Upper Blepharoplasty and Brow Lift: State of the Art

Abstract

This paper will review the effects of upper facial aging and emphasize patient evaluation, surgical techniques and complications of upper blepharoplasty. The philosophy for brow lifting and brief overview of current brow lift techniques will also be presented. Asian blepharoplasty will not be covered.

Introduction

The eyes are the first thing people notice about your face and are a major contributor to overall beauty. We use our eyes and eyebrows to convey a range of expressions and emotions, both intentional and unintentional. Unfortunately, natural aging changes often create unwanted appearances and make people look tired, sad, or angry. Blepharoplasty helps to erase the puffiness, bulges, and drooping tissues that detract from the beauty of the eyes. “Blepharoplasty” derives from Greek, blepharon (eyelid) and plastos (formed) and is one of the most common plastic surgical procedures performed in the United States. This procedure may be undertaken for purely aesthetic reasons or to alleviate visual obstruction or eyelid dermatitis. Distinguishing between functional and cosmetic blepharoplasty is extremely important for reasons of insurance reimbursement. Brow or forehead lifting is often combined with blepharoplasty to give additional upper facial and periorbital rejuvenation.

The traditional approach to upper blepharoplasty involves the artful excision of lax and redundant skin, muscle and herniated fat. However, if overdone, it may leave patients with a skeletonized orbit and an over-operated, sunken appearance. Current methods of periorbital rejuvenation are more conservative and varied, realizing there are different standards for youthful appearance and beauty based on many factors including heredity, sex, race and ethnicity. A precise preoperative evaluation, thorough understanding of the patient’s goals and careful planning and execution of a procedure that involves an appropriate lifting and resection of the coveted soft tissue from the eyelid and eyebrow are now used to restore a youthful upper periocular appearance.

This paper will review the effects of upper facial aging and emphasize patient evaluation, surgical techniques and complications of upper blepharoplasty. The philosophy for brow lifting and brief overview of current brow lift techniques will also be presented. Asian blepharoplasty will not be covered.

Upper Facial Aging

Patients seeking consultation for upper blepharoplasty typically have one or several of the following complaints: droopy or heavy lids; a sad or tired appearance; fullness, bags, or bulges; obstructed vision; reading fatigue; trouble applying makeup or chronic upper eyelid skin inflammation.

These complaints arise from the results of natural aging added onto intrinsic facial structure and configuration. Facial muscle action and balance, gravitational effects, volume changes and skin aging lead to different configurations in different people with no one standard pattern. However, typical changes include: eyebrow descent, especially laterally; skin redundancy and loss of elasticity; lid crease obscuration, loss of sharpness, or elevation; fat prolapse and volume inflation; or, conversely, brow elevation; soft tissue volume deflation with deepening of the superior sulcus and supraorbital rim skeletonization.^1–8

To appreciate how aging effects periorbital appearance, we need to first review normal youthful anatomy. Although there is considerable variation, the brow position in women is at or above the supraorbital rim and arches laterally with peak height above the lateral limbus or canthus. Gunter has presented general criteria for an aesthetic eyebrow that include ⁹: the medial brow vertically above the medial canthus and always below the lateral brow; brow ascent as it goes laterally with a higher peak in women, but never more than 10 mm above a horizontal line drawn from the inferior aspect of the medial brow; periorbital balance with a laterally open oval configuration of eyebrow superiorly to the dorsal nasal line medially to the nasojugal groove inferiorly. Men have a lower and flatter, almost horizontal, brow curvature.^{9, 10} Goldstein also reminds us to consider the third dimension of depth as it was found to be a significant indicator of brow position with the deeper the area below the supraorbital rim, the lower the eyebrow position relative to the ridge and the eye.¹⁰

The general characteristics of a youthful upper eyelid include a full lid with exposed pretarsal platform, distinct lid crease and minimal overhanging supratarsal lid fold. The upper lid crease should parallel the lash line and divide the upper lid into an inferior one-third and superior two-thirds.⁹ The concept of balanced upper eyelid proportions may be formalized by the upper eyelid ratio, which compares the visible distance, in the primary position, between the eyelid margin and the upper eyelid skin fold (termed “pretarsal show”), with that between the skin fold and relaxed brow (termed “preseptal show”).¹¹ Assuming normal brow position and no blepharoptosis, the upper eyelid ratio increases from medial to lateral within the upper eyelid and usually is 1:1.5 to 1:3.

