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Clinical Opthalmology > Eyelid Malpositions > Flashcards

Eyelid Malpositions Flashcards

1
Q

What is entropion? What are the types of entropion?

A
  • In turning of eyelid towards eye
  • More commonly affects lower lid, but can affect upper eyelid as well
  • One of commonest eyelid malpositions which occurs with age
  • CONGENITAL: child born with this, would not really present in primary care
  • ACQUIRED:
    o 90% Senile (involutional) or age-related entropion
    o Spastic entropion
    o Cicatricial entropion
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2
Q

What is involutional entropion and what is the mechanism?

A
  • Most common (90%)
  • Retractors (lower eyelid)– laxity, dehiscence, disinsertion
  • Horizontal eyelid laxity
  • Over-riding orbicularis muscle
  • Mechanism:
    o Overriding of preseptal over pretarsal orbicularis during lid closure – when person tries to close eyelid, because it has become lax, the orbicularis muscle tends to bunch up just in front of the tarsal plate causing the eyelid to turn in
    o Weakness of lower lid retractors (red and blue on diagram) – as the lower eyelid retractors become stretchy/lose, the lower edge of the tarsal plate doesn’t stay in apposition to the globe, it becomes loose
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3
Q

Describe the snap-back test? What is it for?

A
  • Pull lower lid down with finger on centre of orbital rim & release to observe return of eyelid
  • Spontaneous return:
    o Quick – normal
    o Slow – mild lid laxity
  • Return with blink:
    o Moderate lid laxity
  • Incomplete return:
    o Severe lid laxity
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4
Q

What are the symptoms of involutional entropion?

A
  • Constant irritation – eyelashes rubbing against ocular surface
  • Epiphora
  • Recurrent infections e.g. recurrent conjunctivitis due to all the muck on the eyelids
  • Corneal abrasion causing marked photophobia
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5
Q

What is the medical management of involutional entropion?

A
  • Ocular lubricants – reduce FB sensation and protect ocular surface
  • Antibiotic ointments/drops for pxs with recurrent infections
  • Eyelid taping is an effective temporary measure – small piece of tape stuck to lower lid skin to pull eyelid down – used for few hours at time – gives great relief
  • Botox injection to the lower eyelid can temporarily correct entropion – often used in hospital in meantime while px waiting for eyelid surgery to correct it properly
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6
Q

Describe eyelid everting sutures?

A
  • Temporarily corrects entropion
  • Put stitches on eyelid to put eyelid into position – last 6-8 months
  • Like taping but lasts a lot longer
  • Office procedure
  • Sutures pass from conjunctiva, below tarsal plate to the skin 2-4mm below lashes
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7
Q

Describe cicatricial entropion?

A
  • Normally caused by conjunctival contraction/cicatrisation
  • Primary pathology: inflammatory insult to conjunctiva
  • Chemical injuries
  • Stevens-Johnson – inflammatory syndrome
  • Ocular Cicatricial Pemphigoid – conj shrinks & pulls eyelid in
  • Eyelid retractors are normal, and orbicularis is normal, pathology is in conj
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8
Q

What is the treatment for cicatricial entropion?

A
  • More challenging to treat
  • Disease process need to be arrested
  • Release of scar tissue & posterior lamellar graft often required (mucous membrane) – usually taken from inside of the mouth
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9
Q

Describe spastic entropion?

A
  • Ocular irritation – corneal abrasion or corneal ulcer can cause quite marked ocular surface pain
  • Secondary blepharospasm can be induced
  • Botox may help to relieve the spasm or the squeezing
  • Typically seen in small children or elderly patients with dementia – who squeeze eye hard in response to pain in eye
  • Treatment is of the ocular surface rather than the eyelid
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10
Q

Things to remember with entropion

A

Patients with entropion can be quite miserable w/ constant ocular irritation & medical/ surgical treatment can transform their quality of life immediately

When assessing px with entropion, it is important to assess the corneal surface and if there is significant damage and affecting pxs quality of life -> URGENT referral to eye clinic

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11
Q

What is ectropion? List the types?

A
  • V common
  • Opposite of entropion – eyelid hanging down
  • CONGENITAL: not present in primary setting
  • ACQUIRED:
    o Involutional/ age related: >90%
    o Paralytic
    o Mechanical
    o Cicatricial
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12
Q

Describe involutional ectropion?

