January 2015
Volume 56, Issue 1
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Cornea  |   January 2015
Long-term Tear Volume Changes After Blepharoptosis Surgery and Blepharoplasty
Author Affiliations & Notes
  • Akihide Watanabe
    Department of Ophthalmology, Kyoto Prefectural University of Medicine, Kyoto, Japan
  • Dinesh Selva
    Discipline of Ophthalmology and Visual Sciences, South Australian Institute of Ophthalmology and Royal Adelaide Hospital, Adelaide, South Australia, Australia
  • Hirohiko Kakizaki
    Department of Ophthalmology, Aichi Medical University of Medicine, Nagakute, Japan
  • Yutaro Oka
    Department of Ophthalmology, Kyoto Prefectural University of Medicine, Kyoto, Japan
  • Norihiko Yokoi
    Department of Ophthalmology, Kyoto Prefectural University of Medicine, Kyoto, Japan
  • Koichi Wakimasu
    Department of Ophthalmology, Kyoto Prefectural University of Medicine, Kyoto, Japan
  • Naoko Kimura
    Department of Ophthalmology, Kyoto Prefectural University of Medicine, Kyoto, Japan
  • Shigeru Kinoshita
    Department of Ophthalmology, Kyoto Prefectural University of Medicine, Kyoto, Japan
  • Correspondence: Akihide Watanabe, Department of Ophthalmology, Kyoto Prefectural University of Medicine, Kamigyo, Kyoto 602-0841, Japan; awatanab@koto.kpu-m.ac.jp
Investigative Ophthalmology & Visual Science January 2015, Vol.56, 54-58. doi:10.1167/iovs.14-15632
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      Akihide Watanabe, Dinesh Selva, Hirohiko Kakizaki, Yutaro Oka, Norihiko Yokoi, Koichi Wakimasu, Naoko Kimura, Shigeru Kinoshita; Long-term Tear Volume Changes After Blepharoptosis Surgery and Blepharoplasty. Invest. Ophthalmol. Vis. Sci. 2015;56(1):54-58. doi: 10.1167/iovs.14-15632.

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Abstract

Purpose.: To evaluate long-term changes in tear volume by using video meniscometry following blepharoptosis surgery and upper blepharoplasty.

Methods.: Forty-three eyes of 27 patients with blepharoptosis and 29 eyes of 18 patients with dermatochalasis without lacrimal duct obstruction or other eyelid diseases underwent anterior approach levator advancement or blepharoplasty. Tear volume was evaluated by measurement of tear meniscus radius (R), using video meniscometry preoperatively and at 1.5, 3, and 6 months postoperatively. Margin reflex distance-1 (MRD-1) was measured before and after surgery by using photographs.

Results.: After blepharoptosis surgery, the mean MRD-1 was significantly increased: 0.45 mm preoperatively, 3.64 mm at 1.5 months, 3.56 mm at 3 months, and 3.57 at 6 months postoperatively (P < 0.001), and the average R value was significantly decreased: 0.29 mm preoperatively, 0.22 mm at 1.5 months, 0.23 mm at 3months, and 0.24 mm at 6 months postoperatively (P < 0.05). Preoperative R was significantly correlated to the reduction rate of R (ΔR). A higher preoperative R was more likely to be decreased (P < 0.01). Postoperative MRD-1 and change in MRD-1 were not correlated to ΔR. After blepharoplasty, the preoperative mean MRD-1 (3.11 mm) was significantly decreased at 1.5 months (2.47 mm; P < 0.01) and 3 months (2.71 mm; P < 0.05) but recovered at 6 months (3.14 mm). However, the average R was not changed: 0.31 mm preoperatively, 0.34 mm at 1.5 months, 0.31 mm at 3 months, and 0.33 mm at 6 months postoperatively.

Conclusions.: Long-term tear volume was not changed after blepharoplasty but was decreased after blepharoptosis surgery, and even more so in cases with an initial high tear volume.

