Abstract
Purpose:
To compare the incidence of strabismus after upper and lower blepharoplasty in the United States.
Methods:
Retrospective cohort study of adults (age ≥18 years) in the IRIS® Registry (Intelligent Research in Sight) who underwent blepharoplasty between 1/1/2013 and 12/31/2020. The primary outcome was the Kaplan-Meier estimated cumulative incidence of strabismus diagnosis and surgery within three years of blepharoplasty. Multivariable Cox regression was used to determine the association of blepharoplasty type with strabismus diagnosis and surgery, adjusting for patient age, sex, and geographic region.
Results:
Blepharoplasty was performed in 368,623 patients (median [IQR] age, 69 [63–75] years and 69% female). Compared to those undergoing upper eyelid blepharoplasty, patients treated with lower eyelid blepharoplasty were slightly younger (median age, 66 vs. 69 years; p<0.001) and more likely to be female (71% vs. 69%; p<0.001). There was a greater three-year incidence of strabismus diagnosis (2.0% vs. 1.5%; p<0.001) and greater three-year incidence of strabismus surgery (0.15% vs. 0.06%; p=0.003) for individuals undergoing lower vs. upper blepharoplasty. After adjusting for age, sex, and geographic region, lower blepharoplasty was associated with a higher three-year risk of strabismus diagnosis (HR 1.49; 95% CI 1.23–1.81; p<0.001) and surgery (HR 2.53; 95% CI 1.27–5.03; p=0.008).
Conclusions:
This registry-based analysis found that individuals undergoing lower eyelid blepharoplasty were at higher risk of strabismus compared to those undergoing upper eyelid blepharoplasty. Using large databases to understand the incidence of complications of frequently performed procedures may improve ophthalmologists’ ability to provide data-driven counseling on surgical risks prior to intervention.
Keywords: blepharoplasty, strabismus, diplopia, strabismus surgery, oculoplastic surgery, oculoplastics, inferior oblique, inferior rectus, IRIS Registry
Precis
Adults undergoing lower eyelid blepharoplasty are at higher risk of being diagnosed and requiring surgical intervention for strabismus compared to adults undergoing upper eyelid blepharoplasty.
Blepharoplasty is a surgical procedure that removes redundant tissue in the eyelid and may alter skin, fat, and muscle in this region. Although often performed for cosmetic benefit, blepharoplasty has numerous functional indications1 and is among the most common procedures performed by ophthalmologists in the US.2,3
Blepharoplasty may be performed on either the upper or lower eyelids, or both. Upper eyelid blepharoplasty is approached from the anterior surface and focuses on the removal of excess skin and often includes removal of some orbicularis muscle and removal, or repositioning of fat. Extensive fat removal nasally may damage the trochlea and affect the superior oblique muscle motility.4 Lower eyelid blepharoplasty may be approached transconjunctivally focusing on removal of herniated fat or anteriorly including secondary excision of skin and, in some cases, orbicularis muscle. The inferior oblique muscle separates the nasal and central fat pads and is susceptible to damage during extensive fat removal, and damage to the adjacent inferior rectus may occur as well.4,5
Diplopia secondary to extraocular muscle damage or local scarring is a potential complication of both upper and lower blepharoplasty.3,4,6 Several cases reports and series suggest that eye muscle-related complications may be more common following lower blepharoplasty.5,7,8 However, the overall incidence of strabismus following blepharoplasty and the relative risk of upper versus lower eyelid procedures are not known. This study uses a large electronic health record (EHR) registry to describe the incidence of strabismus diagnosis and surgery following upper and lower blepharoplasty in the US.
Methods
This is a retrospective cohort study performed using EHR data of patients followed at practices participating in the American Academy of Ophthalmology IRIS® Registry (Intelligent Research in Sight). The version of the database used was frozen on December 20, 2021 and accessed on April 26, 2023. The data collection methodology of the IRIS Registry has been described previously.9 This investigation was approved by the Massachusetts General Brigham Institutional Review Board with the exemption of informed consent. The research adhered to the Declaration of Helsinki.
Records of all adults (age ≥18 years) in the IRIS Registry who underwent blepharoplasty between January 1, 2013 and December 31, 2020 were included in this study. Blepharoplasty procedures were identified using Current Procedural Terminology (CPT) codes for lower eyelid and upper eyelid blepharoplasty (eTable 1). We excluded all patients with a diagnosis of strabismus or strabismus surgery prior to the blepharoplasty procedure, those without follow-up after the blepharoplasty procedure, and those undergoing combined upper and lower blepharoplasty.
The outcomes of this study included strabismus diagnosis and strabismus surgery. Strabismus diagnoses were identified using International Classification of Diseases (ICD) codes strabismus surgeries were identified using CPT codes (eTable 1). The time between the initial blepharoplasty procedure and strabismus diagnosis or surgery was determined and used in the time-to-event analysis. The initial procedure performed was categorized into upper vs lower blepharoplasty.
