Upper-Eyelid Wick Syndrome Association of Upper-Eyelid Dermatochalasis and Tearing

CLINICAL SCIENCES Upper-Eyelid Wick Syndrome Association of Upper-Eyelid Dermatochalasis and Tearing

Inbal Avisar, MD; Jonathan H. Norris, FRCOphth; Dinesh Selva, FRACS, FRANZCO; Raman Malhotra, FRCOphth

Objective: To highlight a case series of patients mani- tially obscured by upper-eyelid skin (type 2). Five patients festing epiphora and misdirection of tears laterally or along (56%) had linear excoriation of skin in the lateral can- the upper-eyelid skin crease. This association has been thus. All patients underwent upper-eyelid blepharo- termed upper-eyelid wick syndrome. We describe the clini- plasty, 3 combined with ptosis repair and 3 combined cal features and outcomes of management of these pa- with eyebrow-lift. All patients achieved 80% to 100% im- tients. provement in epiphora following surgical intervention to the upper eyelid. The mean (range) follow-up was 2.8 Methods: A retrospective review of patients referred to (1-6) years. 2 oculoplastic centers during a 6-year period for epiphora, who were considered to have misdirection of tears re- Conclusions: We defined upper-eyelid wick syndrome as lated in some way to upper-eyelid dermatochalasis. the misdirection of tears laterally or along the upper- eyelid skin crease causing epiphora, related in some way Results: Nine patients (7 women and 2 men; mean [SD] to upper-eyelid dermatochalasis. In all cases, epiphora age, 61.2 [11.3] years, range, 41-76 years) with bilateral improved with treatment of upper-eyelid dermatochala- epiphora and lateral spillover (100%), occasionally com- sis. Although recognized among physicians, this has never bined with upper-eyelid wetting (n=2). All patients had been formally described in the ophthalmic literature, to upper-eyelid dermatochalasis. Five patients had upper- our knowledge. eyelid skin obscuring and in contact with the lateral canthus (type 1), and in 4 the lateral canthus was only par- Arch Ophthalmol. 2012;130(8):1007-1012

PIPHORA IS OFTEN ETIOLOGI- lids.3,4 Epiphora is not frequently ad- cally multifactorial, ranging dressed as a symptom related to derma- from hyperlacrimation (su- tochalasis. However, patients with pranuclear, infranuclear, and dermatochalasis often report symptoms reflex tearing due to evapo- such as burning, itching, and epiphora. Al- rativeE dry eye) to pump failure to outflow though the impact of upper-eyelid derma- dysfunction, including lower-eyelid mal- tochalasis has been recognized by physi- position or stenosis at the level of the puncti, cians, the role of the upper eyelid as a canaliculi, lacrimal sac, or nasolacrimal duct. causative factor in epiphora is not well de- Addressing a single factor in multifactorial scribed. epiphora may lead to only a moderate im- We describe a series of patients mani- provement in symptoms.1,2 festing epiphora and misdirection of tears Bothersome upper-eyelid dermatocha- laterally or along the upper-eyelid skin Author Affiliations: lasis typically causes symptoms of gradual crease. All patients had a degree of upper- Corneoplastic Unit, Queen increasing heaviness of the upper eyelid, eyelid dermatochalasis, some with skin- Victoria Hospital, East a tired or worn appearance, puffy or swol- fold contact to the lower-eyelid margin, and Grinstead, England (Drs Avisar, len eyes, and diminution of peripheral up- epiphora improved or resolved in all cases Norris, and Malhotra); and per visual fields. Severe dermatochalasis following interventional treatment to re- Discipline of Ophthalmology may overhang the eyelid margin to exac- duce upper-eyelid dermatochalasis. This as- and Visual Sciences, University of Adelaide, and South erbate lash ptosis and cause ocular dis- sociation has been termed upper-eyelid wick Australian Institute of comfort and corneal irritation. Female pa- syndrome. We highlight the clinical fea- Ophthalmology, Adelaide, tients often report difficulty in applying tures and outcomes of management of pa- Australia (Dr Selva). eyeliner and mascara to the upper eye- tients with upper-eyelid wick syndrome.

