Eyelids

Anterior Segment - Exam 1

Eyelash condition where eyelashes turn toward the ocular surface

Trichiasis

In trichiasis the eyelid is in the _____ (normal/abnormal) position and lashes frow from the _____ (right/wrong) place.

normal; right

What eyelash condition is this?

Trichiasis

What is trichiasis caused by?

1. Scarring of the tarsal plate and/or conjunctiva (from trauma, surgery, or trachoma from chlamydia trachomatis)

2. Eyelid inflammation

3. Epiblepharon

4. Conjunctival cicatrizing disorders (OMMP, SJS, TEN)

What condition is this?

Trachoma

This is the management of what eyelid condition:

• Protect the ocular surface

  • Lubrication

  • Contact lenses

  • Epilation - lash removal

    • Forceps (every 6-10 weeks)

    • Argon Laser Photocoagulation

    • Cryotherapy (cold gas freezes lash follicles)

    • Radiofrequency ablation (ablates root of lash follicle)

Trichiasis

Eyelash condition where the pre-septal portion of orbicularis oculi and extra fold of tissue override the lid margin (usually the lower lid)

Epiblepharon

Eyelash condition that is congenital, relatively common, bilateral, and has no definitive cause.

• Common in Asian, Hispanic, and Native American populations

Epiblepharon

What eyelash condition is this?

Epiblepharon

What eyelash condition can resolve with facial bone growth by 2 years old?

• If not, surgical repair, but can recur

Epiblepharon

Eyelash condition that is a rare, chronic, autoimmune disease:

• Bilateral blistering and scarring of conjunctiva and cornea

• Relapsing-remitting

Ocular Mucous Membrane Pemphigoid (OOMP) or Ocular Cicatricial Pemphigoid (OCP)

Eyelash condition that is vision-threatening

• 20% blindness from cornea scarring

Ocular Mucous Membrane Pemphigoid (OOMP) or Ocular Cicatricial Pemphigoid (OCP)

Eyelash condition that can be misdiagnosed in early stages, until symblepharon forms

• F > M, age 60+

• Treat systemically and ocular involvement

Ocular Mucous Membrane Pemphigoid (OOMP) or Ocular Cicatricial Pemphigoid (OCP)

Eyelash condition that is a rare, severe skin reaction triggered by Type VI hypersensitivity reaction primary to medications (sulfonamide antibiotics, anticonvulsants) or infection

Stevens-Johnson Syndrome (SJS) & Toxic Epidermal Necrolysis (TEN)

Eyelash condition that is potentially vision and life-threatening

• Damages mucous membranes

  • Acute: conjunctival hyperemia, corneal epithelial defects

  • Chronic: severe cicatrization of lids and conjunctiva (→ trichiasis)

Stevens-Johnson Syndrome (SJS) & Toxic Epidermal Necrolysis (TEN)

How do you diagnose SJS/TEN?

Biopsy

What eyelash condition is this?

• <10% of body surface area

Stevens-Johnson Syndrome (SJS)

What eyelash condition is this?

• >30% of body surface area

Toxic Epidermal Necrolysis (TEN)

Eyelash condition where there is a “double” row of lashes

• Finer, thinner, and shorter than normal lashes

• Can turn toward the ocular surface like trichiasis

Distichiasis

In distichiasis the eyelid is in the _____ (normal/abnormal) position and lashes frow from the _____ (right/wrong) place.

Normal; wrong

Where does the second row of lashes grow from in distichiasis?

Meibomian glands

What eyelash condition is this?

Distichiasis

Is congenital or acquired distichiasis isolated and associated with lymphedema (L-D Syndrome)?

Congenital

Is congenital or acquired distichiasis caused by chronic blepharitis, OMMP/SJS/TEN, chemotherapy, or trauma?

Acquired

This is the management of what eyelash condition:

• Protect the ocular surface

  • Lubrication

  • Contact lenses

  • Epilation - lash removal

    • Forceps (every 6-10 weeks)

    • Argon Laser Photocoagulation

    • Cryotherapy (cold gas freezes lash follicles)

    • Radiofrequency ablation (ablates root of lash follicle)

• Surgery

  • Lid splitting of anterior and posterior lamella to access lash follicles and then non-surgical method to remove lashes

Distichiasis

Eyelash condition where there is a loss of lashes (and eyebrows)

Madarosis (aka Milphosis)

Is congenital or acquired madarosis caused by Ehlers-Danlos Syndrome and Ichthyosiform erythroderma?

Congenital

Is congenital or acquired madarosis divided into non-scarring and scarring types?

Acquired

Is non-scarring or scarring acquired madarosis caused by:

• Blepharitis

• Dermatological conditions

• Systemic conditions

  • Autoimmune

  • Infection

• Makeup reaction

• Trauma

  • Trichotillomania

  • Eyelid tattooing

• Cocaine vape, barbiturates

• Medications

  • Miotics, cholesterol, anticoagulants, BOTOX

Non-scarring

Is non-scarring or scarring acquired madarosis caused by:

• Malignant lid tumors

• Cancer

• Chemotherapy

• Radiation

Scarring

Is non-scarring or scarring acquired madarosis reversible (non-destruction of the hair follicle)?