Additional demographic data collected from the registry included patient age at the time of blepharoplasty, sex, and geographic region. Age was treated as a continuous variable. Birth sex was treated as a categorical variable. Geographic location was treated as a categorical variable categorized into one of four US Census regions (Northeast, Midwest, South, and West) using the patient’s 3-digit zip code.
Frequencies and percentages are reported for categorical variables and medians and interquartile ranges (IQR) for continuous variables. The cumulative incidence of strabismus diagnosis and strabismus surgery within three years of blepharoplasty were determined using the Kaplan-Meier estimator. Log-rank tests were used to compare the incidence of strabismus between upper and lower blepharoplasty. Cox Proportional Hazards regression was used to estimate the association of blepharoplasty type with three-year risk of strabismus diagnosis and surgery. Adjusted models included age, sex, and geographic region. All analyses were performed using R version 4.2.0 (R Core Team, 2022). All statistical tests were two-sided, and significance was defined as p < 0.05.
Results:
Blepharoplasty was performed in 368,623 patients included in this study (eFigure 1). The median age was 69 years (IQR; 63–75 years) and 69% (268,813) were female patients. Blepharoplasty procedures were performed in the South (46%), West (21%), Northeast (12%) and Midwest (21%) regions.
Lower eyelid blepharoplasty was performed in 11,213 patients. Compared to those undergoing upper eyelid blepharoplasty, patients treated with lower eyelid blepharoplasty were slightly younger (median, 66 vs. 69 years old; p < 0.001) and more likely to be female (71% vs 69%; p < 0.001; Table 1).
Table 1:
Demographics of individuals undergoing lower and upper eyelid blepharoplasty in the IRIS Registry.
Type of blepharoplasty | ||
---|---|---|
| ||
Upper eyelid N = 357,410 | Lower eyelid N = 11,213 | |
| ||
Age (years) 1 | 69 (63 – 75) | 66 (57 – 73) |
Sex, n (%) | ||
Male | 110,110 (31) | 3,271 (29) |
Female | 247,300 (69) | 7,942 (71) |
US Census region, n (%) | ||
Midwest | 73,357 (21) | 1,810 (16) |
Northeast | 41,896 (12) | 1,831 (17) |
South | 161,142 (46) | 5,431 (49) |
West | 73,192 (21) | 1,972 (18) |
Unknown | 7,823 | 169 |
Median (Interquartile Range)
Patients undergoing lower eyelid blepharoplasty had a higher three-year incidence of strabismus diagnosis (2.0% vs. 1.5%; p < 0.001) and a greater three-year incidence of strabismus surgery (0.15% vs. 0.06%; p = 0.003) compared to those undergoing only upper eyelid blepharoplasty (Figure 1). The three-year risk of strabismus diagnosis was greater for lower vs upper blepharoplasty (HR 1.49; 95% CI 1.23–1.81; p<0.001) and after adjusting for age, sex, and geographic region. Similarly, the adjusted three-year risk of strabismus surgery was greater for lower vs upper blepharoplasty (HR 2.53; 95% CI 1.27–5.03; p=0.008; Table 2)
Figure 1:
Kaplan-Meier curves comparing the incidence of strabismus a) diagnosis and b) surgery following upper and lower blepharoplasty.
Table 2:
Cox proportional hazards regression models of the association between blepharoplasty type and three-year cumulative incidence of strabismus diagnosis and surgery.
Strabismus diagnosis | Strabismus surgery | |||||
---|---|---|---|---|---|---|
|
||||||
HR | 95% CI | p-value | HR | 95% CI | p-value | |
| ||||||
Unadjusted | 1.40 | 1.16 to 1.69 | <0.001 | 2.83 | 1.46 to 5.60 | 0.003 |
Adjusted | 1.49 | 1.23 to 1.81 | <0.001 | 2.53 | 1.27 to 5.03 | 0.008 |
HR = Hazard Ratio; CI = Confidence Interval
Models adjusted for age, sex, and geographic region.
Discussion:
This large registry-based analysis including over 350,000 patients provides novel insight into the incidence of strabismus following blepharoplasty. Although strabismus is an uncommon complication of blepharoplasty, those undergoing lower eyelid procedures appear to be at higher risk of being diagnosed and requiring surgical intervention for strabismus. Analyses of large EHR registries enables inquiry into the incidence of infrequent complications of commonly performed procedures and these data may help guide surgeons to counsel their patients on the risks associated with blepharoplasty.
