OPTOM 245 Fall 2024 Eyelids 3 PDF

Eyelids – Part 3 OPTOM 245 - Fall 2024 Poling Website http://nfurtado.participoll.com Nadine M. Furtado, OD, MSc, FAAO Associate Cli...

Eyelids – Part 3 OPTOM 245 - Fall 2024 Poling Website http://nfurtado.participoll.com Nadine M. Furtado, OD, MSc, FAAO Associate Clinical Professor Head, Ocular Disease & Imaging Service 1 Thank you to Dr. Dalton for providing her past notes to prepare this lecture.  Eyelid Positional Issues 6 Case: Eyelid Positional Problems 88yo M c/o constant tearing mainly OS ▪ Occasional FBS OS>>OD ▪ VA OD 20/20 OS 20/25 OU 20/20 Andrew Pearson MD, Eye Surgery in Berkshire. http://www.eyesurgeryinberkshire.co.uk/information_ae/ae_ectropion.html 7 Eyelid Positional Problems Epiphora & FBS Entropion Ectropion Involutional Congenital Cicatricial Spastic Involutional Mechanical Cicatricial Paralytic 8 Entropion Vs. Ectropion Eye Atlas (2014) on Twitter. Retrieved from https://twitter.com/Eye_Atlas/status/546650973809025025/photo/1 9 Entropion ▪ Inversion of the eyelid margin towards the globe Mainly affects LL; UL has a broader tarsus and is more stable Eye Atlas (2014) on Twitter. Retrieved from https://twitter.com/Eye_Atlas/status/546650973809025025/photo/ 1 ▪ Unilateral or bilateral ▪ More common in the elderly Less common than ectropion ▪ Clinical signs: Rolled-in lid, pseudo-trichiasis, hyperemia, http://optometrist.com.au/entropion/ corneal staining (exposure keratopathy) Secondary: pannus, corneal scarring, infection and ulceration ▪ Sx: FBS, epiphora Pannus 10 Atlas of Ophthalmology @ Online Journal of Ophthalmology https://www.atlasophthalmology. net/photo.jsf;jsessionid=A9F6B6CE63905C45F9BA2C601042A720?node=586&locale=pt Involutional Entropion ▪ Occurs more commonly in the elderly population ▪ Due to degeneration of elastic and fibrous tissues within the eyelid Orbital tissue atrophy allowing the globe to move posteriorly (relative enophthalmos) Increased horizontal lid laxity, decreased vertical lid stability, increased orbital septum laxity Clinical Ophthalmology: A Systematic Approach (7th Edition), Figure 1.68 A 11 Congenital Entropion ▪ A true congenital entropion is rare Primary: abnormal development of tarsus, orbicularis or other musculature Secondary: mechanical (anophthalmos, microphthalmos) EyeEssentials (2011). Before. http://eye-essentials.net/ce1.htm ▪ More common is an epiblepharon - Epiblepharon mild entropion seen in young children A fold of skin that overlaps the eyelid margin, pushing the eyelid margin inward Unlike true congenital entropion this improves with age Consultant 360 (September 2006). Photo clinic: Bilateral Epiblepharon. https://www.consultant360.com/articles/photoclinic-bilateral-epiblepharon 12 Cicatricial entropion ▪ Severe scarring of the palpebral conjunctiva pulls the lid margin towards the globe ▪ Common causes: Cicatrizing conjunctivitis Trachoma Trauma Chemical injuries o Acid or alkali burns Inflammatory conditions Dr. Arteaga, Opthalmic Plastic Surgeon. Entropion. http://www.angelarteaga.es/en/entropion-c-5.php o Stevens-Johnson syndrome, ocular pemphigoid 13 Spastic Entropion Spastic Entropion ▪ Occurs secondarily to neurological, inflammatory or irritative processes of the eyelids Commonly due to surgical trauma or blepharospasm Blepharospasm ▪ Uncontrolled abnormal muscle contraction of the eyelids Usually bilateral; can be primary or secondary Symptoms begin gradually (mild contractions) and can progress to being more frequent and forceful o Secondary causes (range): dry eyes to Tourette's syndrome Myokymia ▪ Abnormal sporadic twitching of the