Introduction
Upper eyelid blepharoptosis surgery and blepharoplasty are procedures commonly performed for both functional and aesthetic reasons. Although blepharoplasty may be associated with an increase in dry eye symptoms,15 other reports suggest subjective improvement in dry eye symptoms6 and no significant changes in objective measurements (using the Schirmer 1 test and tear film break-up time).7 With regard to ptosis repair, there has been only 1 objective report9 and 1 subjective report.10 Although objective measurements such as Schirmer 1 test, tear film break-up time, and fluorescein staining score have been studied following blepharoplasty and blepharoptosis surgery,13,79 there has been only one previous study conducted by the authors that investigated short-term (6-week) tear volume changes after blepharoptosis surgery.11 In this study, we report longer term (6-month) tear volume changes after both blepharoptosis repair and upper blepharoplasty. 
Methods
Forty-three eyes of 27 patients with blepharoptosis underwent blepharoptosis surgery, and 29 eyes of 18 patients with dermatochalasis underwent blepharoplasty at the Department of Ophthalmology, Kyoto Prefectural University of Medicine between February 2012 and November 2013 and were included in the study. In the blepharoptosis group, 12 males and 15 females with a mean (±SD) age of 63.8 ± 10.0 years (range, 45–80 years) were recruited. None of these patients were in our previous study. Sixteen patients had bilateral blepharoptosis, and 11 were unilateral. In the dermatochalasis group, 7 males and 11 females with a mean age of 68.4 ± 7.68 years (range, 51–84 years) were recruited. Blepharoptosis surgery consisted of a transcutaneous levator advancement, and blepharoplasty consisted of an en-bloc resection of skin, subcutaneous tissue, and orbicularis oculi muscle. The upper eyelid height before and after surgery was assessed from standardized photographs, using margin reflex distance-1 (MRD-1), which is defined as the distance from the central pupil reflex to the upper eyelid margin, with the eyes in primary position.12 
Patients with preoperative dry eye symptoms, lacrimal drainage obstruction on syringing, ectropion, entropion, periocular trauma causing eyelid malpositions, lagophthalmos, previous eyelid surgery, and punctual plugs were excluded. Further exclusion criteria were evidence of ocular surface disease which might result in epiphora such as conjunctivitis, keratitis, trichiasis, blepharitis, and thyroid eye disease. Patients using any drops such as artificial tears, antiglaucoma drops, antibiotic drops, and topical steroids were also excluded. Patients who underwent blepharoptosis repair and blepharoplasty at the same time were excluded. We also excluded patients with congenital, myogenic, neurogenic, mechanical, and traumatic ptosis and poor levator function (<10 mm), and those <18 years of age. Thus, pure involutional or contact lens-related blepharoptosis and involutional dermatochalasis were included in this study. 
Tear volume was analyzed by measuring the tear meniscus radius (R) with video meniscometry.13,14 This method is a noninvasive method for measuring tear meniscus curvature based on the concave mirror formula, using the image obtained from the central lower tear meniscus, which is correlated with tear volume.15 All measurements were taken of the menisci of both eyes, in the region of the center of the lower eyelid. In order to minimize any effect of gaze position on tear meniscus shape, subjects were asked to look straight ahead in the horizontal plane and were encouraged to blink spontaneously. If the patients used contact lens on the examination day, measurements were taken 2 hours after contact lens removal. Temperature and humidity of the examination room during all tests were maintained at 25°C and 30%, respectively. 
MRD-1 and R were measured preoperatively and at 1.5, 3, and 6 months postoperatively. Fluorescein break-up time (FBUT) was also measured pre- and postoperatively. FBUT was measured three times, and an averaged value was used for evaluation. Patients were questioned regarding dry eye symptoms and foreign body sensation pre- and postoperatively. 
Changes in MRD-1 or R were analyzed by the paired Student t-test. The reduction rate of R (ΔR) after surgery was calculated using the equation ΔR (%) = [(preoperative R – postoperative R)/(preoperative R)] × 100. The correlations between preoperative R and ΔR and postoperative MRD-1 and ΔR and the increased degree of MRD-1 (ΔMRD-1) and ΔR at each postoperative point were analyzed by Spearman rank correlation coefficient as well. 
Informed consent was obtained from each patient prior to the start of the study. The Institutional Review Board of the Kyoto Prefectural University of Medicine approved this study, and it followed the tenets of the Declaration of Helsinki. 
Results
Mean (±SD) MRD-1 was significantly increased after blepharoptosis surgery: 0.45 ± 1.10 mm (range, −2 to 3 mm) preoperatively, 3.64 ± 0.80 mm (range, 2–5 mm) at 1.5 months, 3.56 ± 0.79 mm (range, 2–5 mm) at 3 months, and 3.57 ± 0.73 mm (range, 2–5 mm) at 6 months postoperatively (P < 0.001); and the average R value was significantly decreased: 0.29 ± 0.16 mm preoperatively, 0.22 ± 0.09 mm at 1.5 months, 0.23 ± 0.08 at 3 months, and 0.24 ± 0.11 at 6 months postoperatively (P < 0.05). After blepharoplasty, the preoperative mean MRD-1 (3.11 ± 0.72 mm [2 to 4]) was significantly decreased at 1.5 months: 2.47 ± 1.03 mm (range, 1–4 mm; P < 0.01), and at 3 months: 2.71 ± 0.94 mm (range, 1–4 mm; P < 0.05), but recovered at 6 months: 3.14 ± 0.71 mm (range, 2.5–4 mm; P = 0.80) postoperatively. The average R value for the blepharoplasty group was not changed (0.31 ± 0.09 mm preoperatively, 0.34 ± 0.12 mm at 1.5 months, 0.31 ± 0.11 mm at 3 months, and 0.33 ± 0.15 at 6 months postoperatively (P > 0.05) (Fig. 1). No patients had lagophthalmos at any stage postoperatively. 
Figure 1
 
