Eyelids: Part 2

Question 1

characteristics:

dystrophic levator muscle

Answer 1

congenital ptosis

Question 2

symptoms: visual loss, diplopia, headache, pain
signs: anisocoria, proptosis, ocular motility defects

-superior tarsal fold usually absent/poorly developed
-may have weak/no eyelid crease
-ptosis decreases in down-gaze
—compensates by looking in chin up position

which signs & symptoms are these for?

Answer 2

congenital ptosis

Question 3

characteristics:
neurogenic: innervational defect
—eg, CN3 paresis, Horner’s syndrome

myogenic: myopathy of levator muscle or impairment of transmission of impulses at NMJ
—eg, myasthenia gravis, myotonic dystrophy, progressive external ophthalmoplegia

aponeurotic/involutional → levator aponeurosis
—eg, age-related — fibrous tissue takes over tendon

mechanical → gravitational effect of a mass or from scarring
—eg, hordeolum, chalazion

Answer 3

acquired ptosis

Question 4

symptoms: visual loss, diplopia, headache, pain
signs: anisocoria, proptosis, ocular motility defects

• crease appears higher than usual
• ptosis in affected eye is level w/ or lower than normal lid in downgaze
• bilateral frontalis contraction (raised eyebrows)
• may have increases w/ stress, fatigue (diurnal variation)

what signs & symptoms are these for?

Answer 4

acquired ptosis

Question 5

what is the management for (congenital/acquired) ptosis?

Answer 5

upneeq (oxymetazoline 0.1%): 1 drop per day in affected eye for 6 weeks

—elevates upper eyelid — direct-acting alpha adrenergic receptor → selectively targets Mueller’s muscle

Question 6

characteristics:

false impression of ptosis caused by —
—common cause: TED (thyroid eye disease)
—lack of support of lids by the globe due to orbital volume deficit

Answer 6

pseudoptopsis: contralateral lid retraction

Question 7

signs & symptoms:

• abnormal PFH height & MRD1
• droopy contralateral eyelid
• positive lid lag
• proptotic eye

Answer 7

contralateral lid retraction

Question 8

if cause established & symptoms mild — 
—treatment of underlying condition
     — chalazion: warm compresses w/ massage
     — eyelid neoplasm: excision
—observation
—taping upper lids open
—eyelid crutches attached to glasses

if cause not established &/or symptoms not addressed w/ conservative management, include all findings & refer to —
—neuro-ophthalmology — neurogenic, myogenic
—oculoplastics — congenital (esp. important to prevent occlusion amblyopia), aponeurotic, mechanical

what management is this for?

Answer 8

pseudoptopsis: contralateral lid retraction

Question 9

characteristics:

false impression of ptosis caused by —
—familial tendency
—middle to older age groups

Answer 9

pseudoptopsis: dermatochalsis

Question 10

signs & symptoms:

• usually bilateral
• loose & redundant tissue fold
• draping of superior lid tissue over septum or lid margin

Answer 10

dermatochalasis

Question 11

what is the management for dermatochalsis? what happens if left untreated?

Answer 11

blepharoplasty (if creating problems)

if left untreated → may also cause mechanical ptosis

Question 12

what are these characteristics indicative of?

infectious, involutional, cicatrical

Answer 12

ectropion

Question 13

signs & symptoms:

out-wardly turned eyelid margins

Answer 13

ectropion

Question 14

This management is indicative of what?
lubricating ointment & eyelid taping at night

• identify underlying cause
• artificial tears & cool compresses
• bacitracin or erythromycin

referral to oculoplastics
—only if long-standing, stable
to address significant corneal exposure, permanently correct

Answer 14

ectropion

Question 15

characteristics:

congenital, allergic, mechanical, paralytic (CN7 palsy)

Answer 15

entropion

Question 16

in-wardly turned eyelid margin

Answer 16

entropion

Question 17

This management is indicative of what?

bandage soft CLs

• identify underlying cause
• artificial tears & cool compresses
• bacitracin or erythromycin

referral to oculoplastics
—only if long-standing, stable
to address significant corneal exposure, permanently correct

Answer 17

entropion

Question 18

characteristics:
suspected etiology —
—abnormality of collagen & elastin fibers
—spontaneous eversion of upper eyelid during sleeping
—superior palpebral conjunctiva rubs against pillow/sheets

associations — 
—keratoconus
—skin hyperelasticity & joint hypermobility
—obstructive sleep apnea
      —normal tension glaucoma (NTG)
—diabetes
—mental retardation
—typically seen in obese males

Answer 18

floppy eyelid syndrome

Question 19

signs & symptoms:

• usually bilateral, asymmetric
• chronically red, irritated eyes
• mild mucous discharge
• symptoms worsen during awakening due to eyelid eversion at night

Answer 19

floppy eyelid syndrome

Question 20

• avoid sleeping face down
• eye shields or eyelid taping
• lubricating ointment QHS
• treatment for PEE (erythromycin or bacitracin TID)

refer to — internist to rule out OSA; oculoplastics

what is this management for?

Answer 20

floppy eyelid syndrome

Question 21

characteristics:
abnormal pauses in breathing/instances of abnormally low breathing
—excessive daytime sleepiness & fatigue
—may be recognized as a problem by others witnessing individual during episodes

Answer 21

sleep apnea

Question 22

what is the management for sleep apnea?

Answer 22

may create transient hypoxemia & increased vascular resistance
—consult w/ internist for sleep study
—seek treatment for sleep apnea if needed

Question 23

characteristics:
glaucoma (optic neuropathy) w/
—open, apparently normal anterior chamber angles
—glaucomatous optic nerve damage
—vision loss characteristic seen in pts w/ chronic glaucoma related to elevated IOP
—w/o a clearly abnormal IOP (within normal limits, around ≤21 mmHg)

Answer 23

normal tension glaucoma (NTG)

Question 24

what is the management for normal tension glaucoma (NTG)?

Answer 24

may create transient hypoxemia & increased vascular resistance
—consult w/ internist for sleep study
—seek treatment for sleep apnea if needed