Careful lid evaluation crucial for preoperative cataract exam
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We have come a long way in terms of identifying and treating dry eye before cataract procedures, as well as corneal pathology, but the lids are also crucial to accurate outcomes.
We need pristine measurements for our premium IOLs as well as for nailing the refractive target. When evaluating topography, if a patient’s lids are obstructing part of the cornea, we will not be able to achieve an optimal result.
Ptotic lids can change the curvature of the cornea, which will have an impact on the IOL power and cause an overcorrection of astigmatism. It should also be noted that the lid speculum used during cataract surgery can stretch eyelid muscles. If we do not address ptosis upfront, patients may believe that the cataract surgery caused the ptosis, resulting in a negative outcome.
I advocate for a holistic approach to the preoperative exam, ensuring we address the cornea as well as the entire periorbital area, including lid anatomy, on the front end.
Achieving optimal vision
I always tell patients that our goal is to make sure that their quality of vision is going to be the best that it can be. Therefore, we need to take care of everything we can to make sure that they get the best end result. Even if we have to prioritize a lid procedure for more severe ptosis in advance of cataract surgery, they know that we are looking out for their best interest. By doing a visual field taped and untaped, patients can better understand the severity of their vision loss due to low-lying lids. If I believe the lids are affecting their corneal topography or their measurements on biometry, I will let them know that it impedes the IOL selection. From there, I recommend that we lift the lid, wait 3 months and then do cataract surgery.
Taping patients’ eyes for cataract testing, such as topography, biometry or OCT, can dry them out. One option, particularly for patients with mild to moderate ptosis, is to use Upneeq (oxymetazoline hydrochloride ophthalmic solution 0.1%, RVL Pharmaceuticals) to lift the eyelid to get an accurate measurement and avoid added dryness. Lifting the lid pharmaceutically can reveal how the measurements are being affected and allow us to obtain better quality scans without drying the surface, which can also have an impact on the refractive outcome.
For patients with mild to moderate ptosis who are not interested in lid surgery, oxymetazoline is a good option to give them a more refreshed appearance.
Seeing is believing for patients
It is crucial that patients understand the impact of droopy lids on their vision. In my practice, we do a 64-point superior visual field taped and untaped test, and we then repeat photos and lid height measurements after instilling oxymetazoline and waiting about 20 minutes. When patients realize how much they are missing visually due to low-lying lids, it is a wake-up call.
Take photographs before and after drop instillation to demonstrate for patients where the lid margin sits in relation to their pupil. Showing them the before and after, anatomically, of what the lid positioning can look like with the lift provided by the pharmacologic agent is insightful. Even if they are not ready to decide whether to use the drop or have a blepharoplasty, they can experience what they are not seeing, especially in the superior visual field.
In my practice, because I do oculoplastics, many patients opt for a procedure after seeing what they look like after oxymetazoline. This is true even in my younger patients who are not having cataract surgery. They may start with the drop, love the results and end up choosing a more permanent surgical option. We may bridge the gap with a pharmacologic agent, but in my practice, it usually leads to surgery because they like how they look and notice the improvement in vision.
Conclusion
Paying close attention to the lids is crucial in any assessment as we must be aware of any underlying pathology; systemic conditions such as myasthenia gravis or Horner syndrome can cause a droopy lid and influence lid positioning. I believe the lid is just as important as the cornea, the optic nerve and the retina. When patients present for cataract surgery, we need to be comprehensive in our assessment to ensure optimal visual outcomes postoperatively.
- Reference:
- Dannoue K, et al. PLoS One. 2021;doi:10.1371/journal.pone.0258688.
- For more information:
- Deborah Gess Ristvedt, DO, of Vance Thompson Vision, can be reached at deborah.ristvedt@vancethompsonvision.com.
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