Upper and lower lid blepharoplasty both have their own set of indications and may be undertaken during the same procedure or at different times. However, those with brow ptosis, asymmetry with unilateral anophthalmic socket or other known ocular pathology associated with a visual field defect, such as glaucoma, optic neuropathy, diabetic retinopathy (eg, previous panretinal photocoagulation) or other neurological problems were excluded. Provided by the Springer Nature SharedIt content-sharing initiative, Eye (Eye) The dissection was then carried inferiorly to expose the anterior surface through the tarsal plate. Can you tell us [], Copyright 2023. The number of points missed before blepharoplasty ranged from 2 to 35 (median 17, mean 17.44, SD 8.72), and the height of superior visual field in this group ranged from 0 to 48 (median 24, mean 20.26, SD 12.2). However, we acknowledge that although our modified visual field is a good assessment tool for ptosis, it has limitations. Question 1: How many isopters do I need to plot on the Goldman perimeter to be able to report CPT code 92083 (Visual field examination, unilateral or bilateral, with interpretation and report; extended examination (eg, Goldmann visual fields with at least 3 isopters plotted and static determination within the central 30, or quantitative, automated threshold perimetry, Octopus program G-1, 32 or 42, Humphrey visual field analyzer full threshold programs 30-2, 24-2, or 30/60-2))? Ophthalmic Plast Reconstr Surg 1987; 3: 121127. Acquired senile eyelid ptosis, also known as involutional ptosis, is a common condition in the elderly population. 0000047814 00000 n In total, a maximum of 48 will be tested in the superior visual field. Finally, maximal levator function shows how high the patient can lift his or her lid voluntarily. We agree with Meyer6 that more study on this topic is needed so that third party insurers and Primary Care Trusts ( PCT) can develop uniform specific criteria for functional blepharoptosis, and offer this work as a move towards that goal. The etiology of blepharoptosis can be classified based on whether it is true ptosis or pseudoptosis, and whether it is congenital or acquired. But ophthalmologists use the threshold exam (92083) when they suspect something that causes a slow, progressive dimming of peripheral vision, like glaucoma. The anesthetic consisted of a 2:1 mixture of 2% lidocaine with epinephrine and 0.75% marcaine. 0000011634 00000 n Grid A (above the x axis) has the following co-ordinates: Grid B (below the x axis) has the following co-ordinates: Further information about the setting-up of the test can be obtained via e-mail at [email protected]. Some people with glaucoma do not notice any problems with their vision, but the visual field test shows that peripheral vision is being lost. It is not appropriate to use code 92083 for documentation prior to blepharoplasty. lower lid blepharoplasty; 7. After requesting quantified visual field tests, the patient returns with a black and white printout with numbers (eg, Humphrey fields) or coloured lines on a sheet (eg, Goldmann fields). Some payers require a code from the H40.001-H40.009 (. ) For those who had blepharoplasty alone, 90.9% recorded an improvement in points seen in the modified visual field test and 80.6% had improvement in visual field height. It also looks like they are partnered with Keeler. Most insurance companies will cover blepharoplasty if 3 requirements are met. 0000006942 00000 n Perform formal visual field testing twicefirst with the eyelids in a natural position and then with the skin held off (elevated from) the eyelids. Hemostasis was established here and throughout the procedure with a Bovie Cautery and cotton-tipped applicators. A HVF-teszt szmos lehetsges szembetegsg, pldul a glaukma diagnosztizlsban hatkony. Overall, she is doing great and continues to be pleased with her surgical result. Correlation of the vision-related functional impairment associated with blepharoptosis and the impact of blepharoptosis surgery. 0000003005 00000 n Book an Appointment Find A Doctor Locations During this test, lights of varying intensities appear in different parts of the visual field while the patient's eye is focused on a certain spot. The routine Humphrey 24-2 only tests a limited superior 24 field, which is far less than that used by most people for normal activities of daily living. The validity of this test was evidenced by the high sensitivity and positive predictive value, which were 98.8 and 96.6%, respectively. American Medical Association: Chicago, 1990, pp 153164. SEE RELATED: Ptosis: Droopy eyelid signs and symptoms. Find out When Technical, Professional Components Apply. Automated visual field testing (taped and untaped) is required. If these errors are not too bad, the general gist of the field can be deduced, especially if compared to prior fields. Hint: Always be sure to differentiate 92082 from 92083. One eye remains covered while the other eye is to stay focused on