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. They do this by securing the muscles in your forehead (frontalis), and having you look upward and downward. 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. A 75-year-old white female, who had been under my care for three years, presented for an emergency visit with a chief complaint of red eye.. Do eye exercises work for droopy eyelids. In screening fields, you are testing whether the retina is on or off, while in threshold testing you are testing how dim a light you can perceive? Curious as to what a ptosis test involves? Meanwhile, various custom Humphrey field tests so far reported in the literature, which test more points superiorly have limitations such as not testing points in inferior field,9, 10 which may induce bias, and threshold static testing,8, 11 which is time consuming. Dermatochalasis is corrected by removal of excess skin through a procedure known as upper eyelid blepharoplasty, commonly known as an eye lift. Following surgery, patients should be advised to apply ice to the eyelids for 15 minutes per hour for the first 72 hours. Hemostasis was established here and throughout the procedure with a Bovie Cautery and cotton-tipped applicators. 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. Normal wetting is 10mm to 30mm in five minutes in patients less than 50 years of age. Brow and lid ptosis are other important criteria for the preoperative evaluation. O.U. Its an automated, static perimeter (unlike Goldmann kinetic perimetry which requires a human operator, and uses a moving target). The modified visual field test was jointly designed by two of our authors, AM and JB. Rule of thumb: An intermediate test is one of the screening tests that you would use if you suspected neurological damage. Down gaze ptosis. Often, this will confirm significant visual field loss. Brow Ptosis vs. Dermatochalasis For the 10 eyes who saw fewer points after ptosis surgery, 7 had deterioration by only 5 points or less compared with before the operation (Figure 3). Humphrey Field Analyzer - HFA II- i Series Advanced analysis with comprehensive connectivity options Validated by more than 30 years of research, design and clinical experience, the Humphrey Field Analyzer (HFA) is the accepted standard of care in glaucoma diagnosis and management. An eye lift may be performed for cosmetic reasons, to improve a patients appearance, or for functional reasons, to improve a patients peripheral vision. The rest of this article will explain how to interpret these. 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. It was also being presented in Midlands Ophthalmological Society in September 2010. It has been named as Leicester Peripheral Field Test. 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. 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. for 10 days. Commissioning policy cosmetic plastic surgery procedures 2008. 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))? Visual field testing can detect blind spots A visual field test can determine if you have blind spots (called scotoma) in your vision and where they are. The height of visual field before surgery ranged between 0 to 48 with a median of 12 (mean 18, SD 12.8). Great article, very helpful and educative. First, your eye doctor will observe your eyes in different levels of lighting to check for anisocoria (different sized pupils). Visual field test looks for visual field defects and their location. All of the visual field testing codes have in their description the phrase unilateral or bilateral.. A binary statistical calculation was performed to identify the relationship between the presence of a visual field defect and ptosis. C=KHoI_!eXbxR;(/c& qOF|yOm0 .Pxc|8?d:1`g80C9@ @^b`o]_"moE&7)}# u If the eyelids begin sagging into the field of vision, a functional blepharoplasty may be required. 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 In this case, the appropriate ICD-10 diagnosis code is one of the following, depending on which eye is affected: Humphrey automated static visual field testing were both effective in documenting ptosis-associated visual field loss. We are also grateful for the help of Mr Jonathan Bhargava and Mrs Katya Tambe for their initial work on this project. 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. A mild to moderate amount of excess eyelid skin results in a tired, sad appearance. 0000049511 00000 n volume25,pages 365369 (2011)Cite this article. High Yield Knowledge for the Ophthalmology Trainee. 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. 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. The height of the defect is defined as the lowest point in degrees where there are three horizontal contiguous absolute defects. Visual Field Testing Demonstrate a significant loss of superior visual field and potential correction of the visual field by the proposed procedure(s). A HVF-teszt szmos lehetsges szembetegsg, pldul a glaukma diagnosztizlsban hatkony. Acquired senile ptosis is produced by the disinsertion of the levator aponeurosis and is characterized by a high or absent eyelid crease, thinning of the upper eyelid tissue and abnormal levator function.2 Blepharoplasty of the ptotic lid, without repair of the ptosis, may result in exaggeration of the drooping eyelid postoperatively. A visual field test can also help the doctor find out more about the part of the nervous . Imagine you are assessing a patient with visual difficulties or optic disc swelling. Ophthalmology 1999; 106: 17051712. 0000062377 00000 n The content on this site is for informational purposes only. Differentiate Unilateral, Bilateral Rules. hb```b``b`c` @1v5"n A functional blepharoplasty removes the excess skin that obscures your field of vision. Involvement of the lower eyelids can be quite dramatic; this protruding tissue is known as malar bags or festoons. hbb2``b``3 7? Cosmetic blepharoplasty. 