Major reviewOculoplastic considerations in patients with glaucoma
Introduction
Glaucoma is the leading cause of irreversible blindness globally. In 2013, the total number of people (aged 40–80 years) with glaucoma was estimated to be 64.3 million.95 This chronic disease requires life-long monitoring as well as treatment with topical medications, laser, or surgery. Such patients may develop the periorbital changes of lipodystrophy with prolonged use of topical prostaglandin analogues (PGAs), contributing to functional problems such as lagophthalmos or exposure keratopathy, eyelid malpositions (upper eyelid ptosis, upper or lower eyelid retraction, lower eyelid entropion or ectropion) that may occur independently or following glaucoma medication or surgery, and periorbital asymmetry or premature aging brought about by PGA use.
We shall discuss the incidence and contributory mechanisms of eyelid malpositions or periorbital changes in glaucomatous patients. Corrective eyelid surgery of any type in these patients may be fraught with complications, and we highlight useful pointers when undertaking surgery in this group of patients.
Section snippets
Topical glaucoma medications and effects
Patients with glaucoma are usually prescribed topical medication. First-line drops such as PGA have been associated with eyelid changes distressing to the patient. These influences should be considered in such patients undergoing eyelid surgery.
Blepharoptosis
Blepharoptosis may affect patients with glaucoma by inducing astigmatism, influencing IOP monitoring, and producing visual field impairment.
After trabeculectomy, patients are already at risk of postoperative astigmatism.19, 41 Upper eyelid ptosis aggravated by anterior segment surgery can further induce with-the-rule corneal astigmatism.47, 48 Analysis of changes in corneal topography after ptosis surgeries have shown average dioptric change of 0.60 diopters (D), with nearly 30% of patients
Ptosis surgery in patients with glaucoma
Embarking on ptosis surgery requires consideration of the type of procedure (Levator function is normal in most of these patients, and therefore techniques used would involve either levator advancement or Müller muscle with or without conjunctiva, resection), type of approach (anterior or posterior), amount of correction, adjunctive procedures required, and postoperative care.
Treatment for upper eyelid retraction in patients with filtering blebs
Medical and surgical options on both eyelid and filtering bleb exist to treat eyelid retraction in patients with glaucoma. Botulinum toxin injections to produce therapeutic ptosis resulted in normalization of upper eyelid height in 2 patients reported by Clark and colleagues.15 This is a good option if expeditious lid lowering is required in cases of sight-threatening bleb exposure. Hyaluronic acid gel volume injection (Restylane, Medicis, Scottsdale, AZ, USA) into the retroseptal space in the
Conclusion
Patients with glaucoma may present to the oculoplastic surgeons for the problems of eyelid malposition (whether they be involutional or iatrogenic), medication-related periocular changes, and esthetic concerns. Having knowledge of the incidence of, and risk factors for, these problems, as well as the pitfalls of surgery in this special group of patients will enable the oculoplastic surgeon to have a good functional and esthetic outcome.
Disclosures
The authors report no proprietary or commercial interest in any product mentioned or concept discussed in this article.
Acknowledgments
The authors thank Mr. Ankur Barua for proof-reading the article draft.
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