OPT 221 Eyelids: Malpositions & twitching

What is dermatochalasis?

Lax and redundant upper > lower eyelid skin (produces cosmetic concerns)

What is the etiology of dermatochalasis?

degeneration of connective tissue most commonly the result of aging

What are the demographics for those most commonly affected by dermatochalasis?

-elderly

-sometimes with extreme weight loss or chronic blepharochalasis

Is dermatochalasis generally bilateral or unilateral?

bilateral

What are symptoms of dermatochalasis?

-asymptomatic, cosmesis

-droopy eyelids, "hooded" eyelids

-heavy eyelids

-obstruction of superior visual field

What are signs of dermatochalasis?

-upper eyelid skin laxity and redundancy

-draping of UL tissue over septum or lid margin

-excessive skin and fatty tissue herniation (puffy appearance)

-decreased MRD-1

-pseudoptosis

How is dermatochalasis managed?

-none if asymptomatic

-if symptomatic (or cosmesis), refer out for blepharoplasty (BULB)

If you are referring a patient out for a BULB, what should be done before?

perform superior 36 VF with lids taped and untaped; if there is improvement with them taped, there is a higher likelihood that insurance will cover the surgery

When should BULB not be performed?

right before intraocular surgeries (like cataracts)

What is ptosis?

droopy upper eyelid

What is the etiology of ptosis?

most commonly aponeurotic; levator aponeurosis stretching or dehiscence due to aging, repetitive eye rubbing

less commonly: mechanical, myogenic, neurologic, congenital

Is ptosis generally bilateral or unilateral?

unilateral is more likely

What are symptoms of ptosis?

-asymptomatic, cosmesis

-droopy eyelid

-obstruction of the superior visual field

What are signs of ptosis?

-droopy eyelid; UL is most commonly affected (if LL, called a reverse ptosis)

-decreased MRD-1 and possible MRD-2

-chalazion, EOM restriction, anisocoria, diplopia, high or absent eyelid crease

How is ptosis managed?

determine and treat the underlying condition

-if there is no resolution, or if the ptosis is congenital, consider referral for ptosis surgery

What is entropion?

eyelid turns inwards/towards the globe

What is the etiology of entropion?

-most commonly age related

-less commonly cicatricial, spastic, congenital

Who is most affected by entropion?

elderly (can be unilateral or bilateral)

What are symptoms of entropion?

-asymptomatic

-ocular redness

-ocular irritation

-tearing, lid spasms

What are signs of entropion?

-inversion of the eyelid

-may see vertical tracking on cornea

-signs of underlying cause (conj scarring, spastic contraction of orbicularis oculi)

What are complications associated with entropion?

trichiasis (ocular surface damage)

*simple trichiasis is not due to entropion

How is entropion managed?

-determine and treat underlying condition (surgery if not applicable)

-supportive management for trichiasis and ocular surface damage

What can be done to manage trichiasis caused by entropion?

-lash epilation, electrolysis, cryotherapy, radiofrequency epilation

-aggressive topical lubrication

-BCL or scleral CL

-taping methods

What is ectropion?

eyelid turns out/away from the globe

What is the etiology of ectropion?

-most commonly age related (horizontal eyelid laxity)

-less commonly mechanical, cicatricial, neurologic, congenital

What demographic is mostly affected by ectropion?

elderly (unilateral or bilateral)

What are symptoms of ectropion?

-asymptomatic

-ocular redness

-ocular irritation

-tearing, chronic epiphora

What are signs of ectropion?

-eversion of eyelid (LL most commonly)

-signs of underlying cause

What are complications associated with ectropion?

lagophthalmos (exposure keratopathy; more common in paralytic cases)

How is ectropion managed?

-determine and treat underlying condition (or surgery)

-supportive management for exposure keratopathy (aggressive topical lubrication; AT drop 4-8x/day and ung qhs)

What is lagophthalmos?

incomplete closure of the eyelids

What is the etiology of lagophthalmos?

-mechanical

-cicatricial

-neurologic

-congenital

What are symptoms of lagophthalmos?

-asymptomatic

-ocular redness

-ocular irritation

-tearing

What are signs of lagophthalmos?

