Blepharoplasty is one of the most frequently

COSMETIC Blepharoplasty in the Post Laser In Situ Keratomileusis Patient: Preoperative Considerations to Avoid Dry Eye Syndrome Bobby S. Korn, M.D., Ph.D. Don O. Kikkawa, M.D. David J. Schanzlin, M.D. La Jolla, Calif Background: The authors used a retrospective case series to describe the increased frequency of dry eye syndrome in patients who have undergone both laser in situ keratomileusis and blepharoplasty. Methods: The authors reviewed records from six patients who required surgical correction for exposure keratopathy previously treated by both laser in situ keratomileusis and blepharoplasty. Results: All six patients developed significant exposure keratopathy postoperatively requiring surgical intervention. Four patients had blepharoplasty followed by laser in situ keratomileusis, and two patients had laser in situ keratomileusis followed by blepharoplasty. Symptomatic dry eye symptoms followed the second procedure 1 week to 4 months later. Surgical correction of eyelid malposition and lagophthalmos markedly improved symptoms. Conclusions: Patients with a history of laser in situ keratomileusis contemplating blepharoplasty are at higher risk of developing postoperative dry eye syndrome. Surgeons performing these procedures should perform thorough preoperative evaluation and surgical planning to minimize this potential complication. (Plast. Reconstr. Surg. 119: 2232, 2007.) Blepharoplasty is one of the most frequently performed cosmetic procedures in the United States, with over 465,000 cases annually. 1 Dry eye syndrome is a well-recognized and dreaded complication after blepharoplasty surgery, with an incidence of 8 to 21 percent. 2 5 There are multiple etiologic factors responsible for dry eye symptoms after blepharoplasty, with lower eyelid malposition as the principal mechanism. 6 Lagophthalmos, eyelid retraction, alterations in the tear film, and diminished blink reflex all result in increased tear evaporation and dry eye symptoms. 4,5,7,8 Another frequent cosmetic procedure is laserassisted in situ keratomileusis or laser in situ keratomileusis. Annually, over 1.3 million laser in situ keratomileusis procedures are performed in the United States alone. 9 The laser in situ keratomileusis procedure itself is not without From the Divisions of Ophthalmic Plastic and Reconstructive Surgery and Cornea and Keratorefractive Surgery, Department of Ophthalmology, University of California, San Diego School of Medicine. Received for publication January 23, 2006; accepted May 3, 2006. Copyright 2007 by the American Society of Plastic Surgeons DOI: 10.1097/01.prs.0000260750.15059.17 complications. In a recent survey of the American Society of Cataract and Refractive Surgeons, dry eye symptoms were the most common complaint after surgery, accounting for up to 15 to 25 percent of all cases. 10 With the increasing volumes of these cosmetic procedures performed annually, there will no doubt be an increasing number of patients who have undergone both operations. Laser in situ keratomileusis surgery can induce dry eye symptoms by a variety of different mechanisms. The cornea is richly innervated by the long ciliary nerves of the ophthalmic division of the trigeminal nerve. The majority of these terminal nerve fibers enter the cornea horizontally at the 3-o clock and 9-o clock positions. Activation of these sensitive nerve fibers by foreign bodies or ocular surface desiccation stimulates the blink reflex to sweep the corneal surface with tears. 11,12 During laser in situ keratomileusis flap creation and laser ablation, these nerves are transected, resulting in decreased corneal sensitivity and a transient neurotrophic cornea. 13,14 As a result, the blink reflex arc is blunted, contributing to dry eye symptoms. Battat et al. and Toda et al. reported other possible mechanisms for dry eye, including decreased rates of tear pro- 2232 www.prsjournal.com