a central fixation point. Or, the visual field could just be patchy all over. We have defined ptosis as a margin reflex distance (MRD) of 2mm or less.7. The Humphrey perimeter tests light intensities over 5 orders of magnitudes, from 10,000 apostilbs (asb) to 0.1 asb. A droopy eyebrow is referred to as brow ptosis and often coexists with dermatochalasis and ptosis. In total, 97 patients with 194 eyes were included in the study. A relative defect identifies a stimulus not seen at 6dB above the reference threshold, but seen at an intensity of 0dB. Understand Isopters Question 4: What diagnosis codes would we use for a VF test to rule out the possibility of glaucoma if the results revealed no definitive diagnosis? The patient was then sedated heavily by the anesthesiologist. We have chosen the Humphrey visual field analyzer as it is available in most ophthalmic units in the United Kingdom and therefore has minimal impact on the cost of assessing patients once referred. Additionally, the insertion of the septum is very different in Asian lids than in Caucasian lids and recognizing this is critical for a good surgical outcome. False negative: The user did not see a stimulus which was brighter than one they saw earlier in the same test. Advancing clinical efficiency in glaucoma. 0000062377 00000 n There is lack of consensus among Primary Health Care Trusts (PCTs) and health insurers on how to reimburse ptosis surgery and upper lid blepharoplasty, as these procedures can be regarded as cosmetic. Visual field testing is a measurement of all of the area a person can see while they are facing forward with their eyes fixed on an object in front of them. For blepharoplasty, it is for photographs demonstrating dermatochalasis and a visual field showing a defect to at least 30 above the visual axis and which is significantly improved or restored when the lid is taped.2 Other insurer's guidance reads blepharoplasty will be commissioned for eyelid ptosis and/or excess skin of the upper eyelid, which causes obscured vision.4. Answer 4: Because the results of the VFs were negative they did not confirm glaucoma or any condition you should report the signs and symptoms that prompted the exam, link the diagnosis code(s) to the applicable VF code, and include any additional observations from the VFs in the office notes. They were trigger happy. If results show a significant amount of eyesight is affected by ptosis, corrective surgery (blepharoplasty) becomes medically necessary rather than cosmetic. This exposed the underlying orbital septum. Maximal Levator Function: 12mm O.D., 12mm O.S. Differentiate Unilateral, Bilateral Rules. The patient was marked with a sterile tip marking pen on the upper lids. Answer 4: Because the results of the VFs were negative they did not confirm glaucoma or any condition you should report the signs and symptoms that prompted the exam, link the diagnosis code(s) to the applicable VF code, and include any additional observations from the VFs in the office notes. It indicates how close the upper lid is to the visual axis. The patient complained of constant headaches, bloodshot eyes and tearing. A mild to moderate amount of excess eyelid skin results in a tired, sad appearance. The key to choosing the correct VF code is in the code descriptors themselves. CIGNA Government Services: Visual field testing at both rest and with lid elevation (taped or manually retracted). The otolaryngologist prescribed eardrops that were compounded at a local pharmacy. The key to choosing the correct VF code is in the code descriptors themselves. Patients who had surgery for ptosis or dermatochalasis between January 2006 and December 2009 were prospectively invited to perform a modified visual field test pre- and post-operatively. In contrast to dermatochalasis, ptosis refers to an abnormal position of the eyelid margin. 0000011455 00000 n The patient was undergoing treatment for several months by her otolaryngologist for a blocked salivatory gland on the right side. volume25,pages 365369 (2011)Cite this article. Example 1: A patient presents with high intraocular pressure, a sign of glaucoma, and the eye care specialist decides to perform a visual field (VF) examination. Here, we switch patients over to an HVF 10-2 to better follow their progression. The two most important to look at are the Grayscale Map and the Pattern Deviation. The inferior field test serves as a reference, but is not used in the analysis. Unfortunately, this is end stage glaucoma. Reliable tests have below 33% false negatives. Im certainly also not an expert in perimetry but have worked with Rarebit, another HVF alternative, in the past. Example 1: A patient presents with high intraocular pressure, a sign of glaucoma, and the eye care specialist decides to perform a visual field (VF) examination. Small R, Sebates NR, Burrows D . Droopy lids often prematurely age a person as well as impair vision. Medicaid: Eligibility and Vision Benefits. The patient must be aware that lubrication may