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CASE REPORT
Year : 2019  |  Volume : 26  |  Issue : 2  |  Page : 120-122  

Treatment of persistent chemosis after upper lid blepharoplasty by hand-held fine-tip cautery: Report of a case


Ocular Tissue Engineering Research Center; Ophthalmic Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran

Date of Web Publication26-Aug-2019

Correspondence Address:
Dr. Abbas Bagheri
Labbafinejad Medical Center, Boostan 9 Street, Pasdaran Avenue, Tehran 16666
Iran
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/meajo.MEAJO_218_18

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   Abstract 


Persistent chemosis is an uncommon complication of blepharoplasty, and its treatment is challenging. Herein, the authors report a case of persistent chemosis after a cosmetic upper lid blepharoplasty and present a simple, noninvasive, inexpensive, and successful method of treatment that uses hand-held cautery.

Keywords: Blepharoplasty, cautery, persistent chemosis


How to cite this article:
Bagheri A, Javadi M, Shahraki K. Treatment of persistent chemosis after upper lid blepharoplasty by hand-held fine-tip cautery: Report of a case. Middle East Afr J Ophthalmol 2019;26:120-2

How to cite this URL:
Bagheri A, Javadi M, Shahraki K. Treatment of persistent chemosis after upper lid blepharoplasty by hand-held fine-tip cautery: Report of a case. Middle East Afr J Ophthalmol [serial online] 2019 [cited 2019 Sep 17];26:120-2. Available from: http://www.meajo.org/text.asp?2019/26/2/120/265367




   Introduction Top


Acute chemosis after cosmetic or therapeutic eyelid surgeries, especially with a lower lid blepharoplasty, is not uncommon. It can cause a burning sensation, lacrimation, foreign body sensation, visual impairments, and an undesirable appearance.[1] In contrast, chronic chemosis, which is chemosis persisting >2–3 months, is uncommon and does not respond to conservative treatments such as lubricants, decongestants, steroids, and pressure patching.[2],[3]

Underlying causes of this condition are inflammation, venous congestion, and lymphatic drainage abnormalities in the patient's lids, orbit, and conjunctiva. These problems are known to happen with allergies, infections, trauma, surgeries, radiotherapy, and autoimmune diseases.[1],[2] Chemosis has also been commonly reported to occur after special periocular surgeries, such as canthoplasty, canthopexy, and lower lid blepharoplasty, especially after using extensive cryotherapy or cautery because of the lymphatic drainage disruptions.[1],[2],[3],[4] Some of the local factors leading to persistent chemosis related to changes in the conjunctiva and eyelids due to aging include conjunctivochalasis, laxity, lagophthalmos, and ocular surface abnormalities.[1],[2],[3],[4]

Chemosis occurring after blepharoplasty often appears quickly after surgery and is usually self-limiting. It is most often seen after a lower lid blepharoplasty, and in most case reports, it is unilateral. Only a small fraction of cases become persistent and need treatment.[1],[2],[3],[4],[5],[6],[7],[8],[9]

Different surgical interventions have been introduced to treat this illness, including various methods of conjunctivoplasty and subconjunctival injection of sclerosing materials that produce adhesions between conjunctiva and its underlying tissues.[1],[2],[3],[4],[5],[6],[7],[8],[9]

Herein, the authors present a case of persistent chemosis after an upper lid blepharoplasty that was successfully treated with a simple, inexpensive, and noninvasive outpatient procedure of mild, low-temperature cauterization.


   Case Report Top


A 27-year-old female patient was referred to us because of persistent eye redness and irritation in addition to a gelatinous bulge that had formed over the right eye. She had a history of a cosmetic upper lid blepharoplasty in both the eyes performed 4 months previously. She did not have a history of tobacco, alcohol, or drug use. Her blepharoplasty was reported to have been performed under local anesthesia by crease incision, the septum was opened, central and nasal fats were excised, but orbicularis excision was minimal. They did not report any complication, and sutures were removed 10 days after surgery. Chemosis of the right eye started the day after surgery and did not respond to conservative treatments, which included the use of topical steroids, decongestants, lubricants, and >1 week of pressure patching.

In her vision examination, visual acuity was 10/10 in both the eyes. In the external examination, linear skin scars were seen in both the eyes over the upper lid creases. A diffuse chemosis was seen in the inferior conjunctiva of the right eye from the 2 o'clock to 9 o'clock position, which was associated with a moderate injection in that area [Figure 1]a and [Figure 1]b. Intraocular pressure and the anterior and posterior segment examinations of both the eyes were normal.
Figure 1: Clinical photography; (a) chemosis over the inferior and nasal conjunctiva of the right eye in addition to scars of upper lid blepharoplasty before treatment, (b) conjunctival injection over the chemotic area before treatment, (c) improved chemosis 2 weeks after the second procedure, (d) improved conjunctival injection 2 weeks after the second procedure

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Local anesthesia was applied using a tetracaine 0.5% ophthalmic solution (Sinadarou, Tehran, Iran), and the conjunctiva was grasped using smooth forceps [Figure 2]a. Then, cauterization was performed on the involved conjunctiva using a fine-tip, low-temperature, hand-held cautery (Kirwan Surgical Products LIC. Marshfield, Massachusetts 02050, USA) [Figure 2]b. This cauterization was continued until the conjunctiva was burned, changed to a whitish color, and started to shrink. Afterward, a topical chloramphenicol 0.5% solution (Sinadarou, Tehran, Iran) was prescribed. However, topical steroids were not prescribed to help induce subconjunctival scar formation secondary to the induced inflammation. This procedure was repeated 4 weeks later with the same protocol because of partial response in the first session. Chemosis and conjunctival injection gradually but completely disappeared over a 2-week period after the second procedure and did not recur during a 1-year follow-up period [Figure 1]c and [Figure 1]d.
Figure 2: Instruments used for the treatment; (a) smooth forceps used for grasping the conjunctiva meanwhile cauterization, (b) hand-held fine-tip low-temperature cautery used in this study