Strabismus accompanied by persistent diplopia is a known complication of blepharoplasty.3,4,6 In a series of 12 patients with acquired strabismus following cosmetic blepharoplasty, all had vertical strabismus as a result of either superior oblique muscle palsy (n=5) or inferior rectus paresis (n=7).5 An anonymous survey with a response rate of nearly 53% of 703 ASOPRS members reported that 23% recalled at least one patient with diplopia persisting beyond one week after lower eyelid blepharoplasty. Inferior oblique injury was more common than inferior rectus injury, and paresis was more common than restrictive strabismus.10 Diplopia resolved over time in 73% of these reported cases. Restrictive changes in the movement of the eye secondary to scar tissue formation and pulley restriction may result in strabismus following blepharoplasty.11 Forced duction testing may be helpful in differentiating paretic vs restrictive causation.12 It has been suggested that a history of prior lower lid blepharoplasty may increase the risk of strabismus post lower lid blepharoplasty.13
Knowledge of the anatomy of the eyelids and anterior orbit may help prevent complications of blepharoplasty.14 Strategies to minimize risk of extraocular muscle injury following lower eyelid surgery include the use of bony anatomical landmarks (orbital rim, infraorbital foramen, and supraorbital notch) to identify and avoid injury to the inferior oblique muscle.15 This may more accurately localize the origin and course of the inferior oblique muscle and facilitate fat resection during lower blepharoplasty and decrease the risk of inferior oblique muscle injury. Similarly, bony anatomical landmarks can be used to predict the oblique vector along which the trochlea and superior oblique tendon lie to avoid injury to these structures when performing orbital fat resection with upper blepharoplasty.16
This study has several limitations. First, this study relies on procedure codes that were not collected for the primary purpose of investigation and may be susceptible to miscoding errors. Second, the IRIS Registry follows patients among participating practices; however, those who left a participating practice to undergo strabismus surgery at a non-participating practice would not be included. Third, although the IRIS Registry contains data from across the US, private practices have a greater representation than academic medical centers which may be a source of selection bias. Fourth, the specific details of the surgical approach and extent of dissection may influence the risk of extraocular muscle injury and the incidence of strabismus; however, these clinical factors are not currently available in the IRIS Registry. For instance, we are unable to distinguish between transcutaneous and transconjunctival lower eyelid blepharoplasty –approaches that may have a different postoperative incidence of strabismus. Finally, we are unable to evaluate surgeon training and experience with blepharoplasty procedures in this EHR registry-based analysis. Further investigations that integrate provider-level survey data may provide additional insight into the contribution of surgical expertise on postoperative complications.
In conclusion, this analysis of a nationwide EHR registry found that individuals undergoing lower blepharoplasty were at increased risk of developing and requiring intervention for strabismus. Further investigations are needed to identify specific clinical and procedural factors associated with increased risk of strabismus in this patient population, that may inform practice patterns and improve outcomes for patients undergoing blepharoplasty.
Supplementary Material
Financial support:
a). Funding/Support:
All authors – Massachusetts Eye and Ear Clinical Data Science Fund
TE – National Institute of Health grant number (P30 EY003790)
IO – National Center for Advancing Translational Sciences (K12 TR004381)
IO, DGH, LRD – Children’s Hospital Ophthalmology Foundation, Inc, Boston, MA
The sponsor or funding organizations had no role in the design or conduct of this research.
b). Financial disclosures:
JWM – consultant fees from Genentech/Roche, Sunovion, and KalVista Pharmaceuticals, Ltd, and ON Therapeutics; stock options and grants from the Lowy Medical Research Institute, Ltd Mactel Study; honorarium from Heidelberg Engineering: personal fees from Aptinyx, Inc board of directors; and stock options and other fees from Ciendias Bio Equity outside the submitted work; Patent for US 7,811,832 with royalties paid by ON Therapeutics to Massachusetts Eye and Ear, royalty sharing per institutional policy: not yet commercialized and a patent for US 5,798,349: US 6,225,303; US 6,610,679; CA 2,185,644; CA 2,536,069 with royalties paid by Valeant Pharmaceuticals to Massachusetts Eye and Ear, royalty sharing per institutional policy.
ACL – consultant for Regeneron.
SKF – consultant/advisor for Sling, Horizon, Viridian, Medtronic, Poriferous, WL Gore.
DGH – Rebion, Inc (founder, equity); Luminopia, Inc (advisor, equity)
Appendix:
Members of the IRIS® Registry Analytic Center Consortium
Suzann Pershing, MD;1 Leslie Hyman, PhD;2 Julia A. Haller, MD;2 Aaron Y. Lee, MD MSCI;3,4 Cecilia S. Lee, MD MS;4 Flora Lum, MD;5 Joan W. Miller, MD;6 Alice C. Lorch, MD, MPH6
1. Stanford University, Palo Alto, CA, USA
2. Wills Eye Hospital, Philadelphia, PA, USA
3. eScience Institute, University of Washington, Seattle, WA, USA
4. Department of Ophthalmology, University of Washington, Seattle, WA, USA
5. American Academy of Ophthalmology, San Francisco, CA, USA
6. Department of Ophthalmology, Massachusetts Eye and Ear, Harvard Medical School, Boston, MA
Footnotes
Meeting presentations: None
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