Classification and management of eyelid disorders

Question 1

Congenital anomalies of eyeid occur when?

Answer 1

Most congenital abnormalities of eyelids occur during second month of gestation because of failure of fusion or an arrest of development.

Question 2

Blepharophimosis-Ptosis-Epicanthus Inversus Syndrome

Answer 2

1. Autosomal Dominant
2. Blepharophimosis (horizontally narrow and vertically narrow palpebral fissure), + telecanthus (increased distance between medial canthi) + severe ptosis + epicanthus inversus (eyelid fold prominent in lower eyelid)
3. FOXL2 gene, Chromosome 3
4. Type I = early loss of ovarian function in women, Type II
5. Additional findings = lateral lower eyelid ectropion 2/2 vertical eyelid deficiency, poorly developed nasal bridge, hypoplasia of superior orbital rim, ear deformities, hypertelorism
6. Repair of ptosis usually requires frontalis suspension for adequate lift
   7.

Question 3

Congenital Ectropion

Answer 3

1. Associated with BPES, Down syndrome, icthyosis
2. 2/2 vertical insufficency of anterior lamella of eyelid
3. Chronic epiphora, exposure K
4. Mild = no treatment
5. Severe/symptomatic = Lateral canthal tendon tightening and vertical lengthening of anterior lamella with full-thickness skin graft

Question 4

Euryblepharon

Answer 4

1. Vertical shortening and horizontal lengthening of eyelid
2. Associated with BPS

Question 5

Ankyloblepharon

Answer 5

1. Eyelids fuse 8-20w gestation
2. Partial or complete fusion of eyelids by webs of skin
3. Can usually be opened by scissors

Question 6

Epicanthus

Answer 6

1. Medial canthal fold that may result from immature midfacial bones or a fold of skin and subcutaneous tissue
2. May cause pseudoesotropia because of decrease scleral show
3. Epicanthus tarsalis = can be normal variation in Asian eyelid
4. Most become less apparent with normal growth of facial bones
5. Epicanthus inversus rarely resolves with facial growth
6. Respond to linear revisions = Z-plasty and Y-V plasty

Question 7

Epicanthus

Answer 7

Question 8

Epiblepharon

Answer 8

1. Lower eyelid pretarsal muscle and skin ride above lower eyelid margin causing cilia to assume a vertical position. Eyelid margin in normal position
2. Most common in Asian children
3. Cilia touch K in downgaze
4. May NOT require surgery as tends to diminish with maturation of facial bones
5. May result in acute or chronic K epithelial irritation in which case excess skin and muscle fold excised

Question 9

Congenital Entropion

Answer 9

1. Due to lower eyelid retractor dysgenesis, structural defects in tarsal plate, relative shortening of posterior lamella
2. Unlikely to improve and may need surgery
3. Repaired with removal of skin + orbicularis muscle + advancement of lower eyelid retractors to tarsus
4. Tarsal kink = form of congenital entropion where tarsal plate of upper eyelid folding causing entropion

Question 10

Epicanthus

Answer 10

Question 11

Epiblepharon

Answer 11

Question 12

Congenital distichiasis

Answer 12

1. Extra row of eyelashes in orifices of MG
2. Congenital = embryonic pilosebaceous units improperly differentiate into hair follicles
3. Treatment if symptomatic or keratopathy develops
4. Lubricants and CL may be sufficient
5. May need electrolysis, cryoepilation

Question 13

Congenital coloboma

Answer 13

1. True coloboma includes defect in eyelid margin and eyelid
2. When in lower eyelid = associated with Goldenhar syndrome and lacrimal deformities

Question 14

Crytophthalmos

Answer 14

1. Presents with partial or complete abscence of eyebrow, palpebral fissure, eyelashes, conjunctiva
2. Partially developed adnexa fused to anterior segment of globe
3. Histologically = levator, orbicularis muscle, tarsus, conjunctiva and MG attenuated or absent

Question 15

Infantile Hemangioma

Answer 15

1. Aka capillary hemangioma
2. Usually appear over first weeks or months of life
3. Associated with amblyopia
4. Treatment recommended for those with occlusion of visual axis or disfigurement
5. Increases in size until 1 yo and decreases over next 3-7 years
6. Vision threatened and lesion limited to eyelid = topical timolol gel or intralesional steroid. More widespread involvement addressed with systemic propranolol or oral steroids
7. Non-responders to b blockers or cannot take b blockers = intralesional steroids considered BUT risk of eyelid necrosis, embolic retinal vascular occlusion, systemic adrenal suppression
8. Topical clobetasol proprionate and interferon a have been tried

Question 16

Chalazion

Answer 16

1. Internal posterior hordeolum
2. Caution in removing eyelid margin or lesions adjacent to punctum
3. Rarely greatest inflammation anterior thus skin lesion necessitated
4. Injection of steroids may cause skin depigmentation

Question 17

External Hordeolum

Answer 17

1. 2/2 glands of Zeis aka external hordeolum or stye

Question 18

Eyelid edema

Answer 18

1. Can be caused by local conditions such as insect bites, allergies, or systemic conditions such as CVD, renal disease, collagen vascular diseases, TED, CSF leakage into orbit after trauma

Question 19

Floppy Eyelid Syndrome

Answer 19

1. Ocular irritation and mild mucus discharge in AM
2. Chronic papillary conjunctivitis
3. Tarsal plate easily everted when pulling eyelid
4. Associated with obesity, keratoconus, eyelid rubbing, hyperglycemia, sleep apnea
5. Hx of sleeping prone and causing mechanical upper eyelid eversion and causing superior palpebral conj to rub against pillow
6. Conservative tx = viscous lubrication, eyelid shield at night or patch
7. Lateral tarsal strip may be needed
8. Sleep study may be beneficial
9. Eyelid imbrication syndrome = lax upper eyelid overrides lower eyelid margin during closure resulting in chronic conjunctivitis