ARCH OPHTHALMOL / VOL 130 (NO. 8), AUG 2012 WWW.ARCHOPHTHALMOL.COM 1007

Case No. 123456789 Sex/age, y F/63 F/65 F/61 F/41 M/71 F/65 F/64 M/76 F/45 Frequency of wiping, 5 20 120 30 120 60 180 60 60 min Spillover Lateral Lateral Lateral and Lateral and Lateral Lateral Lateral Lateral Lateral upper upper eyelid eyelid Typea 121212211 Ptosis Yes Yes No No Yes No No No Yes Brow ptosis Yes No No No Yes Yes No Mild Mild Associated symptoms of Yes Yes No No No No No No No reflex tearing Horizontal lower-eyelid No No No No Yes No No Mild Mild laxity Lacrimal syringing PPPPPPPP90%P FDRT result Neg Bilateral pos Neg Bilateral pos Bilateral pos Neg Neg Bilateral pos Bilateral pos Lateral canthus linear No Yes No Yes Yes No No Yes Yes excoriation Other examination No No No No No No No Angular No findings blepharitis Management Ptosis; Ptosis; Bleph Bleph Bleph; Bleph; Bleph Bleph Ptosis; bleph; bleph DBL EBL bleph EBL Resolution, % 100 100 90 100 80 100 100 100 90

Abbreviations: bleph, upper-eyelid blepharoplasty; DBL, direct brow lift; EBL, endoscopic brow lift; FDRT, fluorescein dye retention testing; neg, negative; P, patent; pos, positive; ptosis, posterior approach ptosis repair. a Type of dermatochalasis and relation to lateral canthus: type 1 (lateral canthus obscured and in contact) or type 2 (lateral canthus partially obscured and not in direct contact).

METHODS For the purpose of categorization, upper-eyelid dermatochalasis was retrospectively graded on the basis of standard pho- tographs as either type 1 (lateral canthus in direct contact) or This was a retrospective case series of patients referred to 2 spe- type 2 (lateral canthus partially obscured but not in direct cialist oculoplastic centers from January 1, 2004, through De- contact). cember 31, 2010, for epiphora, considered to have misdirec- The main outcome measures were subjective improve- tion related in some way to upper-eyelid dermatochalasis ment in symptoms (percentage of improvement), objective im- (“wicking of tears”), in whom interventional treatment to the provement in wetting of upper-eyelid skinfold and skin crease, upper eyelid improved epiphora. Institutional review board– improvement in lateral canthus excoriation, and cessation of approval was obtained for this retrospective study. Clinical rec- misdirection of tears using the FDRT with no misdirection of ords were reviewed and patient demographic characteristics, the upper-eyelid skinfold and crease. preoperative frequency of wiping, site of tear spillover (lateral Patients were excluded if during this period their symp- or medial aspect and/or upper-eyelid wetting), and associated toms improved with conservative measures only (without any dry-eye symptoms related to reflex tearing were recorded. Pres- intervention to the upper eyelid), if they underwent addi- ence of lateral canthus skin excoriation, upper-eyelid derma- tional surgery for epiphora to the lower eyelids or lacrimal sys- tochalasis, ptosis, horizontal lower-eyelid laxity including lower tem, or if preoperative symptoms of epiphora were reported eyelid lateral sag, patency to lacrimal syringing, and results of only retrospectively following upper-eyelid surgery. Conser- fluorescein dye retention testing (FDRT) were also recorded. vative measures included ocular lubricants and warm com- Management and postmanagement resolution were docu- presses for evaporative dry eye causing reflex tearing, for ex- mented. ample. All patients were given conservative measures at the time Upper-eyelid wick syndrome was defined as symptoms and of listing for upper-eyelid surgery to exclude this as a signifi- signs of epiphora and upper-eyelid dermatochalasis with evi- cant cause. dence of tear misdirection based on symptoms of lateral spill- Our surgical technique of upper blepharoplasty and posterior- over with or without upper-eyelid wetting and objective signs approach aponeurotic ptosis correction has been previously de- of staining with misdirection of fluorescein on FDRT. The FDRT scribed.5 This was performed under local anesthesia. Our sur- demonstrates misdirection of tears not only laterally but also gical technique of endoscopic eyebrow-lift is based on a standard along the upper-eyelid skinfold and even along the upper- technique and has been previously described.6 Our surgical tech- eyelid skin crease (evident when the upper-eyelid skinfold or nique for direct eyebrow-lift has been previously described.7 eyebrow is lifted). This was performed under local anesthesia. During assessment, the eyebrow was gently elevated with a thumb or finger placed over the eyebrow hair to reduce the degree of apparent dermatochalasis and lateral canthus skin con- RESULTS tact. The FDRT was then repeated to demonstrate a reduction in misdirection and lateral spillover and show the potential benefit of upper-eyelid treatment for dermatochalasis as a cause Nine patients (7 women and 2 men; mean [SD] age, of misdirection before recommending surgery. 61.2[11.3] years, range, 41-76 years) were identified. All

