Lacrimal Secretory Evaluation

I have not found any of the lacrimal secretory tests, including basic tear secretion with Schirmer's tests, helpful in determining whether the patients will fare favorably after surgery performed by myself or elsewhere. Contrary to tradirional teachings,1'2 I do not routinely include these tests in my practice. As we all know, patients who do very well after surgery performed with the highest of precision and care may have lacrimal secretory tests (including the Schirmer's test) that indicate severe dryness, whereas patients who have demonstrated completely normal secretory tests and who have experienced unroward resulrs after surgery can be dramatically symptomatic. In lieu of this, I rely heavily on an accurate history more than formal secretory function tests. The patient's tear function is discussed (during the history and recommendations portion of the consultation and subsequent preoperative evaluations) with regard to their requirement for the use of artificial tears prior to surgery, their tolerance of contact lenses, the general symptoms with reading etc., which I find are a much greater aid in determining whether surgery is likely to impact on lacrimal function and symptomatology related to exposure.
Again, female patients, especially middle-aged (nearing menopause), may be at particular risk for tipping the balance from being entirely asymptomatic to mild to moderately (and even severely) symptomatic after eyelid surgery (due to reduced lacrimal secretion that is hormonally mediated) as are those individuals who have had refractive surgery and must be reminded and warned of this. At times this particular subset of patients are actually of greater risk then the more elderly who have either adapted or compensated for the (preoperative) onset of dry eye symptoms. The possibility of intolerability to future contact lens use (especially in secondary blepha-roplasty patients) should also be discussed, although I have found this less of a problem in my practice. The questions and issues regarding potential dryness after surgery, however, should be discussed with every patient so that should these symptoms occur (which are typically transient) the patient is less alarmed and realizes that the effects are usually temporary. Finally, aesthetic blepharoplasty rarely improves dry eye symptoms and patients should be made aware (especially pre-menopausal women) that the likely possibility of temporary and the rare incidence of worsening of dry eye symptoms exist even when surgery is satisfactory from an aesthetic standpoint.