Permanent blindness can occur after many aesthetic procedures by different mechanisms. This article will discuss various ways that visual loss can happen after aesthetic surgery, so providers offering these services can take precautions to avoid this dire complication.
Blindness post cosmetic surgery is most likely to occur after periorbital procedures, such as a blepharoplasty. There are many vessels in the orbit that course through the fat that is removed during an upper or lower lid blepharoplasty. If these vessels are not adequately cauterized before release back into the orbit, an orbital hemorrhage can ensue, leading to and expanding hematoma, interruption of ocular perfusion and visual loss from compressive optic neuropathy. An orbital hemorrhage is likely to occur within the first 12 to 24 hours and the patient will likely present with pain, proptosis and ecchymosis.
Careful measures must be taken to avoid an orbital hemorrhage. Pre-operatively, discontinue blood thinners. Intraoperatively, meticulous hemostasis is paramount. Avoid excessive traction on the orbital fat and control the blood pressure with the anesthetist. Post-operatively, use ice packs to constrict the blood vessels. Instruct the patient to avoid heaving lifting, bending or straining.
If an orbital hemorrhage should occur, start by opening the wound. Intraocular pressure lowering drugs can be used. It will sometimes be necessary to perform a lateral canthotomy with inferior cantholysis to all expansion of the orbital volume. In rare cases, a surgical exploration or orbital decompression is necessary.
Besides orbital hemorrhage, a patient can suffer from permanent visual loss if care is not taken to preserve the function of the eyelids, which is to protect the globe, and especially the cornea. If patients suffer from lagophthalmos post-operatively, this may lead to exposure keratopathy, ulceration, and in worst-case scenario, corneal perforation.
During blepharoplasty surgery, measurements should be taken in order to preserve enough skin and tissue to maintain eyelid closure. Smooth forceps can be used to gently pinch up the excess skin until the eyelashes are just everted. Leaving at least 10 – 13 mm of skin between the lower brow hairs and the upper incision will help to avoid brow ptosis and lagophthalmos.
If patients do end up with lagophthalmos post-operatively, sometimes massage can help loosen and soften the skin on the upper lids. A lateral canthal tendon plication in the face of dehiscence can help improve closure. In some cases a skin graft is required.
For eyelid surgery in general, care must be taken to direct needles and sharp instruments away from the globe. There have been reports of accidental penetration of the globe by needles during local anesthetic injections. This can lead to permanent damage to the endothelial cells from the solution injected.
As far as non-ocular aesthetic surgery, direct damage to ocular structures can happen during intubation, from instrumentation and from cleaning liquids. Pressure on the globe can lead to interruption of ocular perfusion and ischemic optic neuropathy. The risk of ischemic optic neuropathy is higher with prolonged prone position (duration > 6 hours), excessive blood loss (> 1L), long procedure duration, co-morbid conditions, intraoperative hypotension and excessive volume resuscitation.