ARCH OPHTHALMOL / VOL 130 (NO. 8), AUG 2012 WWW.ARCHOPHTHALMOL.COM 1008

C D B

E F C

Figure 1. Examples of dermatochalasis with lateral hooding causing wick syndrome. A and B, Type 1 lateral canthus obscured and in contact. C and D, Case 1 shows type 1 hooding before and after levator advancement, upper-eyelid blepharoplasty, and endoscopic eyebrow-lift. E, Type 2 lateral canthus partially obscured and in contact. F, Fluorescein tracked into the upper skin crease.

had symptoms of epiphora with lateral spillover, occasionally combined with upper-eyelid spillover or wet- Figure 2. Case 4. A, Lateral and upper spillover of fluorescein along the ting (2 patients [22%]). Clinical details of each patient upper eyelid shown by fluorescein tracking along the right upper eyelid are included in the Table. The mean (range) frequency visible medially. B, Following upper blepharoplasty showing resolved contact of wiping the eyes was every 75 (5-180) minutes, espe- of lateral canthus with upper eyelid. C, Lacrimal scintillography before blepharoplasty showing normal filling of sac with contrast pooling in the cially when outdoors. lateral canthus. Four patients (44%) also reported epiphora occur- ring during tasks associated with reduced blink-rate, such as watching television, reading, using a computer, or driv- derwent further investigation with lacrimal scintillogra- ing, suggestive of a reflex tearing component. phy to exclude outflow dysfunction, and this demon- All patients had upper-eyelid dermatochalasis (100%). strated pooling of dye at and over the lateral canthus but Five patients (56%) had upper-eyelid skin obscuring and no delay in drainage to the sac and nasolacrimal duct in contact with lateral canthus (type 1), and in 4 (44%) (Figure 2C). the lateral canthus was only partially obscured by upper- All patients underwent upper-eyelid blepharoplasty, eyelid skin (type 2). 3 of them combined with aponeurotic ptosis correction Four patients (44%) had coexisting aponeurotic and 3 combined with eyebrow-lift (2 women under- ptosis. Three patients (33%) had associated mild went endoscopic eyebrow-lift and 1 man underwent di- lower-eyelid laxity. Tear clearance (fluorescein dye rect eyebrow-lift). retention test) had positive results bilaterally in 5 All patients noticed a subjective improvement in patients. In all patients, fluorescein tracked laterally epiphora (percentage of improvement, 80% to 100%) along the lateral canthus and often upward to involve following surgical intervention to reduce upper-eyelid the upper-eyelid skin crease (Figure 1F). Upper- hooding. Objective improvement in fluorescein spill- eyelid wicking usually occurred laterally but occasion- over (laterally and along the upper-eyelid skinfold and ally occurred along the medial upper-eyelid skin crease in FDRT) was noted in all patients. Preopera- crease as well. Five patients (56%) had linear excoria- tive linear excoriation of skin in the lateral canthus tion of skin in the lateral canthus. has resolved in all cases. No complications occurred, All were freely patent to syringing except 1, who was and beyond the first 2 postoperative weeks, no patient 90% patent with mild resistance only. One patient un- developed an increase in dry-eye symptoms or was

