3: Eyelids- Malpositions and Twitching Flashcards
dermatochalasis
lax and redundant upper > lower eyelid skin
dermatochalasis etiology
degeneration of connective tissue most commonly the result of aging
dermatochalasis demographics
- most commonly presents in the elderly
- sometimes with extreme weight loss or chronic blepharochalasis
dermatochalasis laterality
bilateral
dermatochalasis symptoms
- asymptomatic
- droopy eyelids
- heavy eyelids
- obstruction of superior visual field
dermatochalasis signs
- upper eyelid skin laxity and redundancy
- excessive skin –> “puffy” appearance
- decreased MRD-1
dermatochalasis management
- none if asymptomatic
- if symptomatic/cosmesis, refer out for blepharoplasty (BLUB- bilateral upper lid blepharoplasty); prior to referral, perform a VF with lids taped vs untaped, preferably super 36 aka a “ptosis VF”; if there is improvement in the VF with the lids taped, higher likelihood insurance will consider the surgery medically necessary; otherwise, patient may pursue blepharoplasty as elective cosmesis “out of pocket” procedure
dermatochalasis clinical pearls:
- BULB can be performed _____
- never perform BULB ______
in office or in outpatient center;
right before intraocular surgery, the speculum will “stretch” the eyelid skin, better cosmetic outcome
ptosis
droopy upper eyelid
ptosis etiology
most commonly: aponeurotic; levator aponeurosis stretching or dehiscence due to aging, repetitive eye rubbing
less commonly:
- mechanical (e.g., eyelid tumor, severe eyelid edema)
- myogenic (e.g., muscular dystrophy, chronic progressive external ophthalmoplegia)
- neurologic (e.g., CN III palsy, Horner syndrome, myasthenia gravis, multiple sclerosis)
- congenital
ptosis demographics
depends on etiology
ptosis laterality
unilateral > bilateral
ptosis symptoms
- asymptomatic, cosmesis
- droopy eyelid
- obstruction of the superior visual field
ptosis signs
- drooping eyelid; UL is most commonly affected; if LL is affected, called a reverse ptosis
- decreased MRD-1 and possibly MRD-2
- signs of underlying cause (e.g., chalazion, EOM restriction, anisocoria, diplopia, high or absent eyelid crease if aponeurotic or congenital)
ptosis management
- determine and treat the underlying condition
- if no resolution or congenital, consider referral for ptosis surgery, which involves resecting the levator aponeurosis
ptosis clinical pearls:
-differentiate from ______
pseudoptosis; ex: dermatochalasis, brow ptosis, enophthalmos, microphthalmia, corneal protective mechanisms, contralateral eyelid retraction
entropion
eyelid turns inwards/towards the globe
entropion etiology
most commonly age-related; horizontal eyelid laxity, retractor disinsertion, and orbicularis override
less commonly:
- cicatricial (e.g., conjunctival scarring in trauma, burn injury, trachoma, OCP, SJS)
- spastic (e.g., sustained orbicularis contraction due to surgical trauma, ocular irritation, or blepharospasm)
- congenital
entropion demographics
most commonly presents in the elderly
entropion laterality
unilateral or bilateral
entropion symptoms
- asymptomatic
- ocular redness
- ocular irritation (e.g., burning, FBS, pain)
- tearing
entropion signs
- inversion of the eyelid
- signs of underlying cause (e.g., conjunctival scarring, spastic contraction of the orbicularis muscle)
entropion complications
trichiasis (lash bending inwards) –> ocular surface damage (conjunctival injection, SPK, pannus, corneal ulceration and scarring)
entropion management
- determine and treat the underlying condition; if no resolution, refer out for entropion surgery for definitive treatment
- supportive management for trichiasis and resulting ocular surface damage; lash epilation, electrolysis, cryotherapy, or radiofrequency epilation; aggressive topical lubrication; BCL or scleral contact lens
entropion clinical pearls:
-trichiasis without entropion is typically _____
idiopathic and only involves a few lashes; can cause irritation of the ocular surface; epilate lashes in office
ectropion
eyelid turns out/away from the globe
ectropion etiology
most commonly age-related; horizontal eyelid laxity
less commonly:
- mechanical (e.g., eyelid tumor)
- cicatricial (e.g., shortening of the anterior lamella from trauma, burn injury, actinic damage, chronic inflammation, atopic dermatitis)
- neurologic (e.g., CN VII palsy)
- congenital
ectropion demographics
most commonly presents in the elderly
ectropion laterality
unilateral or bilateral
ectropion symptoms
- asymptomatic
- ocular redness
- ocular irritation (e.g., burning, FBS, pain)
- tearing
ectropion signs
- eversion of the eyelid; LL is most commonly affected
- signs of underlying cause (e.g., eyelid tumor, eyelid scarring, paralysis of the facial muscles)
ectropion complications
lagophthalmos –> exposure keratopathy; more common in paralytic cases (ex: Bell’s palsy)
ectropion management
- determine and treat the underlying condition; if no resolution, refer out for surgery for definitive treatment
- supportive management for exposure keratopathy; aggressive topical lubrication
- BCL, but lens may fall out due to lid positioning
eyelid retraction
excessive elevation of the eyelid
eyelid retraction etiology
most commonly due to thyroid eye disease; increased sympathetic tone acting on Muller’s muscle, contraction of the levator, proptosis, and/or scarring between the lacrimal gland and levator
less commonly:
- mechanical (e.g., surgical overcorrection of ptosis)