Aging may result in either brow ptosis or elevation. Brow ptosis, typically greatest laterally, is due to less support from deeper structures and imbalance of muscular action with the depressors (orbicularis oculi, corrugator superciliaris, depressor superciliaris, and procerus muscles) overriding the elevators (frontalis).^{1, 3} Descent of the brow causes pseudo excess of the upper lid skin, or secondary dermatochalasis, since the distance from the lashline to brow is vertically compressed making the intervening skin appear excessive. Vertical and oblique glabellar and transverse dorsal nasal and forehead lines develop from chronic muscle action on the overlying skin.

Paradoxical elevation of the eyebrow may occur with aging, especially in women. In a longitudinal facial aging analysis study by Lambros of 123 patients, the brow changes were roughly divided into thirds between visibly elevated, stable in position, or descended by a small amount.⁸ Upward shift of the eyebrow with aging was also found by van den Bosch in a cross-sectional cohort study, contradicting the generally held assumption that aging causes a lower position of the eyebrow.⁴ He speculates that age related laxity of the forehead skin may be compensated for by increased frontalis muscle action. This might cause wrinkling of the forehead skin, while it prevents lowering of the eyebrows.

True excess upper lid skin, or primary dermatochalasis, results from loss of elasticity with the redundant upper lid fold usually overriding and obscuring the lid crease and impinging on the pretarsal platform or resting on the lashes. Orbital septal weakening allows the orbital fat, and sometimes lacrimal gland, to herniate forward causing lid fullness and volume inflation. Descent of the sub-brow, or retro-orbicularis oculi (ROOF), fat pad into the eyelid may also contribute to the increased volume.

However, the causation of the appearance of upper eyelid excessive skin and facial soft tissue descent may rest more on the deflationary effects of regional volume loss with aging rather than the true descent of these regions.⁸ Aging may also cause a higher skin crease in both sexes.⁴ This may be due to age related attenuation of the levator muscle aponeurosis with incipient ptosis and superior migration or atrophy of the orbital fat.

Patient Evaluation

Patients presenting for evaluation of droopy lids are often found to have contributions from several different factors. See Figure 1. The clinical exam should identify and quantitate the different contributing components so that the surgeon can decide which patients may benefit from surgery and allow the proper surgical options to be presented.

Figure 1A.

Facial aging changes with brow and lid fold asymmetry making the right eye look smaller; glabellar and lateral periorbital rhytids also present.

A thorough preoperative history should be taken to document the patient’s complaints and concerns with their appearance and their expectations from surgery. Use of a mirror allows the patient to show what they find objectionable and to see if they have realistic expectations. Review of old photos of the patient are helpful to see their youthful appearance.

The medical history including diseases, prior surgery or injections, periorbital trauma, medications, allergies and smoking are recorded. Particular attention should be given to hypertension, bleeding dyscrasias, cardiovascular and thyroid disease. It is especially worthwhile to ask specifically about aspirin and other over-the-counter medications and supplements, both oral and topical, because many patients do not report their use.

While examining the patient, the following must be evaluated: brow position and contour; dermatochalasis: redundant skin-muscle fold; orbital fat and lacrimal gland prolapse or herniation; and blepharoptosis: abnormally low upper lid margin position. Asymmetries and irregularities between the right and left sides must be noted, usually due to unilateral mild ptosis, with or without compensatory brow elevation, or asymmetric lid creases.

Useful measurements when examining the upper periorbital area are presented in Table 1. Although blepharoplasty is never planned based on measurements alone, the numbers are helpful, especially in assessment of brow position and to detect ptosis. The measurements are made using a millimeter ruler after asking the patient to assume a relaxed facial posture while sitting with the eyes in primary gaze. The margin to fold distance (MFD) and brow to fold distance (BFD) are usually measured centrally and above the medial and lateral limbus. In general, we expect a reduction of the upper lid fold with an increase in the MFD and decrease in BFD after surgery. We do not expect any significant change in the margin to reflex distance (MRD) or brow to margin distance (BMD) with reduction of the upper lid fold tissues. The upper lid margin should cover the superior 1–2 mm of the cornea giving a MRD of 4–5 mm. A reading less than 3 indicates coexisting ptosis and greater than 6 reflects upper lid retraction.

