Cosmetic Surgery and Glaucoma Patients

Cosmetic Surgery and Glaucoma Patients
Chat from April 6, 2011
Guest Speaker – Dr. Michael J. Pro
Steven Beck, Editor
Lorraine Miller, Editor, Chat Topic Researcher

On Wednesday, April 6, 2011, Dr. Michael Pro, a glaucoma specialist at Wills, and the glaucoma chat group discussed “Cosmetic Surgery and Glaucoma Patients”.

Moderator: Our topic this evening is Cosmetic Surgery and Glaucoma Patients. Thank you, Dr. Pro, for agreeing to chat about this topic. To start, what is ptosis and what usually causes it?

Dr. Pro: Ptosis is drooping of the eyelids and it has many causes. I am not an oculoplastics specialist, but I will try my best. The causes can be inflammatory, infectious, tumors, trauma, and age-related changes.

Obviously, age-related ptosis is the most common. The fine muscles that lift the lid can become partially detached and the lid can droop; also the connective tissue in the lids and eyebrows can get lax and cause the lid the come down gradually.
One of the most important distinctions is the time period for the ptosis. Sudden ptosis or ptosis associated with double vision needs to be investigated immediately.

P: What percentage of patients develop ptosis after a trabeculectomy?

Dr. Pro: Good question, and one that I don’t have an exact number. In my experience about 10 percent of patients have some degree of ptosis after surgery. In most cases the ptosis slowly resolves. In my experience, ptosis is more frequently seen in repeat glaucoma surgery, or in tube shunt surgery.

P: What occurs during a trabeculectomy that causes ptosis?

Dr. Pro: In the immediate post-operative period, the inflammation from surgery can cause some lid swelling and ptosis. There are reports that post-operative steroid drops can cause ptosis.

The lid speculum that holds open the eye for surgery may cause some post-operative ptosis. Sometimes more chronic ptosis or later developing ptosis can be from the presence of an elevated filtering bleb that affects the position of the upper lid or causes ocular surface disease (dry eye) that causes a secondary ptosis.

P: I had some drooping prior to my trab, but it is much worse and bothersome now. How long should I wait before seeking a surgical consult, and must this be done by an eye surgeon or a regular cosmetic surgeon?

Dr. Pro: You should consult an oculoplastic specialist after confirming with your glaucoma doctor that your surgery is now stable. I generally ask my patients to wait at least six months to make sure that any post-operative swelling is gone.

P: Are there any cosmetic eye procedures or facial cosmetic procedures glaucoma patients cannot do?

Dr. Pro: Of them all, ptosis surgery is by far the most common that I am asked about. I can not think of any others that would be problematic. Be aware that persons with a bleb may be more prone to dry eyes and ptosis repair can worsen a dry eye situation.

P: What is blepharoplasty?

Dr. Pro: That is the surgical term for eyelid surgery. Cosmetic blepharoplasty is somewhat different from ptosis repair in that there may be no significant functional impairment prior to a cosmetic procedure.

P: Can a blepharoplasty worsen glaucoma in a patient using glaucoma eye drops to keep their pressure under control?

Dr. Pro: Another good question, and the answer in general is no.

P: Are cosmetic fillers or Botox contraindicated in any way after a trab, or generally with glaucoma?

Dr. Pro: Botox is not in general contraindicated. I have never had a patient ask me about fillers but have not read about any bleb related problems.

P: Does ptosis surgery cause the eyelid to droop?

Dr. Pro: Yes it can, especially in the immediate post-operative period, where the post-operative swelling can make the lids have more ptosis than pre-op. Months may be needed for the swelling to decrease. As for long-term worsened ptosis, this can also be possible, but I would think it could be related to a failure in relation to surgery (slipped sutures or tissue detachment).

P: Blepharoplasty is usually not covered under insurance plans. If ptosis is a side effect of a trabeculectomy, is the correction of the side effect covered under insurance?

P: Mine was covered when my right eye was pretty much flat and effecting part of my upper visual field. I had to have taped and untaped visual fields tests prior and I guess the insurance company had to see them and okay it.

Dr. Pro: Exactly; the insurance companies are looking for a functional defect. This can be easily assessed in the office as described.

P: How much of a visual field needs to be compromised for a blepharoplasty to be covered by insurance?

Dr. Pro: I have never seen a written figure and as we all know the insurance companies can be mercurial, but in general when the top 10 degrees of the visual field on a 30 degree field are affected, there does not seem to be a problem with coverage. An oculoplastic surgeon would be more familiar with insurance company rules.

P: Can blepharoplasty and a trabeculectomy be performed at the same time?

Dr. Pro: No. If glaucoma surgery is needed it is usually done first. Post-operative swelling could affect the success of the trab, so it is better to do it alone.

P: How will a trabeculectomy affect a prior blepharoplasty?

Dr. Pro: It could cause some ptosis from the issues I listed previously.

P: What questions should be asked of the surgeon performing the blepharoplasty when a bleb exists?

Dr. Pro: First, ask if the surgeon has operated on patients with blebs before. They may not be able to raise the lid as much as they usually would. After that, one could ask the usual questions of any surgeon such as: How many blepharoplasties do you perform? What are your outcomes? Who is your typical patient? For instance, some oculoplastic surgeons specialize in more complex orbital problems, while others just do cosmetic blepharoplasty.

P: I am glaucoma suspect and have blepahroptosis to some extent that will one day definitely require surgery. So did I hear you say, “If surgery is needed, glaucoma treatment is done first and then blepharoplasty?” How risky is that surgery in terms of risk for vision loss today?

Dr. Pro: That does not apply to glaucoma suspects. From your description it sounds as though your glaucoma is being monitored and you will likely never need glaucoma surgery. In this case, a blepharoplasty can be performed first. I was talking about those individuals who need glaucoma surgery in which case the trab or tube or other glaucoma surgery should be done first.

P: If you have ptosis in one eye, will it develop in the other?

Dr. Pro: Yes, it is possible to develop it in the other eye. An eye that has had more intraocular surgery will often have more ptosis than the other eye.

Moderator: That was the last question. Thank you Dr. Pro. We’ll see you in two weeks!

Dr. Pro: You are all welcome!


About the Author:

The Glaucoma Service Foundation’s mission is to preserve or enhance the health of all people with glaucoma and to provide a model of medical care by supporting the educational and research efforts of the physicians on the Wills Eye Institute Glaucoma Service, the largest glaucoma diagnosis and treatment center in the country.
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