Postoperative mean R (A) and postoperative mean MRD-1 (B) after blepharoptosis surgery and blepharoplasty. R decreased significantly after blepharoptosis surgery. MRD-1 decreased at 1.5 months and at 3 months after blepharoplasty (**P < 0.01; *P < 0.05, paired t-test).
Figure 1
 
Postoperative mean R (A) and postoperative mean MRD-1 (B) after blepharoptosis surgery and blepharoplasty. R decreased significantly after blepharoptosis surgery. MRD-1 decreased at 1.5 months and at 3 months after blepharoplasty (**P < 0.01; *P < 0.05, paired t-test).
Figure 2 shows plots of pre- and postoperative R values at each postoperative point in both blepharoptosis and dermatochalasis. After blepharoptosis surgery, the preoperative R was significantly correlated to the reduction rate of R (ΔR). Preoperative higher R values were more likely to be decreased at each postoperative point (P < 0.01) (Figs. 3A–C). Postoperative MRD-1 and degrees of change in MRD-1 (ΔMRD-1) were not correlated to ΔR (Fig. 4). After blepharoplasty, preoperative R was not significantly correlated to ΔR (Figs. 3D–3F). 
Figure 2
 
Changes in R before and after blepharoptosis surgery (AC) and blepharoplasty (DF). Postoperative R tended to decrease in cases in which the preoperative R was larger after blepharoptosis surgery.
Figure 2
 
Changes in R before and after blepharoptosis surgery (AC) and blepharoplasty (DF). Postoperative R tended to decrease in cases in which the preoperative R was larger after blepharoptosis surgery.
Figure 3
 
Correlation between preoperative R and reduction rate of R (ΔR [%]). After blepharoptosis surgery (AC), preoperative R was significantly correlated to ΔR (Spearman rank correlation coefficient, r = 0.61, P < 0.001 at 1.5 months; r = 0.67, P < 0.001 at 3 months; and r = 0.53, P < 0.001 at 6 months). Preoperative higher R values were more likely to be decreased. After blepharoplasty (DF), preoperative R was not significantly correlated to ΔR (Spearman rank correlation coefficient, r = 0.34, P = 0.07 at 1.5 months; r = 0.20, P = 0.31 at 3 months; and r = 0.34, P = 0.07 at 6 months).
Figure 3
 
