The complication that plastic surgeons and patients dread the most following blepharoplasty is visual impairment. Lelli and Lisman highlight the seriousness of this complication in their well-composed review article entitled “Blepharoplasty Complications” in a recent issue of this Journal.1 The authors document that the final common pathway involves continued orbital bleeding leading to increased intraorbital and intraocular pressure, with resultant ischemic damage to the retina and/or optic nerve, and stress the importance of intraoperative control of hemostasis and avoidance of excessive traction during fat excision to avoid visual impairment.1 However, the authors are remiss in not discussing fat-preserving blepharoplasty as a viable alternative to standard lipectomy procedures to avoid visual loss. We would like to stress this issue and also direct the attention of the readers to the potential complication of blindness as a consequence of steroid injection into the eyelids.
Because the great majority of reported cases of visual impairment related to blepharoplasty result from either injecting the fat compartments or applying traction on the fat during eyelid lipectomy, it follows that the approach that would minimize or perhaps eliminate visual loss related to these causes consists of avoiding injection or traction of the intraorbital fat. The only technique currently available that fulfills these criteria is the use of fat-preserving techniques as described by Sachs and Bosniak in 1986, de la Plaza in 1988, Mendelson in 1993, Camirand in 1997, and by us in 19982 and 2008.3
The concept of fat preservation is based on the observation that intraorbital fat is an important component of an attractive appearance and therefore should not be viewed as excessive, but as fatty hernia that should be corrected by repositioning it to its original compartments.1–3 Correction of the lower eyelid fatty hernia consists of repairing the weakened supporting structures by approximating the capsulopalpebral fascia to the arcus marginalis as shown in Figure 1, and correction of the upper eyelids consists of plicating the attenuated orbital septum to the superior orbital rim.4 The effectiveness of these techniques has been well documented in both short-term and long-term follow-up studies by us and by many other authors.2,3
Intralesional steroid injection into the eyelids also deserves mention as a potential cause of visual impairment and blindness2 because many plastic surgeons commonly use such injections in the management of various conditions affecting the eyelids. The resulting visual impairment after depot steroid injection is often permanent and is theorized to be caused by retinal vascular infarction.5 The most commonly proposed mechanism for vascular occlusion and visual impairment or blindness after such injections is felt to be intraarterial entry of the depot steroid and its retrograde flow from excessive force of injection. Another theorized possibility is the injection of steroids through vascular abnormalities that may exist from previous blepharoplasties.5 This serious complication should prompt immediate ophthalmoscopic fundus examination to allow early recognition of ischemic signs and immediate intervention.
Alan Ali Parsa, M.D.
Daniel Murariu, M.D.
Shannon M. Koehler, M.D.
Presper Daher, M.D.
Fereydoun Don Parsa, M.D.
John A. Burns School of Medicine
University of Hawaii
1. Lelli GJ Jr, Lisman RD. Blepharoplasty complications. Plast Reconstr Surg.
2. Parsa FD, Miyashiro MJ, Elahi E, Mirzai TM. Lower eyelid hernia repair for palpebral bags: A comparative study. Plast Reconstr Surg.
3. Parsa AA, Lye KD, Radcliffe N, Parsa FD. Lower blepharoplasty with capsulopalpebral fascia hernia repair for palpebral bags: A long-term prospective study. Plast Reconstr Surg.
4. Mühlbauer W, Holm C. Orbital septorrhaphy for the correction of baggy upper and lower eyelids. Aesthetic Plast Surg.
5. Yağci A, Palamar M, Eğrilmez S, Sahbazov C, Ozbek SS. Anterior segment ischemia and retinochoroidal vascular occlusion after intralesional steroid injection. Ophthal Plast Reconstr Surg.
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