Is It Safe to Do a Lower Bleph on a Sjogren's Patient?

The most important question is how severe your dry eye problems are today. Further, your doctor will need to determine whether that will become more severe. Given the tendency of people with Sjogren's syndrome to develop dry eye, you will not be able to tolerate any lower eyelid malposition following a lower blepharoplasty. I recommend that you consult with an experienced oculoplastic surgeon who has performed ALOT of eyelid surgery on patients with Sjogren's to ensure that you minimize your risk or dry eye complications. I hope this information is helpful. 

       I am just not sure that any cosmetic improvement would be worth the risk.                                                                                                                                                       Kenneth Hughes, MD                                                                                                                                        Los Angeles, CA

Dry eye can definitely be exacerbated by eyelid surgery particularly the lower. Blepharoplasty can be performed but only with the advise and consent of your ophthalmologist.

Transconjunctival lower blepharoplasty does not alter the tear mechanism and/or the eyelid function and therefore it is safe in dry eye patients.  Transcutaneous lower blepharoplasty carries more risk of altering the eyelid contour and position which in effect can affect eye closure and worsen dry eyes. See an oculoplastic surgeon for evaluation.

A Schirmer's test measures tear production.  However, it is used clinically as an ancillary test.  Much more important is your clinical history which is determined by a very careful guided conversation your surgeon should have with you about dry eye symptoms and in the case of Sjogren's syndrome dry mouth and the nature of any systemic treatments you may need to manage this condition.  A drug history is also important because many drugs we take also have a bearing on tear production.  Specific information is also very important like your ability to tolerate contact lens and any history of refractive surgery.  A detailed physical examination is then performed looking at the blink, evidence of lid closure strength, Bell's phenomena which give us an idea of how well protected the corneal surface when the eyes are closed.  Using a slit lamp microscope, an instrument only used by ophthalmologists and oculoplastic surgeons, the eyelid margins are assessed for evidence of chronic lid margin inflammation, the quality of the physical tear film is studied.  The conjunctiva is then assessed for evidence of chronic inflammation.  Finally, the corneal surface is studies for evidence of active dry spots, old scars and thin spots, and microvascular ingrowth that are used to assess the overall heal of the corneal surface.  It is my opinion that this assessment needs to be performed by the surgeon him or herself.  No one else is really in a position to integrate this information.  Simple "clearance" by the ophthalmologist is not sufficient.  You need to see a surgeon who has to manage dry eye after eyelid surgery so they truly understand the potential impact of these surgeries.  This will be a fellowship trained oculoplastic surgeon.  Even the 6 to 8 weeks of swelling associated with transconjunctival blepharoplasty healing can have a profound impact on corneal heal for someone with significant Sjogren's syndrome.  For this reason, many individuals in this circumstance are advised not to have blephaorplasty but to consider treatments like under eye fillers as a nonsurgical alternative.

A new procedure without any incision in front or behind the lid called lateral access recontouring may be a possibility in your case. The traditional incision is definitely not a good choice and I would be hesitant to remove any fat from a transconjuntival incision as well. The new procedure involves a small incision lateral to the lower eyelid with simple lifting and repositioning of the muscle which keeps it's full innervation and actually improves the support of the lower lid. The central lid is never entered. It has not been done in Sjogrens patients so my comment is purely theoretical, but it is based on solid principles and personal experience with the procedure in over 80 cases which included a few patients with dry eyes which were not made worse. The procedure is not yet on the internet and will be published in the coming year as it has already been accepted.

 A very conservative lower blepharoplasty with a trans-conjunctival approach to the lower lid fat removal and a very conservative  pinch of skin on the outside of the lower lids  in someone who has mild Sjogren's disease would probably be acceptable. Severe dry  eyes are not candidate for lower blepharoplasty. Best to document the degree of dryness prior to proceeding with a lower blepharoplasty.

A few things to consider:


How severe are the dry eyes?

What kind of blepharoplasty is being done?

What is the tone or support for the lower lid?

Is an upper eyelid procedure being done at the same time?


A patient without dry eyes and with normal eyelid support who is having a limited skin and fat excision is less likely to have problems than someone with severe dry eyes, poor lid support and a more extensive procedure. 

How much dry eye symptoms you are experiencing would determine the safety of eyelid surgery in a Sjogren's patient. For some patients with really dry eyes, any eyelid procedure may exacerbate the symptoms. For others with less severity a conservative transconjunctival fat removal and lower eyelid skin pinch may be safely done without significantly worsening the amount of dryness. This is a matter of judgment more than something that can be measured by a test. 

If you have Sjogren's Syndrome, rejuvenating eyelid surgery can result in problematic (even vision damaging) DRY EYES. But typically, this is seen with upper eyelid blepharoplasty, not lower eyelids. If you have a conservative amount of fat removed from your lower eyelids and a very conservative amount of skin tightening, you should be fine- but I'd definitely go ahead and request your surgeon consider scheduling you for a Schirmer's Test to check the amount of tearing you have presently. If your eyes are too dry even before surgery, consider tear trough injections with Restylane and perhaps a lower lid chemical peel, and then call it a day. You can read more about dry eyes and how to avoid it after blepharoplasty in my book, Facial Plastic Surgery Complications, published by Thieme Medical Publishers.