eyelid Typically unilateral; can last a few seconds to several days o Common causes: caffeine, stress, fatigue Note: if other facial muscles may be a neurological condition o E.g., Hemifacial spasm, essential blepharospasm, facial myokymia, facial nerve palsy with synkinesis 14 North American Neuro-Ophthalmology Society (NANOS, 2016). Eyelid Myokymia. Patient Brochure. http://www.nanosweb.org/files/Patient%20Brochures/English/Eyelid%20myokymia.pdf Entropion Tx ▪ Temporary Lubricating drops / ointments, prophylactic antibiotics, lid taping, cyanoacrylate glue, bandage contact lenses, epilation of lashes (minor cases), botulinum toxin ▪ Long Term – treat the underlying cause Electrolysis, mucous membrane graft (cicatricial), eyelid surgery (tighten inferior retractors, horizontally shorten the lid) Clinical Ophthalmology: A Systematic Approach (7th Edition), Figure 1.69 B 15 Ectropion ▪ An outward turning of the eyelid margin Common, especially in the elderly Eye Atlas (2014) on Twitter. Retrieved from https://twitter.com/Eye_Atlas/status/546650973809025025/photo/1 Almost exclusively effects the lower lid ▪ Clinical Signs: Everted lower lid, hyperemia, corneal staining (exposure keratopathy), conjunctival inflammation & thickening Secondary keratinization of tarsal conjunctiva ▪ Sx: FBS, epiphoria Keratinization Clinical Ophthalmology: A Systematic Approach (7th Edition), Figures 1.61 A, B 16 Involutional Ectropion ▪ “Age-related” entropion due to natural aging changes in the lid ▪ Most common form of ectropion ▪ Horizontal lid laxity with medial and lateral canthal tendon laxity Aggravated by gravity Clinical Ophthalmology: A Systematic Approach (7th Edition), Figures 1.62 A and B 17 Mechanical Ectropion ▪ Occurs due to lesions on or near the lid margin that mechanically evert (pull down) the lid Ex: large chalazion, neurofibroma, papilloma Clinical Ophthalmology: A Systematic Approach (7th Edition), Figure 1.67 R. Pace – OPTOM 245 Fall 2012 18 Cicatricial Ectropion ▪ Scarring or contracture of the skin, palpebral conjunctiva or underlying tissues that pulls the eyelid away from the globe Occurs secondary to trauma, burns, radiotherapy, chemical injuries, ichthyosis ▪ Often accentuated by opening the mouth Procianoy F et al Arq. Bras. Oftalmol. vol.72 no.3 São Paulo May/June 2009. https:// Pinna A, et al Eye (2004).https://www.nature.com/articles/6700686 www.scielo.br/scielo.php?script=sci_arttext&pid=S0004-27492009000300020 19 Paralytic Ectropion ▪ Damage to the facial nerve (CN7) Lack of tone of orbicularis Retraction of upper & lower lids med.stanford.edu Brow ptosis (eyebrow droops) o May mimic narrowing of the palpebral aperture ▪ Most commonly seen secondary to Bell’s palsy Less commonly: trauma or tumours along length of nerve Clinical Ophthalmology: A Systematic Approach (7th Edition), Figure 1.65 20 Ectropion Treatment ▪ Temporary / Short Term Tarsorrhaphy Topical lubricants (day - ATs; night – ung) Taping lids shut at night Botulinum toxin injection o Temporary ptosis Temporary tarsorrhaphy Andrew Doan, University of Iowa Health Care, Eye Rounds.org. 7th Nerve Palsy. Retrieved from https:// webeye.ophth.uiowa.edu/eyeforum/atlas/pages/7th-nervepalsy.html Clinical Ophthalmology: A Systematic Approach (7 Edition),Figure 1.63C o Corneal protection Eyelid Weights ▪ Long Term Surgical correction of underlying issue and reconstruction of eyelid Permanent tarsorrhaphy Upper eyelid weights (Bell’s palsy) Ophthalmics FCI (2020). Blinkeze Eyelid Weights. https://fciophthalmics.com/products/blinkeze- eyelid-weights o Gold weight implantation in upper lid 