Table 1.

Upper Periorbital Measurements

Brow position:	BMD= brow to margin distance; equals BFD + MFD
	BFD= brow to fold distance
Lid crease and fold:	ULC= margin to upper lid crease distance
	MFD= margin to fold distance; may be negative if the lid fold overhangs the lid margin
Lid margin position:	MRD= margin reflex distance
Lid ratio: MFD (pretarsal show): BFD (preseptal show)

If the brow rests below the supraorbital rim, it should be elevated to a normal position with the amount of elevation equaling the amount of brow ptosis. The position, definition and symmetry of the upper lid creases must be noted. The upper lid crease (ULC) is measured in millimeters above the lashline with the eye in downgaze. The amount of dermatochalasis, fat herniation of the preaponeurotic and medial fat pads, and lacrimal gland prolapse are quantitated on a 0–4+ scale. Visual acuity, globe prominence, orbicularis muscle tone, slit-lamp exam of the ocular surface and lacrimal secretory function must also be evaluated. Skin type should be noted and forehead, glabellar, and dorsal nasal rhytids graded. Preoperative photographs are taken and visual field testing may be done to evaluate and document visual obstruction.

Upper Blepharoplasty Procedure

Since a variety of factors contribute to the development of droopy lids, surgical repair of the age-related changes may require one or a combination of procedures including brow stabilization or lifting, upper blepharoplasty and ptosis repair. Non-incisional procedures such as chemical peels, laser skin rejuvenation and botulinum toxin and filler injections may also be included in the surgeon’s recommendations, but they will not be covered in this article.

The principal procedure to address upper periorbital aging is blepharoplasty.^12–15 It involves the skillful and artful removal and repositioning of the skin, orbicularis muscle, ROOF and orbital fat and lacrimal gland. Patients should be instructed to discontinue all anti-coagulant and anti-platelet agents one to two weeks prior to surgery.

Skin marking is done using a fine tip surgical marker as a series of dots with the patient’s head elevated or sitting so that gravity is in force. The lid crease (existing or proposed) and the upper extent of the lid fold for resection are marked as an ellipse as in Figure 2. The medial extent of the marking is above the punctum. Lateral to the lateral commissure, the lid crease marking should have a gentle upcurve within a crow’s foot line to address the lateral hood which is usually present except in young patients. The pinch technique is used to mark the superior incision line which follows the brow contour and maintains a safe distance below the inferior aspect of the brow. Generally, there is at least 8–10 mm of thicker sub-brow skin that should not be disturbed or included in the marked area. Recall that symmetry is achieved by the amount of tissue that remains, not by what is removed. Medial modifications such as a W-plasty may be needed for redundant medial skin. The crease height may be modified (unilateral elevation) to treat asymmetry and increase pretarsal show.¹³

Figure 2.

Intraoperative skin markings on the left upper eyelid. The lower marks are made within the existing lid crease and extend laterally beyond the lateral commissure with a mild upcurve. The upper marks are made after the skinpinch technique and parallel the brow. Notice that a series of dots are made as this is more precise and easier that drawing lines.

Upper blepharoplasty is best done utilizing local anesthesia with monitoring and sedation if needed. This allows the patient to open and close the eyes as needed to check for lid function and symmetry. One or two percent lidocaine with 1:100,000 epinephrine is injected with a long 27-gauge needle. The needle is passed from lateral to medial in the suborbicularis plane with infiltration of the anesthetic as the needle is withdrawn. Gentle massage of the lids for several minutes allows the anesthetic to spread and the vasoconstrictive effect of the epinephrine to work. Separate injection of the fat pads is performed as needed under direct visualization after the orbital septum has been opened.

The skin is incised as marked with a #15 blade using gentle skin traction and avoiding penetration of the orbicularis muscle. In my experience, as others agree, laser use does not have a significant advantage.¹⁴ En bloc myocutaneous tissue excision from lateral to medial with the deep plane of dissection at the level of the posterior orbicularis fascia is used most commonly. Excision of skin only or with a selective amount of orbicularis resection unilaterally for mild fissure (slight ptosis) and fold correction preserves orbicularis volume.¹³ Monopolar electrocautery with a needle tip using the cutting current is my preferred technique for tissue excision. The cut edges of the orbicularis muscle, especially laterally where the branches of the lacrimal artery (lateral palpebral) enter the muscle, account for the majority of bleeding. Use of the coagulating current mode with the monopolar cautery, bipolar cautery, battery cautery, radiofrequency unit, or carbon dioxide laser can be used to obtain hemostasis. Meticulous hemostasis from the fat stump is necessary if fat is resected.