Non-scarring

Is non-scarring or scarring acquired madarosis irreversible (destruction of the hair follicle)?

Scarring

What eyelash condition is this?

Madarosis

What eyelash condition is this?

Madarosis

This is the management of what eyelash condition (non-scarring type only):

• Treat underlying cause

• Discontinue offending agent/medication, if possible

• Self-inflicted - patient education; reduce stress/therapy

• Lash serum

  • OTC or Rx bimatoprost (Latisse)

    • Educate re: potential side effects of prostaglandins

      • It can darken the color of the iris and deepen the sulcus

Madarosis

Abnormality of melanin in hair follicles

Poliosis

What eyelash condition is this?

Poliosis

Is congenital or acquired poliosis caused by:

• Piebaldism

  • White forelock and medial forehead depigmentation

• Waardenburg Syndrome

  • With deafness and iris heterochromia

Congenital

Is congenital or acquired poliosis caused by:

• Chronic blepharitis

• Medications

• Melanoma

• Autoimmune disease

  • Thyroid, sarcoidosis

  • VKH Syndrome: with uveitis and vitiligo

• Herpes Zoster

• Stress

• Age

Acquired

Eyelash condition where there is no effective treatment, but temporary measures include hair dye and eyelash tinting

Poliosis

What eyelash condition is this?

Poliosis

Abnormally long eyelashes

• >12mm centrally, >8mm peripherally

• Also increased curling, thickening & pigmentation

Trichomegaly

What eyelash condition is this?

Trichomegally

Is congenital or acquired trichomegaly: isolated or part of a syndrome

• Oliver-McFarlane syndrome

  • Dwarfism, chorioretinal atrophy, intellectual disability

Congenital

Is congenital or acquired trichomegaly caused by:

• Prostaglandins

• Cancer drugs

• VKC, HIV, connective tissue disorders

Acquired

Inward turning of eyelid

Entropion

Causes “Pseudotrichiasis” because the lid in in the wrong position.

Entropion

In entropion the eyelid is in a(n) _____ (normal/abnormal) position and lashes grow from the _____ (right/wrong) place.

Abnormal; right

What eyelid position condition has the following:

• Symptoms

  • FBS

  • Tearing

  • Photophobia

• Signs

  • Redness

  • Corneal involvement

    • Staining, infection, scarring

Entropion

What eyelid position condition is this?

Entropion

What is the most common type of entropion?

Involutional (senile)

What type of entropion is caused by age?

Involutional (senile)

Does involutional entropion involve the upper, lower, or both lids?

Lower

What type of eyelid position condition is this?

Entropion

What type of entropion happens due to "O'HARE"?

• Overaction of palpebral part of orbicularis oculi

  • Pulls inferior part of lower tarsal plate

• Horizontal lid laxity caused by stretching of cantonal tendons

• Atrophy of tarsal plate

• Retractor dehiscence of the lower eyelid retractors

• Enopthalmos of the globe

Involutional (senile)

What type of entropion happens when conjunctival fibrosis shrinks the posterior lamella?

Cicatricial

What type of entropion is this?

Cicatricial

Does cicatricial entropion involve the upper, lower, or both lids?

Both

What type of entropion is difficult to treat and has a high recurrence?

Cicatricial

What type of entropion is caused by the following:

• Autoimmune: OMMP

• Infectious: trachoma, herpes

• Trauma

• Chronic use of glaucoma drops

Cicatricial

What type of entropion is caused by the following and is often associated with involutional entropion:

• Post ocular surgery

• Inflammatory ocular conditions

• Blepharospasm or hemifacial spasm

Spastic

What type of eyelid position condition is:

• A type of dystonia

• Involuntary, tonic, spastic bilateral lid closure

• F > M, 50+

Blepharospasm

What can cause blepharospasm?

Idiopathic, Parkinson's, psychotropic meds

How do we treat blepharospasm?

Anti-cholinergic meds, Botox injections (lasts ~12 weeks)

Entropion test where you:

• Have the patient forcibly blink

• Look for internal rotation of lid and lagophthalmos

Orbicularis override test

What type of eyelid position is managed temporarily by:

• Protect the ocular surface:

  • Lubrication

  • Bandage CL

  • Lash epilation

  • Lid taping

  • Botox for blepharospasm

  • Quickert sutures

    • Tighten lower lid retractors and every lid

Entropion

What type of eyelid position is managed permanently by:

• Involutional: lid surgery

• Cicatricial: mucous membrane or amniotic membrane graft

• Spastic: antibiotics or immunosuppressives

Entropion

Outward turning of the eyelid

Ectropion

What eyelid position condition is this?