Volume 119, Number 7 Dry Eye Syndrome with Blepharoplasty duction and clearance after laser in situ keratomileusis. 8,13 Hori-Komai et al. reported an increase in interpalpebral width after laser in situ keratomileusis surgery, suggesting that dry eye symptoms may result from a change in the apposition of the eyelids with the ocular surface. 15 In our clinical ophthalmic practice, we have noted more frequent presentations of dry eye symptoms in patients who have undergone both blepharoplasty and laser in situ keratomileusis. The relationship between blepharoplasty and laser in situ keratomileusis in the development of postoperative dry eye has not been well studied. In this report, we present the findings in our series of patients with dry eye symptoms who previously had both blepharoplasty and laser in situ keratomileusis. To our knowledge, this is the first report to describe dry eye symptoms exacerbated after both blepharoplasty and laser in situ keratomileusis. PATIENTS AND METHODS All patients were examined at the Shiley Eye Center at the University of California, San Diego, a university-based tertiary referral practice. This study was approved by the University of California, San Diego Human Research Protections Program and conforms with the principles outlined in the Declaration of Helsinki. A total of six patients who had previously undergone both upper and lower eyelid blepharoplasty and laser in situ keratomileusis were reviewed and analyzed retrospectively. In our chart review, we examined age, sex, medial and surgical history (including timing of both blepharoplasty and laser in situ keratomileusis), and details from ophthalmic examination. The ophthalmic data included the presence of ocular symptoms, visual acuity, eyelid position, margin to reflex distance (defined as the distance from the upper eyelid to the central corneal light reflex and the distance from the lower eyelid to the corneal light reflex), lagophthalmos, and corneal staining. Tear breakup time and tear meniscus level were measured as previously described. 16 Laser in situ keratomileusis surgery was performed using the VISX Star excimer laser (VISX, Inc., Santa Clara, Calif.) or the Ladarvision excimer laser (Alcon, Inc., Fort Worth, Tex.). Before creation of the flap, topical anesthetic consisting of proparacaine 1% was instilled. The flap was created at a depth of 160 mm and a diameter of 9.5 mm using the Hansatome microkeratome (Bausch & Lomb, Rochester, N.Y.), NIDEK microkeratome, or automated corneal shaper microkeratome (Chiron, Claremont, Calif.). The laser correction was achieved with a 6.5-mm ablation zone for myopic correction or a 9.0-mm ablation zone for hyperopic correction. At the time of surgery, all patients received topical antibiotics [0.3% ofloxacin (Allergan, Inc., Irvine, Calif.) or 0.3% ciprofloxacin (Alcon, Inc., Fort Worth, Tex.)], an anti-inflammatory (0.1% ketorolac; Allergan), and a steroid (1% prednisolone acetate; Allergan). Postoperatively, all patients were given, four times daily, 1% prednisolone acetate, ofloxacin or ciprofloxacin, and nonpreserved artificial tears. All procedures to correct ocular surface symptoms were performed by one surgeon (D.O.K.). Initial treatment consisted of artificial tear supplementation followed by punctal plug placement or punctal cautery for refractory symptoms. Patients with more severe symptoms required surgical intervention. All operations were performed under local anesthesia with lidocaine 0.5% and epinephrine 1:200,000, with monitored care, and placed on Frost sutures for 3 to 5 days. For cases of lower eyelid retraction with less than 1 mm of scleral show inferiorly, the lower eyelid was recessed beneath the inferior tarsal border. A transconjunctival incision beneath the inferior tarsal border was performed to release the lower eyelid retractors. A 6-0 mild chromic suture was then used to recess the palpebral conjunctiva 2 to 3 mm beneath the inferior tarsal border. In cases of lower eyelid retraction with 2 mm of scleral show, autologous hard palate was used as a spacer graft in the inferior fornix. The graft was secured with 6-0 fast absorbing gut sutures. For lower eyelid retraction with greater than 3 mm of scleral show, hard palate grafting was combined