ARCH OPHTHALMOL / VOL 130 (NO. 8), AUG 2012 WWW.ARCHOPHTHALMOL.COM 1009

©2012 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/26/2021 found to have lagophthalmos. The mean (range) COMMENT follow-up was 2.8 (1-6) years. We highlight 2 cases in particular. This case series highlights a cause of epiphora that we CASE 1 have termed upper-eyelid wick syndrome. We reviewed the published literature regarding the cause and manage- A 63-year-old woman was referred with a 2-year his- ment of epiphora and performed a PubMed literature tory of bilateral epiphora and lateral spillover requir- search using the keyword epiphora with dermatochala- ing her to wipe her eyes every 5 minutes, especially sis, blepharoplasty, surgery, management, or cause. We outdoors and with cold wind but occasionally during found no reports of this term or of such a phenomenon. activities of reduced blink-rate. She had no history of Although we cannot conclude that this has never been contact lens wear or injury. She had upper-eyelid apo- reported, we believe that it is not a widely recognized cause neurotic ptosis and significant upper-eyelid hooding of epiphora. Our findings support the treatment of upper- due to dermatochalasis and eyebrow ptosis with skin eyelid dermatochalasis in patients with this phenom- contact to the lateral canthus (Figure 1C). No skin enon. excoriation was present, tear clearance was normal We define upper-eyelid wick syndrome as symptoms (negative results on FDRT), and fluorescein tracked and signs of epiphora and upper-eyelid dermatochala- laterally along the lateral canthus (wicking). Tear film sis with evidence of tear misdirection based on symp- breakup time was reduced at 2 to 3 seconds bilaterally toms of lateral spillover with or without upper-eyelid with no corneal staining, and she was freely patent to wetting and objective signs of staining with misdirec- syringing. tion of fluorescein on FDRT. The FDRT demonstrates One month following bilateral ptosis repair, upper misdirection of tears not only laterally but also along blepharoplasty, and endoscopic eyebrow-lift, her epiphora the upper-eyelid skinfold and even along the upper- had resolved completely, and she remains asymptom- eyelid skin crease (evident when the upper-eyelid atic at 21⁄2 years with minimal epiphora occasionally dur- skinfold or eyebrow is lifted). During assessment, the ing extremely cold and windy conditions only (Figure 1D). eyebrow is then gently elevated with a thumb or finger placed over the eyebrow hair to reduce the degree of CASE 4 apparent dermatochalasis and lateral canthus skin contact. The FDRT is then repeated to demonstrate a A 41-year-old woman was referred with a 2-year his- reduction in misdirection and lateral spillover to show tory of bilateral epiphora with tears spilling over her the potential benefit of upper-eyelid treatment for der- outer cheek and smudging her upper-eyelid makeup, matochalasis as a cause of wicking before recommend- requiring her to wipe her eyes every 30 minutes, espe- ing surgery. cially in cold and windy weather. She denied any dry- We identified 9 patients manifesting epiphora with po- eye or reflex tearing symptoms. She had upper-eyelid tentially multiple factors for epiphora but all of whom dermatochalasis with linear lateral canthus skin exco- displayed signs of misdirection of tears at the lateral can- riation on the right eye more than the left (Figure 1E) thus as their main cause for epiphora. This was second- but no direct skinfold contact with the lateral canthus. ary to excess skin of the upper eyelid in contact, or par- She immediately felt an improvement in her epiphora tially in contact, with the lateral canthus, resulting in a on manually elevating her eyebrows. Tracking of tears track and allowing tears to escape laterally and in some along her upper eyelid (Figure 2A) was noticed during cases superiorly. In this series, all patients with wicking the FDRT. had moderately severe chronic epiphora with frequent She had signs of meibomian gland dysfunction and wiping of the tears (every 5-180 minutes when out- mild evaporative dry eye with early tear breakup time of doors). All had lateral spillover of tears, and 2 patients 3 seconds but no corneal staining and no eyelid laxity. also had superior spillover toward the eyelid crease. This She was completely patent to syringing with no resis- occasionally resulted in skin excoriation and in pooling tance or reflux. Conservative treatment of evaporative dry of dye at the lateral canthus during lacrimal scintillog- eye with regular ocular lubricants, warm compresses, and raphy (case 4). even a trial of lower punctal plugs failed to improve her In most cases, the site of epiphora—whether it is me- symptoms. dial (nasolacrimal duct obstruction, reflex, punctal or Lacrimal scintillography was then arranged to ex- canalicular stenosis, or ectropion) or lateral (lower- clude nasolacrimal duct outflow dysfunction. It demon- eyelid laxity, lower-eyelid retraction, or upper-eyelid wick strated rapid transit of tracer through the nasolacrimal syndrome)—is an important clue to the cause and should duct and presac conjunctival pooling, particularly later- be identified during the consultation. In the case of upper- ally, with possible misdirection and tracking of tracer eyelid wick syndrome, the lateral spillover is a clue par- along the upper eyelid (Figure 2C). ticularly if combined with upper spillover of the tears. Upper-eyelid hooding with lateral canthus wicking and This can be noticed when lifting the eyebrow to reveal tear misdirection was considered the main cause, and an the crease (Figure 1F). We also note that manual lifting upper-eyelid skin-only blepharoplasty was performed. Her of the eyebrow in the physician’s office can remove the symptoms completely resolved within 2 weeks and she contact between the upper eyelid and the lower eyelid remains asymptomatic at 18 months’ follow-up margin and briefly improve epiphora and spillover of fluo- (Figure 2B). rescein. This can serve as a predictor of surgical success.