0000047814 00000 n The significance of down gaze ptosis causing difficulty in reading and fine work has been emphasized in recent literature.9, 16, 17. 0000049870 00000 n American Medical Association. Contact an eye doctor if you need medical attention. This is sometimes called a Humphrey visual field test because the Humphrey Visual Field Analyzer is the most popular device used to perform this type of test. For the dry eye syndrome, I prescribed Systane Ultra Preservative-Free (Alcon) b.i.d. The visual field efficiency score? Diagnosing ptosis seems pretty straightforward. Its never appropriate to plot additional isopters just to boost your code level. 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. Post-operatively the height of the field ranged from 12 to 48 with an improved median of 36 (mean 37.87, SD 9.14). We therefore believe it to be a useful assessment tool providing evidence for reimbursement by medical insurers or PCT. The visual field test can help the doctor find early signs of diseases like glaucoma that damage vision gradually. Discussion of above reference. CPT code 92082: Visual field ex-amination, unilateral or bilateral, with interpretation and report; intermediate examination (e.g., at least 2 isopters on Goldmann perimeter, or semiquantita - tive, automated suprathreshold screen-ing program, Humphrey suprathreshold automatic diagnostic test, Octopus pro - gram 33). A deficient time is considered any TFBUT of less than 10 seconds. Proper management requires a meticulous preoperative analysis with special regard to brow position, lid crease and lid fold, levator function, tightness of the canthal ligaments, tarsal plate and orbital septum, because these factors will determine the type and extent of procedure. Answer 2: When deciding whether to bill for services unilaterally, per eye, or bilaterally, for both eyes, the first thing to do is read the code description in CPT. If visual field tests are performed, the tests should show loss of 2/3 or greater of a visual field in the upper or temporal areas documented by computerized visual field studies, with visual field restored by taping or holding up the upper lid. Answer 1: A common mistake ophthalmologists make is billing 92082 when they could legitimately report 92083. Article Rule of thumb: An intermediate test is one of the screening tests that you would use if you suspected neurological damage. 0000002851 00000 n Individuals with severe ptosis will have difficulty detecting lights in upper regions of their peripheral vision due to an obstructing eyelid. In the meantime, to ensure continued support, we are displaying the site without styles Visual field testing (92081-92083, Visual field [], Bust These Myths to Collect for IOL Power Calculations, Keep bilateral rules in mind as you navigate these coding situations. This was then carried through the exposed levator aponeurosis several millimeters superiorly. HVF targets come in sizes ranging from 0.25 mm2 to 64.00 mm2 represented by Roman numerals I through V. Typically, a size III stimulus (4 mm2) is used in patients with good visual acuity (usually at least 20/200 or better). The otolaryngologist prescribed eardrops that were compounded at a local pharmacy. H40.012 ( left eye) As the gold standard of perimetry, Humphrey Field Analyzer 3 (HFA3) is your trusted diagnostic partner. We present here a modified visual field test (Leicester Peripheral Field Test), which is valid, quick and easy to perform. Upper and lower lid blepharoplasty both have their own set of indications and may be undertaken during the same procedure or at different times. 0000049173 00000 n Small R, Sebates NR, Burrows D . H40.10X2 (moderate stage) Improvement in superior visual field test with tape compared to without. 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. 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. Here, well only talk about the Humphrey visual field perimeter, which is used for 99% of visual field tests. It indicates how close the upper lid is to the visual axis. At no time should patches be placed on the eyes. 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. In the United Kingdom, most centres use either Goldmann visual field or Humphrey 24-2 as is used for glaucomatous patients. 295 0 obj <> endobj In total, 84 out of 85 eyes with ptosis had a visual field defect, which lead to a sensitivity of 98.8%. It is an age corrected screening test with a three zone strategy (Figure 1). Thorough Pre-op Testing. This is sometimes called a Humphrey visual field test because the Humphrey Visual Field Analyzer is the most popular device used to perform this type of test. Cosmetic claims are not submitted to insurance . 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. These types of inattention errors will usually register as high fixation losses, false positives, or false negatives. Fifteen eyes (15.8%) had no improvement, whilst 3 eyes (3.1%) had a reduction (within 24) in visual field height post-ptosis surgery (Figure 4). Im curious to see how VR based perimetry is implemented in the coming years. Find out When Technical, Professional Components Apply. Risk of dry eye should be objectively measured by evaluating the patients tear film break-up time (TFBUT) and by performing a Schirmers tear test. This was tied with an adjustable suture. 0000006786 00000 n Eye 25, 365369 (2011). Patients with ptosis require a thorough evaluation, as this condition may be caused by neurologic or neuromuscular disorders such as myasthenia gravis, Horners syndrome, myotonic dystrophy, or even a type of brain aneurysm. It is also necessary to evaluate the position of the brow when evaluating patients with a droopy lid. American Journal of Ophthalmology. 