1. Disease of the Eyelashes and Eyelids: Eyelid Variations to Positional Eyelid Disease

Eyelid Variations to Positional Eyelid Disease

What is the upper eyelid made up of?

• Orbicularis oculi

• Tarsal muscle of muller

• Tarsal plate

• Levator muscle

What is the lower eyelid made up of?

• Orbicularis oculi

• capsulopalepebral fascia

• Tarsal plate

Where are the meibomain glands relative to the eyelashes?

Posterior

What are meibomain glands responsible for?

Producing lipid layer of the tears

What are the functions of the eyelids?

• Provide protection/cover the globe

• Assist in drainage of tears/move tears to medial canthus

• Spread tears

• House structures needed in the production of the tear film

What are the eyelashes function?

Aid in blink reflex via nerves which make the cilia sensitive

What are epicanthal folds?

Oblique or vertical folds from the upper lid to the lower lid towards the medial canthus

What causes epicanthal folds?

Excessive skin across the bridge of the nose

When are epicanthal folds present?

• common in infants between 3 and 6 months of age

• 40-90% incidence in asian individals

• 60% incidence in individuals with Down Syndrome

Why do epicanthal folds give the appearance of esotropia?

Decreased scleral show

What are the types of epicanthal folds?

• Tarsalis

• Inversus

• Palpebralis

• Superciliaris

How can you determine if a patient with epicanthal folds has an eye turn?

Purkinje image. If symmetrical, then no eye turn.

How does epicanthus tarsalis present?

Prominent skin along the upper lid, most common variant in asian population

How does epicanthus inversus present?

Prominent skin along lower lid.

How does epicanthus palpebralis present?

Excess skin on both upper and lower lids

How does epicanthus supraciliaris present?

Skin fold originates from the brow and follows down to the lacrimal sack. It is the least common epicanthal fold variant.

How are epicanthal folds graded?

• Mild folds : covers less than 1/3 of the caruncle

• Moderate: covers ½ of the caruncle

• severe: covers all of the caruncle

How are epicanthal folds treated?

• Observation in most cases

• Surgical: rare, done for epicanthus inversus

What is epiblepharon?

Horizontal fold of skin that covers the eyelid margin, typically due to hypertrophic orbicularis oculi muscle. This causes the eyelashes to rotate towrads the globe, giving the appearance of entropion.

Where is epiblepharon commonly seen?

It is commonly seen in Asian and Hispanic individuals

What are the treatments for epiblepharon?

• Spontaneously resolves with age

• Occasionally requires surgery

What is Trichiasis?

Misdirection of lashes

What are the causes of Trichiasis?

Scarring or isolated mis-growth

What are the symptoms of trichiasis?

Ocular irritation that worsens with blinking

What is PEE?

Punctate Epithelial Erosions

What are some complications of longstanding trichiasis?

PEE, Corneal ulceration or scarring (pannus)

Where are PEE seen due to trichiasis?

Usually superior or inferior of the cornea, rarely seen centrally.

What is distichiasis?

When meibomian glands develop into a pilosebaceous unit/hair folicle

What types of distichiasis are there?

Congenital and Acquired

What is congenital distichiasis?

An autosomal dominate distichiasis. Presents with primary lymphedema.

What is acquired distichiasis?

When meibomain glands turn into hair follicles after severe conjunctival inflammation

What causes acquired distichiasis?

Severe conjunctival inflammation

What are the treatments for trichiasis and distichiasis?

• Epilation (temporary relief)

• Electrolysis

• Laser ablation

• Cryotherapy

What is eyelash ptosis?

The downward sagging of the upper lid lashes

What causes eyelash ptosis?

Idiopathic or seen with floppy eyelid syndrome or dermatochalasis

What is trichomegaly?

Eyelashes that exceed the normal length (12mm) or thickness.

What are the causes of trichomegaly?

• Congenital heart disease

• Aquired: atopic dermatits, HIV, vernal keratoconjunctivits

• Drug induced: prostaglandins

What are the treatments for trichomegaly?

None

What is madarosis?

The loss of lashes

What are the causes of madarosis?

• Anterior lid disease

• Burns (thermal & chemicals)

• Generalized alopecia

• Trichotillomania (TTM), or hair-pulling disorder

What is Poliosis?

Premature whitening of the eyelashes and eyebrows

What are the causes of poliosis?

• Anterior blepharitis

• Vogt-Koyanagi-Harada syndrome

• Vitiligo

• Marfan syndrome

• Tuberous sclerosis (non-cancerous tumors throughout the body)

What are the treatments for poliosis?

None

What is ptosis?

Abnormally low position of the upper lid, below 10 & 2 position on the cornea

What are the types of ptosis?

• Neurogenic

• Myogenic

• Aponeurotic

• Mechanical

What are the causes of neurogenic ptosis?

Innervational defects, such as 3rd nerve palsy, Horner’s Syndrome, and marcus gunn jaw winking syndrome.

When is marcus gunn jaw-winking syndrome seen?

Seen at birth, typically unilateral

What are signs of marcus gunn jaw-winking syndrome?

