• Cornea/External Disease, Oculoplastics/Orbit

    Review of: The Effect of a Ptosis Procedure Compared to an Upper Blepharoplasty on Dry Eye Syndrome

    Zloto O, Matani A, Prat D, et al. American Journal of Ophthalmology, April 2020

    This study assessed the effect of combined blepharoplasty and Müller muscle-conjunctival resection (MMCR) surgery on dry eye syndrome.

    Study design

    This prospective, non-randomized, comparative case series includes 54 adults. Twenty-three patients received blepharoplasty and 31 underwent ptosis repair (blepharoplasty and a 9-mm MMCR). The blepharoplasty in both groups was orbicularis sparing. Patients were followed for 90 days.

    The following data were obtained pre- and postoperatively: margin reflex distance 1 (MRD1), ocular surface disease index (OSDI), Schirmer test 2, tear break-up time, fluorescein staining and Lissamine-green staining.


    There was no difference in postoperative MRD 1 in the two groups. The ptosis arm showed significant increases in Lissamine green staining scores and fluorescein staining (P=0.05 and P=0.02, respectively). The OSDI was also higher with this procedure than with blepharoplasty alone (25.38 vs. 17.24; P<0.01). The pre- and postoperative objective and subjective dry eye tests were similar in the blepharoplasty group.


    The study groups were larger than in previous studies but were still relatively small. Although a follow-up of 90 days should be adequate, it is possible that some of the subjective symptoms are due to the conjunctival scar, which may improve with time. It is difficult to confirm if the increase in subjective and objective dry eye after MMCR surgery is secondary to the increase in exposed ocular surface or damage to the accessory lacrimal gland and goblet cells. This could be answered with a third study group undergoing external levator advancement surgery.

    Clinical significance

    This study demonstrates that MMCR surgery causes an increase in subjective and objective dry eye tests. This has been a criticism of MMCR surgery for years due to the potential resection of accessory lacrimal gland tissue, goblet cells and possible damage to the lacrimal gland ductules. Patients undergoing MMCR surgery should be informed and consented for this increased risk and be treated for dry eye during follow-up.