Blepharectomy and Ocular Myasthenia Gravis: Indications and Risks

Blepharoplasty (eyelid surgery) in ocular myasthenia gravis (OMG) is high-risk and generally contraindicated unless specific criteria are met. OMG causes fatigable ptosis and diplopia; surgery can worsen both.

Why Contraindicated

• Ptosis vs. Dermatochalasis: OMG ptosis fluctuates (worse with fatigue). Removing skin (dermatochalasis correction) does not fix levator weakness and may unmask/worsen ptosis.
• Postoperative Diplopia: Altered eyelid mechanics + preexisting extraocular muscle weakness → new/worse diplopia.
• Poor Wound Healing: Corticosteroids/immunosuppressants (common in MG) impair healing.
• Myasthenic Crisis Risk: Surgical stress, anesthesia, medications (neuromuscular blockers, certain antibiotics) can precipitate crisis.

When Surgery May Be Considered (Strict Criteria)

• Stable, well-controlled MG (on stable immunosuppression, no crisis ≥1 year).
• Significant dermatochalasis causing visual field loss (documented by perimetry).
• Minimal ptosis variability (consistent measurements).
• Normal extraocular motility (no diplopia).
• Multidisciplinary clearance: neurologist, ophthalmologist, anesthesiologist.
• Staged approach: conservative skin excision, no levator advancement.
• Postop: ICU monitoring, avoid nephro/neuromuscular toxins, resume pyridostigmine ASAP.

Alternative for Ptosis

• Ptosis crutch (glasses attachment).
• Müller's muscle-conjunctival resection (if good phenylephrine test).
• Frontalis sling (if levator function poor).

Blepharoplasty in OMG is not routine. Shared decision-making with full risk disclosure is mandatory.