Risk Factors for Worsening Dry Eye Symptoms in Patients Undergoing External Levator Advancement Surgery.

Purpose: Few studies have examined dry eye syndrome (DES) as a consequence of external levator advancement surgery. The purpose of this retrospective study was to examine risk factors for dry eye signs and symptoms after external levator advancement in order to improve preoperative planning.

Methods: A retrospective chart analysis was performed on all patients who underwent external levator advancement from January 2010 to April 2015 performed by one surgeon (B.J.W.). Margin reflex distance-1 (MRD1) and margin reflex distance-2 were measured preoperatively and postoperatively. Dry eye symptoms (DSXs) were recorded for visits preoperatively, postoperatively at week 1, and postoperatively at month 3. DSXs were graded 0 to 3. Subgroup analysis was performed on patients with pre-existing DES diagnosis and on eyes undergoing additional simultaneous procedures. Statistical measures included linear regression, Pearson χ2 tests, and analysis of variance with post hoc comparison tests.

Results: A total of 190 eyes (115 patients) were included; 39% were patients with DES and 56% had simultaneous surgeries. Postoperative values for both MRD1 and margin reflex distance-2 and the change in values for MRD1 (postoperatively at month 3 to preoperatively) were statistically significant between patients with worsening versus those without worsening DSX. Differences in DSX in patients with DES were significant preoperatively and postoperatively at week 1 but not postoperatively at month 3. Comparing those patients with DES with worsening DSX versus those with improving DSX, those with worsening DSX had no difference in final MRD1 but did have a greater change in MRD1.

Conclusions: Larger postoperative values of MRD1, margin reflex distance-2, and change in MRD1 are associated with worsening postoperative dry eye symptoms in those undergoing external levator advancement. In patients with DES, there was no significant difference in final MRD1; however, a greater change from preoperative and postoperative MRD1 was associated with worsening DSX. Oculoplastic surgeons may consider doing simultaneous lower eyelid surgery that decreases margin reflex distance-2 to potentially help reduce the chance of postoperative dry eye symptoms.