A retired ophthalmologist, (Bascom Palmer trained, with 34 years of practice, including thousands of lid and facial cases, some lid reconstructions..eg reconstruction of outer 2/3 of lids plus outer canthus for BCC involving periosteum flaps, mucousal graft with Mustarde flaps), I was amazed to learn recently that elective lid surgery is being done without globe safety provided by scleral contact lenses, which also facilitates surgery, elevating, firming up the lid..heard of FT corneal cut.
Does ASOPRS Advise Scleral Contact Lenses Be Routinely Used to Protect the Globe?
Doctor Answers 6
We use these lens when they are needed.
Understand that oculoplastic surgeons are trained to operate on the eye itself as well as the eyelids. Therefore we do not need to routinely hide the globe from errant needles. There are certain maneuvers where the use of a hard contact lens is customary and beneficial. However this is an intraoperative decision made by the surgeon based on moment to moment considerations. Certainly there are many operative situations were the presence of the contact lens will make for a much less accurate surgical result. Please do not confuse the decision to not use a hard contact lens as compromising globe safety in anyway.
No such recommendation
ASOPRS has no blanket recommendation for scleral contact lenses to be routinely used for eyelid surgery. As you know, ASOPRS trained Oculoplastic surgeons are also ophthalmologists that routinely work on ocular surface diseases and are very comfortable and skilled while operating around the eye and ocular structure. In addition, they are quite adept at treating ocular complications [most facial plastic surgeons and general plastic surgeons send us their complications and more difficult cases).
Furthermore, during surgery, we are often checking the pupil for signs of dilation, and in external ptosis repair, checking eyelid position with respect to the cornea/pupil.
As such, their use of corneoscleral protectors is not as common, as compared to Facial plastic surgeons and general plastic surgeons. In addition, the placement of corneoscleral protectors can sometimes cause corneal abrasions which are quite painful.
So the use of the corneoscleral protectors is an individual choice, depending on the surgeons comfort level.
Having said that, a full thickness corneal laceration is not an acceptable complication of eyelid surgery and a corneoscleral shield would have likely helped prevent that complication.
Many surgeons use protective shields when operating
I use the Cox II metallic shields while operating, mainly to block out the bright surgical lighting, which causes patient discomfort. They have the benefit of protecting the eye surface as well from an errant cut. Thankfully I haven't experienced this type of complication, but it always pays to be safe. That being said, as an ophthalmologist and oculoplastic surgeon, I feel comfortable operating on the eyelids without the shields and often can't use them as they may impede a particular surgical procedure. ASOPRS has no official position on their use.
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I completely agree with Dr. Steinsapir on this issue; I believe Dr. Shumway's seatbelt statement is debatable. Since I am not a member of ASOPRS, I cannot comment on their position, but I do not believe there is any blanket recommendation on corneal shields from any organization that considers cosmetic and reconstructive surgery of the eyelid part of their repertoire (ABFPRS, ABPS, etc.). I think that it is important to understand that use of corneal shields also carries risk and will not eliminate potential corneal problems. In my training and practice, I have seen technically excellent Occuloplastic Surgeons, Plastic Surgeons, and Facial Plastic Surgeons opt to use corneal shields and avoid using corneal shields. For example, when performing a transconjunctival Blepharoplasty, the suspended conjuctival flap combined with adequate corneal lubrication is the defacto corneal shield. In fact, use of a hard plastic or metal shield can often interfere with the process of the procedure; the same can be said of a subciliary Blepharoplasty. Therefore, in my opinion, "globe safety" during a procedure (pertaining to the eye or anywhere on the face) is a process that has a number of factors including adequate lubrication, taping of the eyelids (when possible), careful technique by the Surgeon, assistants, and Anesthesia personnel, and when applicable, use of corneal protectors. I have seen corneal injuries with and without corneal protectors, and I would caution anyone against considering their use the primary factor in "globe safety".
Low profile scleral and corneal protectors are routine and are a wise choice for all Facial Cosmetic Surgeons. I suppose those who drive without seat belts are just "asking" for it too!
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