ARCH OPHTHALMOL / VOL 130 (NO. 8), AUG 2012 WWW.ARCHOPHTHALMOL.COM 1010

©2012 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/26/2021 Only 1 patient (case 4) had medial wicking that was de- do not change significantly after blepharoplasty, whereas monstrable on FDRT and resolved following upper subjective ocular symptoms improve. blepharoplasty only. We cannot reliably make any con- Upper-eyelid wick syndrome, frequently accompa- clusions regarding the possibility of medial wicking be- nied by eyelid lateral canthus contact, may indeed yond this observation. contribute to symptoms such as epiphora, itching, We do not believe that the administration of con- burning, and excoriation of skin in the lateral canthus servative measures in the form of lubricants and warm in patients with dermatochalasis. In all our cases, we compresses confounded the results of this study deliberately and specifically aimed to preoperatively because patients underwent upper-eyelid surgery only evaluate symptoms of evaporative dry eye that may after review following conservative treatment. Each cause reflex tearing. Furthermore, we routinely treated patient acted as his or her own control. Furthermore, patients preoperatively with a regimen to exclude none of our patients had significant lateral retraction evaporative dry eye and reflex tearing, including a trial that would be an obvious cause of lateral spillover; of intensive lubricants. In addition, none of the and following upper-eyelid surgery, on reviewing pho- patients developed postoperative dry eye beyond the tographs, none of the patients have any significant or immediate postoperative period or any signs of eyelid even noticeable change in lateral canthus height or malposition or lagophthalmos. Therefore, it is unlikely lower-eyelid contour. This suggests that the improve- that in our series blepharoplasty reduced epiphora ment in symptoms is not due primarily to an indirect simply by inducing dry eye.14-16 change in the lower-eyelid position or laxity following We suspect that in some cases, upper-eyelid wick syn- upper-eyelid surgery. 8 drome occurs because of capillarity when upper-eyelid Vold et al retrospectively reported subjective im- dermatochalasis lies in contact with the lateral canthus, provement in what they described as “dry-eye” symp- forming a wick to misdirect tears either to spill over the toms following blepharoplasty. These symptoms in- lateral canthus or toward and along the upper-eyelid cluded mattering, burning, itching, redness, epiphora, crease. This is particularly likely in type 1, where there foreign-body sensation, and photophobia. Aqueous de- is obvious contact. The cause of misdirection in type 2, ficiency or evaporative dry eye was clearly demon- where lateral canthus contact is less apparent, is less evi- strated preoperatively, and a Schirmer test without an- dent. There is no clear capillary action to explain wick- esthesia was used to assess dry eye. ing of tears in this group. Possible contributing factors Disadvantages of the Schirmer test without anesthe- are relative lateral lash ptosis or an altered upper-eyelid sia include low reproducibility, sensitivity, and specific- excursion during blink due to a descended upper-eyelid ity, and perhaps most relevant is the lack of control over skinfold. It is