Correlation between preoperative R and reduction rate of R (ΔR [%]). After blepharoptosis surgery (AC), preoperative R was significantly correlated to ΔR (Spearman rank correlation coefficient, r = 0.61, P < 0.001 at 1.5 months; r = 0.67, P < 0.001 at 3 months; and r = 0.53, P < 0.001 at 6 months). Preoperative higher R values were more likely to be decreased. After blepharoplasty (DF), preoperative R was not significantly correlated to ΔR (Spearman rank correlation coefficient, r = 0.34, P = 0.07 at 1.5 months; r = 0.20, P = 0.31 at 3 months; and r = 0.34, P = 0.07 at 6 months).
Figure 4
 
Correlation between postoperative MRD-1 and reduction rate of R (ΔR) (AC), increased degree of MRD-1 (ΔMRD-1) and ΔR after blepharoptosis surgery (DF). Postoperative MRD-1 was not significantly correlated with ΔR (Spearman rank correlation coefficient, r = 0.14, P = 0.38 at 1.5 months; r = 0.0005, P = 0.97 at 3 months; and r = 0.0012, P = 0.99 at 6 months). ΔMRD-1 was not significantly correlated with ΔR (Spearman rank correlation coefficient, r = 0.15, P = 0.33 at 1.5 months; r = 0.04, P = 0.80 at 3 months; and r = 0.009, P = 0.96 at 6 months).
Figure 4
 