21 Floppy Eyelid Syndrome ▪ Uncommon condition where patients exhibit an extremely “rubbery” upper lid Spontaneous eversion of the upper eyelid during sleep o Unilateral or bilateral o Superior palpebral conjunctiva rubs against a pillow or mattress Usually seen in obese, middle-aged men who sleep face down (lids everted) o Consider referring for sleep study if sleep apnea risk factors are present ▪ Causes persistent ocular surface issues Dry eye, blepharitis, keratoconjunctivitis Clinical Ophthalmology: A Systematic Approach (7th Edition), Figures 1.74 A, B, C Stuart, A. (2013). Obstructive Sleep Apnea and the Eye: The Ophthalmologist’s Role. Clinical Update: EyeNet Magazine. American Academy of Ophthalmology. https://www.aao.org/eyenet/article/obstructive-sleep-apnea-eye-ophthalmologist-s-role 26 Ptosis ▪ Abnormally low position of the UL due to loss of function of UL muscles ▪ Congenital or acquired ▪ Sx: ▪ Asymptomatic if not affecting visual axis / FOV ▪ Decreased VA if covers visual axis ▪ Superior visual field defect Ahmad, A. (2019). Ptosis Repair. http://www.chicagoeyelids.com/before- andafter/ptosis-repair/ 27 Congenital Ptosis ▪ Striated muscle dystrophy of the levator muscle Often cause unknown, some are hereditary ▪ Unilateral or bilateral ▪ Clinical signs, in addition to ptotic lid: Absent upper lid crease Poor levator function Woong Chul Choi and Juwan Park. Plastic Surgery Key (2020). 17 Correction of Ptosis. https://plasticsurgerykey.com/17-correction-of-ptosis/ Compensatory chin elevation (if bilateral) Refractive errors are common 28 Case: Acquired Ptosis 81yo M c/o superior shadow in FOV, OS>OD - Started a few weeks ago - No other visual symptoms He also reports that his wife has started noticing that his lids are droopy MHx: Unremarkable BCVA: OD 20/20-3 OS 20/25-2 OU 20/20-3 29 Clinical Ophthalmology: A Systematic Approach (7th Edition), Figures 1.48 A, B, C, D; 1.77A, 3.13A, 3..14A ACQUIRED PTOSIS Acquired Ptosis Aponeurotic Mechanical Myogenic Traumatic Neurogenic Horner CN3 Palsy Syndrome PAGE 30 Aponeurotic Ptosis ▪ Most common type of acquired ptosis, due to disinsertion (split), dehiscence (rupture), or stretching of levator aponeurosis Clinical Ophthalmology: A Systematic Approach (7th Edition), Figures 1.55 A, B ▪ Mainly age-related (involutional) or postoperative, but can also be due to blunt trauma and RGP contact lens wear ▪ Clinical signs: High / absent lid crease Good levator function Thin eyelid above tarsal plate Deep upper sulcus Clinical Ophthalmology: A Systematic Approach (7th Edition), Figures 1.55 A, B 31 Mechanical Ptosis ▪ Impaired mobility of upper lid ▪ Most common cause in elderly is dermatochalasis (top image), but can https://www.researchgate.net/publication/318568795_Updates_on_upper_eyelid_blepharoplasty also be caused by large tumours (neurofibromas), heavy scars, severe edema, hemangiomas, anterior orbital lesions 32 Clinical Ophthalmology: A Systematic Approach (7th Edition), Figure 1.56  Cranial Nerve III Palsy ▪ Any interruption of CN III pathway can result in a CN III palsy ▪ Clinical signs: Ptosis, mydriasis (dilated pupil), exotropia (strabismus) CN3 innervates CN3 palsy with pupil ▪ Levator, pupillary sphincter, ciliary muscle involvement requires ▪ Superior rectus, medial rectus, inferior rectus, immediate inferior oblique, parasympathetic neurological exam Remaining functional EOM (not innervated by CN3): (MRI) ▪ Superior oblique (abduction, depression, internal rotation) ▪ Lateral rectus (abduction) ▪ Normal pupil vs affected pupil (mydriasis) ▪ Normal pupil → microangiopathy to CN III (HTN, DM); typically, spontaneous recovery within 3 months ▪ Defective pupil (mydriasis) → compression of CN III nerve (aneurysm, trauma) → LIFE-THREATENING! Hakim W, et al. An acute case of Herpes Zoster Ophthalmicus with Opthalmoplegia. Case Reports > Case Rep Ophthalmol Med. (2012); 2012:953910. doi: 10.1155/2012/953910. https://www.researchgate.net/publication/225081149_An_Acute_Case_of_Herpes_Zoster_Ophthalmicus_with_Ophthalmoplegia 33 1) Fang C, Leavitt JA, Hodge DO, Holmes JM, Mohney BG, Chen JJ, (2017). Incidence and Etiologies of Acquired Third Nerve Palsy Using a Population-Based Method. JAMA Ophthalmol. 135(1):23–28. doi:10.1001/jamaophthalmol.2016.4456 Horner syndrome ▪ Oculosympathetic palsy (damage to ocular sympathetic nerve supply) Stroke, tumours (lung (Pancoast), thyroid, neuroblastoma (kids), cavernous sinus, spinal cord) cluster migraine, Herpes Zoster, diabetic autonomic neuropathy ▪ Clinical signs - triad on affected side ▪ Ptosis: mild (1-2mm), weakness of Muller muscle ▪ Miosis: no dilator function, unopposed sphincter muscle ▪ Anhydrosis: only in acquired cases, if lesion is below the superior cervical ganglion ▪ Congenital Horner Syndrome → results in hypochromia of ipsilateral iris 34 Ophthalmology: A Systematic Approach (7 Edition), Figure 19.36 A Clinical Myogenic Ptosis Myasthenia Gravis ▪ Impaired muscular function of levator Neurological or muscular; acquired or congenital ▪ Causes: Myasthenia gravis (neurological autoimmune disease) Myotonic dystrophy (genetic mutation) Chronic progressive external ophthalmoplegia (gradual ocular muscle degeneration) Clinical Ophthalmology: A Systematic Approach (7th Edition), Figure 19.93 o May be genetic (Kearns-Sayre syndrome, oculopharyngeal dystrophy) 35 Traumatic Ptosis ▪ Blunt or sharp trauma to the levator muscle or its aponeurosis Orbital fractures and foreign bodies may impair levator function directly or indirectly Ocular surgery may cause injury to levator aponeurosis Denver Eyelid Trauma Services (2018). https://www.drfante.com/services/reconstructive-surgery/eyelid-trauma/ o Esepcially cataract and trabeculectomy surgery Injury to the periocular tissues may cause edema or hemorrhage and can cause ptosis 36 Ptosis Documentation ▪ Measuring margin-reflex distance (MRD) is the most accurate way to document a ptosis Unlike measuring interpalpebral opening height, MRD is not impacted by any asymmetry in the LL positioning between the eyes ▪ Use a ruler to measure the distance between the UL and the corneal reflex to get the MRD for each eye; if there is no UL ptosis present, these measurements should be equal. 37 https://www.researchgate.net/publication/255987754_Muller's_Muscle_Conjunctival_Resection_Ptosis_Repair_in_the_Aesthetic_Patient Ptosis Management ▪ Specific management depends on the cause ▪ Ptosis crutch A “sturdy shelf” curved to miss the globe; provides mechanical support to the lids ▪ Surgery (levator resection most common) Be wary of postsurgical corneal exposure Bakalor P. (2008). https://www.blepharospasm.org/gallery3/index.php/non-surgical- aids/Ptosis_crutch_in_place 38 Pseudoptosis ▪ Variety of causes Lack of support of lids by globe ▪ Artificial eye, microphthalmos, phthisis bulbi, enophthalmos Contralateral lid retraction ▪ Thyroid eye disease Ipsilateral hypotropia ▪ Upper lid follows globe downwards ▪ Disappears when hypotropic eye is fixating Brow ptosis ▪ Excessive skin on the brow, CN7 palsy Dermatochalasis ▪ Excessive skin on upper lids Preseptal or orbital cellulitis ▪ Primarily infectious causes; may be life threatening ▪ Will be discussed with “Orbit” 39