eyelids 2 (ptosis)

neurogenic ptosis

innervational defect such as third nerve palsy and Horner syndrome

>Horner’s mild ptosis (about 3mm down)

>3rd nerve palsy: down and out & ptosis

myogenic

caused my myopathy of levator muscle

usually myasthenia gravis

a common sign of MG is tiredness throughout the eye

young females

aponeurotic or involutional

levator aponeurosis

dropping down/sagging

elderly

mechanical

tumors, gravitational effect of mass or scarring

pseudoptosis

dermatochalasis simulates ptosis

symmetrical

measure MRD if pt really has ptosis

palpebral fissure heights

males vs females

males 7-10mm

females 8-12mm

avg 10mm

ptsosis crease measurement

look for superior crease

aponeurotic: elevation in distance

congenital: NO crease

associated signs (pupils)

·      Horner’s syndrome (miosis)

·      3^rd nerve palsy

causes of pseudoptosis

-lack of support

-contralateral lid retraction

-ipsilateral hypotropia

-brow ptosis (excessive skin on brow) or CN7 palsy

>recognize by doing Hirchburg test

-dermatochalasis

simple congenital ptosis

failure of neuronal migration

signs: absent lid crease

due to poor levator function

congenital vs acquired ptosis

CONGENITAL

downgaze ptotic lid is higher than normal due to poor relaxation of levator muscle

>pts may elevate chin to see better

ACQUIRED

downgaze ptotic lid is level with or lower due to superior rectus weakness

tx: surgical tx

(levator resection)

marcus gunn

5% of all cases

unilateral

CN 7 misdirected to levator muscle

easy and fast to diagnose

horner’s syndrome cocaine 2-4% test

eye should dilate

if positive, pupil will not dilate

3rd nerve misdirection syndrome

3^rd nerve misdirection syndromes

may be congenital

       more frequently follow acquired 3^rd nerve palsy

 

>bizarre movements of upper lid

eye in down and out position

involutional ptosis

age related

caused by dehiscence, disinsertion or stretching or levator aponeurosis

>fatigue of Muller’s muscle

       worsens towards end of day

eyelid crutches

used if pt doesn’t want sx

uncommon but can be used

mechanical ptosis

result of impaired mobility of the upper lid

ectropion

Outward turning of the eyelid margin

Symptoms:

• Tearing

• FBS
• Epiphora
• Redness
• Asymptomatic

signs:

-positive snap-back test

-SPK

-dry eye

involutional ectropion

Eyelid horizontal laxity and gravity act to evert lid or disinsertion of lower lid retractors

age related

cicatricial ectropion

caused by scarring or contracture of the skin and underlying tissues, which pulls the eyelid away from the globe

• Causes:

  • Trauma

  • Burns

  • Dermatitis

  • Ichthyosis

  • Excessive skin excision (or laser) in blepharoplasty

  • Glaucoma drops (dorzolamide (Trusopt), brimonidine (alphagan)) due to allergic reaction – d/c

paralytic ectropion

mainly caused by ipsilateral facial nerve palsy

signs: Flattening of the entire face with loss of forehead wrinkles, infraorbital fold and nasolabial fold

tx: -protect cornea (lubrication and close eye during sleep)

>botulinum toxin injection into levator

>temporary tarsorrhaphy

>permanent paralytic ectropoin

mechanical ectropion

Caused by tumors on or near the lid margin that mechanically evert the lid

tx: removal of cause

correction of lid laxity

entropion

Symptoms: • Irritation

• FB sensation
• Pain
• Spastic closure of lids

Signs
• Lid margin toward the globe
• Trichiasis (“secondary trichiasis)

involutional entropion

age related

affects mainly lower lid

floppy eyelid syndrome

uncommon unilateral or bilateral

soft, rubbery easily everted lid

obese middle-age who sleep face down

blepharochalasis

uncommon

>recurrent episodes of painless, non-pitting edema of both upper eyelids

eyelid becomes stretched (wrinkled cigarette paper)

how does blepharochalasis differ from dermatochalasis

blepharochalasis has recurrent episodes of edema but derm does not

eyelid myokimia

signs:

-eyelid twitching, fasciculations or orbicularis muscle

symptoms:

my eye appears to jump

unknown pathogenesis

blepharospasm

Involuntary hyper-contractions of Orbicularis muscle–uncontrollable lid closure

essential blepharospasm

Patient complains that eyes

keep closing from “spasm”

lagophtalmos

Incomplete lid closure

3 types

mild

mod

severe