Is young Asian blepharoplasty surgery actually a feminizing procedure?

A recent study from Korea looked at the incidence of eyelid asymmetry in a large pool of young (20-49yrs, mean 33.1yrs)Korean men (273) and women (321) and found some interesting patterns emerge. (None of the volunteers had a history of eyelid trauma or surgery.) Regarding eyelid creases (”double eyelid” vs “single eyelid”), they found that men were significantly more likely to have the single eyelid configuration than women, 66% vs 43%. One tenth of their volunteers(10.3% men and 11.5% women), possessed only one crease. Surprisingly, this unilateral crease was over twice as likely to occur in the left eyelid (7.4%) than the right (3.5%). This pattern of left sided dominance for crease formation was also reported in Japanese infants by Ishikawa. The Korean study also found that the palpebral fissure heights (vertical height between the upper and lower lids of the open eye) were significantly larger for the right eyes than the left in both men and women, and that women had significantly larger fissure heights than men. The opposite was true for horizontal fissure widths, with the left side being wider in both men and women, with men’s being significantly wider than women’s.

What was most interesting to me was that a taller vertical fissure height, narrower horizontal fissure width and a double eyelid configuration was more likely to be found naturally in Korean females than males. Although it is not discussed in this study, I believe that the data might actually explain the perceived “beautifying” result of Asian blepharoplasty surgery in Korean women. Asian blepharoplasty is not a Westernizing surgery, but more of a feminizing procedure. This also explains why some men seek the procedure to make them appear more “friendly”, and perhaps less masculine. These results also highlight the horizontal fissure width as an under appreciated feature for aesthetic eyelid reconstruction.

Not a Pressure Dependent Glaucoma in Young Myopic Chinese Males

Myopia has been found to be associated with an increased prevalence and progression (OHT to POAG) (POAG progression) of glaucomatous optic neuropathy. The Blue Mountain Eye Study revealed that patients with moderate to high myopia (equal or greater than -3.00 Diopters) were over 3 times more likely to have visual field loss and optic disc cupping that was characteristic of glaucoma. Although intra-ocular pressure (IOP) was found to be on average slightly higher in myopes (0.5mmHg) this was not statistically significant.

The Beijing Eye Study similarly revealed that Chinese high myopes (greater than -6.00 Diopters) were over 7 times more likely to have glaucomatous appearing visual field loss and optic discs (compared to emmetropes -0.5 to +2Diopters). In this study, IOP was not found to be associated with myopia. Importantly, neither of these two studies however looked at progression.

There seemed to be clues that myopia associated glaucomatous optic neuropathy was pressure independent.

The Malmo Eye Survey done in Sweden showed that the association between myopia and glaucoma was greatest at low IOP and is perhaps a form of Normal Tension Glaucoma (NTG).

The big question is: “What is the target pressure for these high myopes who present with a glaucomatous appearing optic neuropathy?“

The answer seems to depend on whether or not you are Chinese!

In the Collaborative NTG Study Group, Asians with NTG were discovered to have a very low rate of progression compared with Caucasians and Blacks. The refractive differences between the racial groups was not discussed in this study.

In a recent publication from San Francisco, ophthalmologists discovered an interesting pattern of stability within a specific demographic subset of their glaucoma suspect patients. These 16 patients were young Chinese males, most with myopia and tilted optic discs, and were followed without progression over an average of 7 years. It is believed that they may have developed this glaucomatous appearing visual field loss during the growth phase of their myopia. After the end of this axial growth, their risk of further progression would therefore be expected to be low.

We must remain cautious however in assuming that these patterns are similar in other Asian populations. A study done of a Japanese population over 10 years ago showed that severe myopia (greater or equal to -4.00 Diopters) was associated with a higher risk (1.5 OR) of progressive field loss.

Myopia and associated eye problems:

High myopia can be defined as near sightedness requiring stronger than -6.00 Diopters of prescription glasses to see clearly at distance. Most people with high myopia develop the condition as a result of excessive eye growth during their teens and early twenties (axial myopia). Why young Asians are more likely to have this excessive growth is a long discussion and is still being researched. What is alarming however is that besides the obvious need to wear thicker glasses, there are more serious long term ramifications for our eyes, including a higher incidence of cataracts, retinal detachments, macular thinning, retinal degenerations and optic nerve damage.

