NOV 2012

EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.

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48 EW CATARACT November 2012 Cataract editor's corner of the world Post-surgical ptosis: Causes and treatments by Jena Passut EyeWorld Editor ataract surgery is now commonly considered refractive surgery due to the abundance of specialty intraocu- lar lenses and the introduction of the fem- tosecond laser. Although great strides have been made in perfecting the visual out- comes after surgery, the patients are also concerned with the cosmetic appearance of their eyes after surgery. Ptosis, ecchymosis, and conjunctival erythema have long been considered necessary evils of cataract sur- gery. With the trend away from retro and peribulbar injections and toward topical anesthesia, the risk of ptosis has decreased. However, ptosis still occurs in a significant percentage of patients after intraocular sur- gery. In this column, we asked two special- ists their opinions about the etiologies and treatments for post-op ptosis. C Bonnie An Henderson, M.D., cataract editor had less give, maybe that would cause less trauma to the muscle than if you have a firm speculum "If the speculum was weaker and " Erin M. Shriver, M.D. Use of a speculum may increase the risk of ptosis in cataract surgery patients D espite being somewhat common, post-surgical ptosis is a multifactorial condition that can be minimized or treated, ac- cording to oculoplastics specialists who spoke to EyeWorld. The main culprit that causes droopy eyelids after surgery appears to be the speculum used to pull back a patient's lids and keep the eye accessible for the procedure, said Erin M. Shriver, M.D., assistant pro- fessor of clinical ophthalmology, Bascom Palmer Eye Institute, Uni- versity of Miami Miller School of Medicine. Dr. Shriver said she sees ptosis after all types of ocular surgery in- cluding complicated cataract, refrac- tive, corneal, and glaucoma surgery. Studies differ, but ptosis has been reported to occur in anywhere from 0-21% of patients following surgery. "We have one rigid eyelid speculum that we have nicknamed the 'ptosis maker,'" Dr. Shriver said, adding that a good portion of her ptosis referrals are post-surgical pa- tients. "The 'ptosis maker' is used for ocular surgeries that require signifi- cant conjunctival exposure such as glaucoma-filtering procedures. The benefit in exposure for the proce- dure is felt to outweigh the risk of ptosis. Although this has not been researched, a more rigid speculum theoretically causes more trauma to the eyelid than a more flexible wire eyelid speculum as it would not yield to the contracting forces of the concentric orbicularis muscle." Theories abound about what causes post-surgical ptosis, including the eyelid speculum, a predisposi- tion to the condition, retrobulbar or peribulbar anesthesia, duration of surgery, and eyelid inflammation re- sulting from corneal sutures. "The problem is that no one has looked at each factor alone," Dr. Shriver said. "It's not clear cut." With the speculum at play, pto- sis "could be related to edema or is- chemia from the speculum compressing the lid, dehiscence of the levator muscle, or horizontal stretching of the lid," Dr. Shriver noted. Anesthesia was also suspected to be an offender potentially causing ptosis. "In a study by John J. Alpar, M.D., [Amarillo, Texas], there was a 10-fold increase in post-operative ptosis following cataract surgery using a retrobulbar injection vs. gen- eral anesthesia, but other studies have found an equal incidence," said Wendy W. Lee, M.D., associate professor of clinical ophthalmology, Bascom Palmer Eye Institute. Dr. Shriver said the anesthetic can be both neurotoxic and my- otoxic. "Two percent lidocaine with 1:100,000 epinephrine has been shown to cause degeneration of human muscle within 18 hours of injection," she said, adding that the epinephrine augments the myotoxic effects. "Degeneration may be is- chemic or non-ischemic resulting in

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