unlikely that the upper-eyelid lashes are reflex lacrimation when the test is performed without anesthesia.9 A Schirmer test without anesthesia may be rea- scooping tears across because this would give rise to symp- sonably considered valid only with moderate repeatabil- toms and signs of wetting of, or splashing from, upper ity for severe dry eye.10 It lacks sufficient sensitivity and lashes. Upper-eyelid entropion, a feature that we delib- is too variable to be used in the diagnosis or grading of erately examined, was also not apparent in any of this milder dry eye. However, no definitive conclusions may cohort. On the basis of the fact that not all patients with be drawn about the ability of the Schirmer test with an- upper-eyelid wick syndrome have actual skin contact with esthesia to detect and grade mild dry eye and to distin- the lateral canthus, it is clear that the severity of symp- guish categorically between aqueous deficiency and evapo- toms does not correlate with the severity of dermatocha- rative dry eye syndromes.11 lasis. Furthermore, patients looking to have upper- More than 80% of patients in the series by Vold et al,8 eyelid blepharoplasty may overplay their symptoms of who sought care because of combined dermatochalasis epiphora. The fact that our series is small reflects that and “dry eye” symptoms, had improved dry-eye symp- this entity is underrecognized and that the diagnosis is toms following blepharoplasty. The authors proposed that often confirmed postoperatively. However, signs such as sustained elevation of the eyebrows causes periorbital fa- misdirection of fluorescein and improvement with manual tigue and interference with normal complete blinking. elevation of the lateral eyebrow, and less constant fea- Although unable to demonstrate this, they proposed that tures, such as lateral canthus excoriation, are more ob- this led to increased evaporation of the tear film result- jective signs that may be relied upon. ing in relatively dry eye and observed thinning or dis- In conclusion, we define upper-eyelid wick syndrome ruption of the tear film. as the misdirection of tears laterally or along the upper- Abell et al12 demonstrated that upper-eyelid blepha- eyelid skin crease causing epiphora, related in some way roplasty did not result in an altered blink mechanism 2 to upper-eyelid dermatochalasis. Patients often report wet- and 12 months postoperatively. Floegel et al13 also re- ting of the upper-eyelid skin and smudging of makeup ported a subjective improvement in dry-eye symptoms and may experience an improvement with manual el- but no significant improvement in the Schirmer test with- evation of the eyebrow. Objective signs include spill- out anesthesia or in the fluorescein breakup time at 3 over of fluorescein from the lateral canthus, often track- months in 5 of 11 patients who underwent upper-eyelid ing along the upper-eyelid skin crease, that may improve blepharoplasty. In 70% of cases, there was no surface with eyebrow elevation. Lateral canthus linear skin ex- change on impression cytology in the follow-up period. coriation may also be seen occasionally. Epiphora and Floegel et al13 concluded that, except for the surface in- excoriation improve with treatment of upper-eyelid der- flammatory reaction, these objective ocular parameters matochalasis.

