What is the recommended preoperative evaluation for an elderly female patient with a past medical history (PMH) of well-controlled hyperlipidemia (HLD) and hypertension (HTN) undergoing elective lower eyelid blepharoplasty?

Preoperative Evaluation for Elective Lower Eyelid Blepharoplasty

For this elderly female with well-controlled hypertension and hyperlipidemia undergoing elective lower eyelid blepharoplasty (a low-risk procedure), routine preoperative laboratory testing and formal medical clearance are not indicated. 1, 2

Blood Pressure Management

Proceed with surgery if blood pressure is <180/110 mmHg on the day of surgery. 3, 2

• Stage 1 or 2 hypertension (systolic <180 mmHg and diastolic <110 mmHg) is not an independent risk factor for perioperative cardiovascular complications in low-risk surgery 3
• Continue all chronic antihypertensive medications throughout the perioperative period 3, 2
• If blood pressure is ≥180/110 mmHg in the preoperative clinic setting (not day-of-surgery), refer to primary care for blood pressure optimization before scheduling surgery 3
• Day-of-surgery readings may be elevated due to situational anxiety ("white coat hypertension"), so refer to the patient's baseline ambulatory blood pressure rather than relying solely on day-of-surgery measurements 2

Required Preoperative Assessment

The operating surgeon should perform the preoperative assessment to establish rapport and formulate the surgical plan. 1

Ocular-Specific Evaluation:

• Assess eyelid laxity, position abnormalities (ectropion, entropion), and lagophthalmos 3, 4
• Evaluate for concurrent upper-eyelid blepharoptosis, which can induce corneal astigmatism 1
• Screen for dry eye disease, as visually significant dry eye may require pretreatment 1
• Document baseline visual acuity and intraocular pressure 3
• Examine for malar descent, tear trough deformity, pseudoherniated fat, and skin texture changes 4

Medical History Review:

• Confirm current antihypertensive and lipid-lowering medications and dosages 3
• Document any history of bleeding disorders or anticoagulant use 5, 6
• Assess ability to cooperate and position for surgery 1
• Identify barriers to communication (language, hearing impairment) 1

Physical Examination:

• External examination of skin for rosacea, telangiectasia, or other dermatologic conditions 3
• Slit-lamp biomicroscopy if available, focusing on eyelid margins, conjunctiva, and cornea 3
• Fundoscopic examination may provide data on chronicity of hypertension 3

Laboratory Testing

No routine preoperative laboratory testing is required. 1, 2

• Directed testing may be considered only if specific medical problems are identified during history and physical examination that would alter perioperative management 1
• Three randomized trials failed to show reduction in systemic or ocular complications with routine preoperative testing for low-risk ophthalmic procedures 2

When to Consider Medical Evaluation

Formal preoperative medical evaluation by primary care is generally not needed for well-controlled chronic conditions. 1

Consider referral to primary care only if the patient has:

• Poorly controlled hypertension (≥180/110 mmHg in clinic setting) 3, 2
• Recent myocardial infarction or unstable angina 1
• Poorly controlled congestive heart failure 1
• Poorly controlled diabetes 1
• Chronic obstructive pulmonary disease requiring optimization 1

Common Pitfalls to Avoid

• Do not delay surgery for blood pressure <180/110 mmHg on day of surgery, as this leads to unnecessary patient inconvenience, increased costs, and no demonstrated improvement in outcomes 3, 2
• Do not abruptly discontinue beta blockers or clonidine perioperatively, as withdrawal can cause sympathetic discharge and acute hypertension 2
• Do not order routine ECG, chest X-ray, or metabolic panels for this low-risk procedure in a patient with well-controlled chronic conditions 1, 2
• Ensure thorough preoperative assessment to identify conditions like ptosis, brow ptosis, or eyelid malposition that may need concurrent correction for optimal functional and aesthetic results 5, 6