What is the optic nerve and optic disc and how does the disc become tilted?

The optic nerve can be thought of as the cable that connects the the eye to the brain. The optic disc is the 1.5mm opening where the nerves of the eye exit to the optic nerve, and can be seen by the ophthalmologist from the inside of the eye by looking through the pupil. Ophthalmologists evaluate the optic disc appearance and thickness of the nerve fiber layer to assess for damage to the optic nerve, such as that caused by glaucoma. Tilted optic discs can be found in high myopes, or near sighted people with glasses prescriptions greater that -6.00 Diopters. The optic nerve normally exits the eye at a slight angle, but in eyes that are especially long, it is as if the nerve is exiting from the side of the eye. When looking at the optic disc from the perspective of the pupil, the disc appears tilted.

Are “double-eyelids” inherited genetically?

The configuration of the lid crease, or the presence of a “double-eyelid”, is influenced by many factors. Many of these factors are inherited from your parents. Naturally, being Asian is a complete package of inherited genes. Which subgroup of Asian genes that makes you can make all the difference in your eye lid crease formation. For example, in Japan and Korea, it is estimated that 80% of adults are naturally of the “single-eyelid” configuration, whereas for the Chinese population, prevalence is closer to 50:50.

The appearance of the eyelid crease is influenced by many structures deep to the surface of the skin, all of which come from your parents. From deep at the level of the skull, the shape of the lateral orbital rim relative to the medial orbital rim determines the angle and width of the eyelids. The more anterior the lateral orbital rim (as in Asians), the sharper the angle of the outer corner of the open eye. The more posterior the lateral orbital rim (as in African Americans or Caucasians) the more rounded the shape of the outer canthus.

The height of the nasal bridge exerts vectored forces on the medial eyelid skin. In most people this bridge rises in early childhood and pulls the medial canthal skin towards the nose. Many children each year are brought in to see their pediatric ophthalmologist for crossing of the eyes. Quite often they are normal, and have what is called pseudo-esotropia. In most children growth of the nasal bridge needs to “catch-up” with the “excess” medial canthal skin. In many Asians however this bridge never further elevates even into adulthood. In these Asians there is inevitably a more prominent epicanthal fold which must be addressed if they choose to under-go “double-eyelid” surgery. It is my impression that this flatter nose configuration could be inherited as a single autosomal dominant gene, where half of the children might inherit it and half do not.

There are of course other tissue layers that significantly differ in patients with and without a “double-eyelid”. A fibrous band of tissue called the tarsus, creates the firm and straight edge of your eyelid margin and can be seen when you pull down your lower lid or flip your upper eyelid inside out. The height of the tarsus averages over 10mm in the upper eyelid in most non-Asians. In Asians however, the upper lid tarsus is slightly shorter averaging closer to 8mm. It is also indirectly from the upper edge of the tarsus where fine fibrous attachments (from the levator aponeurosis) penetrate the overlying orbicularis muscles to form a connection to the eyelid skin. A microstructure analysis of Chinese eyelids has found that these fibers are significantly stronger in patients born with the “double-eyelid” configuration than in patients who either gradually developed the crease or those who have the single eyelid configuration.

In Asians there is an additional layer of pretaral fat that lies below the orbicularis muscle with a lower insertion of the orbital septum, as well as a thicker layer of skin. This makes the pre-tarsal Asian eyelid significantly thicker than in non-Asians. (This thicker eyelid is believed to have evolved for the colder Northern Asian populations, to shield the eyes from cold, wind and glare off of snow.) It is the relative length and strength of the attachments between the skin to tarsus vs. the thickness of the surrounding eyelid tissues that ultimately determines whether on not a crease will form. This also explains why sometimes morning eyelid puffiness can induce a temporary crease which goes away later on in the day.

The bottom line is that the Asian lid crease formation is most certainly inherited, but precisely how is somewhat complicated. That said, I believe that the cumulative inherited features of the periocular anatomy of non-Asians will have a “dominant” effect on the formation of the “double-eyelid”. For parents planning to have Hapa children I would “bet-the-farm” on your child having the “double-eyelid” at birth.

One last observation is the similarity between the periocular anatomy of Asians and the Bushmen in Africa. Is this the result of a similar environmental pressures to protect the eyes in two distict populations or is there data in The Genographic Project that can show a more recent genetic link?