be needed temporarily after the blepharoplasty until the lids loosen a bit. 0000043036 00000 n Biomicroscopy revealed Grade 2+/3 bulbar hypermia and follicular hypertrophy, droopy lids (dermatochalasis O.U. Does anyone know how to differentiate a functional defect from a cosmetic one? Article The Humphrey uses fixed points of light which are shown at different intensity levels. Ophthalmology 1999; 106: 17051712. Margin Reflex Distance: 0.5mm O.D., 0.0mm O.S. 6 of visual space 41 Humphrey 30-2 test pattern 42 Humphrey 30-1 test pattern 43. This means that the payment that has been established for the service is for one or two eyes, and you should only submit a bill for one service even if the optometrist performed it on both eyes. PubMedGoogle Scholar. These types of inattention errors will usually register as high fixation losses, false positives, or false negatives. To introduce a modified visual field designed to assess the functional disability associated with ptosis and dermatochalasis and to demonstrate the effectiveness of surgery in improving the visual field. As a very, very general guideline, you can look at the density / size of the field defect, the pattern standard deviation, and the mean deviation (MD) to see if it is worsening. The reason these look like arcs and come off the blind spot is that they represent the loss of bundles of nerves as they come out of the optic nerve head. Investigation of automated perimetry in the evaluation of patients for upper lid blepharoplasty. Small RG . American Journal of Ophthalmology. Here, well only talk about the Humphrey visual field perimeter, which is used for 99% of visual field tests. A binary statistical calculation was performed to identify the relationship between the presence of a visual field defect and ptosis. Visual field testing (92081-92083, Visual field examination) is a big component of what many eye care practices do this test is used on patients from glaucoma suspects to blepharoplasty candidates. H40.013 ( bilateral) 0 Modified visual field test for ptosis surgery (Leicester Peripheral Field Test). Her medical history was also positive for diabetes mellitus, long-term heterotopic ossification joint pain (>45 years). Central 30-2 threshold visual field testing showed markedly improved visual fields with eyelids taped, which underscored the medical necessity of blepharoplasty in this patient. Question 4: What diagnosis codes would we use for a VF test to rule out the possibility of glaucoma if the results revealed no definitive diagnosis? A minimum 12 degree OR 30 percent loss of upper field of vision with upper lid skin and/ or upper lid margin in repose and elevated (by taping of the lid) to demonstrate potential Best-corrected visual acuity measured 20/20 O.D. As this test is a screening test rather than a threshold test, it may not be able to identify a visual field defect associated with more subtle degrees of ptosis.11 Therefore, the few patients complaining of a reduced visual field who have no measured defect could be offered ancillary tests, such as photographs, a threshold visual field test or a quality of life questionnaire. 0000007407 00000 n 295 49 Curious as to what a ptosis test involves? The time taken to perform the test pre-operatively was 2.206.47min, with a median of 4.18min (mean 4.04min, SD 0.58min). However, the vast majority of patients have normal eyelids when they are born and develop droopy eyelids in adulthood, a condition known as acquired ptosis. Learn more about the different tests administered when diagnosing ptosis and what happens after youve been diagnosed. Thirty six were male and 61 were female. American Hospital Association ("AHA"), Reader Question: Medicare Covers Some Glaucoma Screenings for Asymptomatic Patients, Part B Errors: CMS: Ophthalmologists Among Specialties With Highest Error Rates for Office Visits. Although it is hard to be dictatic about the extent of the defect before patients are considered eligible for surgery, we propose that any three contiguous points missed up to 48 should be considered a significant defect and that those patients will benefit from intervention. 0000040668 00000 n Your eye doctor will be able to evaluate the position of your eyelids during the exam and recommend the best course of action to help resolve your ptosis. H40.10X1 ( mild stage) What are your thoughts on the VR based perimeters vs HFA (or as a complement)? Example 2: The eye care physician performs visual fields for a patient who presents with high intraocular pressure, open angle, and the VFs confirm the presence of small scotomas in the areas of the VF related to glaucoma. Ninety five eyes had aponeurotic repair with or without blepharoplasty and 77 eyes had blepharoplasty alone. American Society of Plastic Surgeons. Three questions: Does this chart tell me the actual degree of blindness in the visual field? In cases of decreased visual acuity, a size V (64 mm2) target is used to garner useful information. This was performed without complication. 