Upper blepharoplasty is performed for two reasons: to make the patient look better or to make the patient see better.  Insurance usually has an interest in helping the patient see better, and I can assess whether or not each patient is a candidate for insurance-related upper lid blepharoplasty. This procedure generally takes about 45 minutes and is suitable for the operating room or office.

 Cosmetic upper lid blepharoplasty is an individualized surgery.  No two patients are treated the same. Examples of individual variations include:

• Primary brow elevation procedures with secondary skin / soft tissue removal
• Upper blepharoplasty with trans-blepharoplasty brow stabilization
• Upper blepharoplasty with trans-blepharoplasty “frown-line” softening (corrugator resection)
• Upper blepharoplasty with dermis fat graft, free fat graft, or adjacent fat rotation to add volume to the upper lids
• Brow fat pad reinflation with filler or micro fat injections
• Asian blepharoplasty with dedicated lid crease fixation

 In general, upper blepharoplasty is a procedure that has minimal pain in the postoperative period, with swelling that is largely gone by 10 days.  Incisions are carefully placed in the lid fold, and the thin skin of the eyelid heals quite well. 

 Upper blepharoplasty can competently be performed by multiple specialists, including: general ophthalmologists, plastic surgeons, otolaryngologists, and dermatologists.  Reasons to strongly recommend an oculoplastic surgeon include: true eyelid malposition (e.g. ptosis or lagophthalmos), ocular or periocular inflammatory disease (Grave’s disease), ocular surface disease (DES), and reoperation.  A unique feature of my practice is cosmetic reconstruction, e.g. repairing the referred unhappy post-cosmetic surgery patient.

Recent preoperative and postoperative photos can be viewed at: http://josephwalrathmd.com/results/.

By Tom Spetalnick, OD; Clinical Director at Woolfson Eye Institute

In LASIK, a laser reshapes the cornea underneath a “corneal flap.”  The flap is then repositioned, and your vision improves because of your new and improved corneal shape.  Historically, an instrument called a microkeratome was used to create the LASIK flap.  A microkeratome contains a surgical blade that oscillates as fast as 10,000 times per minute.  But that’s not the only way to make a LASIK flap.  Ten years ago, a laser called Intralase was approved by the FDA for creating LASIK flaps with laser energy instead of a blade.  Shortly after that, other similar “femtosecond lasers” appeared that can provide “Bladeless LASIK.”  

When Bladeless LASIK first arrived, it was all the rage in refractive surgery.  The manufacturer of the laser claimed that it would reduce complications, make better LASIK flaps and improve vision results from LASIK.  The Woolfson Eye Institute approach was to remain a little skeptical until we could see research that justified the exciting claims. We knew that some patients were less fearful of the word “bladeless,” and that patients expect a practice with our strong reputation to offer “the latest technology,” so we began offering Bladeless LASIK to the patients that we knew would benefit from it. 

A recent meta-analysis of studies comparing femtosecond (bladeless) outcomes to microkeratome (blade) outcomes provided good evidence that the keratome continues to be a safe method for offering LASIK, with vision results being comparable between the two methods.  One aspect in which the femtosecond laser does offer greater safety, however, is when a patient has an unusual shape to their corneas—fewer complications occur with those patients when bladeless LASIK is used.    

Another legitimate advantage of bladeless LASIK is the lesser degree of “epithelial ingrowth” that occurs post-operatively.  Ingrowth is when the outermost cells that line the cornea find their way underneath the LASIK flap.  Ingrowth is uncommon after LASIK performed with a blade, but even more rare after Bladeless LASIK.

So, which is best, blade or Bladeless LASIK?  Our job as Woolfson eye doctors is to be sure to cover that ground with each patient based on their specific findings, and make the best recommendation to each patient.  The short answer, however, is that Bladeless is gradually becoming the preferred method for offering LASIK.

Q:  How long does the dilation last after a LASIK consult, and how many days after the dilation can I have surgery?

A:  The dilation usually lasts around 12 hours, but some patients are still partially dilated 2 days later.  That’s why we try to give patients 72 hours to recover from dilation prior to surgery.  For some patients, we can use milder dilation drops that don’t last as long.

Q:  Do I have to be dilated during my consult?                                   

A:  We call it a “consult” when the LASIK exam includes the dilation, but we can do a “screening” (without the dilation) to determine if you’re a candidate.  Once you’ve decided to move forward with surgery, you would then have the dilation done at a later date either at Woolfson Eye Institute or with your referring doctor.