with midface elevation. Lateral canthoplasty was performed using 5-0 polygalactin sutures to secure the inferior crus of the lateral canthal tendon to the superior crus. RESULTS A summary of demographic and clinical characteristics is provided in Tables 1 and 2. CASE REPORTS Patient 1 A 63-year-old woman underwent bilateral upper and lower eyelid blepharoplasty in October of 2001. Postoperatively, the patient was noted to have 1 mm of lagophthalmos and lower eyelid retraction bilaterally but denied any dry eye symptoms. On clinical examination, there was no punctate keratopathy of the cornea. In November of 2001, she underwent bilateral hyperopic laser in situ keratomileusis. A superiorly hinged corneal flap was created with the Hansatome microkeratome. One 2233

Plastic and Reconstructive Surgery June 2007 Table 1. Patient Demographics and Timing of LASIK and Blepharoplasty Case Age/Race/Sex Date of LASIK Operated Eye Type of Hinge Microkeratome Date of Upper Blepharoplasty Date of Lower Blepharoplasty 1 63/W/F 11/2001 OU Superior Hansatome 10/2001 10/2001 2 73/W/F 4/1999 OD Nasal ACS 6/1998 6/1998 3 42/W/F 2/2002 OU Nasal Nidek 1993 1981 4 57/A/F 1/2002 OU Nasal Unknown 1992 2000 5 45/W/F 1999 OD Nasal Unknown 5/2000 5/2000 6 57/W/M 7/1997 OD Nasal Unknown 1/2002 1/2002 LASIK, laser in situ keratomileusis; W, white; F, female, M, male, A, Asian; OU, both eyes; OD, right eye; ACS, automated corneal shaper. Table 2. Clinical Characteristics before Corrective Surgery Case MRD 1 /MRD 2 OD OS Lagophthalmos Superficial Punctate Kerabottomathy 1 3/8 3/8 OD, 1 mm OU 1 mo after LASIK OS,1mm 2 4/8 4/8 OD, 2 mm OD inferior 4 mo after LASIK OD OS,2mm 3 4/7 4/9 OD, 1 mm OU 1 wk after LASIK OS,3mm 4 4/7 4/7 OD, 1 mm OS,1mm OU inferior Reports Symptoms of Dry Eyes Baseline 1 mo after lower blepharoplasty, markedly worsened 1 wk after LASIK 5 3.5/7 3/7 OD, 2 mm OU inferior 1 mo after blepharoplasty OS,2mm 6 5/8 5/7 OD, 2 mm OD 2 mo after blepharoplasty OS,2mm MRD, margin to reflex distance (MRD 1 and MRD 2, defined as the distance from the upper eyelid to the central corneal light reflex and distance from the lower eyelid to the corneal light reflex, respectively); LASIK, laser in situ keratomileusis; OD, right eye; OS, left eye; OU, both eyes. month after laser in situ keratomileusis, the patient presented to the clinic with foreign body sensation in both eyes. Inferior punctate staining of the cornea was noted bilaterally. Initial treatment consisted of aggressive ocular lubrication followed by bilateral lower punctal plug placement. Despite these treatments, the patient continued to have intractable dry eye symptoms and elected to undergo surgical correction. The patient underwent bilateral lower eyelid retraction repair with hard palate grafting (Fig. 1). Two months after surgery, the patient reported marked improvements in her dry eye symptoms, with no lagophthalmos. Visual acuity improved from 20/40 preoperatively in both eyes to 20/25 postoperatively in the right eye and 20/30 in the left eye. Patient 2 A 73-year-old woman underwent bilateral upper and lower eyelid blepharoplasty in June of 1998 resulting in 2 mm of lagophthalmos bilaterally. In April of 1999, she elected to undergo laser in situ keratomileusis for monovision in the right eye. A nasally hinged corneal flap was created with the automated corneal shaper microkeratome. Four months after laser in situ keratomileusis, the patient began to experience intense foreign body sensation in the right eye. Ocular examination disclosed confluent punctate staining of the cornea in the right eye and no staining in the left eye. Before laser in situ keratomileusis, the patient developed lagophthalmos and inferior displacement of the lateral canthus but was without dry eye symptoms. She was managed with aggressive lubrication initially but continued to have persistent exposure keratopathy in the right eye. After lateral canthoplasty was performed, the patient s ocular symptoms resolved. Patient 3 A 42-year-old woman underwent bilateral lower eyelid blepharoplasty in 1981. In 1993, she underwent