0000023882 00000 n Dermatochalasis is a condition in which there is excess upper eyelid skin. . SCODI: 92132-92134 Visual field testing with eyebrows relaxed, patient looking straight ahead, and the eyelids in normal relaxed position; Visual field is repeated with the eyelids taped up. The inferior visual field also serves as a useful guide to the technician that the patient understands the test well enough to perform reliably. South Staffordshire Primary Care Trust. It includes the area straight ahead as well as the peripheral vision. Understand Isopters 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. The TFBUT measures the quality and stability of the tear film. Your doctor will then typically use a flashlight from the side of your face to direct light into each of your eyes to test how your pupils respond to light. The extent of visual field defect associated with ptosis, dermatochalasis or a combination ranged between 0 to 35 points missed with a median of 19 (mean 19, SD 9.32). 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. 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. 5/25/2018 8 Patterns of threshold testing, cont. Comparison of pre-op and post-op points missed after ptosis surgery +/blepharoplasty. Quantitating the superior visual field loss associated with ptosis. CAS Is formal visual field testing essential prior to upper eyelid surgery in a post-COVID-19 era? Coding involving lab orders, E/M [], Question: Notes indicate that the provider treated a patient with a retinal migraine. Ive never [], Question: Have the modifier 25 rules changed now that the E/M guidelines are different? 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. When the test begins, small light flashes of different intensities appear (one at a time) from different positions within the bowl structure. But ophthalmologists use the threshold exam (92083) when they suspect something that causes a slow, progressive dimming of peripheral vision, like glaucoma. Provided by the Springer Nature SharedIt content-sharing initiative, Eye (Eye) Change in points seen after ptosis surgeries +/ blepharoplasty vs blepharoplasty only. 1998;125:819-829. The septum was incised with a Westcott scissor, allowing the preaponeurotic fat pad to prolapse forward. 0000003158 00000 n You should avoid reporting multiple units of the code if you address both eyes, and you also should avoid appending modifier 50 (. If a patient presents with signs and symptoms of glaucoma, and a VF confirms the condition, you should report the code for the confirmed diagnosis. The patient complained of constant headaches, bloodshot eyes and tearing. Now, with both upper lid levators ressected on adjustable sutures, the patient was asked to open her eyes and the lids were checked for height, contour and symmetry. 0000043262 00000 n It also looks like they are partnered with Keeler. What does a 1% VFI percentage mean? In women, the optimal position of the brow is above this rim, especially on the lateral side. Signs and Symptoms May Apply The two most important to look at are the Grayscale Map and the Pattern Deviation. Page published on Tuesday, September 22, 2020. What has to happen [], Question: We read about new remote therapeutic monitoring codes coming out. Here, well only talk about the Humphrey visual field perimeter, which is used for 99% of visual field tests. There were 39 patients who had blepharoplasty with 38 bilateral and one unilateral, which accounted for 77 eyes in total. The patient also expressed an interest in being able to wear eye makeup again. Blepharoplasty can be performed either in the physicians office or in the hospital operating room. 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. You can determine lid ptosis using three measurements: First, measure the vertical palpebral fissure (interpalpebral fissure or IPF) in primary gaze, The patient was brought to the operating room and placed on the operating table in the supine position. 0000043130 00000 n startxref 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. Diagnostic Data. Arch Ophthalmol 1992; 110: 6367. What are your thoughts on the VR based perimeters vs HFA (or as a complement)? ascertaining that the patients brow and forehead are relaxed. The requirement from some PCT for an individual case review for each procedure has also created a significant workload for those involved in the decision making process. This recurrence causes loose skin and orbital fat herniation. But ptosis testing doesnt end at eyelid observation. The patient was marked with a sterile tip marking pen on the upper lids. Guide to the evaluation of permanent impairment 3rd Ed (rev). 0000017999 00000 n Nottinghamshire County Teaching Primary Care Trust. You may never see full reimbursement for your work, but here's how you can code to get most of what you're due. 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). The age range was 2087 with median of 67. https://doi.org/10.1038/eye.2010.210, DOI: https://doi.org/10.1038/eye.2010.210. The HFA 30-2 tests 76 points in the central 30 degrees of the visual field. Functional Blepharoplasty . The slightly down gaze position also counteracts the involuntary frontalis over action in some ptotic patients and therefore reduces this bias. The surgeon to whom I referred my patient confirmed the significant ptosis and dermatochalasis. 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? 