Eyelid Surgery Has More Than Cosmetic Benefits

Troy Brown

December 07, 2011

December 7, 2011 — Upper blepharoplasty and blepharoptosis repair are functionally indicated and beneficial, according to a report published in the December issue of Ophthalmology.

Kenneth V. Cahill, MD, from Ophthalmic Surgeons and Consultants in Columbus, Ohio, and colleagues analyzed results from 13 studies that examined the functional indications and outcomes of blepharoptosis repair and blepharoplasty.

"As oculoplastic surgeons, we see the visual improvement and comfort that patients obtain from the surgical correction of upper lid ptosis and dermatochalasis. This study was performed to analyze the scientific data available to substantiate this," explained Dr. Cahill in an email interview with Medscape Medical News.

"Patients are sometimes denied the opportunity to have therapeutic blepharoplasty and ptosis repair surgery by third party payors based on arbitrary and/or incorrect policies regarding the functional indications for these procedures," he added.

"Medicare and many of the third party carriers have used [a] threshold of margin reflex distance (MRD) less than or equal to 2 mm and/or visual field of 12 degrees or improvement of 25-30% for consideration of coverage of ptosis repair or upper lid blepharoplasty for some time," said Tamara R. Fountain, MD, clinical correspondent for the American Academy of Ophthalmology and executive committee member of the American Society of Ophthalmic Plastic and Reconstructive Surgeons, in an email interview with Medscape Medical News. "Some carriers have enacted stricter criteria for coverage of these procedures," she added. Dr. Fountain was not involved in the analysis.

The researchers conducted a literature search of the MEDLINE and Cochrane Library databases on July 24, 2008, and identified 1147 citations that met their criteria. Two reviewers screened the citations and identified 87 articles to review in full text. After reading the 87 articles, they selected 13 studies to analyze further.

"This report confirms with great correlation among various studies, the degree of visual impairment associated with various upper lid to visual axis clearance measurements," said Dr. Fountain.

The studies examined the "functional effects or treatment results of simulated ptosis; several types of blepharoptosis repair, including conjunctiva-Müller’s muscle resection, frontalis suspension, and external levator resection; and upper eyelid blepharoplasty," write the authors. The authors note that blepharoplasty and blepharoptosis repair are 2 distinctly different surgeries that may both be performed on the same patient.

The literature showed that surgery is functionally beneficial for MRD 1 (MRD1) of 2 mm or less measured in primary gaze; superior visual field loss of 12 degrees or 24%; and downgaze ptosis that impairs reading, documented by MRD1 of 2 mm or less measured in down gaze.

"Acquired ptosis is sometimes more symptomatic in downgaze for reading than it is in the straight-ahead position of vision," said Dr. Cahill.

Subjective findings for which surgery can be functionally beneficial are patient-reported impairment caused by upper-eyelid droop; chin-up backward tilt due to visual field impairment from droopy lids; interference with work-related activities and safety related to visual impairment from upper lids; and discomfort, eye strain, or visual interference caused by the upper-eyelid position.

The researchers found that surgery for ptosis or dermatochalasis improves visual function and quality of life. "Patient-reported quality-of-life impairment caused by ptosis and dermatochalasis is highly correlated with functional improvement from ptosis surgery," said Dr. Cahill.

"The visual field improvement and elimination of the fatigue that results from forehead muscle compensation, both seen after successful ptosis repair or upper lid blepharoplasty, is often a dramatic improvement for the patient. It never ceases to amaze me how life-changing seemingly small amounts of lid lifting and skin removal can be," Dr. Fountain explained.

"For my patients who have been denied coverage and then choose to pay out of pocket, they often tell me it was the best investment they'd ever made and only wish they'd done it sooner. This ophthalmic technology assessment confirms, via robust data analysis, what we see in our offices every day: Patients have real benefit from fixing the peripheral vision impairment and facial fatigue that often results from ptosis and excessive upper lid skin," she added.

The extent to which third-party insurers are complying with the recommendations of this ophthalmic technology assessment will need to be examined further, the authors write.

"Hopefully, the review of these studies will drive home the positive benefits of these procedures and highlight the quality-of-life value to the patients who undergo them," said Dr. Fountain.

The authors believe that larger studies are needed that include prospective comparative studies of visual field function before and after surgery, and outcome analysis of the effect of surgery on functional abilities.

The study was funded without commercial support by the American Academy of Ophthalmology. The authors and Dr. Fountain have disclosed no relevant financial relationships.

Ophthalmology. 2011;118:2510-2517. Abstract