OPT 221 Midterm 1 part 1 (Eyelids total)

What is dermatochalasis?

lax, redundant UL (> LL) eyelid skin creating cosmetic concerns

What is the etiology of dermatochalasis?

CT degeneration from time, stretching, etc.

What 3 demographics are most affected by dermatochalasis?

elderly

extreme weight loss

chronic blepharochalasis

Is dermatochalasis typically unilateral or bilateral?

bilateral

What are the S/S of dermatochalasis?

asymptomatic, cosmesis

droopy eyelids, "hooded" eyelids

heavy eyelids

obstruction of superior visual field

draping of UL tissue over septum or lid margin

excessive skin and fatty tissue herniation = “puffy” appearance

decreased MRD-1

pseudoptosis

What is the tx for dermatochalasis?

reassurance

OR

blepharoplasty (BULB) = bilateral UL blepharoplasty = remove eyelid skin

While insurance won't cover a cosmetic BULB for dermatochalasis, what can we do to increase likelihood of insurance considering it medically necessary?

perform superior 36 "ptosis VF" with lids taped vs untaped = if VF improves with taped lids, more likely to cover

BULB can make which condition worse?

dryness bc harder to blink

Never perform a BULB right before what?

intraocular surgery (as speculum will stretch eyelid skin anyways)

What is ptosis?

droopy upper lid

What is the most common etiology of ptosis?

aponeurotic = levator aponeurosis stretching, dehiscence from aging, repetitive eye rubbing

What are some etiologies of ptosis?

mechanical = tumor, eyelid edema

myogenic = muscular dystrophy, etc

neurologic, CN III palsy, Horner syndrome, MG, MS

congenital

What is the laterality of ptosis?

unilateral more common

What are some S/S of ptosis?

asymptomatic, cosmesis

droopy eyelid

obstruction of the superior VF

UL is most commonly affected

if LL is affected, called a reverse ptosis (lower eyelid is higher)

decreased MRD-1 > MRD-2

signs of underlying cause (e.g., chalazion, EOM restriction, anisocoria, diplopia, high or absent eyelid crease if aponeurotic or congenital)

What is the tx for ptosis?

tx underlying condition

OR

if congenital, ptosis surgery = resecting the levator aponeurosis

What things can cause a pseudoptosis which must be differentiated from ptosis?

dermatochalasis, brow ptosis, enophthalmos, microphthalmia, corneal protective mechanisms, contralateral eyelid retraction

What is entropion?

eyelid turns inwards towards globe

What is the most common etiology for entropion?

age related = horizontal eyelid laxity, retractor disinsertion, orbicularis override

What are some other etiologies of entropion?

cicatricial = conj scarring from trauma, burn injury, trachoma, Stevens-Johnson

spastic = orbicularis contraction from trauma, ocular irritation, blepharospasm

congenital

What is the laterality of entropion?

unilateral or bilateral

What is the demographic most affected by entropion?

elderly

What are the S/S of entropion?

asymptomatic

ocular redness

ocular irritation (e.g., burning, FBS, pain)

tearing, lid spasms

inversion of the eyelid

may see vertical tracking on cornea

signs of underlying cause (e.g., conjunctival scarring, spastic contraction of the orbicularis muscle)

What is a possible complication of entropion?

trichiasis = lashes poke inwards = ocular surface damage = injection, SPK, pannus, corneal ulceration/scarring

What is the tx for entropion, from first line to more severe?

treat underlying condition

lash epilation, electrolysis, cryotherapy, RF epilation

topical lubrication (drops 4-8x/day and ung qhs)

bandage or scleral CL

taping

entropion surgery

What is trichiasis w/o entropion?

idiopathic, involves only a few lashes

What is ectropion?

eyelid turns out/away from globe

What is the most common etiology of ectropion?

age related = horizontal eyelid laxity

What are some other etiologies of ectropion?

mechanical = eyelid tumor

cicatricial = shortening anterior lamella from trauma, burn, actinic damage, chronic inflam, dermatitis

neurologic = CN VII palsy

congenital

What is the laterality of ectropion?

unilateral or bilateral

What is the most common demographic affected by ectropion?

elderly

What are the S/S of ectropion?

asymptomatic

ocular redness (palpebral conj)

ocular irritation (e.g., burning, FBS, pain)

tearing, chronic epiphora

eversion of the eyelid

LL is most commonly affected

signs of underlying cause (e.g., eyelid tumor, eyelid scarring, paralysis of the facial muscles)

What is a common complication of ectropion, especially in paralytic cases like Bell's palsy?

lagophthalmos = exposure keratopathy

What is the tx for ectropion?

treat underlying condition

topical lubrication (drops 4-8x/day and ung qhs)

ectropion surgery

What is lagophthalmos?

incomplete closure of the eyelids

What is the etiology of lagophthalmos?

mechanical = eyelid laxity, eyelid tumor, post eyelid surgery, proptosis, FES, severe conjunctival chemosis

cicatricial = eyelid scarring, eyelid retractor mm scarring

neurologic = dorsal midbrain syndrome, CN VII palsy

congenital

What is the laterality of lagophthalmos?

unilateral or bilateral

What are the S/S of lagophthalmos?

asymptomatic

ocular redness

ocular irritation (e.g., burning, FBS, pain)

tearing

inadequate blinking or closure of the eyelids

signs of underlying cause (e.g., eyelid tumor, proptosis, chemosis, eyelid scarring, restriction in upgaze, paralysis of the facial muscles)

What are 2 tests we can do to dx lagophthalmos?

