobulbar hemorrhage in a hypertensive patient demonstrating sudden proptosis and chemosis (B).

Many theories exist to explain the cause of retrobulbar hemorrhage, with vascular trauma being the most common. The final common pathway involves continued orbital bleeding leading to increased intraorbital and intraocular pressure with resultant ischemic damage to the retina and/or optic nerve.

Pearls

Pearls to avoiding retrobulbar hemorrhage include:

• Detailed preoperative evaluation with particular attention to medical problems such as diabetes, hypertension, coagulopathies and both prescription and over-the-counter anticoagulant medication use. Stopping all anticoagulants far enough in advance to allow normalization of bleeding parameters and platelet function is important.

• A past ocular history is necessary to rule out pre-existing causes of visual dysfunction, as rare reports of malpractice cases where patients have claimed pre-existing visual loss as a consequence of blepharoplasty do exist.

• Intraoperative control of hemostasis is critical. Koorneef’s description of the delicate connective tissue scaffold connecting the anterior orbital fat to deep orbital fat underscores the necessity to avoid excessive traction during fat excision. It is advantageous to delay wound closure by proceeding to another surgical site, returning later to reassess hemostasis prior to suturing.

• Postoperative prevention of hemorrhage involves all of the following:

– Elevation of the head of the bed decreases intravascular pressure.

– Avoidance of the Valsalva maneuver prevents a sudden rise in intraorbital pressure that may open a bleeding site. Consultation with the anesthesia team should include routine postoperative antiemetics, and when necessary, cough suppressants.

– Ascertain that the patient can at least count fingers. Decreased vision in the hand motions or light perception range is cause for concern. Recovery staff should be instructed to test the vision in each eye individually.

– Avoid “pressure dressings” as they delay diagnosis.

– Place ice compresses on each eye.

Once the diagnosis of retrobulbar hemorrhage is made, the treatment requires immediate attention. The first step should be to identify those hemorrhages that require medical or surgical care, based on the ophthalmic examination. If the intraocular pressure is elevated, as measured by tonometry or emergently by tactile evaluation, topical and systemic glaucoma medications can be used. Systemic corticosteroids are used for significant edema. When the bleeding threatens the visual system, or is worsening, surgical therapy is required. The first step is to open the incision widely through the orbital septum and explore the surgical site and orbit for signs of bleeding. Clots are evacuated and cautery is applied when bleeding sites are identified. If the condition remains unresponsive, a lateral canthotomy and cantholysis is performed. In severe cases, both the inferior and superior crus of the lateral canthal tendon can be released. When these measures fail, an emergent CT scan without contrast is warranted. If posteriorly organized hemorrhage is identified, bony decompression may be warranted to relieve orbital apex compression (Fig. 34.3). The treatment should be aggressive for the first 24–48 hours postoperatively, as vision has been reported to return in patients with “no light perception” that was present for 24 hours.

Fig. 34.3 CT scan after transcutaneous blepharoplasty showing aggregated clot and hemorrhage in the orbital apex. Posterior findings create the possibility for treatment with decompression rather than lateral canthotomy.

Globe perforation

Inadvertent globe penetration can result from any periocular procedure. Caution is necessary during local anesthetic injection, particularly in the thin upper eyelid of older patients. Prevention of this complication begins with the use of protective corneal shields during injection and surgery. Corneal shields should be lubricated with ophthalmic ointment prior to placement within the lids to avoid corneal abrasion. The range of potential ocular damage from penetration includes an open globe, corneal perforation, traumatic cataract, intraocular hemorrhage, a hypertensive or hypotensive globe, retinal tears and detachment (Fig. 34.4). Perforation of the globe is an ophthalmic emergency and necessitates emergent consultation with an ophthalmologist. A Fox shield should be placed over the eye in the interim and the patient should be instructed not to rub or press on the eye.

Fig. 34.4 A retinal flap tear with tractional retinal detachment is present after inadvertent corneal perforation during injection for an upper eyelid blepharoplasty. The patient also suffered from a traumatic cataract secondary to lenticular penetration.

How to place a corneal protective lens:

• Instill a tetracaine or proparacaine ophthalmic eye drop into the eye.

• Lubricate the protective shield with ophthalmic ointment.

• Insert the shell under the superior fornix from below.

• Evert the lower eyelid to allow the lower edge of the shell to move into the inferior fornix.

How to remove a corneal protective lens:

• Instill a tetracaine or proparacaine ophthalmic eye drop into the eye.

• Gently place an ocular muscle hook posterior to the lower edge of the shell.

• Guide the shell inferiorly over the lower lid.