1) Nonspecific / low Reliability / inattention / patient hungry, 4) Severe constriction with a central island, Unfortunately, this is end stage glaucoma. Department of Ophthalmology, Leicester Royal Infirmary, Leicester, LE1 5WW, UK, You can also search for this author in Whether youre a VF coding newbie or a seasoned expert, the answers to these questions that readers have submitted to Ophthalmology and Optometry Coding Alert can help you get all of your deserved reimbursement for these tests. In total, 97 patients amounting to 194 eyes were included in the study. It is often accompanied by varying amounts of dermatochalasis. Append modifier TC (Technical component) to the code to report your work. This can be seen in glaucoma, but also can occur with papilledema and optic nerve head swelling. However, since Medicare will only pay for functional dermatochalasis or ptosis, a visual field is necessary before a referral can be made for a functional eyelid lift. 0000011634 00000 n This project has been presented as a poster in British Oculoplastic Surgery Society (BOPSS) meeting, Edinburgh in June 2010. Yes, there are a lot of graphs. 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. Direct response (how the pupil in which the light is being shone reacts) and consensual response (if the opposite pupil reacts the same as the one exposed to light) are noted during the exam. However, this is difficult to achieve without a trained photographer in a standardised setting, which has significant cost implications. Tobradex (tobramycin and dexamethasone, Alcon) ointment was placed over the wounds. This is awesome thanks a lot for putting this together Ben! Can someone tell me what this means? Investigation of automated perimetry in the evaluation of patients for upper lid blepharoplasty. Ophthal Plast Reconstr Surg 1997; 13: 7780. Here, we'll only talk about the Humphrey visual field perimeter, which is used for 99% of visual field tests. All About Vision and AllAboutVision.com are registered trademarks of AAV Media, LLC. Ninety five eyes had aponeurotic repair with or without blepharoplasty and 77 eyes had blepharoplasty alone. In most men, the optimal position of the brow is at the bony rim above the eye. 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. They were trigger happy. People in this category are good candidates for cosmetic blepharoplasty. The impact of surgery and the correlation of objective and subjective measures with postoperative improvement in quality-of-life. Norcom Commissioning Policy Specialist Plastic Surgery Procedures 2007. A defect in the visual field is defined as absolute when the stimulus is not being seen at 0dB. It has a wider angle and can capture peripheral field defects. Correspondence to 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. 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. 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 xref Let them know that they can expect a minimal to moderate amount of bruising and swelling for seven to 10 days after surgery. 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. In: Engelberg AL (ed). In screening fields, you are testing whether the retina is on or off, while in threshold testing you are testing how dim a light you can perceive?. Watch on. Please switch to one of those browsers if available. and JavaScript. Medicaid: Eligibility and Vision Benefits. Her ocular history was positive for non-proliferative diabetic retinopathy, posterior vitreous detachment, O.D., and asteroid hyalosis, O.S. Ophthalmic Plast Reconstr Surg 1987; 3: 121127. The patient tolerated the procedure well and was moved to recovery room in stable condition. Thirty six were male and 61 were female. Mayo Clinic; 2021. 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. 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). Meyer DR . Approximately 2cc to 3cc were used in each upper lid. Name, demographics, etc: Make sure you are looking at the right patient! Appropriate pain management includes Tylenol, ice and ophthalmic antibiotic/steroid ointments. The results of the visual field were normal, and the doctor ruled out the possibility of glaucoma. SEE RELATED: Ptosis: Droopy eyelid signs and symptoms. 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. 0000000016 00000 n This is a measurement of the center of the pupil to the upper lid margin. Repair of Ptosis, Policy number : SURGERY 018.6 T2. Ophthal Plast Reconstr Surg 1989; 5 (3): 171175. trailer [1] The results of the analyser identify the type of vision defect. It's an automated, static perimeter (unlike Goldmann kinetic perimetry which requires a human operator, and uses a moving target). 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. Central testing to view into the macula with SITA Faster 24-2C. 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). 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. 0000040668 00000 n Ophthal Plast Reconstr Surg 1993; 9: 8389. This was performed without complication. 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. 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). The pedicle was cauterized before the clamp was released. Sixty two eyes (80.6%) demonstrated an improvement in visual field height after surgery (Figure 4). Question 2: Are the visual fields codes unilateral or bilateral? Margin Reflex Distance: 0.5mm O.D., 0.0mm O.S. Its never appropriate to plot additional isopters just to boost your code level. Etiology, Patients who need blepharoplasty procedures often present complaining of tired eyes, sad eyes, or extra tissue around the eyes. His precise measurements of the patients bilateral ptosis included the following findings: Interpalpebral fissure: 8mm O.D., 6mm O.S. Identification of glaucoma-related visual field abnormality with the screening protocol of frequency doubling technology. Patients also must be advised to avoid vigorous exercise for one week following surgery.