1. lid seal test = shine light over lid, Dx confirmed if some light shines through bottom

2. pt looks up with eyes closed = see if any of bulbar conj is exposed

What is a common complication of lagophthalmos?

exposure keratopathy and neurotrophic keratitis

What is the tx for lagophthalmos?

treat underlying conditions

aggressive AT (q1-2h), ung qhs

topical steroid (Lotemax) for SPK

Restasis or Xiidra bid

sleep mask

bandage or scleral CL

AMT with BCL

surgery

What is floppy eyelid syndrome?

flaccid/loose UL due to lax tarsal plate

What is the etiology of floppy eyelid syndrome?

unknown, but commonly associated with obstructive sleep apnea

What is the demographic affected by floppy eyelid syndrome?

men > women

obese

age 45-65

What is the laterality of floppy eyelid syndrome?

bilateral

What are the S/S of floppy eyelid syndrome?

ocular redness/injection

ocular irritation (e.g., burning, FBS, itching)

mild mucous discharge

**symptoms are typically unilateral (side that the patient sleeps) and worse upon waking (due to eyelid eversion during the night)

UL easily everted w/o counterpressure

rubbery superior tarsal plate

eyelid imbrication (UL overrides the LL on closure)

palpebral papillae superior (due to eyelid eversion during sleep and rubbing against bedding)

SPK

ptosis

What are 2 possible complications of floppy eyelid syndrome?

1. lagophthalmos = exposure keratopathy

2. bacterial conjunctivitis from eyelid eversion during sleep

What will we refer a pt with floppy eyelid syndrome out for?

sleep apnea (refer to PCP) if not already diagnosed

What is the tx for floppy eyelid syndrome?

topical lubricant

eyelid taping/patching qhs

no sleeping face down

surgery

What is eyelid retraction?

excessive elevation of the eyelid

What is the most common etiology of eyelid retraction?

thyroid eye disease = increased symp on Muller's mm, levator, proptosis, scarring between lacrimal and levator

What are some other etiologies of eyelid retraction?

mechanical = surgical overcorrection of ptosis

cicatricial = scarring of the levator and/or Muller's muscle

neurologic = dorsal midbrain syndrome

pharmacological = sympathomimetic drops

congenital

What is the most common demographic eyelid retraction?

women > men

THINK: same as thyroid diseases

What is the laterality of eyelid retraction?

unilateral or bilateral

What are the S/S of eyelid retraction?

asymptomatic

ocular redness

ocular irritation (e.g., burning, FBS)

excessive elevation of the eyelid

UL is most commonly affected

considered abnormal if superior sclera is exposed in primary gaze

increased MRD-1 and/or MRD-2

signs of underlying cause (e.g., proptosis, deficiency of upward gaze)

scleral show

What are the complications of eyelid retraction?

lagophthalmos = exposure keratopathy

What is the tx of eyelid retraction?

treat underlying condition

treat exposure keratopathy

What form of eyelid retraction can be a normal anatomic variant?

lower eyelid retraction

What is myokymia?

subtle eyelid twitch due to spontaneous contracture of the orbicularis muscle

What is the etiology of myokymia?

unknown but triggered by stress, caffeine, alcohol, ocular irritation, lack of sleep

What is the laterality of myokymia?

unilateral

What are the S/S of myokymia?

eyelid twitch - typically subtle and difficult to observe

painless, but annoying

What is the tx for myokymia?

self-limiting = goes away on it's own

avoid triggers

maybe tonic water bc quinine to inhibit nerve pulses?

What is it important to differentiate myokymia from?

hemifacial spasm = unilateral contracture of the entire side of the face; requires brain MRI to rule out tumor

What is blepharospasm?

spastic (sudden involuntary muscular contraction) twitching, blinking, or closure of the eyelids due to contraction of the orbicularis muscle

What is the etiology of blepharospasm?

unknown, but may be associated with Meige's syndrome

What is the demographic affected by blepharospasm?

women > men

What is the laterality of blepharospasm?

bilateral

What are the S/S of blepharospasm?

increased blink rate initially

spasmodic eyelid closure as it progresses

disappears during sleep

interference with ADLs

may be functionally blind

ocular redness

ocular irritation (e.g., burning, FBS)

tearing

conjunctival injection

SPK

What is the tx for blepharospasm? Include the gold standard tx.