The Genographic Project

Last night I went to hear Dr Spencer Wells speak at Benaroya Hall. He is the leading geneticist and director of The National Geographic Genographic Project. If you have not yet heard of his project, it is quite fascinating. By collecting DNA samples from every corner of the Earth, he is creating a very detailed family tree that reveals how every one of us is related. His data has shown that we were all related to each other through a common ancestor only 2000 generations ago. Last night, he gave an update on the data that he and his colleagues have collected so far over the past 2 years. One important theme he stressed was how the migration pattern of DNA responded to climatic change. He showed several slides of how the earth appeared over the past 50,000 years, showing how the African deserts as well as Asian coast lines were significantly affected by the 20,000 yr cycle of the Earth’s axial shift. He also showed how this time line corresponded to the time when our human ancestral “Adam” and “Eve” first migrated out of Africa. Another interesting story was how a Hungarian woman who participated by supplying her DNA, complained that her lineage analysis must have been incorrect because it showed that she was from Asia. That led him to further analyze all the Hungarians in the data pool which confirmed the early Asian origins of at least 5% of the Hungarian population.

Although analysis is currently limited to only the Y and mitochondrial DNA, perhaps migration patters will be sufficient to help explain some of the interesting patterns of disease incidence found in some populations but not others.  For example, the Inuit Eskimos and ethnic Chinese share a high incidence of angle closure glaucoma, where as the Japanese population does not.  An early separation of the Japanese population from the ethnic Chinese might explain this.  This information might help clinicians to better asses risk for diseases that might be more common in certain populations but that we do not have a specific genetic test for yet.  Especially for patients who are Hapa or of mixed ancestry, this type of individualized ethnic background data could help patients at least receive more optimized preventative medicine.

Angle Closure Glaucoma

When you last saw your ophthalmologist (EyeMD) or optometrist (OD), did he or she examine your eyes to rule out angle closure glaucoma?

Asians, particularly South Asians, ethnic Chinese and the Inuit Eskimos have been found to have a significantly higher incidence of a certain form of rapidly progressive and blinding glaucoma. In Caucasian and the African American population, the incidence is approximately 0.5%. In some Asian populations however, angle closure glaucoma is found as high as 3%, with 14% of the population having anatomically narrow angles. (Bourne RR 2003). Interestingly there is a significant amount of diversity among the Asian populations. A study of a Japanese population found incidence rates more comparable to those of non-Asian populations. (Iwase A et al) For those high risk Asian populations, this condition is their leading cause of blindness (Foster PJ 2000). More importantly, if detected early, this blindness is essentially preventable with a laser procedure.

Why are some Asians so much more likely to develop this type of eye problem?

The primary reason is because for these populations, the eye anatomy is significantly different. Although these differences can seem extremely small, measured in microns, comparative data over the past few years is beginning to reveal how clinically significant these differences can be. As with any difference, there is always a plus and a minus side.

Iris differences are an extremely interesting topic and probably deserve a separate discussion elsewhere. Beyond the most visible and obvious, iris color, the iris thickness, surface area and texture are also significantly different in Asians. Iris recognition technologies will soon (if not already) be able to categorize us all by racial ethnic background. As would be expected, for any differences in anatomy, there will be medically significant differences that result in varying disease incidence. As it turns out, some of the differences in the iris shape and positioning also greatly influence the likelihood of developing a certain type of glaucoma.

First I must explain which eye structures are involved in glaucoma. Where the iris meets the inside surface of the eyeball or globe, an angle is formed between the cornea and the shelf of the iris. In the corner of this angle is a drain that lies just anterior to the edge of the iris, called the trabecular meshwork. This is the primary outlet for the liquid aqueous humor, which is produced behind the iris, to slowly drain out of the eye and back into the blood stream. If this trabecular meshwork becomes clogged or malfunctions and the aqueous humor builds up, the eye pressure increases like much like pumping up a basketball. The higher the eye pressure, the smaller the pressure gradient for blood flow into the eye. Over time, high eye pressures essentially choke the retinal cells to death, resulting in an irreversible blindness called glaucoma.

Different types of glaucoma are typically classified by how the trabecular meshwork is inhibited. In open angle glaucoma, which causes nearly all the glaucoma in Caucasians and African Americans, the iris tissues are not occluding the trabecular meshwork. For them, the cause is usually with the trabecular meshwork itself. In angle closure, however, the trabecular meshwork is covered by the base of the iris. If the angle closes suddenly, the eye pressure can rise rapidly characteristically causing severe pain, nausea and “smoky” vision. More often however, the angle closes slowly in a creeping fashion or following recurrent milder episodes.

