Ectropion/Entropion Flashcards
What forms supratarsal fold?
Attachments of levator aponeurosis to skin. 8-11mm in caucasians, in Asians, weaker attachment, less distinct fold
What forms infratarsal fold?
Attachment of CPF to skin
What is importance of Zeiss glands?
sebaceous glands of eyelids, drain into lash shaft and obstruction causes stye
What is the impotantce of meibomian glands
Intratarsal, drain to grey line. Obstruction causes chalazion
Describe Asian eyelid anatomy differences (2)
1- More ROOF/SOOF 2- Levator aponuerosis attachement to dermis is inferior - causing supratarsal fold to be 0-6mm from lash line
WHat is the main function of each section of the o/oculi? -pretarsal -preseptal -preorbital
Pretarsal - presses lid to globe Preseptal - lacrimal drainage Preorbital - tight closure
What is the orgin adn insertion of levator?
Oirgin - lesser wing of spehnoid Insertion - anterior tarsal plate, dermis, O.O
What is the function of CPF?
Analogou to levator - transmits the function of the voluntary muscle (IR), inserts on the edge of the tarsal plate and dermis- linked to downward gaze CN3
What is the function of inferior tarsal muscle?
Analogous to mullers - poor fx definition - sympathetic innervation
What is lockwood ligameent?
supports globe invests the IR and IO
Describe the innervation of the eyelids (sensory and motor)
Sensory V1 - frontal (supraorbital,supratrochlear), lacrimal, nasociliary (infratrochlear) V2 - ZT, ZF, infraorbital Motor CN3, CN 7, SNS
Define symblepharon
cicatrix between eyelid and globe conjunctiva
Define blepharochalasia
laxity of skin and lower lid retractors due to allergy recurrence and edema
Define blepharophimosis
congenital SHORTENING of eyelid structures
Define blepharophimosis syndrome
congenital AD, blepharophimosis, ptosis, telecanthus and epicanthus inversus
Dermatochalasia
Upper lid skin only redundancy
Describe the snap test
to test for laxity Pull lower lid vertically down and release- lid should return to appose globe. if not suggests laxity
Describe the distraction test
to test for laxity If can be distracted anterior to the globe >10mm, suggests laxity
Describe physical exam for entropion
Comprehensive ophtho exam including VA, globe position Cicatricial? exmaine lids and conjunctiva Involutional? snap and distraction test, check LCT Spastic? hypertrophy of orbicularis pretarsal muscle Congenital? look for epiblepharon
How do you classify entropion
Congenital vs acquired CONGENITAL - epiblepharon - corrected by traction - true congenital - dettached lower lid retractors from skin along entire margin - not corrected by traction ACQUIRED - Cicatricial (deficiency of tissue) - Involutional (corrected with traction) - Spastic
What causes involutional entropion?
1- LAXITY in horizontal or vertical dimensions - of Horizontal support (MCT,LCT) - of lower lid retractors (tarsus falls into globe) 2- ENOPHTHALMUS
What causes cicatricial entropion?
Vertical deficiency of posterior lamella 2’ - infection - trauma -inflammation - iatrogenic (TC approach)
What causes spastic entropion?
o.oculi spasm 2’ corneal irritation - keratitis/FB
How do you manage involutional entropion?
VERTICAL LAXITY (retractors) - Lid everting sutures (Quickert) - everting skin/wedge excision - CPF plication - excision/reattachment of CPF to skin HORIZONTAL LAXITY (MCT/LCT/lockwood) - canthopexy - Tarsal strip procedure - horizontal excision and lid everting sutures
Describe a lateral tarsal strip procedure
Lateral end of tarsus is secured to orbital rim as new canthal limb of tendon. Combined with everting sutures 1- subciliary incision w lateral extension 2- dis-insert LCT near tarsal plate 3- mobilize tarsus in submuscular plane 4- attach lateral tarsal strip to inner superiolateral periosteum w 5-0 ticron 5- trim oo and skin excess
Describe Lid everting suture (Quickert-rathburn)
Chromic 4-0 suture, full thickness suture from below lash line to inferior fornix.
How do you manage cicatricial entropion?
-wait for scar to mature (tape,lubricate in the interim) - release and reconstruct with interpositional graft (paalte mucoperiosteum, nasal chondromucosa, FT buccal membrane, ear cartilage)
How do you manage epiblepharon?