1998;125:819-829. A defect in the visual field is defined as absolute when the stimulus is not being seen at 0dB. However, a recent review of 141 medical records of patients with dermatochalasis found that nearly 87% of patients with keratoconjunctivitis sicca (KCS) had subjective improvement of symptoms after upper lid (UL) blepharoplasty.3 This suggests that UL blepharoplasty may be a useful element in the treatment of patients with both dermatochalasis and dry eye. In: Engelberg AL (ed). You should avoid reporting multiple units of the code if you address both eyes, and you also should avoid appending modifier 50 (Bilateral procedure) or the LT (Left side) and RT (Right side) modifiers. At less than 5mm of wetting, the patient has clinically significant dry eye. For every interpretable, reliable visual field you get, you will also get another in which the patient thinks he should be scanning the dome for lights the whole time, is poorly positioned, is exhausted from waiting in your clinic for hours, or is too elderly and arthritic to push the button in time. The software automatically varies the intensity of the points of lights at each location to determine the threshold the intensity of light where the patient can see it 50% of the time. In the second category, patients complain of visual difficulties related to heavy upper eyelid tissue. 0000041939 00000 n 0000043262 00000 n NYU Langone Health explains that in order to determine how much your eyelid is drooping, the marginal reflex distance must be measured. Question 3: How should our optometry practice code a VF ordered by an ophthalmologist outside the practice, which will be sent back to the ordering doctor for interpretation? In total, 80 out of 95 eyes (84.2%) improved, 5 eyes (5.2%) were unchanged and 10 eyes (10.5%) had deterioration in the number of points seen (Figures 2 and 3). Its never appropriate to plot additional isopters just to boost your code level. This is awesome thanks a lot for putting this together Ben! . ascertaining that the patients brow and forehead are relaxed. Eyeglass temples: How do you know if they're the right length? H\n0y Involvement of the lower eyelids can be quite dramatic; this protruding tissue is known as malar bags or festoons. Visual field testing is Comparison of frequency doubling perimetry with humphrey visual field analysis in a glaucoma practice. 0000003158 00000 n Visual field testing is one way your ophthalmologist measures how much vision you have in either eye, and how much vision loss may have occurred over time. Brow and lid ptosis are other important criteria for the preoperative evaluation. It is recommended that visual field testing demonstrates a minimum of at least 20 degrees or 30% loss of upper field vision with upper lid skin and/or upper lid margin in repose and elevated (by taping of the lid) to Here, we switch patients over to an HVF 10-2 to better follow their progression, Confirm its the right patient with name and date of birth, Look at the GHT, mean deviation, VFI, and pattern standard deviation. In the majority of cases of involutional ptosis (senile or age-related), patients have good levator function, allowing for levator resection procedures. The ordering ophthalmologist should report their work by appending modifier 26 (Professional component) to the code. Approximately 2cc to 3cc were used in each upper lid. Ophthal Plast Reconstr Surg 1997; 13: 7780. Twenty healthy individuals (40 eyes) with an average age of 51 were also tested; only three eyes in three separate patients showed just three contiguous absolute missed points. This is supported by Small et al's study showing that 97% of patients with a marginal reflex distance of 2mm or less had upper visual field restriction of 30 or less.7 In the United States, our American colleagues use Goldmann or automated static perimetry, which is either a 10dB threshold (Humphrey analyzer) or a 7dB threshold (Octopus analyzer).8 Although the latter is accurate, it is time consuming and subject to a huge learning curve with high false positives and negatives. H40.10X0 (Unspecified open-angle glaucoma, stage unspecified) Blepharoplasty can remove excess skin in cases of dermatochalasis, as seen here. While this is done in all comprehensive eye exams, its especially important when testing for ptosis because it can indicate nerve weakness. Other sizes and colors are used for patients with late disease or retinal disease. Change in points seen after ptosis surgeries +/ blepharoplasty vs blepharoplasty only. A determination of how much vision is affected is done by checking the peripheral visual field with an instrument called the Humphrey Visual Field (HVF) Analyzer. The test involves having the patient place their head on a chin rest within the opening of the large bowl-like structure of the field analyzer. An eye lift may be performed for cosmetic reasons, to improve a patients appearance, or for functional reasons, to improve a patients peripheral vision. Although there is a great deal of overlap, patients who desire blepharoplasty generally fall into two broad categories. Funding or reimbursement of ptosis surgery and blepharoplasty within the healthcare setting has long been a contentious issue.1 Various arbitrary guidelines have been issued by medical insurers and Primary Health Care Trusts (PCTs).2, 3, 4, 5, 6 The lack of consistency and clarity of these guidelines has created a significant amount of confusion, causing anxiety for patients and raising questions of a postcode lottery. Patients typically return to work several days following the operation. 