Although it is rare, loss of vision is the most dreaded complication of blepharoplasty and is usually associated with lower blepharoplasty. Such blindness is typically thought to occur secondary to postoperative retrobulbar hemorrhage, with the increased intraorbital pressure causing ischemic compression of the ciliary arteries supplying the optic nerve. Other mechanisms of injury include ischemia caused by excessive surgical retraction or constriction of retrobulbar blood vessels in response to epinephrine in the local anesthetic. Orbital hemorrhage may result from injury to the deeper orbital blood vessels or from bleeding anteriorly. Risk factors for this complication include hypertension, blood dyscrasias, and anticoagulant use. Postoperative pressure dressings should be avoided: they increase orbital pressure and obscure underlying problems.
Patients should be observed immediately postoperatively to detect possible orbital hemorrhage. Those with significant pain, marked asymmetric swelling, or new proptosis should be evaluated. In addition, visual dimming or darkness, as well as significant or asymmetric blurred vision, following eyelid surgery may indicate orbital hemorrhage and should be assessed and treated immediately (see the discussion of orbital compartment syndrome in Chapter 6 for management).
Diplopia, another serious complication of blepharoplasty, may result from injury to the inferior oblique, inferior rectus, or superior oblique muscle. The inferior oblique muscle originates in the anterior orbital floor lateral to the lacrimal sac and travels posterolaterally within the lower eyelid retractors. It separates the central and medial fat pads of the lower eyelid and, thus, may be injured during removal of fat in lower blepharoplasty. In upper blepharoplasty, the trochlea of the superior oblique muscle may be damaged by deep dissection of orbital fat in the superonasal aspect of the upper eyelid.
Excessive removal of skin is a complication that can lead to lagophthalmos of the upper eyelids, as well as cicatricial ectropion or eyelid retraction. Topical lubricants and massage may be helpful for managing mild postoperative lagophthalmos, retraction, or ectropion, all of which may resolve over time. Injectable steroids or 5-fluorouracil can be used if a deep cicatrix contributes to the retraction. Severe cases require the use of free skin grafts, lateral canthoplasty, or surgical release of scar tissue or eyelid retractors. Even if no skin has been excised, inferior scleral show can occur secondary to septal scarring, orbicularis hematoma, and malar hypoplasia.
Excerpted from BCSC 2020-2021 series: Section 10 - Glaucoma. For more information and to purchase the entire series, please visit https://www.aao.org/bcsc.