If fat sculpting is needed, the orbital septum should be dissected open widely across the full horizontal extent of the lid for an open sky exposure of the fat pads. The septum should be opened high in the lid, over the fat, to avoid damage to the levator aponeurosis. Prolapsed preaponeurotic and medial upper lid fat is exposed with gentle dissection and traction and trimmed flush with the superior orbital rim. Ballottement of the globe helps to identify the fat. Excision with the monopolar cautery works well. Clamping and traction of the fat is discouraged and is painful. Alternately, the fat pads can be gently cauterized without excision or in addition to excision. This lipo-cautery shrinks the fat for final sculpting. Occasionally, the ROOF is also debulked if it descends into the eyelid space. Over-removal of fat should be avoided to avoid a hollow, or concave, upper lid sulcus.

Occasionally, a bulge in the lateral aspect of the upper lid will be encountered due to prolapse of the orbital lobe of the lacrimal gland. The gland is deep to the septum, has a pinkish color, and should be distinguished from the lateral aspect of the yellowish preaponeurotic fat. It should be repositioned, not excised. Resuspension to the periosteum inside the superolateral orbital rim is accomplished with 6-0 polypropylene or other permanent sutures placed through the capsule of the gland and the periosteum.

Since the pretarsal orbicularis and the levator aponeurosis have not been disturbed in the dissection, lid crease reformation sutures are often not needed. If deepening, elevation or recreation of the crease is desired, it is done with supratarsal fixation sutures of 6-0 chromic or polyglactin passed between the pretarsal orbicularis at the lower edge of the incision and the anterior surface of the levator aponeurosis at the desired height.

Orbicularis muscle closure is necessary only in the lateral aspect of the incision if the wound edges have tension or do not lie in approximation. One or two buried interrupted sutures of 6-0 chromic or polyglactin will suffice. The skin is then closed with a simple running or subcuticular suture of the surgeons choice (polypropylene, nylon, fast-absorbing gut).

After surgery, patients are instructed to use continuous iced gauze compresses on the eyes and maintain an elevated head position for 24 hours. Moderate discomfort and a small amount of bloody drainage may be expected the first one to two days. Patients should limit their activities and obey a 10-pound lifting restriction for two to three days. Ophthalmic antibiotic ointment is applied to the suture lines twice a day for seven to ten days and non-aspirin and non-NSAID containing analgesics are used for pain relief. Patients are further instructed to call immediately if they experience severe pain, significant bleeding or a dramatic change in the amount of bruising or sudden visual changes. Initial bruising and swelling subsides in 10–14 days with complete healing by three to four months postoperatively. Examples of patients before and after upper blepharoplasty are seen in Figures 3 and 4.

Figure 3A.

Preop photo of older patient seeking blepharoplasty for lid heaviness and visual obstruction from hooding.

Figure 4A.

Preop photo of patient complaining of a chronic tired appearance. She has good brow position and contour with the excessive upper lid fold resting on the lashes and obscuring the pretarsal platform.

Brow & Forehead Lifting

Brow and forehead lifting are also often considered as an integral component in upper periorbital rejuvenation. The goal of the brow lift is to reposition and reshape the eyebrow to enhance the periorbital appearance. In addition to brow elevation or stabilization, glabeller and forehead rhytids can be smoothed. The multitude of brow lifting techniques includes the following approaches^16–20: transblepharoplasty internal browpexy, direct supraciliary, mid-forehead, pretrichial, coronal, and small incision endoscopic and non-endoscopic.