0000004914 00000 n It is important to note that the relationship between adnexal structures and upper eyelid function is delicate, but critical. Its normal for your eye doctor to test your pupillary reaction when diagnosing ptosis. The upper lid margin should fall 1mm to 2mm below the superior limbus, while the lower lid margin should rest at the level of the lower limbus. I recently saw an ad from Olleyes (https://olleyes.com/) seems comfortable. Dermatochalasis is a condition in which there is excess upper eyelid skin. You should always document medical necessity for the level of visual field testing that is ordered. An advanced amount of excess eyelid skin can block parts of a patients peripheral vision, especially at the top and sides. and JavaScript. This means that the payment that has been established for the service is for one or two eyes, and you should only submit a bill for one service even if the optometrist performed it on both eyes. Blepharoplasty corrects these problems and also removes puffiness and bags from under the eyes that can create a worn, tired look. For example, if the eye care specialist plots only two isopters on the Goldmann perimeter, CPT would call that intermediate, based on its description of 92082. Individuals with severe ptosis will have difficulty detecting lights in upper regions of their peripheral vision due to an obstructing eyelid. [1] The results of the analyser identify the type of vision defect. Patients were seated 33cm from the target, without corrective lenses, and the centre of fixation is shifted 15 inferiorly to allow for maximum superior field-testing. Google Scholar. She was sedated, but awake during the entire procedure because the surgeon needed to ask her to look in different positions of gaze to check the symmetry of the lid margins between the right and left eye. 0000048252 00000 n H40.10X3 ( severe stage) After a bedside visual field examination with waggling fingers and even a red hatpin, you decide that there is an abnormality. The otolaryngologist prescribed eardrops that were compounded at a local pharmacy. Question 3: How should our optometry practice code a VF ordered by an ophthalmologist outside the practice, which will be sent back to the ordering doctor for interpretation? A neuro-ophthalmologist will be able to test further and potentially treat the underlying condition and, in turn, resolve your ptosis symptoms. H40.019 ( unspecified eye) 0000003892 00000 n To prove that blepharoplasty is medically necessary, you have to perform two sets of visual fields per patient -- but many Medicare carriers will pay only for one set. Blepharoplasty is one of the top five plastic surgical procedures performed in the United States for both men and women, and it is becoming more and more common every year. Seventy eyes (90.9%) had an improvement in points seen post blepharoplasty while 3 (3.5%) were unchanged and 4 (5.2%) saw up to five points fewer than pre-op (Figure 3). Central and peripheral vision is tested by using visual field tests. 0000018300 00000 n If this is the case, your eye doctor will likely refer you to an oculoplastic surgeon who specializes in cosmetic surgery of the eyelids. Use this order to interpret your Humphrey visual field every time: Great help in understanding the VF pattern. We therefore designed a modified visual field test specifically to assess ptosis and dermatochalasis. Along with the eyelids themselves, your eye doctor will check the effectiveness of the levator muscles: the muscles responsible for lifting your eyelids and keeping them open. Many people have eyelid surgery for cosmetic reasons, but it is more commonly done for reconstructive or functional reasons. A #15 blade was used to incise the skin in the previously demarcated area. A functional blepharoplasty removes the excess skin that obscures your field of vision. The goal is to determine how much of an individuals vision is inhibited by the droopy eyelid. Append modifier TC (Technical component) to the code to report your work. The patient was brought to the operating room and placed on the operating table in the supine position. https://www.plasticsurgery.org/cosmetic-procedures/eyelid-surgery. The fissure height can range from 7mm to 12mm, with an average height of 10mm. Patients also must be advised to avoid vigorous exercise for one week following surgery. The slightly down gaze position also