Corneal abrasion

Corneal abrasion is generally a rapidly reversible cause of decreased vision postoperatively. The diagnosis is made by patient symptoms (pain, foreign body sensation, light sensitivity) and is usually apparent immediately after surgery. The diagnosis is confirmed by evaluating the cornea under a cobalt blue light after instillation of fluorescein (Fig. 34.5). Even though corneal abrasion is the leading cause of ocular pain and irritation following blepharoplasty, patients who complain of severe eye pain should be carefully examined under a slit-lamp to rule out globe perforation. Abrasions are often caused by drying of the corneal surface during surgery or inadvertent damage to the surface corneal epithelial layer. Sometimes, taping of the eyes during anesthetic induction causes an abrasion if the eyes are accidentally taped in an open position. Careful insertion and removal of well-lubricated corneal shields prevents this complication; as does the use of ophthalmic ointment into each eye at the completion of the procedure. Abrasions can be treated with ophthalmic antibiotic ointment four times daily, and should be resolved within 24 hours. Patching should be avoided, as it may mask a more serious complication, such as retrobulbar hemorrhage. Persistent signs and symptoms should prompt ophthalmologic evaluation.

Fig. 34.5 Pericentral corneal abrasion following blepharoplasty surgery. This is likely secondary to trauma, since exposure-related abrasions would be horizontal and linear.

Dry eye

Corneal irritation is somewhat common after blepharoplasty and symptoms are similar to, but less severe, than an abrasion. Patients may complain of foreign body sensation, dryness, irritation, blurry vision, photosensitivity and redness. These symptoms often arise from dried accumulation of clot or ointment in the eye and will respond to ocular lubrication with preservative-free tear drops and cool compresses. Alternatively, poor eyelid closure can cause exposure keratopathy, particularly inferiorly. This diagnosis is made by slit-lamp examination after the instillation of fluorescein. The examiner will see punctate corneal staining under blue light illumination in the affected region of the cornea. Treatment is with lubricating drops and ointment.

Very rarely, ophthalmic lubricant may be inadvertently introduced into deeper eyelid tissues from a transconjunctival surgical wound. This can result in encapsulation of the ointment within the wounds, and subsequent cyst formation that responds to excision (Fig. 34.6). Although this complication is extremely rare, physicians should keep in mind that excessive amounts of ointment are unnecessary and may result in inoculation of the wound.

Fig. 34.6 This patient returned to her plastic surgeon after a lower eyelid blepharoplasty complaining of recurrent fullness of each lower eyelid (A). The lower eyelid masses appeared cystic and upon evacuation were firmly encapsulated (B,C). Opening of the capsule and chemical analysis of its contents revealed Lacri-Lube (Allergan, Irvine, CA) ophthalmic ointment encapsulated from a foreign body reaction (D).

Eyelid hematoma

Hematomas usually develop from bleeding of the orbicularis oculi muscle. Evaluation for symptoms consistent with retrobulbar hemorrhage should proceed first. Once ruled out, mild superficial hematomas can usually be treated conservatively with ice compresses. Larger, stable hematomas should be followed for 7–10 days, until adequate liquefaction has occurred. Rarely do they need to be drained by needle aspiration or reopening of the wound. In severe cases, they may result in tissue fibrosis and lid scarring. Expanding hematomas require immediate surgical exploration, evacuation and control of the bleeding source.

Infection

The development of cellulitis or abscess formation is exceedingly rare in the well-vascularized eyelid. Nonetheless, both complications have been reported and should be managed with appropriate oral or intravenous antibiotics. Abscesses require surgical drainage. Figure 34.7 shows a patient who developed pseudomonas cellulitis in three of four lids after blepharoplasty. She was treated with a combination of surgical drainage and intravenous antibiotics, but ultimately developed late cicatrization and skin dimpling.

Fig. 34.7 Three days postoperatively, a blepharoplasty patient developed pseudomonas cellulitis with associated abscess formation.

Eyelid sloughing

Eyelid necrosis has been reported sparingly in the literature and can follow inadvertent injection with formaldehyde or other substances (i.e. atropine, alcohol, boric acid) instead of local anesthetic. Complete eyelid sloughing can develop, necessitating multiple eyelid reconstructive procedures and setting the patient up for scarring, persistent lagophthalmos and chronic ocular irritation from dry eye (Fig. 34.8).

Fig. 34.8 Severe eyelid sloughing is seen in a patient after injection with formalin (A,B). The surgeon was inadvertently handed formalin instead of local anesthesia and the patient immediately complained of pain. Four stages of eyelid reconstruction were needed to provide sufficient corneal coverage (C).

Chemosis

Conjunctival edema can develop in the early or intermediate postoperative period as the result of incomplete eyelid closure, ocular allergy, sinusitis or surgical edema. Chemosis can be worsened by systemic conditions, such as renal failure (Fig. 34.9). Corneal drying may occur, as the edematous conjunctiva balloons around the cornea preventing adequate tear film dispersion. Additionally, the exposed conjunctival surface may keratinize, leading to worsening foreign body sensation and ocular irritation. Treatment is with preservative-free artificial tears and ointment. A mild topical steroid eye drop can be prescribed, but should only be given in conjunction with ophthalmic evaluation to assure normalcy of the intraocular pressure and to rule-out secondary infectious keratitis. Rarely, a temporary suture tarsorrhaphy may be needed.

Fig. 34.9 A patient with chronic renal failure who developed postoperative chemosis following lower eyelid blepharoplasty (A

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