bilateral upper eyelid blepharoplasty. Her postoperative course was complicated by 1 mm of lagophthalmos in the right eye, 3 mm of lagophthalmos in the left eye, and mild exposure keratopathy maintained with artificial tears for 9 years. In February of 2002, she underwent bilateral hyperopic laser in situ keratomileusis. One week after laser in situ keratomileusis, the patient reported intense dry eye symptoms greater in the left eye than in the right eye. Ophthalmic examination revealed dense inferior punctate staining greatest in the left eye. Initial treatment consisted of nightly lubricating ointment with eyelid taping and punctal plug placement. Despite these measures, the patient continued to have persistent symptoms necessitating further surgery. The patient underwent bilateral lower eyelid retraction repair with hard palate grafts and midface lifting. Two months after surgery, corneal staining was negative and the patient reported resolution of all dry eye symptoms (Fig. 2). Patient 4 A 57-year-old woman underwent bilateral upper eyelid blepharoplasty in 1992. In July of 2000, bilateral lower eyelid blepharoplasty was performed. Immediately after surgery, the patient reported mild foreign body sensation greater in the right eye than in the left eye. The dry eye symptoms were managed successfully with artificial tears. In January of 2002, the patient underwent bilateral laser in situ keratomileusis. One week after this procedure, the patient reported marked exacerbation of dry eye symptoms greatest in the right eye. Examination revealed bilateral lower eyelid retraction with 1 mm of 2234

Volume 119, Number 7 Dry Eye Syndrome with Blepharoplasty Fig. 1. (Above) Preoperative photographs of a patient demonstrating lower eyelid retraction and lagophthalmos. (Below) Postoperative photographs showing return of normal eyelid position after repair consisting of bilateral mucosal hard palate grafting. Fig. 2. (Above) Preoperative photographs of patient 3 demonstrating lower eyelid retraction and lagophthalmos. (Below) Postoperative photographs showing return of normal eyelid position after repair consisting of bilateral mucosal hard palate grafting and midface lifting. 2235

Plastic and Reconstructive Surgery June 2007 lagophthalmos and inferior punctate staining. Initial treatment consisted of increased frequency of artificial tear instillation followed by bilateral punctal plug placement. Despite these treatments, the patient continued to experience exposure keratopathy. Bilateral canthoplasty was subsequently performed to address the eyelid retraction. After surgical correction, the patient reported marked improvement in her dry eye symptoms, with decreased punctate staining. Patient 5 A 45-year-old woman underwent laser in situ keratomileusis for monovision in the right eye in July of 1999. She tolerated the procedure well, without any dry eye symptoms. In May of 2000, the patient had bilateral upper and lower eyelid blepharoplasty. Within 1 month after surgery, the patient noted marked foreign body sensation greatest in the right eye. Use of copious artificial tears and adjunct placement of punctal plugs did not alleviate the dry eye symptoms. Definitive surgical treatment consisted of repair of lid retraction with hard palate mucosal grafting and bilateral canthoplasty with resolution of symptoms. Patient 6 A 57-year-old man underwent laser in situ keratomileusis for monovision in the right eye in 1997. One month after laser in situ keratomileusis, the patient noted increasing foreign body sensation in the right eye. Initial treatment consisted of artificial tears followed by punctal placement to control dry eye symptoms. Ophthalmic examination of the cornea revealed no punctate staining. In January of 2002, bilateral upper and lower eyelid blepharoplasty was performed. Two months after blepharoplasty, the patient reported marked worsening of dry eye symptoms greatest in the right eye. Examination disclosed bilateral inferior punctate staining with bilateral lower eyelid retraction and lagophthalmos. Despite aggressive lubrication and punctal