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Blepharoplasty, Laser In Situ Keratomileusis, and the Corneal Reflex Arc

Afrooz, Paul N. M.D.; Gorantla, Vijay S. M.D., Ph.D.

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Plastic and Reconstructive Surgery: April 2008 - Volume 121 - Issue 4 - p 1506-1507
doi: 10.1097/01.prs.0000305374.68393.4d
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We applaud Korn et al.1 for their article in the July 2007 issue of the Journal. Prior studies in the literature have reported dry eye syndrome as a complication of either blepharoplasty or laser in situ keratomileusis (LASIK). The current study by Korn et al. provides insight into the combined effect of blepharoplasty and LASIK on the incidence of dry eye.

In their retrospective study, the authors examined six patients who underwent both blepharoplasty and LASIK. Of particular interest are the two patients who underwent monocular LASIK and subsequent bilateral upper and lower blepharoplasty. After blepharoplasty, these patients manifested the symptoms of dry eye syndrome. However, the symptoms were confined only to the LASIK-treated eye. The authors hypothesize that the dry eye symptoms (in the LASIK eye) were the result of a blunted corneal reflex arc on that side (secondary to LASIK)1 and that the lack of dry eye in the opposite eye (with blepharoplasty alone) was due to the preservation of the blink response on that side. To examine the validity of this hypothesis, we wish to elaborate on the neurophysiology of the corneal reflex.

It is known that blunting of the corneal reflex arc does in fact occur when raising a corneal flap and transecting the afferent nerves in the cornea during a LASIK procedure.2–4 However, the authors should note that the corneal reflex arc comprises an afferent pathway from each eye and a consensual efferent response that is bilateral.5 In the case of the two patients treated with LASIK in only one eye, the intact afferent arc in the opposite eye (with the blepharoplasty only) would preserve the blink response bilaterally, thus preventing a possible dry eye in the LASIK-treated eye. Taken together, the eye with blepharoplasty alone will have an uninterrupted afferent reflex arc and both eyes will have fully intact efferent motor nerves, resulting in a preserved blink response. Barring disruption of lid mechanics, the impulse for normal bilateral closure remains unaffected; thus, sweeping and lubrication of the corneal surfaces should theoretically be unchanged. In this regard, we ask the authors to reconsider their hypothesis in these patients.

We appreciate the reporting of an association between LASIK and blepharoplasty in inducing dry eye syndrome. Further studies should aim to examine the incidence of dry eye syndrome in each eye after monocular LASIK and subsequent bilateral upper and lower blepharoplasty in a larger patient population. If dry eye symptoms consistently occur only in the LASIK-treated eye, causes other than the corneal reflex arc will need to be explored and elucidated.

Paul N. Afrooz, M.D.

Vijay S. Gorantla, M.D., Ph.D.

Division of Plastic and Reconstructive Surgery

University of Pittsburgh Medical Center

Pittsburgh, Pa.


Neither author has any financial interest in any of the products, drugs, or devices described in this communication.


1. Korn, B. S., Kikkawa, D. O., and Schanzlin, D. J. Blepharoplasty in the post-laser in situ keratomileusis patient: Preoperative considerations to avoid dry eye syndrome. Plast. Reconstr. Surg. 119: 2232, 2007.
2. Toda, I., Asano-Kato, N., Komai-Hory, Y., et al. Dry eye after laser in situ keratomileusis. Am. J. Ophthalmol. 132: 1, 2001.
3. Lee, H. B., McLaren, J. W., Erie, J. C., et al. Reinnervation in the cornea after LASIK. Invest. Ophthalmol. Vis. Sci. 43: 3660, 2002.
4. Calvillo, M. P., McLaren, J. W., Hodge, D. O., et al. Corneal reinnervation after LASIK: Prospective 3-year longitudinal study. Invest. Ophthalmol. Vis. Sci. 45: 3991, 2004.
5. Esteban, A. A neurophysiological approach to brain stem reflexes: Blink reflex. Neurophysiol. Clin. 29: 7, 1999.

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