BLOG: Ptosis and TANSTAAFL: Heinlein steps up to the slit lamp

ByDarrell E. White, MD

Add topic to email alerts

Receive an email when new articles are posted on

Please provide your email address to receive an email when new articles are posted on .

Subscribe

Added to email alerts

You've successfully added to your alerts. You will receive an email when new content is published.

Click Here to Manage Email Alerts

You've successfully added to your alerts. You will receive an email when new content is published.

Click Here to Manage Email Alerts

Back to Healio

We were unable to process your request. Please try again later. If you continue to have this issue please contact customerservice@slackinc.com.

Back to Healio

Robert A. Heinlein, the famous science-fiction author, was also a noted libertarian intellectual.

Much like Ayn Rand in We the Living, Heinlein explored the possibility of a “pure” libertarian society in The Moon is a Harsh Mistress. Having been colonized by a collection of adventurers, convicts and sundry misfits, the moon was home to a society that governed itself according to the near-perfect elaboration of the simplest of libertarian principles: Your rights extend no further than the length of your nose. Commerce was carried out in the purest of capitalist systems, disagreements solved through a type of gaming, and underlying it all was one of the most memorable phrases ever written in any literary genre.

TANSTAAFL (tanstaffle): There ain’t no such thing as a free lunch.

Uttered with equal parts resignation and finality, TANSTAAFL was the foundation upon which the moon’s economy rested. More than that, it was an accepted principle of societal cause and effect. Nothing came without payment; every action (or inaction) had a consequence. I find myself muttering TANSTAAFL in all walks of my life, including as a dry eye disease doctor. It was the first thing I thought of when I read the article “The effect of a ptosis procedure compared to an upper blepharoplasty on dry eye syndrome.”

Darrell White

Fifty-four patients with dermatochalasis were studied, all of whom underwent a blepharoplasty. Those who had ptosis that improved after instillation of 10% phenylephrine also underwent a Müller muscle-conjunctival resection (MMCR, or Putterman procedure). Study patients were treated to the usual array of DED testing including Ocular Surface Disease Index, tear breakup time and staining. Preop, there was no significant difference in any DED parameter between the blepharoplasty and blepharoplasty plus MMCR groups.

To the shock of literally no one who has ever taken care of a patient with DED, there was a massive worsening in both the signs and symptoms of patients who had a portion of their tarsal conjunctiva amputated.

We have long known that the increased exposure of the ocular surface experienced by ptosis postop patients can lead to a worsening of both DED symptoms and signs. If you only operate on periocular skin and fat, the study demonstrates that any increase in peripheral vision gained is not at the expense of worsening DED. Lifting the upper lid with a levator resection, an anterior approach, was not evaluated. Subjects who underwent MMCR had a significant worsening of their OSDI, as well as fluorescein and lissamine green staining; doing a posterior procedure that results in a net loss of goblet cells, as well as a possible deleterious effect on meibomian glands, worsens DED. Zloto and colleagues stand in for Heinlein and prove that there is a dry eye price to be paid for surgeries that affect the conjunctiva.

TANSTAAFL.

Reference:

Zloto O, et al. Am J Ophthalmol. 2020;doi:10.1016/j.ajo.2019.11.021.

Published by: