29.1 Preoperative Steps

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  The first step in the consultation is to obtained a through medical history that includes the following:

  
  
  
  
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    History of hypertension, cardiac disease, bleeding or clotting disorders, diabetes, thyroid dysfunction, and autoimmune disease.

  
  
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  Once the medical history has been obtained, the surgeon should obtain a focused ophthalmologic history including the following:

  
  
  
  
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    When was the last time the patient had his or her visual acuity checked?

    
    
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    Does he or she use any corrective lenses or glasses?

    
    
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    Any prior history of facial or periorbital trauma, glaucoma, excess tearing and/or dry eyes, prior ophthalmologic/periorbital surgery, or LASIK or refractive surgery?

  
  
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  A systematic approach should be used for the periorbital physical examination:

  
  
  
  
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    The presence of the protective Bell’s phenomenon is documented, which is the upward movement of the globe with eye closure.

    
    
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    Forehead and brow examination:

    
    
    
    
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      Brow and forehead should be part of a comprehensive periorbital examination.

      
      
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      Presence of hyperactive frontalis and brow elevation should be noted at baseline. The patient should be asked to relax the forehead in order to determine the resting brow level.

      
      
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      In females, the eyebrow should be 1 cm above the supraorbital rim, and slightly peaked at the lateral third. The eyebrow may be at the level of the supraorbital rim in males without peaking laterally.

      
      
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      Forehead length should be documented. The normal length is 6 cm.

      
      
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      Fat atrophy in the supraorbital region particularly in the central, middle, and lateral temporal fat compartments should be documented.

    
    
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    Skeletal support:

    
    
    
    
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      The underlying skeletal support of the periorbita should be examined. This includes the orbital rim, zygomatic prominence at the malar eminence, and temporal bone of the forehead.

      
      
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      Facial aging includes a component of bone resorption, which may also contribute to some of the findings in periorbital aging.

    
    
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    Upper eyelid skin quality and quantity (Fig. 29.1):

    
    
    
    
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      The upper eyelid is examined with the eyebrows at resting neutral position.

      
      
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      Dermatochalasis is the extent of excess upper eyelid skin.

      
      
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      Supratarsal fold location should be about 6 to 7 mm above the lash line. An elevation in this with eyelid ptosis is indicative of levator dehiscence.

    
    
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    Upper eyelid position:

    
    
    
    
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      The upper eyelid position is determined relative to the superior limbus.

      
      
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      Marginal to reflex distance 1 is the measured distance from the upper eyelid to the corneal light reflex. The normal value is 4 mm. Values less than this indicate the degree of blepharoptosis.

    
    
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    Levator excursion:

    
    
    
    
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      This is the value given to the distance the upper eyelid moves from inferior to superior gaze.

      
      
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      Values for normal function are between 10 and 15 mm, moderate function is 5 to 10 mm, and poor function is 0 to 5 mm.

    
    
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    Lower eyelid position (Fig. 29.2):

    
    
    
    
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      The lower eyelid should sit at the inferior corneo-scleral junction. Any scleral show between these points indicates lower eyelid ptosis secondary to one of two common causes: lateral canthal laxity or lower eyelid horizontal excess.

      
      
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      The lower eyelids should be examined for protuberant fat from the three compartments along with the presence of a tear trough deformity.

    
    
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    Lateral canthal position (Fig. 29.3a–c):

    
    
    
    
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      The lateral canthus should be 2 mm superior to the medial canthus with a positive tilt. Lack of a positive tilt indicates lateral canthal laxity.

      
      
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      The lateral canthal angle should be sharp. A blunted angle indicates lateral canthal laxity or a history of prior surgery.

    
    
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    Anterior distraction:

    
    
    
    
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      The lower eyelid is distracted anteriorly to the globe. A distraction of >6 mm indicates horizontal excess, best managed with a lateral tarsal strip canthoplasty.

    
    
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    Snapback test:

    
    
    
    
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      This test evaluates the lower eyelid tone. The lower eyelid is pulled inferiorly and then allowed to return to normal position without the blinking mechanism. A sluggish return to normal indicates poor tone.

    
    
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    Malar eminence vector (Fig. 29.4):

    
    
    
    
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      A critical part of the examination is determining whether the patient has a positive or negative vector.

      
      
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      A positive vector is demonstrated when the malar eminence is anterior to the corneal surface of the globe on lateral view.

      
      
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      A negative vector is demonstrated when the malar eminence is posterior to the corneal surface of the globe.

      
      
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      Patients with a negative vector are at an increased risk for lower eyelid malposition after lower eyelid blepharoplasty.

    
    
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    Dry eye:

    
    
    
    
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      In patients with a history of dry eye, a Schirmer’s test is performed.

      
      
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      Patients who demonstrate an abnormal Schirmer’s test are referred for ophthalmologic evaluation.