-inadequate blinking or closure of the eyelids

-signs of underlying cause

-lid seal test

What are complication associated with lagophthalmos?

exposure keratopathy

How is lagophthalmos managed?

-determine and treat the underlying condition (surgery)

-supportive treatment for exposure keratopathy

What are examples of supportive management for exposure keratopathy?

-Aggressive AT regime (q1-2h), ung qhs

-Topical steroid (Lotemax) for SPK

-Restasis or Xiidra bid

-Sleep mask*

-BCL, Scleral lens fit

-AMT with BCL

What is floppy eyelid syndrome?

flaccid/loose upper eyelids due to a lax tarsal plate

What is the etiology of FES?

unknown; but commonly associated with obstructive sleep apnea

What demographics are most affected by FES?

-45-65 years

-men>women (obese)

Is FES generally bilateral or unilateral?

bilateral

What are symptoms of FES?

-Asymptomatic

-ocular redness

-ocular irritation

-mild mucous discharge

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

What are signs of FES?

-Upper eyelids are easily everted without exerting counterpressure

-rubbery/stretchy superior tarsal plate

-eyelid imbrication (UL override the LL on closure)

-conjunctival injection

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

-superficial punctate keratitis (SPK)

-mild mucous discharge

-ptosis

What are complications associated with FES?

-Lagophthalmos (due to eyelid imbrication) → Exposure keratopathy

-Bacterial conjunctivitis (due to eyelid eversion during sleep)

How is FES managed?

-supportive management

-refer out for surgery for definitive treatment

-if not perviously diagnosed, refer to PCP for sleep apnea

What are examples of supportive management that can be done for FES?

-topical lubricant

-eyelid taping or patching qhs with topical lubricant

-refrain from sleeping face down

What is eyelid retraction?

excessive elevation of the eyelid

What is the etiology of eyelid retraction?

-most commonly: TED

-less commonly: mechanical, cicatricial, neurologic, pharmacological, congenital

Why does TED cause eyelid retraction?

Increased sympathetic tone acting on Müller's muscle, contraction of the levator, proptosis, and/or scarring between the lacrimal gland and the levator

Who is most affected by eyelid retraction?

women>men (can be unilateral or bilateral)

What are symptoms of eyelid retraction?

-Asymptomatic

-Ocular redness

-Ocular irritation

What are signs of eyelid retraction?

-Excessive elevation of the eyelid (mostly upper eyelid)

-Increased MRD 1 and/or MRD 2

-Signs of underlying cause (proptosis, deficiency of upward gaze, UL retraction and pupillary constriction on downgaze or adduction, dilated pupil)

What are complications associated with eyelid retraction?

lagophthalmos (exposure keratopathy)

How is eyelid retraction managed?

-determine and treat underlying condition (refer to surgery if needed)

-supportive management for exposure keratopathy

What can a lower eyelid retraction be?

normal anatomic variant

What is eyelid myokymia?

Subtle eyelid twitch due to spontaneous contracture of the orbicularis muscle.

What is the etiology of eyelid myokymia?

unknown; commonly triggered by stress, caffeine, alcohol, ocular irritation, lack of sleep (unilateral**)

What are symptoms of eyelid myokymia?

-Eyelid twitch

-Painless, but annoying

What are signs of eyelid myokymia?

Eyelid twitch is typically subtle and difficult to observe

How is eyelid myokymia managed?

-self limiting

-modify/avoid triggers

-5-6 oz tonic water (quinine inhibits nerve impulses)

How do we differentiate eyelid myokymia from hemifacial spasm?

hemifacial spasm is unilateral contracture of the entire side of the face, requires MRI to rule out tumor

What is blepharospasm?

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

What is the etiology of blepharospasm?

unknown but can be associated with Meige's syndrome

Who is more affected by blepharospasm?

Women>men (bilateral**)

What are symptoms of blepharospasm?

-Increased blink rate initially

-Spasmodic eyelid closure as it progresses

-Interference with ADLS (can be functionally blind)

-Ocular redness

-Ocular irritation

-Tearing

What are signs of blepharospasm?

-Spastic twitching, blinking, or closure of the eyelids

-conjunctival injection

-SPK

How is blepharospasm managed?

-rule out neuromuscular causes

-refer for botox or surgery (botox is currently gold standard)

-supportive management for dry eye

-Meige's syndrome