manage dry eye

refer out for Botox (gold standard) or surgery

What do we need to rule out before diagnosing blepherospasm?

neuromuscular causes (MS, MG)

What is Meige's syndrome?

dystonia (movement disorder in which a person's muscles contract uncontrollably) = often of the jaw, tongue, and eyelids

What is blepharochalasis?

recurrent episodes of eyelid inflam/edema throughout pt's lifetime

What is the etiology of blepharochalasis?

unknown, but associated with Ascher syndrome

What is Ascher syndrome?

idiopathic eyelid swelling (blepharochalasis), narrow horizontal palpebral fissure, lip swelling (double lip sign), euthyroid (non-toxic) goiter

What demographic is most associated with blepharochalasis?

women > men

teens-20s onset, recurring throughout lifetime

What is the laterality of blepharochalasis?

bilateral > unilateral

What are the S/S of blepharochalasis?

painless, eyelid swelling

droopy eyelid(s) with fine wrinkles

eyelid edema

repeated episodes = atrophy and laxity of UL tissues

thin, stretched, redundant skin with fine wrinkles

ptosis

deep superior sulci

What complication of blepharochalasis is shown here?

swelling due to lacrimal gland prolapse/drop

What is the tx for blepharochalasis?

self-limiting but can recur (episodes become less frequent)

no standard tx

oral acetazolamide + topical hydrocortisone

oral doxycycline

BULB and other Sx for redundant skin, ptosis, lacrimal gland prolapse

What is helpful to do when diagnosing blepharochalasis?

look at pt outside the slit lamp first

What is a chalazion?

obstruction and localized inflam of meibomian gland = accumulation and formation of lipogranulomatous material

What are the 2 subtypes of chalazion?

anterotarsal/external = anterior to the tarsal plate (skin side)

retrotarsal/internal = posterior to the tarsal plate (conjunctiva side)

What is the etiology for chalazion? 3 possible categories.

chronic blepharitis, ocular rosacea, or MGD

inflammation within MG, gland of Zeis

previous hordeolum

What is the common demographic affected by chalazion?

low SES

urban

mostly women 10-29 yrs, men >60 yrs

What is the laterality of a chalazion?

unilateral > bilateral

What are the S/S of chalazion?

"bump” on eyelid = red, puffy, “cyst”, “knot”, or “stye”

painless, perhaps mild tenderness

discharge or “drainage”

multiple chalazia OR Hx of chronic occurrences

visible or palpable nodule pointing anteriorly through the skin OR posteriorly through the palpebral conjunctiva

What must we do to determine whether a chalazion is external or internal?

evert lid = cannot determine just from looking at it

What are some non-invasive tx for chalazion?

warm compress w/ massage to express the contents (BID 5-10min)

massage the eyelid toward the lashes

eyelid hygiene (scrubs, baby shampoo) w/ warm compress for blepharitis

What is the oral medication tx for chalazion? Include dosage.

oral doxycycline (esp if chronic, ocular rosacea, MGD):

100mg bid x 2wks (prominent chalazion)

- OR -

50mg bid x 4 wks, then 50mg qday for another 2 months (MGD > chalazion)

NOTE: takes mos to resolve!

What is the injection medication tx for chalazion?

intralesional corticosteroid Kenalog-40 either dermal/external or conjunctival/internal w/ 27 or 30 gauge needle

NOTE: can cause skin hypopigmentation adverse effect from steroid precipitate

What is the "rule of 6" for injection tx for chalazion?

success rate ~60% for lesions <6 months in duration and <6 mm in size (longer they're there = harder to inject)

While we can inject a chalazion, we should never inject what?

active infection/hordeolum = painful, risk of spreading infection

What is the more invasive tx for chalazion?

incision and curettage Sx

NOTE: OD's only do internal (external requires skin reconstruction)

If a chalazion recurs in the same location, especially with pertinent malignant findings (like madarosis), we should consider what DDx?

sebaceous gland carcinoma

What is anterior blepharitis?

chronic non-infectious inflam of the eyelid margin anterior to the mucocutaneous junction

What are the 2 main etiologies of anterior blepharitis?

staphylococcal = inflam reaction to bacterial colony/biofilm (but NOT infectious)

seborrheic = excess sebum released by glands

What demographic is most affected by anterior blepharitis?

adults

What is the laterality of anterior blepharitis?

bilateral

What are some S/S of anterior blepharitis?

crusty debris along lid margins

lid margin redness, edema

may extend beyond the margin

ocular irritation (e.g., burning, FBS)

tearing

scurf within the eyelashes and on the skin surrounding the lashes

if seborrheic, greasy appearance to the eyelid margin (as well as the scalp, nasolabial folds, behind the ears)

madarosis (mechanical from rubbing, not malignant)

tear film debris

How can a pt's eye rubbing help differentiate between anterior blepharitis and allergies?

blepharitis = rubbing along lashline

allergy = rubbing entire eye, inner corner