ARCH OPHTHALMOL / VOL 130 (NO. 8), AUG 2012 WWW.ARCHOPHTHALMOL.COM 1011

©2012 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/26/2021 Submitted for Publication: November 29, 2011; final re- 7. Booth AJ, Murray A, Tyers AG. The direct brow lift: efficacy, complications, and vision received March 13, 2012; accepted March 27, 2012. patient satisfaction. Br J Ophthalmol. 2004;88(5):688-691. 8. Vold SD, Carroll RP, Nelson JD. Dermatochalasis and dry eye. Am J Ophthalmol. Correspondence: Raman Malhotra, FRCOphth, Corneo- 1993;115(2):216-220. plastic Unit, Queen Victoria Hospital, Holtye Road, East 9. Cho P, Yap M. Schirmer test, II: a clinical study of its repeatability. Optom Vis Grinstead, West Sussex RH19 3DZ, England (raman Sci. 1993;70(2):157-159. [email protected]). 10. Tsubota K, Xu KP, Fujihara T, Katagiri S, Takeuchi T. Decreased reflex tearing is Financial Disclosure: None reported. associated with lymphocytic infiltration in lacrimal glands. J Rheumatol. 1996; 23(2):313-320. 11. Savini G, Prabhawasat P, Kojima T, Grueterich M, Espana E, Goto E. The chal- REFERENCES lenge of dry eye diagnosis. Clin Ophthalmol. 2008;2(1):31-55. 12. Abell KM, Cowen DE, Baker RS, Porter JD. Eyelid kinematics following 1. Meyer DR. Lacrimal disease and surgery. Curr Opin Ophthalmol. 1993;4(5):86-94. blepharoplasty. Ophthal Plast Reconstr Surg. 1999;15(4):236-242. 2. Cohen AJ, Mercandetti M, Brazzo BG. The Lacrimal System: Diagnosis, Man- 13. Floegel I, Horwath-Winter J, Muellner K, Haller-Schober EM. A conservative blepha- agement, and Surgery. New York, NY: Springer-Verlag; 2006:43-74. roplasty may be a means of alleviating dry eye symptoms. Acta Ophthalmol Scand. 3. DeAngelis DD, Carter SR, Seiff SR. Dermatochalasis. Int Ophthalmol Clin. 2002; 2003;81(3):230-232. 42(2):89-101. 14. Lelli GJ Jr, Lisman RD. Blepharoplasty complications. Plast Reconstr Surg. 2010; 4. Karesh JW. Diagnosis and management of acquired blepharoptosis and 125(3):1007-1017. dermatochalasis. Facial Plast Surg. 1994;10(2):185-201. 15. Pacella SJ, Codner MA. Minor complications after blepharoplasty: dry eyes, che- 5. Patel V, Salam A, Malhotra R. Posterior approach white line advancement ptosis mosis, granulomas, ptosis, and scleral show. Plast Reconstr Surg. 2010;125 repair: the evolving posterior approach to ptosis surgery [published online Sep- (2):709-718. tember 10, 2010]. Br J Ophthalmol. 2010;94(11):1513-1518. 16. Hamawy AH, Farkas JP, Fagien S, Rohrich RJ. Preventing and managing dry eyes 6. Mavrikakis I, DeSousa JL, Malhotra R. Periosteal fixation during subperiosteal after periorbital surgery: a retrospective review. Plast Reconstr Surg. 2009; brow lift surgery. Dermatol Surg. 2008;34(11):1500-1506. 123(1):353-359.

ARCH OPHTHALMOL / VOL 130 (NO. 8), AUG 2012 WWW.ARCHOPHTHALMOL.COM 1012