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Fall 2014 Neuro Ophthalmic Disease > Fall 2014: Lecture 6: Eyelid Disorders > Flashcards

Fall 2014: Lecture 6: Eyelid Disorders Flashcards

1
Q

Eyelid Anatomy

  1. Purpose of Eyelid Function?
  2. What muscle causes the Eye to close?
  3. What muscles cause the eye to open and CNs involved?
A
  1. Protect Cornea from FBs. Maintain Corneal Tear Film.
  2. Orbicularis Oculi (CN 7)
  3. a. Frontalis Muscle (CN 7)
    b. Levator Palpebrae (CN 3)
    c. Aponeurosis of Levator Palpebrae
    d. Mueller Muscle (Sympathetic Innervation)
    e. Inferior Tarsal Muscles (Sympathetic)
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2
Q

Eyelid

  1. Normal Eye
    a. Upper eyelid covers how much of Superior Iris?

b. Palpebral Fissure opening (Vertical and Horizontal)?
c. Marginal Reflex distance?
d. Levator Function is usually what?

A
  1. a. 1-2 mm
    b. Vertical: 10-12 mm; Horizontal: 25-30 mm
    c. 4-5 mm
    d. at or >12mm
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3
Q

Clinical Examination

  1. Associated Symptoms
  2. Gross Examination includes…?
  3. Eyelid movement should be monitored for what?
  4. What drop should be used to dILATE?
A
  1. (Like…Dyspnea, Dysphagia, Dysarthria)
  2. Contour, Shape, Symmetry, Overt Abnormalities (Edema, Erythema, Lesions)
  3. Blink Rate, Synkinesis (lid movement accompanying Eye movements), tics, fasciculations, or blepharospasm.
  4. 2.5% Phenylephrine (slightly raises a PTOTIC LID).
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4
Q

Clinical Exam (2)

  1. How is LEVATOR Fatigue Examined?
    a. Progressive Drooping is a sign of what?
  2. How do you evaluate Orbicularis Oculi?
A
  1. Ask Pt to MAINTAIN upgaze for 1 MINUTE!
    a. of Ocular MG.
  2. Tell them to squeeze the eyes shut as tight as possible, and the examiner attempts to pry the lids open.
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5
Q

Ptosis: Neuropathic

  1. It’s Caused by one of the following (8)
A
  1. a. Supranuclear Lesion
    b. CN 3 Nuclear
    c. Fascicle
    d. Nerve Lesion
    e. Oculosympathetic Pathway Lesion
    f. Levator Aponeurosis Disinsertion
    g. Dehisence
    h. Thinning
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6
Q

Ptosis: Cortical Ptosis

  1. Usually Uni/Bi?
  2. It’s a RARE manifestation of dysfunction of what?
  3. What else is also Possible?
    a. Usually associated with what?
A
  1. UNILATERAL
  2. of Cerebral hemisphere Dysfunction (Angular Gyrus Lesion, Temporal Lobe Seizure, CVA, AVM)
  3. Bilateral Ptosis
    a. CVA (can happen several days to 5 months after the inciting event)…Treat underlying Etiology
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7
Q

Ptosis: Apraxia of Eyelid Opening

  1. It’s the Transient ability to initiate what?
  2. Charcot Sign: What is it?
  3. It also occurs with what?
A
  1. Voluntary Eyelid Opening
  2. Absence of Orbicularis Ocular contraction (like lowering of the brow beneath the orbital rim)
    * *Frontalis Contraction and Facial Grimacing during attempts to open the eyelids is noted.
  3. Essential Blepharospasm and s/p bilateral frontal lobe CVA.
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8
Q

Ptosis: CN 3 Palsy

  1. How does it present?

a. If Pupil is involved?
i. What neuroimaging should be done?

ii. If Neuroimaging is positive?
2. Special attention to what exams?

A
  1. Unilateral Ptosis w/DOWN and OUT EYEBALL POSITION w/or w/o Pupillary Involvement.
    a. Usually a Posterior Communicating Artery Aneurysm until PROVEN OTHERWISE.
    i. Digital Subtraction Angiography to evaluate for a small aneurysm if pupil is involved and the CTA or MRA is Inconclusive.
    ii. Neurosurgical consult STAT!
  2. CN Exam and BP!!
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9
Q

Ptosis: Horner Syndrome

  1. Triad?
  2. What will cause a reverse Ptosis?
  3. What Iris changes will occur?
  4. Acute Painful Horner’s Syndrome: ASSUME WHAT?!
    a. In children, what has to be ruled out?
  5. What should be used to test for Horners?
    a. If test is negative…?
A
  1. Ipsilateral Ptosis, Miosis, Anhidrosis
  2. Hypofunction of Mueller’s Muscle will result in a reverse Ptosis w/MRD2 Assessment
  3. Heterochromia (Congenital and Long-Standing Cases)
  4. ICA Dissection until proven otherwise. Evaluate STAT w/MRI and MRA of head and neck w/ and w/o Contrast.
    a. Neuroblastoma
  5. 0.5% or 1% Aproclonidine (Test is + if pupil DILATES!)
    a. Cocaine testing should be performed on a SEPARATE DAY (GOLD STANDARD!)
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10
Q