- cicatricial (e.g., scarring of the levator and/or Muller’s muscle)
- neurologic (e.g., dorsal midbrain syndrome)
- pharmacological (e.g., sympathomimetic drops, like phenylephrine)
- congenital (rare)
eyelid retraction demographics
women > men
eyelid retraction laterality
unilateral or bilateral
eyelid retraction symptoms
- asymptomatic
- ocular redness
- ocular irritation (e.g., burning, FBS)
eyelid retraction signs
- excessive elevation of the eyelid; UL is most commonly affected; in general, eyelid position is abnormal if superior sclera is exposed in primary gaze
- increased MRD-1 and/or MRD-2
- signs of underlying cause (e.g., proptosis, deficiency of upward gaze, UL retraction and pupillary constriction on down gaze or adduction, dilated pupil)
eyelid retraction complications
lagopthalmos –> exposure keratopathy
eyelid retraction management
- determine and treat the underlying condition; if no resolution, refer out for surgery for definitive treatment
- supportive management for exposure keratopathy
eyelid retraction clinical pearls:
-lower eyelid retraction can be ____
a normal anatomic variant
floppy eyelid syndrome (FES)
flaccid/loose upper eyelids due to a lax tarsal plate
floppy eyelid syndrome (FES) etiology
- unknown etiology
- commonly associated with obstructive sleep apnea
floppy eyelid syndrome (FES) demographics
- typically presents between the ages of 45-65. years
- men (obese) > women
floppy eyelid syndrome (FES) laterality
bilateral
floppy eyelid syndrome (FES) symptoms
- asymptomatic
- ocular redness
- ocular irritation (e.g., burning, FBS, itching)
- mild mucous discharge
- symptoms are typically unilateral (side that the patient sleeps) and worse upon waking (due to eyelid eversion during the night)
floppy eyelid syndrome (FES) signs
- upper eyelids that are easily everted without exerting counter pressure
- rubbery superior tarsal plate
- eyelid imbrication (UL overrides the LL on closure)
- conjunctival injection
- palpebral papillae superior (due to eyelid eversion during sleep and rubbing against bedding)
- superficial punctate keratitis (SPK)
- mild mucous discharge
- ptosis (due to redundancy of skin surrounding tarsal plate)
floppy eyelid syndrome (FES) complications
- lagophthalmos (due to eyelid imbrication) –> exposure keratopathy
- bacterial conjunctivitis (due to eyelid eversion during sleep)
floppy eyelid syndrome (FES) management
- supportive management (topical lubricant, eyelid taping or patching qhs with topical lubricant, refrain from sleeping face down)
- refer out for surgery for definitive treatment
- if not previously diagnosed, refer to PCP for sleep apnea
lagophthalmos
incomplete closure of the eyelids
lagophthalmos etiology
- mechanical (e.g., eyelid laxity, eyelid tumor, post eyelid surgery, proptosis, FES, severe conjunctival chemosis)
- cicatricial (e.g., eyelid scarring, eyelid retractor muscle scarring)
- neurologic (e.g., dorsal midbrain syndrome, CN VII palsy)
- congenital
lagophthalmos demograhpics
depends on etiology
lagophthalmos laterality
unilateral or bilateral
lagophthalmos symptoms
- asymptomatic
- ocular redness
- ocular irritation (e.g., burning, FBS, pain)
- tearing
lagophthalmos signs
- inadequate blinking or closure of the eyelids
- signs of underlying cause (e.g., eyelid tumor, proptosis, chemosis, eyelid scarring, restriction in up gaze, paralysis of the facial muscles)
lagophthalmos complications
exposure keratopathy
lagophthalmos management
- determine and treat the underlying condition; if no resolution, refer out for surgery for definitive treatment
- supportive treatment for exposure keratopathy (aggressive AT regime, topical steroid for SPK, Restasis or Xiidra bid, sleep mask, BCL, scleral lens, AMT with BCL)
eyelid myokymia
subtle eyelid twitch due to spontaneous contracture of the orbicularis muscle
eyelid myokymia etiology
- unknown etiology
- commonly triggered by stress, caffeine, alcohol, ocular irritation, lack of sleep
eyelid myokymia demographics
no predilection
eyelid myokymia laterality
unilateral***
eyelid myokymia symptoms
eyelid twitch
eyelid myokymia signs
eyelid twitch is typically subtle and difficult to observe
eyelid myokymia management
- self-limiting
- modify/avoid triggers
- 5-6 oz tonic water (anecdotal); contains quinine which may inhibit nerve impulses
eyelid myokymia clinical pearls:
-differentiate from _____
hemifacial spasm (unilateral contracture of the entire side of the face; requires brain MRI to rule out tumor)
blepharospasm
spastic (involuntary muscular contraction) twitching, blinking, or closure of the eyelids due to contraction of the orbicularis muscle
blepharospasm etiology
- unknown etiology
- may be associated with Meige’s syndrome
blepharospasm demographics
women > men
blepharospasm laterality
bilateral***
blepharospasm symptoms
- increased blink rate initially
- spasmodic eyelid closure as it progresses; disappears during sleep
- interference with ADLs; may be functionally blind
- ocular redness
- ocular irritation (e.g., burning, FBS)
- tearing
blepharospasm signs
- spastic twitching, blinking, or closure of the eyelids
- conjunctival injection
- superficial punctate keratitis (SPK)
blepharospasm management
- refer out for Botox or surgery; Botox is currently gold standard
- supportive management for dry eye
- Meige’s syndrome is characterized by dystonia (movement disorder in which a person’s muscles contract uncontrollably); often of the jaw, tongue, and eyelids