Asians are predisposed to this more severe form of glaucoma partly because their irises attach to the inside surface of the sclera (white fibrous framework tissue that shapes the globe) slightly more anteriorly, closer towards the cornea. This results in an anatomically narrower angle with a less exposured trabecular meshwork to begin with. This is particularly true of hyperopes, people who are far-sighted and wear magnifying type glasses. These hyperopic eyes are shorter than normal or near sighted eyes, and therefore have some extra crowding of their iris/cornea angles.

How do you know if your angles are narrow?

Gonioscopy is the close examination of the iris angle under a microscope using a contact lens. The angle structures are not visible without this contact lens. Although this procedure is still the gold standard to detect narrow or occludable angles, new machines are being developed for screening purposes. Using high frequency ultrasound, or UBM (Ultrasound Bio Microscopy), a cross sectional image can be taken through the eye to reveal narrow or suspicious angles. The advantage to this machine is that it will allow visualization through the iris to see what might be causing the iris to be pushed forward. A newer machine called the Visante-OCT (Carl Zeiss Meditec), can image the anterior structures without requiring any contact with the eye surface and performs as well as UBM. The comfort and simplicity of use will likely make this the easiest screening tool for patients. As it can be performed in the dark, when angle structures are likely to be most crowded, OCT may prove to be a better method of screening than gonioscopic examination.

If you do have narrow angles, what can be done to prevent angle closure glaucoma?

A laser treatment, called Laser Peripheral Iridotomy (LPI) has been used to prevent angle closure from occurring in at risk patients by preventing pupillary block. Pupillary block is usually only a transient event when the pupil opening forms a valve like seal against the lens. This typically occurs during transition into a darker room where the pupil achieves mid-dilation. When this happens, the aqueous fluid which is produced behind the iris builds up volume and pushes the lens-iris complex forward, shallowing the entire anterior chamber. In narrow angled patients, this can suddenly block off the trabecular meshwork inducing acute angle closure.

By lasering a hole through the iris, a safety passage is created that allows the aqueous to flow through the iris during these normally harmless transient episodes of pupillary block. This prevents pressure built up that moves the entire iris forward pushing an anatomically narrow patient into closure.

Unfortunately, persistently narrow angles after a LPI appears to be significantly more common than we once believed, occurring in perhaps 20% (updated 4/07) to 50% of Chinese. Sometimes this is due to scar tissue keeping the angles held closed, but in many the angle remains narrow be caused by what has been called plateau iris configuration.

In plateau iris, there is an anatomical tendency for the iris base to be pushed forward by the ciliary body, but leaving the rest of the iris flat. Narrowing of the angle in plateau iris is not the result of pupillary block, so LPI will have little or no effect. For these patients, another laser procedure called Iridoplasty can be performed to create a ring of scars on the peripheral iris surface that “pulls” the iris base away from the trabecular meshwork. This procedure is not without complications, and unfortunately it does not relieve the anterior positioning of the iris processes that have been pushed forward by a thick lens. Following earlier reports that standard cataract surgery with implantation of an artificial lens deepened the angle by about 10 degrees and deepened the anterior chamber by as much as 850um, some have proposed that cataract surgery be performed prophylacticly rather than LPI and iridoplasty, as removal of the lens relieves both pupillary block and the anterior positioning of the ciliary body. I believe narrow angles will become a new indication for cataract surgery, especially for the aging Asian population.

What is an Eye MD?

From the American Academy of Ophthalmology:

An Eye M.D. is an ophthalmologist - a medical doctor who provides the full spectrum of eye and vision care. From eyeglasses to contact lenses, to medication and surgery, your Eye M.D. will help you keep your sight for life.

The American Academy of Ophthalmology describes the difference in training between ophthalmologists and optometrists, as well as other eye care providers on their web site.

Hapa

“What are you?” is the question asked of each person in Kip Fulbecks beautiful portrait book “part asian - 100% hapa“. It is a collection of uniformly photographed faces all looking into the camera in frontal gaze.  With my understanding of how we all perceive average as attractive, this book opened a new door for me. These were the faces of my own future generations.