Correlation between postoperative MRD-1 and reduction rate of R (ΔR) (AC), increased degree of MRD-1 (ΔMRD-1) and ΔR after blepharoptosis surgery (DF). Postoperative MRD-1 was not significantly correlated with ΔR (Spearman rank correlation coefficient, r = 0.14, P = 0.38 at 1.5 months; r = 0.0005, P = 0.97 at 3 months; and r = 0.0012, P = 0.99 at 6 months). ΔMRD-1 was not significantly correlated with ΔR (Spearman rank correlation coefficient, r = 0.15, P = 0.33 at 1.5 months; r = 0.04, P = 0.80 at 3 months; and r = 0.009, P = 0.96 at 6 months).
The FBUT was not significantly changed after blepharoptosis surgery (7.5 ± 2.8 seconds preoperatively vs. 7.6 ± 2.6 seconds at 1.5 months, 7.5 ± 2.7 seconds at 3 months, and 7.6 ± 3.0 seconds at 6 months postoperatively; P > 0.05, paired t-test) and also was not significantly changed after blepharoplasty (7.4 ± 3.0 seconds preoperatively vs. 7.5 ± 3.2 seconds at 1.5 months, 7.4 ± 2.9 seconds at 3 months, and 7.6 ± 3.1 seconds at 6 months postoperatively; P > 0.05). 
New-onset postoperative dry eye symptoms were noted in 3 eyes of 2 patients (6.9%) after blepharoptosis surgery and in 3 eyes of 2 patients (10.3%) after blepharoplasty. Mean R values in this group were 0.15 mm (0.11–0.20) preoperatively and 0.09 mm (0.08–0.10) at 1.5 months postoperatively after blepharoptosis surgery, and 0.18 mm (0.11–0.24) preoperatively and 0.12 mm (0.10–0.14) at 1.5 months postoperatively for the blepharoplasty patients. Their symptoms were treated with ocular lubricants and were resolved by 6 months. 
Discussion
We recently reported our analysis of tear volumes following blepharoptosis surgery and found a decreased tear volume at 6 weeks in those patients in whom the higher tear volumes decreased the most.11 This study confirms that this short-term tear volume change seen following blepharoptosis surgery is maintained at 6 months. In addition, the study documents a lack of change in tear volume after upper eyelid blepharoplasty. 
Although several reports have shown a subjective increase in dry eye symptoms after upper eyelid blepharoplasty,15 Vold et al.6 reported subjective improvement in dry eye symptoms. Objective measurements using the Schirmer 1 test, FBUT, and fluorescein staining score following blepharoplasty yielded various results including decreased Schirmer 1 test score13,9 and no significant changes in Schirmer 1 test result FBUT.7,8 However, objective dry eye assessments following blepharoptosis surgery are rare. There is 1 report of an objective study using Schirmer 1 test9 and 1 subjective study10 after blepharoptosis surgery. Kim et al.9 showed postoperative increased tear production after blepharoptosis but a follow-up of only 1 month. 
For objective assessment of dry eye following these procedures, we chose to measure tear volume by using video meniscometry.13,14 This is a noninvasive method of measuring tear meniscus curvature, which is correlated with tear volume.15 Although the Schirmer 1 test might show the basal and/or reflex tear production, it is a more invasive procedure, and video meniscometry may be able to measure finer changes in tear volume. Thus, we used video meniscometry in this setting. Recently, anterior segment optical coherence tomography has been used for the assessment of the tear meniscus and may be an alternative method of assessing tear volume.16,17 
In this study, the postoperative tear volume was significantly decreased especially in cases with initially high tear volume after blepharoptosis surgery for at least 6 months. Because we found similar results at 1.5 months in our previous paper, we revised the protocol to lengthen the follow-up duration in a new cohort of patients. Furthermore, although the correlation between the postoperative change in MRD-1 and the change in R value was seen in our previous study, postoperative MRD-1 and the degree of change in MRD-1 were not correlated to the reduction of R (ΔR) at each postoperative point in this study. 
The most intuitive explanation for the decrease in tear volume seen following blepharoptosis surgery is an increase in tear film distribution and evaporation as a result of an increased aperture. However, as noted above, there was a lack of correlation between the change in MRD and the reduction of tear volume. Hence, it is possible that postoperative decrease in R does not reflect an increase in tear distribution but a decrease in tear volume, as R has a linear correlation with tear volume on the ocular surface.15 
In our previous paper, we discussed the possibility that surgery for blepharoptosis increases the function of the lacrimal pump, resulting in postoperative increase in tear drainage because of an increase in the blink velocity after blepharoptosis surgery, which may possibly have an effect on the lacrimal pump. Changed ocular surface sensations might also have an effect on blinks. Kim et al.9 examined the effects of upper eyelid surgery on ocular surface sensation and tear production. They showed a postoperative increase in tear production after blepharoptosis surgery by using the Schirmer 1 test and a temporary decrease in ocular surface sensation on the first postoperative day, although this had reversed by 1 month. In addition, their data were from only 11 patients with a 1-month follow-up. Pre- and postoperative lacrimal drainage and tear clearance assessment would be helpful to further investigate the cause of tear volume changes. 
Postoperative MRD-1was significantly increased after blepharoptosis surgery, maintained at least for a half year; however, the mean postoperative MRD-1 was significantly decreased after blepharoplasty at 1.5 and 3 months, with recovery at 6 months. Possible explanations for transiently mild ptosis following blepharoplasty include local anesthetic effect on Müller's muscle, edema, or intramuscular hematoma. Because these factors resolve, ptosis is usually self-correcting as seen in our patients. 
New-onset dry eye symptoms were seen in 2 patients (6.9%) after blepharoptosis surgery and 2 patients (10.3%) after blepharoplasty. There seemed to be some correlation between their symptoms and tear volume change. Their tear volume was relatively low preoperatively and became lower postoperatively. All were successfully managed with ocular lubricants, and symptoms resolved by 6 months. Our results suggest new-onset dry eye is infrequent and, as expected, may be more of an issue in those with pre-existing low tear volumes. However, because dry eye is a multifactorial disease,1820 the decreasing tear volume may be only one factor in the development of dry eye symptoms postoperatively. For instance, it is also possible that changes in blinking after upper eyelid surgery might affect dry eye, and some investigators have suggested blepharoplasty techniques with orbicularis preservation may help maintain normal blink. 
The present study had several limitations. There were relatively few eyes, and that may have been desirable to check reductions in R over an even longer postoperative period. In addition, different surgical techniques, such as posterior approach to blepharoptosis repairs, might have different results. Furthermore, it may be useful to assess tear volume changes following surgery in patients with preoperative dry eye, a group that was excluded from this study. It may also be possible that for patients with functional epiphora with blepharoptosis and high tear volume, blepharoptosis surgery might ameliorate their symptoms. 
In conclusion, tear volume was not decreased after blepharoplasty but was decreased after blepharoptosis surgery for at least 6 months, possibly more so in cases with an initially high tear volume. 
Acknowledgments
The authors have no proprietary or commercial interest in any materials discussed in this article. The authors alone are responsible for the content and writing of the paper. 
Disclosure: A. Watanabe, None; D. Selva, None; H. Kakizaki, None; Y. Oka, None; N. Yokoi, None; K. Wakimasu, None; N. Kimura, None; S. Kinoshita, None 
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Figure 1
 
