Exposure Keratopathy After Cosmetic CO2 Laser Skin Resurfacing

Anita I. Miedziak, M.D., John D. Gottsch, M.D., and Nicholas T. Iliff, M.D.

Purpose. To report two cases of exposure keratopathy after cos- had also a full face lift with bilateral lower lid blepharoplasty 25 metic CO2 laser skin resurfacing. Methods. Two patients pre- years before this evaluation. Patient’s past and present medical sented with bilateral intrapalpebral epitheliopathy. They were ex- history was negative. Her best corrected visual acuity was 20/20 amined, treated, and followed for several weeks. Results. Nonsur- OD and 20/30 OS. Her external examination revealed a 3-mm gical treatment options, including a variety of lubricants, punctal bilateral lower lid retraction, mild bilateral ptosis (Fig. 1A), and a plugs, and lid taping, did not lead to a complete resolution of 1-mm lagophthalmos OU. There was a mild, bilateral lower lid symptoms. Surgical options were recommended. Conclusion. Ex- posure keratopathy should be recognized as a potential side effect laxity noted (tested by distraction test) with slight left lower punctal ectropion. Otherwise lid approximation to the globe was good of not only incisional lid surgery but also facial CO2 laser skin resurfacing procedures. OU. Pupillary and visual field examinations were normal. Con-

Key Words: Exposure keratopathy—CO2 laser skin resurfacing— junctivae were 2+ injected OD and 1+ OS. Corneas manifested Cosmetic lid surgery—Iatrogenic keratopathy—Lower lid retrac- intrapalpebral punctate epitheliopathy that was more prominent in tion. the right eye (Fig. 2). Corneal stroma, endothelium, and anterior segment were normal bilaterally. Funduscopic examination was unremarkable. Basal secretion test was 9 mm OD and 4 mm OS. The patient was treated with aggressive lubrication in the form of Exposure keratopathy can manifest itself as burning, stinging, nonpreserved artificial tears every 1–2 hours while awake (Refresh itching, foreign body sensation, photophobia, soreness, tearing, Plus and Celluvisc; Allergan, Irvine, CA, U.S.A.), a lubricating blurred vision, or ocular fatigue. Excessive exposure is usually a ointment at bedtime, and overnight lid taping. Bilateral upper and 1 result of inadequate lid apposition or diminished blink reflex. lower punctal plugs were originally inserted, but the patient de- Thyroid eye disease, facial nerve palsy, and ectropion are the most veloped excessive tearing and the upper plugs were removed. Over 1,2 common causes of exposure keratopathy. Iatrogenic causes re- a several week period the patient’s symptoms improved somewhat lated to cosmetic lid and facial surgery are also known etiolo- but she still suffered irritation (corneal staining was completely 3,4 gies. absent only when all four plugs were in place). She was unable to We report two cases of exposure keratopathy arising as com- decrease the frequency of topical lubricating medications to <4–6 plications of CO2 laser cosmetic lower lid and mid-facial surgery. times a day without recurrence of symptoms. Exposure keratopathy resulting from laser skin resurfacing is not well documented in the ophthalmic literature as a possible side effect of this procedure.

CASE 1 A 73-year-old woman presented reporting bilateral redness, tearing, photophobia, and ocular pain, especially upon awakening. These symptoms had persisted for 2 years, but she noticed a sig- nificant increase in their severity over 4 weeks before presentation. Her past ocular history was pertinent for a bilateral upper blepharoplasty 10 years previously, a CO2 laser skin resurfacing 2 years prior, and another resurfacing 4 weeks before presentation. She

Submitted October 27, 1999. Revision received February 23, 2000. Ac- cepted February 26, 2000. From the Cornea and External Diseases Department (A.I.M, J.D.G.) and the Oculoplastics Department (N.T.I.), The Wilmer Eye Institute, The Johns Hopkins University, Baltimore, Maryland, U.S.A. Address correspondence and reprint request to Dr. J. Gottsch, Cornea Department, The Wilmer Eye Institute, The Johns Hopkins University, 600 N. Wolfe Street, Maummene 327, Baltimore, MD 21205, U.S.A. E-mail: FIG. 1. External photograph presenting lower lid retractions in pa- [email protected] tientsfromcase1(A)and2(B).

846 EXPOSURE KERATOPATHY AFTER COSMETIC CO2 LASER SKIN RESURFACING 847

CASE 2

A 68-year-old woman presented reporting a decrease in visual acuity in her right eye. She had noticed constant bilateral dryness and intolerance of daily wear soft contact lenses that she had successfully worn in the past. Symptoms were present for 1 year but increased over 3 months before presentation. Contact lenses were discontinued a year before her initial evaluation at our insti- tution. The patient’s surgical history was pertinent for a full face lift 20 years previously. Her past ocular history was positive for bilateral upper and lower blepharoplasty 10 years prior. She also had a combined face lift and CO2 laser total face skin resurfacing 1 year before presentation. She used artificial tears four times a day OU and a lubricating ointment at bedtime. Her best corrected visual acuity was 20/50 OD and 20/25 OS. She demonstrated bilateral lower lid retraction (3 mm OD and 2 mm OS), and mild ptosis OU (Fig. 1B). There was no lid laxity noted by snap-back testing. A mild lagophthalmos was present OD. The patient had prominent eyes with retrusion of the inferior orbital rims. Pupillary and visual field examinations were normal. Conjunctivae were 1+ injected OU. Corneas manifested bilateral intrapalpebral punctate epitheliopathy. Heaped-up corneal epithelium, mild subepithelial haze, and fibrosis were also noted OD (Fig. 3). Corneal stroma,