Retraction of ptotic lid with stimulation of the ipsilateral pterygoid muslces, such as chewing, sucking, and opening of the mouth

What are the treatments for marcus gunn jaw-winking syndrome?

Surgical if ptosis causes functional or cosmetic problems

What is myogenic ptosis?

Myopathy of the levator muscle or impairment of impulses at neuromuscular junction

What causes myogenic ptosis?

• Myastenia gravis (ptosis that worsens with fatigue)

• Myotonic dystrophy

What is myasthenia gravis?

An immunologic disorder that affects the neuromuscular junction and transmission. Voluntary muscles fatigues due to sustained or repeated muscle activity

What diagnostic tests are ran to diagnose myasthenia gravis?

• Tensilon testing (PCP contacts neurologist for test)

• In office diagnostic testing: sustained up gaze and ice pack test

If a Pt has myasthenia gravis, what results should you expect to see with the in office diagnostic tests?

• Sustained up gaze: should see a worsening ptosis from looking up for 5 minutes

• With the Ice Pack Test ptosis should improve/reduce

What are the treatments for myasthenia gravis?

• Systemic: medication, thymus gland removal

• Ocular: occlusion (diplopia), prism (diplopia), surgery

What is myotonic dystrophy?

Genetic condition (autosomal dominant) disorder characterized by increased muscle contraction and slow muscle relaxation, muscle weakness and muscle atrophy.

What age is myotonic dystrophy commonly seen at?

20-30 yr olds

What are the treatments for myotonic dystrophy?

Medication and surgery as needed

What is aponeurotic ptosis?

A defect to levator aponeuroris

What types of aponeurotic ptosis are there?

• Involutional ptosis

• Mechanical ptosis

How does involutional ptosis present?

• Bilateral

• High upper lid crease

• Good levator function

• In severe cases: upper lid crease will be absent, eyelid will be thin over tarsal plate and the upper sulcus will be deep

What are some causes of mechanical ptosis?

Chalazion, eyelid inflammation, or edema

What are the treatments for ptosis?

Surgery. 3 types: conjunctiva-Muller resection, levator resection, brow lift

What is pseudoptosis?

False impression of ptosis

What causes pseudoptosis?

• Lack of support seen with deficit of orbit volume-prosthetic eye

• Contralateral lid retraction

• brow ptosis

• dermatochalasis (most common)

What is entropion?

The inward turning of the lid margin that pushes eyelashes onto the globe.

What are common associated signs of entropion?

PEE, conj injection, and in severe cases, corneal thinning and ulceration

What types of entropion are there?

• Involutional

• Cicatricial

• Spastic

• Congenital

What is involutional entropion?

The inward turning of the lower lid margin

When and where is involutional entropion seen?

Commonly seen with aging and mainly affects the lower lid as the superior lid has a broader tarsal plate and is more stable.

What are the treatments for involutional entropion?

Temporary: lubrication, lid taping, bandage, contact lenses, botulinum toxin injection to lower lid
Permanent treatment: surgical

What are the causes of involutional entropion?

• Horizontal lid laxity

• Vertical lid instability

• Over-riding of the pretarsal

• Orbital septum laxity

What is cicatrical entropion?

The inward turning of the lid margin due to severe scarring of the palpebral conjunctiva.

What are the treatments of cicatrical entropion?

Treatment of complications and surgery

What is spastic entropion?

Entropion due to excessive contraction of the orbicularis oculi muscle, often due to irritation, inflammation, or muscle spasms

What causes spastic entropion?

Inward turning of the eyelid with forceful eyelid closure. Can lead to active inflammation or infection which worsens the condition.

What are the treatments for spastic entropion?

• Eyelid taping

• Botulinum toxin injections

• Surgical

What are the unique characteristics of congenital entropion?

• rare

• can affect the upper or lower lid

• upper lid due to mechanical effects of microphthalmos

• lower lid due to improper development of the inferior retractor aponeurosis

Why does upper lid have entropion in congenital entropion?

Due to mechanical effects of microphthalmos= eyeball not big enough.

What is ectropion?

Outward turning of the eyelid margin.

What are common associated signs of ectropion?

• PEE

• Conj injection

• conj thickening and keratinization

• conj dryness

What are the types of ectropion?

• Involutional

• Cicatricial

• Paralytic

• Mecahnical

Who commonly has involutional ectropion?

Elderly individuals

Where is involutional ectropion typically seen?

Lower lid

What are the treatments for ectropion?

Surgical, if underlying conditions merit surgery

What causes cicatricial ectropion?

Scarring or contracture of the skin and underlaying tissues that pulls the eyelid away from the globe

What are the treatments for cicatricial ectropion?

For local, scar tissue will be surgically removed. For severe, surgical placement of skin grafts

What causes paralytic ectropion?

Caused by ipsilateral facial nerve palsy (CN 7). Can be bell’s palsy or removal of acoustic neuroma.

What is another concern with paralytic ectropion?

Lagophthalmos

What are the treatments for paralytic ectropion?

Temp: relieve symptoms

Permanent: Surgical repair: upper and lower lids sutured together medial, gold weight implantation in upper lid, later canthal sling, upper lid lowering