Postoperative mean R (A) and postoperative mean MRD-1 (B) after blepharoptosis surgery and blepharoplasty. R decreased significantly after blepharoptosis surgery. MRD-1 decreased at 1.5 months and at 3 months after blepharoplasty (**P < 0.01; *P < 0.05, paired t-test).
Figure 1
 
Postoperative mean R (A) and postoperative mean MRD-1 (B) after blepharoptosis surgery and blepharoplasty. R decreased significantly after blepharoptosis surgery. MRD-1 decreased at 1.5 months and at 3 months after blepharoplasty (**P < 0.01; *P < 0.05, paired t-test).
Figure 2
 
Changes in R before and after blepharoptosis surgery (AC) and blepharoplasty (DF). Postoperative R tended to decrease in cases in which the preoperative R was larger after blepharoptosis surgery.
Figure 2
 
Changes in R before and after blepharoptosis surgery (AC) and blepharoplasty (DF). Postoperative R tended to decrease in cases in which the preoperative R was larger after blepharoptosis surgery.
Figure 3
 
Correlation between preoperative R and reduction rate of R (ΔR [%]). After blepharoptosis surgery (AC), preoperative R was significantly correlated to ΔR (Spearman rank correlation coefficient, r = 0.61, P < 0.001 at 1.5 months; r = 0.67, P < 0.001 at 3 months; and r = 0.53, P < 0.001 at 6 months). Preoperative higher R values were more likely to be decreased. After blepharoplasty (DF), preoperative R was not significantly correlated to ΔR (Spearman rank correlation coefficient, r = 0.34, P = 0.07 at 1.5 months; r = 0.20, P = 0.31 at 3 months; and r = 0.34, P = 0.07 at 6 months).
Figure 3
 
Correlation between preoperative R and reduction rate of R (ΔR [%]). After blepharoptosis surgery (AC), preoperative R was significantly correlated to ΔR (Spearman rank correlation coefficient, r = 0.61, P < 0.001 at 1.5 months; r = 0.67, P < 0.001 at 3 months; and r = 0.53, P < 0.001 at 6 months). Preoperative higher R values were more likely to be decreased. After blepharoplasty (DF), preoperative R was not significantly correlated to ΔR (Spearman rank correlation coefficient, r = 0.34, P = 0.07 at 1.5 months; r = 0.20, P = 0.31 at 3 months; and r = 0.34, P = 0.07 at 6 months).
Figure 4
 
Correlation between postoperative MRD-1 and reduction rate of R (ΔR) (AC), increased degree of MRD-1 (ΔMRD-1) and ΔR after blepharoptosis surgery (DF). Postoperative MRD-1 was not significantly correlated with ΔR (Spearman rank correlation coefficient, r = 0.14, P = 0.38 at 1.5 months; r = 0.0005, P = 0.97 at 3 months; and r = 0.0012, P = 0.99 at 6 months). ΔMRD-1 was not significantly correlated with ΔR (Spearman rank correlation coefficient, r = 0.15, P = 0.33 at 1.5 months; r = 0.04, P = 0.80 at 3 months; and r = 0.009, P = 0.96 at 6 months).
Figure 4
 
Correlation between postoperative MRD-1 and reduction rate of R (ΔR) (AC), increased degree of MRD-1 (ΔMRD-1) and ΔR after blepharoptosis surgery (DF). Postoperative MRD-1 was not significantly correlated with ΔR (Spearman rank correlation coefficient, r = 0.14, P = 0.38 at 1.5 months; r = 0.0005, P = 0.97 at 3 months; and r = 0.0012, P = 0.99 at 6 months). ΔMRD-1 was not significantly correlated with ΔR (Spearman rank correlation coefficient, r = 0.15, P = 0.33 at 1.5 months; r = 0.04, P = 0.80 at 3 months; and r = 0.009, P = 0.96 at 6 months).
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