Ptosis: Levator Dehisence:

  1. MOST COMMON cause of ACQUIRED PTOSIS in ADULTS seen in the ELDERLY, CL wearers, and post-surgical
    a. What is seen w/the eyelid skin?
  2. Test ordered?
    a. Visually Significant = ?
A
  1. Uni or bi Ptosis. ABSENT SUPERIOR LID CREASE
    a. Thinning of skin above tarsal plate. Ptosis can look worse in downgaze (interferes with reading)
  2. VF test w/lids taped and untaped.
    a. At or below 20 degrees of central fixation —> Blepharoplasty.
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11
Q

Myopathic Ptosis

  1. Define
A
  1. Due to LPS Muscle damage (Congenital/developmental or mitochondrial causes)
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12
Q

Myopathic Ptosis: Congenital Ptosis

  1. Most common form of Ptosis in what?
  2. Cause?
  3. Mostly Uni/Bi?
  4. Signs?
  5. Systemic?
A
  1. KIDS!
  2. Decreased striated muscle fibers, hyaline degeneration, fatty replacement and increase in endomysial collagen and loss of cross-striations.
  3. UNILATERAL!
  4. Chin up head posture, Frontalis muscle contraction.
  5. Heart, Brain, skeletal, auditory, or urogenital abnormalities.
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13
Q

Myopathic Ptosis: CPEO

  1. what is it?
  2. Ptosis: Symmetric or not?
  3. Signs?
  4. DDx?
  5. Bx?
  6. Tx?
A
  1. Mitochondrial myopathy w/Bilateral Ptosis that usually precedes ophthalmoplegia by months to years.
  2. Symmetric, SLOW PROGRESSION (chin up posture, excessive brow wrinkling, and general tolerance to ptosis and diplopia)
  3. Eyelid opening and closure is WEAK!
  4. MG, Myotonic Dystrophy
  5. Ragged red fibers.
  6. Nothing works.
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14
Q

Ptosis: Neuromuscular: MG

  1. Pupil involvement?
  2. Ptosis?
  3. Diplopia?
  4. Symptoms
  5. Onset
  6. 15% of cases have what?
  7. Treatment
A
  1. No
  2. varies. (Uni/Bi)
  3. varies.
  4. arm/leg weakness, diplopia, ptosis, diffiiculty chewing, dysarthria, dysphagia, dyspnea.
  5. Any. (Female: 60)
  6. Thymoma
  7. Mestinon (Pyridostigmine) and or Immunosuppressants
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15
Q

Ptosis: Mechanical

  1. Causes?
A
  1. Neoplastic, inflammatory infiltration, mass effect, edema (trauma), Cicatricial (Trachoma, erythema multiforme, Pemphigoid).
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16
Q

Ptosis: Pseudoptosis

  1. Most common cause?
  2. Other etiologies
A
  1. Dermatochalasis

2. Anophthalmos, Phthisis bulbi, microphthalmos, enophthalmos, hypertropia

17
Q

Retraction: Neuropathic

  1. Cause?
  2. Parinaud Syndrome
  3. Most common etiologies?
  4. Eyelid Nystagmus: what is it?
    a. Convergence-evoked eyelid nystagmus may be seen in Pts with what?
    b. Gaze Evoked Eyelid Nystagmus seen in Pts with what?
A
  1. Supranuclear Lesion (or can present as EYELID NYSTAGMUS)
  2. Symmetric, sustained lid retraction (COLLIER’s SIGN), normal lid movement on downgaze, setting sun sign or downgaze preference.
    * Convergence Retraction nystagmus.
  3. Posterior Commissure Lesion (Pineal Gland Tumor) or Hydrocephalus.
  4. Repetitive up and down movement of the upper eyelids. It’s a rapid phase stimulating eyelid retraction followed by a slow downward drift.
    a. MS and Cerebellar Tumors
    b. Hx of damage to Brainstem, Cerebellum, or Both.
18
Q

Retraction: Myopathic

  1. TED: causes what?
  2. Diplopia?
  3. Things that can cause TED?
  4. Signs?
  5. Dx is typically clinical but what else could be done?
  6. Tx for Severe orbital congestion?
A
  1. Transient or Constant uni/Bilateral Lid Retraction
  2. Intermittent or Constant Diplopia can occur
  3. Hyper/Hypo thyroidism. Euthryroidism.
  4. Disc Edema, Blurred Vision, Dyschromatopsia, Central Scotoma, or other VF loss may result.
  5. Orbital CT w/o Contrast may be warranted.
  6. Oral or IV Corticosteroids, Orbital Decompression, or Radiation Therapy may be warranted.
19
Q

Retraction: Neuromuscular: MG

  1. Signs?
  2. Testing?
A
  1. Cogan’s Lid Twitch (Orbicularis Oculi Weakness, Ocular Motility Disorders, and Strabismus)
  2. Tensilon or Prostigmin induce some retraction in some patients.
20
Q

Retraction: Mechanical

  1. Primary Etiologies?
A
  1. TED, Mass, Cutaneous Cicatricial Disorders (Burns, Lacerations), CL Wear, Post-Surgical (Blepharoplasty overcorrection, Rectus Muscle Surgery, Trabeculectomy, Cataract Extraction, Scleral Buckling, Orbital floor repair, and blow-out fracture)
21
Q

Retraction: Evoked by Jaw Movement

  1. Marcus Gunn Jaw-Winking
    a. Define

b. What happens?
c. Affected Eyelid is what at REST?