plug placement, the patient continued to experience exposure keratopathy necessitating surgical correction. Lower eyelid retraction repair consisting of canthoplasty and hard palate mucosal graft was performed bilaterally. After surgical correction of eyelid malposition and lagophthalmos, the patient reported partial improvement in dry eye symptoms with reduced punctate staining. DISCUSSION The association between blepharoplasty and laser in situ keratomileusis in the development of postoperative dry eye syndrome has not been well studied. Each procedure has been shown to independently cause dry eye. 4,5,7,8,13 In this case series, we report the development of dry eye syndrome in patients with previously stable blepharoplasty and laser in situ keratomileusis patients who subsequently underwent the second procedure. Symptoms of dry eye occurred within an average of 1.2 months (range, 1 week to 4 months) after the second procedure and persisted on average 12.6 months until surgical treatment (Table 2). In each case, initial management consisted of artificial tear supplementation followed by punctal plug placement. Benitez and Toda previously noted that decreased tear secretion and corneal sensation were maximal up to 3 months after laser in situ keratomileusis surgery, and by 6 months after laser in situ keratomileusis, most patients returned to baseline tear secretion and corneal sensation. 13,17 In patients undergoing uncomplicated blepharoplasty, exposure keratopathy was noted maximally up to 8 weeks postoperatively. 4 In our series, none of the patients experienced relief with artificial tears and punctal plugs and each required surgical correction. Depending on the severity of the eyelid malposition, repair of lower eyelid retraction with or without mucosal hard palate grafting was required for resolution of dry eye symptoms. Lagophthalmos was a common finding in all symptomatic patients. In four of the cases, blepharoplasty was performed before laser in situ keratomileusis. Pre laser in situ keratomileusis lagophthalmos was present and dry eye symptoms were managed conservatively with ocular lubrication. However, after creation of the corneal flap and laser in situ keratomileusis, conservative management with artificial tears was no longer sufficient to control dry eye symptoms in these patients. Presumably, despite the lagophthalmos, corneal sensation was intact, and during periods of ocular surface dryness, the corneal reflex arc would stimulate increased blinking, lessening the dry eye symptoms. After laser in situ keratomileusis, the blink reflex was blunted, exacerbating the dry eye symptoms. The additive effect of laser in situ keratomileusis and preexistent postblepharoplasty lagophthalmos is best demonstrated in the monocular laser in situ keratomileusis cases (cases 2, 5, and 6). Dry eye symptoms in those patients only developed in the eye that underwent both laser in situ keratomileusis and had postblepharoplasty lagophthalmos. The non laser in situ keratomileusis eye with postblepharoplasty lagophthalmos remained at baseline state, with no exacerbation of dry eye symptoms, presumably because the blink reflex remains intact in the fellow eye. In the post laser in situ keratomileusis patient considering eyelid surgery, the responsibility is on the blepharoplasty surgeon to avoid lid retraction and lagophthalmos. In our practice, we delay any elective eyelid surgery until 6 months after the last laser in situ keratomileusis surgery. The return of normal corneal sensation after creation of laser in situ keratomileusis flaps generally occurs after a 6-month period. 18,19 We propose the following algorithm, outlined in Figure 3. First, the patient is evaluated for any dry eye symptoms. Next, we evaluate for quantitative signs of tear dysfunction with Schirmer s testing, tear breakup time, and tear meniscus evaluation. If any of these findings are 2236