Each method has advantages and disadvantages. Direct and midforehead brow lifts have a mechanical advantage for the greatest lift and are the least technically challenging, but leave a visible scar. Coronal brow lifts conceal the incision behind the hairline and allow open myectomy of the brow depressors and scoring of the frontalis, but require large scalp flap creation with elevation of the hairline, increased recovery time and risks of hypesthesia and alopecia. Endoscopic brow lifts utilize smaller incisions and have shorter recovery times, but require expensive endoscopic equipment, are harder to master, and may have decreased longevity of lifting. Small incision nonendoscopic brow lifts utilize scalp and upper blepharoplasty incisions.¹⁹ Via the lid incision; the brow depressor muscles are directly visualized and excised. Transblepharoplasty internal browpexy is performed though a single lid incision. It may use suture or alloplastic periosteal fixation or alter the muscle balance by excision of the lateral orbicularis, release of the orbital ligament laterally, sculpting of the sub-brow fat and removal of the medial brow depressors.¹⁷

It is beyond the scope of this article to describe the techniques of brow lifting in detail. However, I will comment on some of the controversies regarding the need for a brow lift and what constitutes a good brow lift result. The need for concurrent brow lift surgery in patients undergoing upper blepharoplasty has long been debated. Certainly in patients with significant brow ptosis, some form of brow lifting is required. In addition, numerous authors caution about creating or uncovering brow ptosis after upper blepharoplasty. Cicatricial changes from removing a large amount of upper eyelid tissue or frontalis relaxation due to a decreased need to recruit this muscle to elevate the heavy skin laden upper eyelids are cited as the mechanisms for causing brow ptosis.^{5,17,18,20,21} Therefore, they feel performing an upper blepharoplasty without first resuspending the eyebrows is rarely advisable. Frontalis recruitment in patients with ptosis is common and well documented, but evidence for it with dermatochalasis alone is sparse. The only study to document a significantly lower brow position after upper blepharoplasty, to my knowledge, is that of Troilus.²¹ For the 10 patients he studied, all had a 3–4 mm lowering of the brow six months after surgery.

We recently undertook a study which found that brow ptosis was not created, unmasked, or exacerbated postoperatively in 20 patients undergoing functional upper blepharoplasty.²² These patients had significant excess upper lid myocutaneous tissue resected for visual obstruction and are the group that would be most expected to habitually use the frontalis to help alleviate their visual compromise. They were not concerned with their appearance. This is in agreement with Fagien’s findings in 15 patients with predisposing significant brow ptosis undergoing a blepharoplasty alone.²³ They had no marked induction of brow ptosis and the patients were satisfied with their postoperative results. Therefore, we feel the decision to perform concurrent brow surgery should not be made based solely on an expected drop in brow position.

In my oculoplastic surgery practice, more patients present for eyelid surgery than for brow lift, and even those who request brow lift or upper facial rejuvenation usually also require upper blepharoplasty to achieve a higher upper lid fold. Many patients who present for eyelid surgery reject invasive forehead surgery, but will consider botulinum toxin and filler injections. They often fear or decline brow lift procedures wishing to avoid an “operated appearance” with over elevated inanimate brows and hollow upper lids.

The philosophy on what constitutes a good brow lift result has evolved. Knoll has shown in the youthful face that digital image alterations in brow contour elicit profound changes in perceived facial expression and do so to a greater degree than absolute position of the brow.²⁴ Others agree that brow shape outweighs brow position in importance.^{5, 6, 9, 18} Knize states, “A patient will be pleased if only one requisite for eyebrow shape and position is observed. This condition is positioning the lateral eyebrow segments visibly higher than the medial segments for the female patient and positioning the lateral segments horizontal with or slightly higher than the medial eyebrow segments for the male patient. It is unnecessary to make eyebrow resuspension goals more complex.”¹⁸ The best shaping procedures for brows may also involve tweezers and pencils rather than surgery.⁶

Therefore, most patients require brow reshaping by restoration of the brow apex to above the lateral limbus or canthus. This is achieved by preferential elevation of the lateral brow, minimal or no elevation of the medial brow and little or no manipulation of the glabellar musculature. Over elevation of the brow or medial displacement of the brow peak causes a surprised, startled or unintelligent look and is a mistake in brow lifting. Over-resection of the medial brow depressors may cause widening or contour deformities of the glabellar region. Again, persistent forehead and glabellar rhytides after surgery may subsequently be treated with botulinum toxin or fillers as needed.

Complications of Upper Blepharoplasty

Complications of upper blepharoplasty are many and varied. Most are due to postoperative asymmetry and are manageable with minor revisions. Nevertheless, there is a potential for blindness and this must be included in the informed consent process^25–27 Complications are best avoided by thorough preoperative preparation and education of the patient, respect of eyelid anatomy and meticulous surgical technique.