counteracts the involuntary frontalis over action in some ptotic patients and therefore reduces this bias. Patients enrolled in the study underwent a complete oculoplastic evaluation prior to and at 4-6 weeks after their procedure. Case Report: Solving Functional and Cosmetic Complaints. Change in visual field height post-ptosis surgeries with and without blepharoplasty vs blepharoplasty only. This was then carried through the exposed levator aponeurosis several millimeters superiorly. If there is traumatic or neurologic dysfunction, then simply shortening the levator aponeurosis will not fix the problem. The most common early to mid stage glaucomatous field. O.U. This is significantly faster than the custom static full-threshold 60 test strategy as suggested by Meyer et al11 and has advantages for patients with ptosis as they are often elderly and may have other health co morbidities causing difficulty with prolonged concentration. Humphrey automated static visual field testing were both effective in documenting ptosis-associated visual field loss. We aim to use this new assessment tool to demonstrate the functional disability associated with these conditions and the effectiveness of surgery in improving the superior visual field. If you plotted three isopters, however, that would be an extended examination, which would qualify for 92083. startxref We therefore believe this will be a very useful initial test to prove a functional deficit in upper lid malposition for the consideration of reimbursement after surgery. Title: Blepharoplasty Author: CGS Subject: J15 Created Date: 7/18/2014 10:36:28 AM for 10 days. 0000002655 00000 n We are grateful for the help of Mr Bernie Higgins from Portsmouth University for his statistical advice. It is essential to differentiate dermatochalasis from the less common blepharochalasis, which is the expansion of the orbital septum and preseptal muscles secondary to repeated angioneurotic edema and is seen less commonly in younger patients. A deficient time is considered any TFBUT of less than 10 seconds. Generally, we order this for neuro patients. What does a 1% VFI percentage mean? The Humphrey visual field test measures the entire area of peripheral vision that can be seen while the eye is focused on a central point. Patients who were referred for surgery were requested to perform a modified Humphrey visual field test. (average IPF is 10mm). Here, well only talk about the Humphrey visual field perimeter, which is used for 99% of visual field tests. 343 0 obj <>stream Pontszm: 5/5 ( 49 szavazat). Arthur G. Fernandes, Adriana Berezovsky, Solange R. Salomo, Quintin R. Richardson, Rajesh S. Kumar, Jeremy D. Keenan, Takashi Ono, Yosai Mori, Kazunori Miyata, Jason Bacharach, Wendy W. Lee, Thomas F. Freddo, Raoul Kanav Khanna, Marta Dorvault, Sophie Arsene, Praveen J. Patel, David H. Steel, on behalf of the MeMo Study Group, Yating Tang, Dongjin Qian, Xiangjia Zhu, Eye Arch Ophthalmol 1990; 108: 16851686. 0000002698 00000 n This would likely be seen in patients with idiopathic intracranial hypertension (aka pseudotumor cerebri). Thorough Pre-op Testing. No jargon, very nicely put and clearly explained. If you plotted three isopters, however, that would be an extended examination, which would qualify for 92083. If you simply cannot get a visual field due to patient cooperation or attention, you can order an optic nerve OCT to follow the optic nerve head objectively (though thinning does not always necessarily correlate to field loss). At this point, many patients still have great central vision of 20/20 to 20/50, but peripheral vision is nearly gone. Blepharoplasty refers to the aesthetic or functional surgical manipulation of the upper or lower eyelids. Rule of thumb: An intermediate test is one of the screening tests that you would use if you suspected neurological damage. In 20 eyes (21%) the number of points seen improved by more than 20 points. Commissioning policy cosmetic plastic surgery procedures 2008. Leitlinien der Kommission fr Okuloplastik (Orbita + Dakryologie) der OG, Brow ptosis: are we measuring the right thing? Although Goldmann test is sensitive and comprehensive, it is also time consuming, operator dependent and less specific, as some patients can predict the next point. O.U. The Visual System. The Humphrey Field Analyzer central 30-2 threshold test (HFA 30-2) and central 24-2 threshold test (HFA 24-2) are tests that can meet these criteria. It is an age corrected screening test with a three zone strategy (Figure 1). Prolapsing fat pads were clamped over with a hemostat and excised. Our site is most compatible with Chrome, Firefox, or Safari. All of the visual field testing codes have in their description the phrase unilateral or bilateral. Internet Explorer). By Autumn Sprabary; reviewed by Gary Heiting, OD. Macular diseases including plaquenil toxicity exams also need 10-2. Following surgery, patients should be advised to apply ice to the eyelids for 15 minutes per hour for the first 72 hours.