Hapa and their parents are typically well aware that the combination of two very different racial-ethnic gene pools creates a mix that appears quite new and noticeably different from either parent.  As with any big change, there is always a positive as well as a negative aspect to these differences.  Most Hapa probably appreciate by now that other people seem to find them interestingly attractive.  Why is this so? 

It has to do with the mental process by which we all perceive and recognize a face.  A lot of research has gone into facial recognition as well as into understanding what we all consider beautiful, but the bottom line is this:  average faces appear more attractive than faces with more extreme features.  (More on this topic read here and here) 

In very diverse cities where everone is exposured to a wide spectrum of extreme facial features, the averaged mental template of a face represents one that lies somewhere between an Asian, Caucasian, African American and Hispanic person.  Faces that most resemble this average face are perceived as the most attractive.  Perhaps you might have noticed that there are significantly more Hapa celebrities in the media than there are in the general population of the United States(1.9%).

Being more attractive is certainly a plus.  What could possibly be a minus?

As a physician trained in Ohio and Louisiana, I must admit that I’ve treated few Hapa patients. One patient however stands out in my memory. She was part Vietnamese and part Caucasian, in her late 20’s, and complained of a chronic conjunctivitis that just wouldn’t go away with any kind of eye drops. She said it had started a few years ago and had already seen 3 other eye doctors who couldn’t find a cause. Her face appeared about midway between a German’s and a Vietnamese. She had relatively wide eyes with visible lid creases (double-eyelid). On closer examination at the slit lamp, I found something I’d never seen before. Although her eyelashes were dark and fairly straight like an Asian’s, they seemed slightly longer and exited the skin a little closer to the lid margin. At her lateral canthi on both sides, I found her problem. The most lateral 3-4 eyelashes from her upper lid were growing straight under her lateral lower eyelid, rubbing on her bulbar conjunctiva! This is called trichiasis.

  

The straight lash cilia (eyelashes) of her mother evolved in harmony with the other structures of the flatter featured Asian periorbita.  When made to grow on a wider and more contoured lid and skull structure of a more Caucasian like lateral orbital rim, unanticipated problems might present themselves.  The shape and function of her parents’ eyelids and tissues have benefitted from over 10,000 years of divergent evolution.  For my Hapa patient however, she expressed a random assortment of the features from both of her parents, resulting in intermediate structures that are neither here nor there.  This new configuration is in some ways like a new mutation that has yet to be influenced by the last 10,000 years of evolution.

I believe that her eye problem represents just the tip of the iceberg of a new generation of medical problems about to surface in this next generation of medicine.

Refractive Surgery

LASIK and PRK, the most commonly performed refractive procedures, are great for a lot of people, but there are many newer procedures now that can help minimize the risk of complications. With regards to Asian patients in particular, there is fairly recent evidence that Asians are much more likely to develop dry eye problems than non-Asians after LASIK, even after factoring out the amount of myopia. It has also been shown that the corneal nerves do not seem to completely grow back to normal like we had once believed. Even if the nerves appear to grow back morphologically, their function is ultimately what must return to equilibrium.

What causes post LASIK dry eyes?

A sophisticated feed-back-loop links the corneal epithelium, stroma, nerves to the central nervous system, then back out through the facial nerve to the lacrimal gland and orbicularis fibers. When corneal nerves are damaged, the feed-back-loop is disrupted. As the sensation of dryness deminishes, the blink rates decrease and tear secretion is slowed.

LASIK induced neurotrophic epitheliopathy (LINE) initially described by Wilson, was found to correlate with blink rate. Because LASIK first requires the creation of a large corneal flap, a larger area of sub epithelial corneal nerves are damaged in LASIK than by PRK. This is believed to be part of the reason why PRK seems to have fewer problems with post operative dry eyes.

For patients especially at risk of developing dry eyes, nasal flap orientation was believed to help save a portion of the nerves (that enter the cornea from 3 and 9 o’clock) and reduce the incidence of dry eye symptoms. A recent prospective randomized clinical trial however found no significant difference in symptoms between the superior or nasal flapped patients, but did however find a correlation with the amount of preoperative myopia and ablative depth.