Visual loss as a complication of blepharoplasty is rare and is almost universally due to orbital hemorrhage. The incidence of orbital hemorrhage associated with cosmetic eyelid surgery is 0.055% (1:2,000), and orbital hemorrhage with permanent visual loss is 0.0045% (1:10,000).²⁶ Development of orbital hemorrhage is most common within the first 24 hours after surgery, especially within the first three hours, but can occur as late as nine days after surgery.^26,27 Intra and post-operative hypertension, perioperative aspirin use, postoperative vomiting, and excessive physical activity after surgery increase the risk of hemorrhage.

Orbital hemorrhage develops only if the septum is violated and orbital fat is manipulated or removed. Wide opening of the septum allows better visualization of the fat for identification and control of bleeding. It is generally accepted that traction on orbital fat can tear deep orbital vessels, stimulating some bleeding. The mechanism of visual loss from orbital hemorrhage is optic nerve compression or ischemia or central retinal artery occlusion from increased intraorbital and intraocular pressure.

As previously stated, patients should elevate their head, use ice compresses and avoid strenuous activity or bending for the first 24 hours after surgery. Symptoms of orbital hemorrhage are rapidly accelerating pain, pressure, swelling, or blurred vision. Patients should be instructed to report these symptoms promptly to their surgeon with emergent evaluation when indicated. Eye patches should be avoided so that patients are aware of dramatic changes in their appearance or vision. Treatment of orbital hemorrhage includes wound opening and drainage, clot evacuation and cauterization of active bleeders. Lateral canthotomy and cantholysis, intravenous steroids, and intraocular pressure lowering medications may also be used. Rarely, orbital decompression is needed. Prompt treatment will hopefully reverse or minimize permanent visual loss.

Wound infections are exceedingly rare after eyelid surgery. Allergic dermatitis from topical ointments, especially those containing neomycin, and sterile suture abscesses, usually from polyglactin material, may simulate cellulitis. If infection does occur, wound drainage or abscess contents should be cultured and appropriate oral antibiotics administered. Methicillin resistant staph aureus and atypical mycobacterial organisms must be considered.

Asymmetries in the lid fold, lid crease, or fat contour are usually amenable to minor revision procedures if they persist after allowing adequate initial healing. Ptosis may develop if the levator aponeurosis or muscle is damaged and may require a ptosis repair if it fails to resolve. Upper lid retraction, lagophthalmos and exposure keratitis may occur if the incision closure inadvertently incarcerates the orbital septum or if skin is over-resected. See Figures 5. Again, surgical revision may be required if lubrication and massage fail to correct the problem or if the cornea is at significant risk. Diplopia is possible if the superior oblique or trochlea is damaged while working on the medial upper lid fat pad. Permanent muscle imbalance may require prism glasses correction or ocular realignment surgery.

Figure 5A.

Postoperative photo showing downgaze lid retraction due to incarceration of the orbital septum in the wound leading to incomplete eye closure and corneal exposure.

Summary

Upper blepharoplasty is a common and very successful procedure to erase the aging changes of the upper periorbital region and may be done in combination with brow lifting. A precise preoperative evaluation, thorough understanding of the patient’s goals and careful planning and execution of a procedure that involves an appropriate lifting and resection of soft tissue from the eyelid and eyebrow are used to restore a more youthful upper facial appearance. Serious complications of upper blepharoplasty are rare and are minimized by proper patient preparation and education; using skillful and meticulous technique and prompt recognition and intervention.

Figure 1B.

Facial aging with dermatochalasis, medial fat prolapse, mild ptosis and vertical glabellar lines giving an angry or tired appearance. Note also the manicured lower brows for thinning and attempted reduction of the brow heaviness.

Figure 3B.

Postop photo after skinmuscle resection showing stable brow position, increased pretarsal show (MFD) and relief of visual obstruction.

Figure 4B.

Postop photo showing a brighter rested appearance, visible pretarsal platform and normal upper eyelid ratio.

Figure 5B.

Downward traction on the lid confirms the tethering of the lid to the supraorbital rim due to the septal incarceration preventing downward lid movement.

Biography

David B. Lyon, MD, FACS, MSMA member since 1995, is Associate Professor in the Department of Ophthalmology at University of Missouri-Kansas City School of Medicine, Eye Foundation of Kansas City and Vision Research Center, Kansas City, Missouri.

Contact: dlyon1@kc.rr.com