A
  1. Synkinesis of the Pterygoid Muscles (CN 5) and the Levator (CN 3).
    b. Elevation of 1 eyelid with jaw movement.
    c. Ptotic at rest.
    * Jaw muscles contract, eyelid retraction occurs.
22
Q

Retraction: Combined Paradoxical Levator Excitation & Contralateral Levator Inhibition

  1. Aberrant Regeneration CN 3 may be what?
  2. Eyelid Retraction occurs with what movement?
  3. w/Abduction, what happens?
  4. Lateral Rectus Contracts, what happens?
A
  1. Congenital, Acquired s/p trauma, CN3 Palsy, Aneurysm, or Mass
  2. Infraduction, Adduction, or BOTH.
  3. Contralateral Eye becomes Ptotic!
  4. Ipsilateral MR and Levator are Inhibited
23
Q

Insufficiency: Neuropathic

  1. Supranuclear Paralysis of Voluntary Lid Closure
  2. Peripheral CN 7 Palsy
    a. Tx?
    b. Most common cause?
  3. Aberrant Regeneration of the Facial Nerve (AFR)
    a. Occurs in what % of Bell’s Palsy Patients?
    b. Where’s Ptosis noted?
A
  1. 2ndary to frontal lobe CVA, CJ Dz, PSP, Motor Neuron Dz. (Pt can’t start voluntary eyelid closure even tho they understand the task and have an intact reflex for it).
  2. Pt has insufficient closure or weakness of eyelid closure.
    a. ATs and Ointments, Eyelid Taping, Tarsorrhaphy, and Eyelid Weights.

b. Bell’s PALSY!

  1. a. 10-20%
    b. on affected side w/decreased palpebral aperture opening. (Reduced MRD1 and 2 as well)
24
Q

Insufficiency: Myopathic

  1. The Orbicular Oculi Muscle is ALWAYS weakened by any Dz that weakens what?
A
  1. the Facial Musculature esp in Mitochonridrial Cytopathies like CPEO, Congenital Muscular Dystrophy, and Myotonic Dystrophy
25
Q

Insufficiency: Blepharospasm

  1. Can be a result of what?
A
  1. Brainstem or Basal Ganglia Dz, Ocular abnormality, or a drug-induced tardive dyskinesia.
26
Q

Excessive: Facial Tics & Tourette Syndrome

  1. What are Facial Tics?
  2. Eye-Winking Tics
    a. Common in whom?
    b. Typically what?
  3. Tourette Syndrome
A
  1. Brief, Clonic, Jerk-like, stereotyped and repetitive movements that vary in frequency. (Increase in Boredom, Fatigue, or Anxiety)
  2. a. Children
    b. Unilateral and have a male predilection. (usually resolve spontaneously after months or years)
  3. Tics…Onset: 7-10 yrs of age w/Female Predilection. Vocalizations (Echolalia and Coprolalia)
27
Q

Excessive: Frontal Eyefield Seizure

  1. Results in what?
A
  1. Contralateral Spasmodic Eyelid Closure, Facial Twitching, Spastic Lateral Gaze, and Eyelid Blinking or fluttering (May be bilateral and symmetric or alternatively unilateral blinking ipsilateral to the seizure focus)
28
Q

Excessive: Facial Myokymia

  1. What is it?
  2. Eyelid Myokymia
  3. Spastic-Paretic Facial Contracture
A
  1. Involuntary, fine, continuous, undulating contraction…spreads across facial muscles (typically unilateral phenomenon)
  2. Most common type of myokymia w/lower eyelid orbicularis oculi affected greater than the upper eyelid region. can be induced by fatigue, stress, or excessive caffeine intake and usually benign.
  3. myokymia that starts w/orbicularis oculi and gradually spreads to most of the muscles on one side of the face. Voluntary facial movements on one side of the face diminish.
    * Pontine Dysfunction in the region of CN 7 is the culprit namely MS, Tumor, Vascular Lesion, Guillain-Barre Syndrome, or hydrocephalus.
29
Q

Excessive: Hemifacial Spasm

  • Involuntary, Paroxysmal burst of painless, unilateral, tonic or clonic contraction of muscles innervate by CN7.
  • Mainly Middle aged adults.
A
  1. Cause: Vascular Compression of CN 7 (by normal arteries or veins in 99% of cases).
  2. Tx: Meds, Botox, Posterior Fossa Microvascular Decompression
    * Rare cause: tumor, aneurysm, arterial dissection, granuloma, cyst, MS or infarction

Fall 2014 Neuro Ophthalmic Disease (14 decks)

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