Patient complaints, education are first concerns when considering blepharoplasty

Issue: June 2004

Patient complaint a must

Paul M. Karpecki, OD, FAAO: This is a great question, because in order to qualify for Medicare reimbursement, the patient must pass testing that will show he or she has significant visual field loss (12° or 30%) secondary to the condition.

The first criterion is that the patient must have a complaint. It is not sufficient to look at the patient and, based on your measurements, refer the patient for a blepharoplasty if he or she has not stated problems related to dermatochalasis in the history. Because this is a gradual condition, it may not be as evident to many patients as it would appear.

There are a number of indicators to begin with, and each state has specific guidelines for qualifying a patient. Some states will accept only visual field results on an automated field analyzer, while others may accept the results from a tangent screen. Either way, it requires the test to be performed with the eyelids taped open and untaped. The difference allows the patient to qualify.

Our clinic works closely with Jemshed Khan, MD, in Overland Park, Kan., and he taught me a very effective way of being able to determine if a patient might qualify and when to then recommend further testing. Simply use a penlight or transilluminator and shine the light directly at the patient, noting the corneal reflex. If this spot of light is 2 mm or less from the upper lid, that patient will qualify in almost all cases.

Another suggestion is to see the patient later in the day or have him or her relax his or her eyebrows. Because this is such a gradual condition, many patients will subconsciously raise their eyebrows higher to keep the lids up. This is easier to maintain early in the day, so it might be wise to consider testing later in the day so a more appropriate measure of the lid dermatochalasis can be determined.

Paul M. Karpecki, OD, FAAO, practices at Moyes Eye Center in Kansas City and is a Primary Care Optometry News Editorial Board member. He can be reached at Moyes Eye Center, Barry Medical Park, St. Luke’s Northland Campus, 5844 N.W. Barry Rd., Ste. 200, Kansas City, MO 64154; (816) 746-9800; fax: (816) 587-3555; e-mail: pkarpecki@kc.rr.com.

Start with patient complaints

Leonid Skorin Jr., OD, DO, FAAO, FAOCO: The workup begins with the documentation of the patient’s complaints as they relate to the dermatochalasis, blepharochalasis or blepharoptosis. Specific complaints that help justify functional surgery include interference with the patient’s vision; loss of peripheral or superior visual field; difficulty reading due to upper eyelid drooping, looking through the eyelashes or seeing the upper eyelid skin; chronic blepharitis or lateral canthal maceration or frontal headaches due to constant brow elevation. I also document any history of thyroid disease, previous periorbital trauma and any resulting scar tissue, dry eye and eyelid lesions (papillomas, verruca, etc.) or skin conditions. I incorporate any scar tissue or lesions into my surgical plan.

I evaluate the patient’s basic tear secretion with a Schirmer’s tear test using topical anesthetic. If the secretion is insufficient, symptoms of ocular irritation may develop or increase following a blepharoplasty. In a patient with low basic tear secretion, blepharoplasty might be contraindicated, or if such a procedure is done, only a very conservative skin excision should be performed. Interestingly, a recent study found that nearly 87% of patients with dry eye had subjective improvement of symptoms after an upper lid blepharoplasty (Vold SD, Carroll RP, Nelson JD. Dermatochalasis and dry eye. Am J Ophthalmol. 1993;115(2):216-220).

The best way to document visual field compromise is with formal visual field testing. A minimum of 12° or 30% loss of superior visual field should be demonstrated when comparing visual fields with the eyelids at rest and after the redundant skin is taped out of the way.

Clinical photographs are also used to document if the upper eyelid margin approaches to within 2.5 mm (one-fourth of the diameter of the visible iris) of the corneal reflex, if the upper eyelid skin rests on the eyelashes, if the patient has dermatitis, or if the upper eyelid position contributes to difficulty in tolerating a prosthesis in patients with an anophthalmic socket. The photos should be full face, canthus-to-canthus, with the head perpendicular to the plane of the camera and of sufficient clarity to show a light reflex on the cornea. I use these photos postoperatively to show the patients the improvement they have received from their eyelid surgery. Seeing their preoperative photos gives them a renewed appreciation of their operation.

Finally, patients are advised to discontinue any use of anticoagulant medications, such as aspirin, ibuprofen, coumadin and vitamin E, 1 week prior to surgery. This decreases intraoperative bleeding time and the risk of postoperative hematoma.

Leonid Skorin Jr., OD, DO, FAAO, FAOCO, practices in Albert Lea, Minn., and writes and lectures on ocular disease and neuro-ophthalmic disorders. He underwent fellowship training in neuro-ophthalmology. He can be reached at the Albert Lea Eye Clinic, Mayo Health System, 1206 W. Front St., Albert Lea, MN 56007; (507) 373-8214; fax: (507) 373-2819; e-mail: skorin.leonid@mayo.edu.

Patient education, documentation, follow-up

Albert D. Woods, MS, OD, FAAO: My approach to a patient needing blepharoplasty secondary to dermatochalasis revolves around three points: patient education, documentation and follow-up.

While some patients will complain of decreased superior/temporal visual field loss, others are not aware of the loss until you physically hold the lids up. You must educate the patient that you will be documenting a functional need for the procedure and not a cosmetic need.

In general, if it is a field loss, you need to document at least 12° or 30% superior field loss using a testing strategy on a Goldmann or automated perimeter that includes testing up to 50° to 60° above fixation. You must also show any potential improvement by repeating the visual field with the lids taped up. Both the pre-taped and post-taped visual fields should be included in the referral for surgery.

While field loss is the most common reason for functional blepharoplasty, other indications can include excessive upper lid skin that is weighing down the upper lashes if symptomatic to the patient, a chronic symptomatic dermatitis due to the dermatochalasis and problems inserting or retaining a prosthetic eye if due to the dermatochalasis. If you photo document these conditions, make sure to include the patient name and date on the photo. I usually just have the patient hold a card with that information and take a frontal shot that includes a full view of both eyes, the lids and the card.

Finally, I schedule a follow-up visit after surgery to get a new baseline visual field and to check for any dry eye findings. While some patients with dry eye complaints prior to blepharoplasty will actually improve after surgery, other patients will see a worsening or development of dry eye, especially if they now have an incomplete blink.

Albert D. Woods, MS, OD, FAAO, is an associate professor and director of electrodiagnostic service at the Eye Institute, College of Optometry, Nova Southeastern University, 3200 South University Dr., Ft. Lauderdale, FL 33328; (954) 262-1478; fax: (954) 337-0270; e-mail: albert@nsu.nova.edu.