Volume 119, Number 7 Dry Eye Syndrome with Blepharoplasty Fig. 3. Algorithm for preoperative blepharoplasty evaluation. abnormal, any surgery is delayed for an additional 3 months. Artificial tear supplementation and punctal plug placement are performed if necessary. If the preoperative evaluation is normal, we will consider conservative blepharoplasty with several considerations. First, we avoid excessive skin and fat removal, particularly in the lower eyelid. Next, during the dissection, we remove the skin only, leaving the orbicularis oculi muscle intact. To prevent lid retraction after blepharoplasty, we address any lower eyelid laxity and midfacial descent at the time of surgery. 20,21 Finally, all patients receive postoperative artificial tear supplementation for 1 month after surgery. Aggressive ocular lubrication is particularly important in the early postoperative period because of transient paralysis of eyelid closure by local anesthesia. When contemplating laser in situ keratomileusis surgery in the postblepharoplasty patient, particular attention is paid to the periocular examination. Any preexisting lagophthalmos or eyelid retraction should be surgically corrected before performing laser in situ keratomileusis. Correction requires a two-fold approach: (1) increasing 2237

Plastic and Reconstructive Surgery June 2007 tear availability with removable punctal plugs or permanent closure supplemented with artificial tears, and (2) return of the eyelids to physiologic position with eyelid retraction repair, with possible hard palate grafting and/or midface elevation in severe cases. There are multiple procedures designed to address correction of lower eyelid retraction. The surgical techniques for the patients in this study are described in the Patients and Methods section and represent the personal experiences of the authors and are not implied to be the standard of care. Once all eyelid abnormalities are corrected, laser in situ keratomileusis surgery can be considered. An interesting point this study raises is the potential cause of dry eye symptoms in patients who have undergone laser in situ keratomileusis alone. Up to 15 to 25 percent of patients undergoing routine laser in situ keratomileusis experience dry eye symptoms. 10 Although laser in situ keratomileusis is predominantly a procedure performed in younger patients, the presence of senile eyelid malposition was not addressed in these patients, and a subset of these dry eye cases may in fact be attributed to preexisting malposition. Thus, a thorough ocular adnexal examination should be performed in the routine preoperative assessment of the nascent laser in situ keratomileusis patient. This study underscores the need for complete preoperative periocular examination before laser in situ keratomileusis. In addition to a thorough ophthalmic preoperative evaluation, the examination should document, at a minimum, the presence of lagophthalmos, margin-to-reflex distance measurement, eyelid position, Schirmer s testing, and corneal sensation. The shortcomings of our series are inherent in the retrospective nature of this type of study. Some selection bias may be present in that only patients with the most severe exposure keratopathy present. Presumably, there are patients who have undergone both procedures with subclinical dry eye but do not present clinically. These patients could have served as suitable controls, but we were unable to identify these individuals. However, cases 2, 5, and 6 do serve as excellent internal controls because each of these patients with preexistent bilateral lagophthalmos underwent monocular laser in situ keratomileusis and only experienced symptoms in the post laser in situ keratomileusis eye. In addition, we did not study outcomes of patients who underwent eyelid malposition correction before laser in situ keratomileusis. CONCLUSIONS We report an association between laser in situ keratomileusis and blepharoplasty to induce dry eye syndrome. The combination of an eyelid malposition with the transient neurotrophic keratopathy induced by laser in situ keratomileusis can result in debilitating dry eye symptoms. With the numbers of patients undergoing both of these cosmetic procedures increasing, the incidence of dry eye symptoms will likely