FIG. 3. Case 2. Narrow (A) and wide (B) beam slit-lamp photographs presenting findings of intrapalpebral epitheliopathy, heaped-up epithelium, and subepithelial haze OD.

endothelium, anterior segment, and fundi were normal bilaterally. Corneal sensation and tear break-up times were normal in both eyes as well as basal secretion test (>10 mm bilaterally). The patient’s artificial tears regimen (Refresh Plus) was increased to every 2 hours while awake and the bedtime ointment was contin- ued. Bilateral lower lid silicone punctal plugs were used and the patient’s symptoms improved but did not completely resolve. She was unable to resume her contact lens wear. Midface lift was recommended for the management of the lower lid retraction.

DISCUSSION

Exposure keratopathy results from neurologic or mechanical disorders leading to an increase in the palpebral fissure width and/or inadequate lid closure.1,2 Evaporation of tear film is directly related to exposed ocular surface area and to the amount and quality of tears produced. Excessive exposure of a cornea to the external environment can lead to desiccation and loss of surface epithelium. Epithelial punctate keratopathy of intrapalpebral cor- FIG. 2. Case 1. Wide beam slit lamp photograph of fluorescein nea is the usual initial manifestation of the disease; later punctate stained cornea with bilateral interpalpebral punctate epitheliopathy lesions may coalesce forming chronic, nonhealing epithelial de- OD (A) and OS (B). fects. Infectious keratitis, corneal vascularization, or melting can

Cornea, Vol. 19, No. 6, 2000 848 A.I. MIEDZIAK ET AL. subsequently develop. Unless a prompt and appropriate treatment and the suborbital orbicularis fat) can help to restore a more nor- is undertaken, permanent scarring or visual loss can occur. mal lower lid position.8 These two cases represent a milder (punctate keratitis, case 1) A complete ocular examination should be considered before any 9 and more severe (corneal subepithelial fibrosis, case 2) spectrum elective periocular surgery, including CO2 laser skin resurfacing. of corneal complications due to lower lid retraction. The proce- Pertinent aspects of ocular history and any risk factors for potential dure, which appeared to precipitate the symptoms of exposure in postoperative ocular problems should be identified. The presence these cases, was CO2 laser skin resurfacing of the lower lids and of dry eye syndrome, thyroid disorder, lower lid laxity, myopia, face. The CO2 laser application vaporizes the epidermis and ther- shallow orbits, maxillary hypoplasia, or nerve palsy (fifth and/or mally shrinks papillary dermis, causing an increase in skin elas- seventh nerve) should be sought, documented, and assessed to ticity and a decrease in the amount of wrinkling.5 A recent histo- avoid complications such as those presented in this short case logic analysis of eyelid skin after CO2 laser resurfacing by Mannor series. The history of prior cosmetic lid or facial surgeries should et al.6 reviewed progression of skin changes occurring after this be elicited and their potential ocular consequences should be type of procedure. It described early disorganization of both epi- evaluated and incorporated into the final decision making process dermis and dermis, tissue edema, and disruption of elastin fibers. when any additional periocular procedures are contemplated. These changes were mostly resolved 3 months posttreatment, re- vealing reorganized epidermis and dermis, flattened rete pegs, and REFERENCES new collagen and elastin deposits. These specific changes in skin architecture result in a smoother-looking and thicker skin. But 1. Donzis PB, Mondino BJ. Management of noninfectious corneal ulcers. thermal shrinkage of collagen fibers can also cause up to 25% Surv Ophthalmol 1987;32:94–110. reduction in the surface area of treated skin7 that could lead to the 2. Murillo-Lopez F, Pflugfelder SC. Dry eye. In: Krachmer JH, Mannis MJ, Holland EJ, eds. Cornea and external diseases: clinical diagnosis secondary lower lid retraction noted in the two reported cases. and management. St. Louis: Mosby-Year Book, Inc., 1998:663–86. Both patients had undergone multiple cosmetic surgeries. Each 3. Hamako C, Baylis HI. Lower eyelid retraction after blepharoplasty. consecutive cosmetic lid procedure increases the risk of corneal Am J Ophthalmol 1980;89:517–21. exposure. The repetitive horizontal and vertical lid shortening lim- 4. Shorr N. “Madame Butterfly” procedure: total lower eyelid reconstruc- tion in three layers utilizing a hard palate graft. Management of the its options for therapy of potential future complications associated unhappy post-blepharoplasty patient with round eye and scleral show. with the excessive palpebral fissure width. Int J Aesth Restor Surg 1995;3:3–26.

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Cornea, Vol. 19, No. 6, 2000