Q:  Would it be best if I have Custom LASIK, and how is that determined?

A:  Custom LASIK is one of the technologies that we use to improve the chances of 20/20 or better vision, and to decrease the chances of glare symptoms at night.  Not all patients qualify for Custom LASIK—we use a test called the Wavescan to obtain information that enables us to provide Custom LASIK.  Sometimes other technologies are more appropriate for specific patients—the doctors here will make a recommendation based on the test results from your screening or consult.

Q:  Is 18 years old a good age to have LASIK and, if not, what’s the best age to start? My son is 18; should I wait until he’s 21? A lot of doctors are telling me to wait…..

A:  If a patient is 18, and we have good evidence that his vision is stable, it’s ok to have LASIK at that age.   Not all 18 year-olds will be offered LASIK, but our doctors are glad to do the testing and compare previous prescriptions to determine if it’s sensible to proceed. 

Q:  How bad does my prescription have to be for me not to qualify for LASIK?

A:  Most patients who wear contacts or glasses most of the time for their distance vision end up being candidates for LASIK.  Some patients who just need glasses for reading end up opting for monovision.  Most of our patients have vision before surgery that’s 20/30 or worse.    

Q:  If I want mono vision surgery, how long will I need to try the cls before coming in for a consult?

A:  You don’t have to be successful in monovision prior to your consult.  Our doctors are able to demonstrate to you in the exam room what monovision would look like, and can then tell you if it’s worth trying in contact lenses to be sure.  Some patients know within a day that it’s what they want; some take 2 weeks to adapt.  If you haven’t adapted in 2 weeks, you probably won’t. 

Q:  If a woman just gave birth, how soon can she come in for a LASIK consult?

A:  We don’t offer LASIK to patients who are pregnant, but after the pregnancy we often can permit patients to proceed.  We used to require patients to discontinue nursing and resume normal menstrual cycles prior to offering LASIK, but we no longer do that, as the research demonstrates that vision does not typically change during that time.

Dry eyes are not necessarily a reason for you to fear LASIK.  In fact, it’s frequently the reason people seek an alternative to contact lenses.  Patients with mild dryness often are intolerant of their contact lenses, but usually do very well with LASIK.  Our approach at Woolfson Eye Institute is to simply assess the degree of dryness based on your responses to our questions and the results of your dry eye testing.  Our job is to classify your dry eye problem as mild, moderate or severe, and then counsel and treat you accordingly.   

Fortunately, there are plenty of ways to predict who is more likely to have dry eyes and also plenty of methods for treating it.  If you already have dryness as a symptom, you’re more likely to have similar symptoms or worse right after LASIK.  Or, if you’re over 50 years-old, you’ll need to be prepared for the higher chance of at least temporary dryness after LASIK.  Farsighted patients often have a tougher time, as well.  Some health conditions, like thyroid disease and rheumatoid arthritis can also increase the chances of annoying dryness symptoms. 

If your history and our testing lead us to determine that you have mild dry eyes, using lubricant drops before and after surgery is usually the only treatment needed.  Moderate dry eyes sometimes need more aggressive treatment, like plugs in the tear canal (called punctal plugs) or prescription eye drops in order to transform you into a candidate for LASIK.  Severe dryness typically means that LASIK is not for you.

Dry eye treatment with punctal plugs often improves the problem very quickly.  Your plugs can be inserted either all the way into the canal (called the canaliculus)

Does LASIK cause your near vision to change sooner?  No, LASIK is an alternative to glasses and contacts.  But if you’re a nearsighted patient who’s approaching 40, it may be hard for you to imagine having difficulty with your near vision, since near vision has always been what you do best.

You, like everyone, will eventually develop an eye disorder call Presbyopia (which literally translates to “old eyes”).  If you’re over 40, it’s probably already happening.  The lens and muscle system within your eyes is simply programmed to break down over time—like an auto focus camera that wears out.

Once that occurs, glasses are needed for near vision whether you’re wearing contacts or you have LASIK.  We spend a lot of time explaining this concept to patients, because there’s nothing more disappointing than a vision-related surprise.

During your LASIK evaluation, we can help you recognize that near vision fades, with or without LASIK, and we can even show you what your intended result will look like.  That way, you can move forward with realistic expectations about what Woolfson LASIK can do for you. 

What if you just can’t live with having eye surgery that still leaves you wearing glasses for near?  It turns out we can provide alternative that WILL give you everything—monovision LASIK or multifocal lens implants.  But those are topics for another day.