A
  • Similar changes as for entropion – horizontal & vertical eyelid laxity
  • Main difference is orbicularis – in entropion there is over-riding but not in ectropion, orbicularis is unchanged in ectropion causing eyelid to drop down with gravity
  • When lid margin begins to evert, conjunctiva begins to get exposed resulting in tarsus thickening further exacerbating ectropion
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13
Q

Symptoms of involutional ectropion?

A
  • Asymptomatic – eyelid just hangs down
  • Epiphora – tears don’t have access to tear duct and leak down from eye
  • Exposed chronically irritated conj
  • Eyelid skin changes – salty tears cause skin irritation – red, scaly
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14
Q

Describe lid laxity regarding the Medial Canthal Tendon (MCT)?

A
  • Horizontal eyelid laxity
  • Pull eyelid laterally & observe punctal migration
  • 1-2mm migration – normal
  • Up to limbus – mild MCT laxity
  • Limbus to pupil – moderate laxity
  • Beyond pupil – severe MCT laxity
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15
Q

Describe lid laxity regarding the Lateral Canthal Tendon (LCT)?

A
  • Observe lateral canthal angle – normally acute angle
  • Rounded canthus – LCT laxity
  • Pull lid medially & observe lateral canthal migration (normal <2mm)
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16
Q

Describe mechanical ectropion?

A
  • Eyelid tumours/lesions causing ectropion by their weight
  • Treatment – removal of lesion +/- eyelid tightening – eyelid may have stretched from hanging down for number of months before it’s treated
17
Q

Describe paralytic ectropion?

A
  • VII nerve palsy- Bell’s Palsy – causes paralysis of orbicularis muscle, support to lower eyelid is lost so can hang down causing ectropion
  • Inadequate eyelid closure (Lagophthalmos) – can lead to chronic corneal exposure, damage to ocular surface & is at risk of significant visual loss unless treated soon
  • Often associated with MCT and LCT laxity
  • Brow ptosis – loss of function of frontalis muscle of eyebrow
18
Q

Management of paralytic ectropion?

A
  • Aim of treatment – protect cornea, improve cosmesis
  • Significant number will get better spontaneously as VII nerve palsy often recover in 3-6 months
  • Ocular lubrication & temporary tarsorrhaphy (stitch between upper and lower tarsal plates to close eyelid temporally till it corrects itself) if recovery expected
  • If no recovery in 3-6months, surgical procedures can be done to tighten lower eyelid:
    -Lower eyelid tightening using stitches
    -Lower eyelid slings
  • Lagophthalmos may need correction with upper lid lowering with gold weights – to cause a ptosis which helps to close eye mechanically
19
Q

Describe cicatricial ectropion?

A
  • Eyelid scarring on skin from previous trauma/surgery
  • Some cicatrising tumours which cause scarring and mechanically pull eyelid down
20
Q

Medical management of ectropion?

A
  • Some are asymptomatic with no effect on the ocular surface – they can be left alone
  • Lubricants for eye
  • Antibiotics for recurrent infection
  • If there are skin changes on lower lid skin secondary to tears irritating it, using skin emollients e.g. Vaseline or E45 for cicatricial changes. These protect the lower lid skin whilst these patients are waiting for surgery
21
Q

What is distichiasis?

A
  • Can be congenital or acquired
  • Eyelashes arise from meibomian glands on posterior lamella of eyelid margin
  • Congenital: autosomal dominant
    o The lashes are thinner & shorter & often directed posteriorly – only become symptomatic ~age of 5
  • Acquired: intense conj inflammation (e.g. chemical injury, Steven-Johnson Syndrome, ocular cicatricial pemphigoid)
    o The lashes are non-pigmented & stunted, usually symptomatic
22
Q

What is trichomegaly?

A
  • Excessive eyelash growth
  • Causes:
    o Drug-induced – topical prostaglandin analogues, phenytoin & ciclosporin
    o Malnutrition
    o AIDS
    o Porphyria (abnormal metabolism of the blood pigment haemoglobin)
    o Hypothyroidism
    o Familial
    o Congenital: Oliver-McFarlane, Cornelia de Lange, Goldstein-Hutt, Hemansky-Pudlak syndromes
23
Q

What is poliosis?