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   Discussion Top


Although transient chemosis is a common complication that occurs after eyelid surgeries, persistent chemosis is an uncommon finding and is often attributed to a traumatic surgery that disrupts the lymphatic drainage system or that produces local congestion and thereby increases local inflammatory reactions. These reactions, in turn, increase conjunctival exposure and produce a vicious cycle that cannot be treated with conservative measures.[1],[2],[3],[4]

There is no gold standard treatment for persistent chemosis after eyelid surgeries. Enzer and Shorr [4] used a modified Snellen suture in the lower fornices to improve chemosis. Thakker et al.[3] used regional conjunctivoplasty and repair with absorbable sutures in the chemotic area. Jones et al.[6] introduced a technique of snip conjunctivoplasty without a need to repair to extract the trapped serum under the conjunctiva. Cheng and Lu [5] introduced perilimbal needle manipulation to produce a subconjunctival hemorrhage and inflammation, which induced a subconjunctival scar to relieve the chemosis. Moesen and Mombaerts [7] injected a tetracycline 2% solution as a sclerosing agent under the conjunctiva to induce adhesions between the conjunctiva and the underlying tissue. Woo and Choi [9] implemented a method most similar to ours in which they performed a high-frequency radiowave electrosurgery to treat persistent chemosis after blepharoplasty. In addition, Youm et al.[10] used this electrosurgery method to treat conjunctivochalasis, but this method was more invasive than ours because they used fine-needle electrodes to transfer heat beneath the conjunctiva, while we did not invade the epithelium.

The previously mentioned methods sometimes had complications, such as a subconjunctival hemorrhage, and sometimes were not completely successful in eradication of the postblepharoplasty chemosis.[1],[2],[3],[4],[5],[6],[7],[8],[9] Moesen and Mombaerts [7] reported that the patient in their study experienced continuous burning after the injection of the subconjunctival tetracycline 2% solution for some days after the procedure. In our method, none of the above-mentioned complications were seen.

An interesting finding of our case was that the patient developed persistent chemosis after an upper lid blepharoplasty, while in most previous reports, it has developed after a lower lid blepharoplasty [1],[4],[5] or a four-lid blepharoplasty.[2],[3],[6],[7],[8] Another interesting finding was that although the blepharoplasty was performed bilaterally, this illness was only seen in the patient's right eye. This is a comparable finding to those in previous studies.[3],[6],[7] Woo and Choi [8] reported eleven cases, and only one case had bilateral persistent chemosis.

The technique of hand-held fine-tip cauterization is an inexpensive, simple, and fast outpatient method for the treatment of persistent chemosis after a blepharoplasty and produces minimal complications. It can safely be repeated if the response to the first session was not complete. The authors believe that this method causes shrinkage of the conjunctiva and produces adhesions to underlying tissues by vaporizing the collected serum beneath the conjunctiva. We suggest this technique to be evaluated in a larger series of patients.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
McCord CD, Kreymerman P, Nahai F, Walrath JD. Management of postblepharoplasty chemosis. Aesthet Surg J 2013;33:654-61.  Back to cited text no. 1
    
2.
Levine MR, Davies R, Ross J. Chemosis following blepharoplasty: An unusual complication. Ophthalmic Surg 1994;25:593-6.  Back to cited text no. 2
    
3.
Thakker MM, Tarbet KJ, Sires BS. Postoperative chemosis after cosmetic eyelid surgery: Surgical management with conjunctivoplasty. Arch Facial Plast Surg 2005;7:185-8.  Back to cited text no. 3
    
4.
Enzer YR, Shorr N. Medical and surgical management of chemosis after blepharoplasty. Ophthalmic Plast Reconstr Surg 1994;10:57-63.  Back to cited text no. 4
    
5.
Cheng JH, Lu DW. Perilimbal needle manipulation of conjunctival chemosis after cosmetic lower eyelid blepharoplasty. Ophthalmic Plast Reconstr Surg 2007;23:167-9.  Back to cited text no. 5
    
6.
Jones YJ, Georgescu D, McCann JD, Anderson RL. Snip conjunctivoplasty for postoperative conjunctival chemosis. Arch Facial Plast Surg 2010;12:103-5.  Back to cited text no. 6
    
7.
Moesen I, Mombaerts I. Subconjunctival injection of tetracycline 2% for chronic bulbar chemosis after transcutaneous four-eyelid blepharoplasty. Ophthalmic Plast Reconstr Surg 2008;24:219-20.  Back to cited text no. 7
    
8.
Woo KI, Choi CY. High-frequency radiowave electrosurgery for persistent conjunctival chemosis following cosmetic blepharoplasty. Plast Reconstr Surg 2014;133:1336-42.  Back to cited text no. 8
    
9.
Prischmann J, Sufyan A, Ting JY, Ruffin C, Perkins SW. Dry eye symptoms and chemosis following blepharoplasty: A 10-year retrospective review of 892 cases in a single-surgeon series. JAMA Facial Plast Surg 2013;15:39-46.  Back to cited text no. 9
    
10.
Youm DJ, Kim JM, Choi CY. Simple surgical approach with high-frequency radio-wave electrosurgery for conjunctivochalasis. Ophthalmology 2010;117:2129-33.  Back to cited text no. 10
    


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  [Figure 1], [Figure 2]



 

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