Tears are necessary for the protection and health of the surface of the eye. Our eyelids play a crucial role in the production of healthy tears, which are made up of three layers. The first layer contains an oily substance secreted by the glands located in the eyelids. This layer’s main function is to prevent tears from evaporating, thus keeping the eyes from drying out quickly. Proper eyelid function is also necessary for maintaining a healthy corneal surface. Our tears are distributed evenly on the surface of the eye with each blink, which acts as a safeguard from the drying effects of the wind and brushes away debris.
Normal blinking depends on a delicate balance between skin elasticity and eyelid muscle contraction. Eyelid skin is extremely thin but remarkably elastic. Each blink must be perfectly synchronized to distribute the tear film on the eye’s surface; the upper eyelids must meet with lower eyelids to close completely with each blink.
With every surgical intervention on an eyelid there is a risk of disrupting its delicate function. If the blinking mechanism is significantly affected, distribution of the tears is decreased and the eye may become dry. This is a common cause of irritation, light sensitivity and watery eyes.
In this blog, we will present a brief explanation of causes of dry eye after eyelid surgery and how to manage the symptoms.
Less is more
One element of successful eyelid surgery is knowing how much skin to remove. An eyelid must have sufficient skin to allow normal blinking. If too much skin is removed, the eyelids will not close adequately and the tears will evaporate. This will result in corneal dryness and all the symptoms that accompany it. Therefore, an eyelid surgeon must use good judgement when performing a blepharoplasty or a ptosis (droopy eyelid) surgery. Nevertheless, dry eye symptoms may occur even in a best-case scenario, when the surgeon has been careful to leave sufficient skin in the eyelids. Fortunately, in these cases the symptoms improve within the first the postoperative month.
Another important element to consider is that multiple procedures will increase the risk of postoperative dry eye. A blepharoplasty (upper eyelid lift) will cause more dry eye symptoms if performed at the same time as a brow lift or in conjunction with lower lid surgery. Therefore, a patient who has dry eyes before surgery may want to put off multiple procedures and only do one procedure at a time.
Treatment of dry eye symptoms after eyelid surgery
Mild to moderate dry eye symptoms frequently occur after eyelid surgery. However, severe dry eye can be prevented by treating any preexisting symptoms before the surgery. If you are experiencing itchiness, foreign body sensation, and watery eyes before considering an eyelid operation, your surgeon will want to treat the dry eye before embarking on a surgery that may worsen your symptoms. Many patients don’t experience any of these symptoms until after the surgery, especially during the first postoperative month.
Preservative-free artificial tear drops are an excellent option for controlling dry eye symptoms during the postoperative period. They should be used at least three to six times a day depending on the severity of the symptoms. Ophthalmic ointments and gels are also effective to soothe the eye and decrease discomfort. If symptoms do not improve, it may be helpful to add topical anti-inflammatory drops or mild steroids. The use of these medications requires monitoring by an ophthalmologist or oculoplastic surgeon.
Surgical options for treating postoperative dry eye symptoms
Upper eyelids
Although rare, postoperative stiffness on the upper eyelids may produce lagophthalmos –an inability to close the eyelids – or a slow blink, which can be extremely bothersome for the patient. This stiffness may result from skin shortage or unpredictable scarring of the upper eyelids. These cases may be treated with steroid injections to soften the scar or, in extreme cases, with an upper eyelid skin graft.
Lower eyelids
Postoperative dry eye can also occur if lower eyelid surgery is performed without correcting eyelid laxity, or if too much skin is removed during the operation. The lower eyelids will retract after surgery producing exposure of the white part of the eye. This leads to significant tear evaporation that causes great discomfort. Unfortunately, these cases are very hard to treat and they will almost certainly require a second operation. If retraction occurs after the operation, it may be necessary to place a skin graft on the lower lids. This graft may be visible but it will improve eyelid closure mechanics and will protect the surface of the eye.
Your eyelid surgeon knows how to treat this condition
One of the main benefits of consulting with an oculoplastic (eyelid) surgeon when preparing for your eyelid surgery is that he has been trained in ophthalmology. Your oculoplastic surgeon is also an eye specialist who has the tools, the knowledge, and the experience for treating dry eye. An eyelid surgeon knows the eye well and will also plan the surgery in such a way to prevent skin shortage, lower eyelid retraction, and alteration of the blink mechanism after surgery. It is important to remember that, in most patients, dry eye symptoms will subside with time.
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