A
  • Premature localised whitening of hair, may involve lashes & eyebrows
  • Causes:
    o Ocular:
     Chronic anterior bleph
     Sympathetic ophthalmitis
     Idiopathic uveitis
    o Systemic:
     Vogt-Koyanagi-Harada Syndrome
     Waardenburg syndrome
     Vitiligo
     Marfan Syndrome
     Tuberous sclerosis
24
Q

What is a ptosis?

A
  • Abnormal low-lying upper eyelid margin with eye in primary gaze
  • Normal adult upper eyelid margin – about 1.5mm below superior corneal limbus
  • Highest point of upper eyelid just nasal to pupil
25
Q

Classification of ptosis?

A
  • Congenital or acquired
  • True or pseudoptosis:
  • Etiologic classification:
    -Aponeurogenic – commonest senile ptosis
    -Myogenic
    -Neurological
    -Mechanical
26
Q

Describe aponeurogenic (senile) ptosis?

A
  • Most common type
  • Weakness of levator aponeurosis – inserts into anterior surface of tarsal plate & upper lid skin crease
  • Droopy upper eyelid – worse at end of day – muscle gets tired working all day
  • High/absent skin crease
27
Q

Describe myogenic ptosis?

A
  • Due to an abnormality in the muscle
  • Ptosis secondary to generalised muscular disease that affect eye
  • Myasthenia Gravis – variable ptosis, diplopia, other systemic disorders like difficulty in swallowing, proximal muscle weakness that gets worse at end of day and in severe cases this can lead to breathing difficulties
  • Often in younger patients – more at risk of developing muscular disorders
  • Chronic progressive external ophthalmoplegia
  • Myotonic dystrophy – “genetic condition that causes progressive muscle weakness & wasting”
28
Q

Describe neurogenic ptosis?

A
  • Problem with nerve
  • Oculomotor (III) nerve palsy – ptosis, fixed dilated pupil, paralysis of MR, SR, IR, IO
  • Horner’s syndrome – paralysis of Muller’s muscle secondary to sympathetic abnormalities usually in neck
29
Q

Describe mechanical ptosis?

A
  • Eyelid swelling
  • Eyelid tumours that cause eyelid to droop down
  • Treatment: treat causative disorder causing eyelid to droop
30
Q

What would give the impression of a ptosis but is actually a pseudoptosis?

A
  • Loss of volume in the orbit– Artificial Eye, Phthisis bulbi – shrunken eye, Microphthalmos
  • Contralateral eyelid retraction – thyroid eye disease
  • Ipsilateral hypotropia
  • Enophthalmos
  • Brow ptosis
  • Dermatochalasis – “loose & redundant eyelid skin”
31
Q

Important history questions for px with ptosis?

A
  • Onset – “how long have you had it?” – congenital vs acquired (looking at old photos often helpful)
  • Family history – congenital ptosis
  • Trauma – can cause damage to levator
  • Previous ocular surgery
  • CL wear – long term – especially RGP – due to micro trauma happening with every blink of the eyelid happening over many years with gas permeable lenses
  • Diplopia, variability – points towards Myasthenia Gravis
32
Q

What would you look for in ptosis evaluation?

A
  • Rule out pseudoptosis – look at other eye to make sure that looks normal
  • Cover test/ocular motility – will reveal any vertical muscle imbalance which causes ptosis
  • Pupil evaluation – neurogenic ptosis – small pupil in Horner’s syndrome – fixed, dilated pupil in 3rd nerve palsy
  • Check for jaw winking
  • Levator fatigue – typical feature of Myasthenia Gravis – get px to look up for 30 seconds – pxs with Myasthenia Gravis cannot hold eyelid up for long enough
33
Q

What is the correction for ptosis?

A
  • Almost always surgical
  • Depends on strength of levator palpebrae superioris
  • Degree of eyelid excursion from downgaze to up gaze determines how strong levator is
  • If levator function good, then levator resection surgery is appropriate
  • Brow suspension procedures for patients with very poor levator function

Clinical Opthalmology (65 decks)

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