With this evidence, I believe that it is the deeper stromal corneal nerves that play a greater role in the development of dry eyes. Because LASIK begins ablation deeper within the stroma than PRK, this may also help explain why PRK patients suffer less from dry eyes. I will further discuss how each of the three different types of corneal nerves (cold sensors, nociceptors, and propriocepts) impact the blink rate on my Dry Eye page.

Phakic IOL’s

For people with higher degrees of myopia that require deeper ablations there are now more options that avoid corneal ablation. Phakic intra ocular lenses (P-IOLs) have been used for years in Europe but are starting to be used here in the US. Two types of lenses are currently FDA approved for use in myopic eyes. The Verisyse PIOL by Ophtec BV was approved 9/2004 for implantation infront of the iris. The Visian ICL (Implantable Collamer Lens) by STAAR surgical was approved 12/2005 for implantation behind the iris.

For highly myopic Asian patients who are particularly at risk of dry eyes, I believe this will become the best choice refractive procedure.

Botulinum Toxin

Before jumping into getting botulinum toxin for the face, we really need to understand what we’re messing with.  I believe that the facial muscles and their connection to the brain, are the most highly evolved of all human bodily functions.  Firstly, what are the functions of the face?Most practitioners of botulinum toxin approach the face as two halves.  The upper half that is more forgiving, and the lower half that requires more caution.  Mobility of the lower face is essential to clear speech and enunciation. The muscles around the mouth and cheeks keep a tight seal at the lips to prevent drooling and are major components in the process of eating and drinking.

What is under appreciated however is that there are similarly important autonomic functions for the upper half of the face as well.  The eyelids move to protect our precious eyes from the environment, and automatically adjust their positions in response to what the eyes sense.  In dry and windy conditions, the orbicularis muscles tighten the aperture to minimize mucus membrane exposure. Sudden bursts of light similarly cause an immediate reflexive closing of the eyes to shield the retina from photo-toxicity.  Although complications from botulinum toxin injections in the upper face are relatively mild and rare, they nearly always involve eyes.

I believe however that the most sophisticated function of our faces is in communication. The face is the single most visible portion of our bodies, especially for this Seattle’s winter.  As an ophthalmologist, I am acutely aware that our eyes are our windows to the world. But as an oculoplastic surgeon, I have learned to appreciate how the muscles and skin around the eyes serve as the window into our souls. They are the focus of gaze during conversations with other people and even animals. We have evolved to “read” eyes and are surprisingly good at it. Everyone knows that the difference between a true smile and a fake one is in the eyes.

Botulim toxin injections were first approved by the FDA for human use by an ophthalmologist who injected the substance into the muscles on the eyes to straighten strabismus.  It was first approved for cosmetic purposes in the muscles around the eyes at the glabellar folds. Since then use of the chemical has spread to all areas of the face. In Shanghai, we even injected it into the masseter muscles of the jaw for aesthetically pronounced jowls. The technique however to apply it to the facial muscles truly requires some appreciation for not just the anatomy, but also for how they work in dynamic facial expression. Although commonly used to reduce the visibility of dynamic wrinkles, there is growing use of botulinum toxin to aesthetically alter the balance of facial expressions. By minimizing the contractions of typically negative expressing muscles, the face at rest develops a more positive and confident pose. The downside however is that when the “negative” expressions are attempted, the balance can be some what abnormal appearing. Unfortunately there is give and take in everything, even for botulinum toxin.

I have helped to write a review article with my Cleveland Clinic colleague and mentor regarding the medical and aesthetic uses for botulinum toxin injections around the eyes and face. Further details to come upon publication.

Dry Eyes

Dry Eye Syndrome (DES) or Dysfunctional Tear Syndrome (DTS) is extremely common, and until recently, had been a fairly poorly understood problem. Treatment was only for symptomatic relief and patients continued to suffer.A new paradigm is surfacing with our new understanding of the different mechanisms and pathways involved in keeping the ocular surface and tear film stable.

The Yin and Yang of Dry Eyes

The ocular surface quality is vital to our vision, and has adapted to combat the environment despite being the most exposed of all our mucus membranes. A delicate balance maintains appropriate exposure, tear film constitution, as well as inflammatory mediators, for each given environment. As in all homeostatic systems, the tear surface maintenance system requires a sensory as well as action arm.

I will discuss in greater detail how this impacts refractive surgery soon. I am also a co-author on an article reviewing the use of punctal plugs in a soon to be published article in Comprehensive Ophthalmology Update.