Many people who suffer from dry eyes can potentially benefit eyelid surgery to treat under eye
bags, hooded upper eyelids, or eyelid ptosis.
At the same time if you have dry eyes, you may be hesitant about surgery because of potential
surgery related causes which may make dry eyes worse . In this video, I will explain
how I approach patients with dry eyes in my practice, and how eyelid surgery can be done
for many patients with dry eyes.
I’m Dr. Amiya Prasad.
I’m a Board Certified Cosmetic Surgeon and Fellowship Trained Oculofacial Plastic & Reconstructive
Surgeon.
I’ve been in practice in Manhattan and Long Island for over 20 years.
To be an oculoplastic surgeon, you have to first be trained in ophthalmology (B roll
Dr P using a slit lamp).
As an oculoplastic surgeon, I have expertise with disorders of the lacrimal system, which
includes the lacrimal gland, which produces tears and the tear duct system, which drain
the tears.
This background informs all cosmetic surgery I perform in the eye area.
It is often the case where a general plastic surgeon performs eyelid surgery, and then
sends the patient to an ophthalmologist once the patient complains of dry eye symptoms.
The plastic surgeon essentially puts the burden of the surgical outcome onto the ophthalmologist
is now put in a difficult position of having to manage the patient’s dry eyes for years
long after the plastic surgeon compromised the eyelid function.
A systematic approach to identifying the degree of dry eye prior to surgery is very important.
Further, I would add that specific aspects of eyelid anatomy directly affects eyelid
function and will impact future dry eye management.
For example, lower eyelid surgery for eye bag removal is a very popular procedure.
The lower eyelid is very important for proper distribution of tears over the eyes.
You can think this interaction of the action of the upper and lower eyelids to be working
like a windshield wiper to evenly distribute tears over the surface of the eyes.
If there is any change in the anatomy of the lower eyelid, particularly the position of
the eyelid margin, this tear distribution function will be impacted
For example, a very commonly performed technique for lower eyelid surgery is the transcutaneous
method, where an incision is made below the eyelashes to remove and sculpt the fat which
cause eye bags.
It’s common practice to also remove skin at the same time in an attempt to improve
fine lines and wrinkles under the eyes.
Without managing the critical structural support of the lower eyelid, this technique often
compromises the position of the lower eyelid as well as its function.
The result is a pulled down appearance referred to as lower eyelid retraction, which can cause
an inability to fully close the eyes resulting in eye exposure and dryness.
Tear film distribution is also compromised.
For primary lower eyelid surgery for under eye bags, I evaluate the anatomy and function
of the lower eyelid using what’s called a pull test and a snap back test.
These tests help me decide if any additional support procedures would be appropriate such
as a lateral tarsal strip to position the lower eyelid for optimal tear distribution.
My preferred approach to addressing lower eyelid fat pockets is called a transconjunctival
lower eyelid blepharoplasty.
This means I address the fat pockets from inside of the eyelid.
This technique better preserves lower eyelid support structures in particular the support
muscle called the orbicularis oculi and maintain the position of the eyelid margin.
This means the tear distribution is properly maintained.
I routinely perform this surgery on patients with dry eyes, even those with a history of
severe dry eyes.
Additionally, my patients appreciate that there is no visible external scar and the
natural shape of the eyes are maintained.
Oftentimes people who have dry eyes will actually have improvement in their dry eye symptoms
after eyelid surgery.
This is because procedures which improve the tone and position of the lower eyelid combined
with the relief of weight from extra skin on the upper eyelid help the eyelids protect
and lubricate the eyes.
Eyes that look good function well.
When it comes to upper eyelid blepharoplasty, it’s critically important to not remove
too much skin, particularly in patients with dry eyes.
I would also add that with upper eyelid surgery, particular care must be taken to protect a
gland, which produces tears called the lacrimal gland.
The lacrimal gland exists in the same space where the fat pockets in the upper eyelid
are present.
When the upper eyelids appear full and heavy, both the fat and the lacrimal gland can be
responsible for this appearance.
It’s routine to sculpt and remove some fat to create more space.
Unfortunately, it’s been well known that the lacrimal gland has been mistakenly removed
by general plastic surgeons which resulted in significant loss of tear production.
As an oculoplastic surgeon, during evaluation as well as during surgery I look for the lacrimal
gland which is often prolapsed or displaced downward.
Instead of removing the lacrimal gland, I perform a procedure called lacrimal gland
resuspension to restore the anatomical position of the lacrimal gland as well as preserve
the function of the lacrimal gland.
It’s important to have a clear strategy for dry eye management before and after surgery.
It’s well established that there may be some short term decrease in tear production
after eyelid surgery so generally, I advise my dry eye patients to increase the frequency
of lubricating eye drop use prior to surgery.
Further, I work with my patients to help them with dry eye management after surgery.
As far as the anesthesia experience, I perform all my eyelid surgeries with local anesthesia
with LITE sedation.
My patients recover comfortably and quickly so they typically are able to return to work
in about 1 week.
Cosmetic eyelid surgery can be done safely for people with dry eyes.
As mentioned earlier, there are often opportunities to help improve dry eye symptoms with specific
procedures, which are well known to oculoplastic surgeons.
I would state without reservation that a cosmetic eyelid surgery specialist with training in
ophthalmology is ideally suited to perform cosmetic surgery for people with dry syndrome.
I hope you found this information helpful...thank you for your question