Ectropion

What eyelid position condition occurs when the lid is not in apposition to the ocular surface?

• Unilateral or bilateral

Ectropion

What eyelid position condition has the following symptoms?

• Epiphora d/t poor tear flow into puncta with increased tear lake

  • Tears run down cheek

• Redness, irritation, dryness, FBS

Ectropion

What eyelid position condition has the following signs?

• Thickened, hyperemic, and possible keratinized conjunctiva

• Eversion of punctum

• Mucus discharge

• Corneal involvement

  • Exposure, staining, neurotrophic infection

Ectropion

What type of ectropion is the most common?

Involutional (senile)

What type of ectropion is caused by weakness of the pretarsal part of the orbicularis oculi or laxity of canthal ligaments?

Involutional (senile)

What type of ectropion is caused by the shortening of the anterior lamella, trauma, scarring, chronic sun exposure, or inflammation?

Cicatricial

What type of ectropion is caused by CN VII (Facial) palsy?

• Stroke, tumor, surgical complication

• Look for Bell’s phenomenon

Paralytic

What type of ectropion is caused by mass or edema that physically pulls the lower lid down?

• Chalazion, orbital fat, tumor

Mechanical

What type of ectropion is caused by tightening of the lid skin?

• Eczema, rosacea, atopic dermatitis, medications

Inflammatory

What type of ectropion is caused by chromosomal abnormalities?

• Blepharophimosis

  • Craniofacial disorder

    • Ptosis, wide-set eyes, poorly developed superior orbital rim

• Down’s Syndrome

Congenital

Ectropion testing:

• The distance from the corneal reflex to the lid margin in primary gaze

MRD

Ectropion testing:

• The distance from the corneal reflex to the upper lid margin (~4-5mm)

MRD 1

Ectropion testing:

• The distance from the corneal reflex to the lower lid margin (~5mm)

MRD 2

Ectropion testing:

• MRD 1 + MRD 2 = ____

  • M: 7-10mm

  • F: 8-12mm

Palpebral fissure height (PFH)

Ectropion testing:

• Pull down lower lid, hold for several seconds; let go and count the seconds until it returns to position

Snap Back Test

Ectropion testing:

• Move the lid away from the globe

• Measure the displacement of the lid margin from the globe

• >10 mm is abnormal

Lid Distraction Test

What is an abnormal result in the lid distension test?

>10mm

What lid position condition could be treated by the following?

• Temporary

  • Protect the ocular surface

    • Lubrication

    • Contact lenses

    • Lid taping

    • Tarsorrhaphy - glue

• Permanent

  • Tarsorrhaphy - suture

  • Surgical repair

Ectropion

Eyelid position condition where the upper eyelid(s) are lower then the normal position

Ptosis

What eyelid position condition is this?

Ptosis

The lid appears to be in an abnormal position but it isn’t

Pseudoptosis

Type of pseudoptosis that is an age-related “sagging” of upper and lower lids

• M>F

• Eyelash ptosis

• Dry eye

• Epiphora

  • Lateral canthi are touching

• Superior VF defect

Dermatochalasis

Type of pseudoptosis that is characterized by rare, intermittent, repeated episodes of painless upper lid edema

• Spontaneous resolution

• Unknown trigger, pathogenesis

• Starts in childhood and improves with age

• Leads to aponeurotic disinsertion

• Thin, wrinkled “tissue paper” lids with discolored periorbital skin

Blepharochalasis

Type of pseudoptosis characterized by a decrease in elastin of eyelid skin and/or tarsal plate

• Easy superior lid eversion

  • Papillary conjunctivitis

  • Ropy discharge

• Poor apposition to ocular surface

• Association with sleep position if unilateral

• Lid and lash ptosis

• Lagophthalmos

• Abnormal lid position

Floppy Eyelid Syndrome (FES)

FES is associated with what other condition?

Obstructive Sleep Apnea (OSA)

What are the risk factors of Obstructive Sleep Apnea (OSA)?

• Obesity

• Middle ages man

• Snoring

• Large neck girth

• Alcohol use

What are the ocular associations of FES

• Keratoconus

• Glaucoma

• Non-Arteritic Anterior Ischemic Optic Neuropathy (NA-AION)

What eyelid position condition can be treated with the following?

• Treat OSA - refer for a sleep study

• Treat ocular surface disease

• Use overnight shield or lid tape to prevent eversion

• Weight loss

• Lid surgery

Floppy Eyelid Syndrome (FES)

Type of pseudoptosis typically acquired:

• Caused by age or trauma

• Laxity of the CT, skin, or frontalis muscle

• Descent of the brow fat pad

  • Temporal > medial

• Mimics dermatochalasis

Brow ptosis

How do you differentiate dermatochalasis from brow ptosis?

Lift the brow

How could you treat a brow ptosis?

• Temporary

  • Fillers, BOTOX

    • Best for younger patients (improperly placed can also cause

• Permanent

  • Brow lift