increase. Ophthalmologists must complete thorough preoperative adnexal evaluation in postblepharoplasty patients before performing laser in situ keratomileusis. Likewise, surgeons performing blepharoplasty must be aware of the potential complications in the post laser in situ keratomileusis patient. Future prospective studies should be designed to evaluate the efficacy of correcting eyelid malposition from blepharoplasty before performing laser in situ keratomileusis and to identify theoptimal timing for performing laser in situ keratomileusis after blepharoplasty. Don O. Kikkawa, M.D. Department of Ophthalmology Shiley Eye Center University of California, San Diego 9415 Campus Point Drive La Jolla, Calif. 92093-0946 dkikkawa@ucsd.edu ACKNOWLEDGMENT This work was supported by a grant from the Bell Family Foundation. REFERENCES 1. Brunk, D. Liposuction ranks as top cosmetic procedure. Fam. Pract. News 15, 2001. 2. Floegel, I., Horwath-Winter, J., Muellner, K., et al. A conservative blepharoplasty may be a means of alleviating dry eye symptoms. Acta Ophthalmol. Scand. 81: 230, 2003. 3. Saadat, D., and Dresner, S. C. Safety of blepharoplasty in patients with preoperative dry eyes. Arch. Facial Plast. Surg. 6: 101, 2004. 4. Vold, S. D., Carroll, R. P., and Nelson, J. D. Dermatochalasis and dry eye. Am. J. Ophthalmol. 115: 216, 1993. 5. Graham, W. P., III, Messner, K. H., and Miller, S. H. Keratoconjunctivitis sicca symptoms appearing after blepharoplasty: The dry eye syndrome. Plast. Reconstr. Surg. 57: 57, 1976. 6. Hamako, C., and Baylis, H. I. Lower eyelid retraction after blepharoplasty. Am. J. Ophthalmol. 89: 517, 1980. 7. Hovanesian, J. A., Shah, S. S., and Maloney, R. K. Symptoms of dry eye and recurrent erosion syndrome after refractive surgery. J. Cataract Refract. Surg. 27: 577, 2001. 8. Battat, L., Macri, A., Dursun, D., et al. Effects of laser in situ keratomileusis on tear production, clearance, and the ocular surface. Ophthalmology 108: 1230, 2001. 9. Market Scope Report, 2002. 2238

Volume 119, Number 7 Dry Eye Syndrome with Blepharoplasty 10. Solomon, K. D., Fernandez de Castro, L. E., Sandoval, H. P., et al. Refractive surgery survey 2003. J. Cataract Refract. Surg. 30: 1556, 2004. 11. Muller, L. J., Pels, L., and Vrensen, G. F. Ultrastructural organization of human corneal nerves. Invest. Ophthalmol. Vis. Sci. 37: 476, 1996. 12. Muller, L. J., Vrensen, G. F., Pels, L., et al. Architecture of human corneal nerves. Invest. Ophthalmol. Vis. Sci. 38: 985, 1997. 13. Toda, I., Asano-Kato, N., Komai-Hori, Y., et al. Dry eye after laser in situ keratomileusis. Am. J. Ophthalmol. 132: 1, 2001. 14. Donnenfeld, E. D., Solomon, K., Perry, H. D., et al. The effect of hinge position on corneal sensation and dry eye after LASIK. Ophthalmology 110: 1023, 2003. 15. Hori-Komai, Y., Toda, I., and Tsubota, K. Laser in situ keratomileusis: Association with increased width of palpebral fissure. Am. J. Ophthalmol. 131: 254, 2001. 16. Burkat, C. N., and Lucarelli, M. J. Tear meniscus level as an indicator of nasolacrimal obstruction. Ophthalmology 112: 344, 2005. 17. Benitez-del-Castillo, J. M., del Rio, T., Iradier, T., et al. Decrease in tear secretion and corneal sensitivity after laser in situ keratomileusis. Cornea 20: 30, 2001. 18. Kanellopoulos, A. J., Pallikaris, I. G., Donnenfeld, E. D., et al. Comparison of corneal sensation following photorefractive keratectomy and laser in situ keratomileusis. J. Cataract Refract. Surg. 23: 34, 1997. 19. Linna, T. U., Vesaluoma, M. H., Perez-Santonja, J. J., et al. Effect of myopic LASIK on corneal sensitivity and morphology of subbasal nerves. Invest. Ophthalmol. Vis. Sci. 41: 393, 2000. 20. Patipa, M. Transblepharoplasty lower eyelid and midface rejuvenation: Part I. Avoiding complications by utilizing lessons learned from the treatment of complications. Plast. Reconstr. Surg. 113: 1459, 2004. 21. Kikkawa, D. O., Lemke, B. N., and Dortzbach, R. K. Relations of the superficial musculoaponeurotic system to the orbit and characterization of the orbitomalar ligament. Ophthal. Plast. Reconstr. Surg. 12: 77, 1996. 2239