Excision of infratarsal skin and orbicularis, 1.5mm below lashes at inturned area. Suture skin edges to lower edge of tarsus
Describe your exam for ectropion
Comprehensive ophtho assessment with VA Bell’s, lagophthalmus, CN7 fx, scleral show, punctum asymmetry, lid laxity (snap/distraction), difference b/w voluntary and spontaneous lid closure
How do you classify ectropion
CONGENITAL - poor developed structures (CT, tarsus, anterior lamella) ACQUIRED - Cicatricial (inflammaotry, infx, iatrogenic, trauma) - Involutional (H or V laxity) - Mechanical (edema, mass) - Paralytic (bells, myasthenia, botox)
How do you manage congenital ectropion
- reposition//tighten
How do you manage cicatricial ectropion
Release scar and reconstruct Recon options - z plasty/tripier/FTSG - chondral/mucoperiosteal graft
How do you manage involutional ectropion
HORIZONTAL LAXITY 1- wedge excision + canthopexy 2- Lateral tarsal strip procedure 3- fascial sling VERTICAL LAXITY - add structure with graft (cartilage/mucoperisoteal)
How do you manage mechanical ectropion
excise lesion or treat cause
How do you manage paralytic ectropion
Canthopexy, wedge excision, tarsorhaphy, static sling
Describe non-operative management of ectropion cases in the interim.
taping lubrication temporary tarsorrhaphy scar management
What is ptosis
- lid margin falls below normal position (midway between pupil and corneoscleral jx or 2mm below limbus
What causes ptosis
dysfunction of levator complex (mueller/levator muscle, aponeurosis)
What is normal levator excursion?
from max upward to max downward gaze is >12mm
How do you classify ptosis?
CONGENITAL - Isolated - Synkinetic - with SR dysfx - Blepharophimosis syndrome ACQUIRED - Traumatic - Aponeurotic - Myogenic - Neurogenic - Mechanical
How do you diagnose congenital isolated ptosis
lagophthalmus on downward gaze - indicates stiffness of levator complex
What is synkinetic ocngenital ptosis?
marcus gunn jaw winking : aberrant synkinesis between V3 and CN3 - ptosis resolves with clenching teeth
What is blepharophimosis syndrome
telecanthus, ptosis, ectropion, epicanthus inversus AD
What are causes of acquired aponeurotic ptosis?
involutional - aponeurosis laxity, dehiscence. Increased distance to supratarsal fold, may have normal levator excursion
What are causes of acquired neurogenic ptosis?
palsy of CN3, associated with ophthalmoplegia or horners
What are causes of acquired myogenic ptosis
myasthenia gravis, thyroid ophthalmopathy, involutional
Describe key questions in your assessment of patient presenting w ptosis
Is it true ptosis or pseudoptosis Hx: onset is key - acquired vs congenital Levator function/excursion and dehiscence? * most importnat for treatment decision History of previous eye surgery Protective mechanisms present? bells Is enurologic workup needed?
What is a schirmer test
testing for basic and reflex secretion - 35x5mmfitler pper adjacent to conjunctiva and leave for 5mins. if less than 10mm wetting, abnormal Can also block reflex secretions with local anesthetic
What is your PE for patient presenting with ptosis
Comprehensive ophtho asx - EOM, pupils, VA, VF - lid position, brow position, intact bells phenomenon
What are common findings of patient with acquired aponeurotic ptosis
- normal levator excursion - absent or elevated supratarsal crease
What is bells phenomenon
involuntary upward movement of eye with closure of eyelids - indicates normal SR function
What are surgicla options for treatment of ptosis
- Fasanella-Servat procedure (tarsal conjunctival mullerectomy - levator plication/resection* - levator advancement/aponeurosis repair/resection* - Frontalis suspension sling * can combine w upper bleph
Describe a fasenella servat procedure (tarsomyectomy)
Lid eversion En bloc excision of conjunctiva and posterior lamella at superior tarsus margin - attempt to excise muller and conj and induce scarring Indicated if good levator function and mild ptosis
Describe levator resection/aponeurosis repair
aponeurosis is cut horizontally and reattached to tarsus indicated if good levator function - and aponeurotic involution
Describe frontalis suspension
tarsus suspended from frontalis w TPF, tensor fascia lata Indicated for svere congenital ptosis w no levator fx
