Lids and Lashes (pt 7)

Potential Dx for “there is something wrong with my eyelid position”

• Ptosis and pseudoptosis

• Epiblepharon

• Entropion

• Ectropion

• Lagophthalmos

• Floppy eyelid syndrome

Ptosis

Abnormally low position of upper lid with varying causes

Types of ptosis

• Neurologic: Innervation defect

• Myogenic: Impulse impairment at neuromuscular junction

• Aponeurotic: Levator defect

• Mechanical: Mass or scarring

Marcus Gunn Jaw Winking Syndrome

Neurologic ptosis, congenital that is typically unilateral

Cause may be mandibular branch of CNV is misdirected into levator instead of jaw

Marcus Gunn Jaw Winking Syndrome clinical findings

• Lid opens when mouth opens

• Seen with chewing, sucking, and opening of mouth

Marcus Gunn Jaw Winking Syndrome Tx

Surgery if functional or cosmetic problems, refer if VAs aren’t 20/20

Observation if minor

Myasthenia Gravis

Myogenic ptosis, affects neuromuscular junction and transmission

Muscle weakness and fatigue due to sustained or repeated activity

Occurs in all ages, spikes in 20-30 and 50-60

Myasthenia gravis clinical findings

Ptosis with sustained muscle use that is worse at the end of the day

Testing for myasthenia gravis

• Tensilon testing (anticholinesterase test)

• Sustained up gaze and ice pack test

Myasthenia gravis Tx

• Medication or thymus gland removal (systemic)

• Occlusion, prism, surgery (ocular)

Myotonic dystrophy

Myogenic ptosis, autosomal dominant disorder where muscles struggle to relax after contraction

Occurs in 20-30 pts

Myotonic dystrophy clinical findings

• Bilateral symmetric ptosis

• EOM involvement

• Cataract

• Hypotony

Myotonic dystrophy Tx

Medication or surgery

Ptosis hallmark signs

Upper lid does not cross at 10-2

Pseudoptosis

False impression of ptosis

Lack of support (prosthetics), contralateral eye retracts, brow ptosis, dermatochalasis (most common)

Dermatochalasis

Excess skin of upper/lower lid caused by loss of elastic skin and weakening of connective tissue with age

Dermatochalasis clinical findings

• Redundant upper lid skin that appears as ptosis

• Wrinkles and thin skin

Dermatochalasis complications

Obstruction of superior VF

Dermatochalasis Tx

Surgical removal of excess skin

Pseudoptosis hallmark signs

Upper lid sits at normal 10-2 position

Epiblepharon

Horizontal fold of skin that covers lower lid margin caused by hypertrophy of orbicularis oculi

Seen in asian and hispanics

Epiblepharon clinical findings

Inward pointing of lashes with normal lid position

Epiblepharon complications

Trichiasis, PEE (lashes)

Epiblepharon Tx

Resolves with age or surgery intervention

Epiblepharon hallmark signs

Meibomian glands are in normal position

Entropion

Inward turning of lid margin causing lashes to rub against globe

Meibomian glands up against globe

Involutional, cicatricial, spastic, congenital

Involutional entropion

Age related, weakening of lid muscles/tendons causing inward turn

Tx: Lubrication or surgical repair

Cicatricial entropion

Scarring of palpebral conj causing inward turn

Tx: Lubrication or surgical repair

Spastic entropion

Spasm secondary to irritation, inflammation, or trauma causing inward turn (acute cause)

Tx: Lubrication, resolves when inflammation is treated

Congenital entropion

Malformation causes inward turn

Tx: Lubrication, surgical repair if spontaneous resolution doesn’t occur

Entropion complications

PEEs, conj injection, PEE (lashes)

How can you determine the type of entropion?

Ask case Hx

Entropion hallmark signs

Meibomian glands against globe

Ectropion

Outward turning of lid margin

Involutional, cicatricial, paralytic, mechanical

Involutional ectropion

Age related, weakening of lid muscles/tendons causing outward turn

Tx: Lubrication or surgical repair

Cicatricial ectropion

Scarring of skin causes outward turn

Tx: Lubrication, surgical removal with skin graft

Paralytic ectropion

Ipsilateral facial nerve palsy causes outward turn

Tx: Lubrication, spontaneous resolution, surgical repair if doesn’t resolve

Mechanical ectropion

Tumors herniated fat cause outward turn

Tx: Lubrication or removal of causative agent

Ectropion complications

Dry eye, PEE (from dryness)

Ectropion hallmark signs

Lashes not near globe

Lagophthalmos

Inability to fully close lids

Neurological (7th nerve palsy), systemic disease (TED), ocular conditions (proptosis, floppy eyelid), trauma (chemical/thermal burns), lid surgery complications, just occurs

Lagophthalmos clinical findings

Inferior scleral showing when lid is closed

Lagophthalmos complications

• PEE

• Conj injection

• Dry eye

• Neovascularization if cornea is involved

Lagophthalmos Tx

• Artificial tears

• Surgery if cornea is involved

• Sleeping mask

Lagophthalmos hallmark signs

Sclera showing when eyes are closed

Lid retraction

Displacement of upper lid superiorly or lower lid inferiorly

Idiopathic, systemic disease (TED), mechanical (surgery complication), congenital (Down syndrome), neurological (Marcus Gunn Jaw Winking Syndrome)

Lid retraction clinical findings

Sclera showing above or below limbus

“Scared look”

Lid retraction complications

PEE and conj injection (dryness)

Lid retraction Tx

• Lubrication

• Tx of systemic disease (if applicable)

• Surgery

Lid retraction hallmark signs

Upper or lower lid is displaced

Floppy eyelid syndrome

Bilateral lid malposition from loss of elasticity

Floppy eyelid syndrome risk factors

• Fat snoring men (obese, male, sleep apnea)

• Metabolic syndrome

• Keratoconus

Floppy eyelid syndrome pathophysiology

Lid eversion during sleep resulting in chronic irritation

Floppy eyelid syndrome clinical findings

• Redundant lid skin

• Loose superior tarsal plate (easy to evert)

• Papillary reaction of superior palp conj with injection

Floppy eyelid syndrome complications

• PEE

• Filamentary keratitis

• Lagophthalmos

• Eyelash ptosis

• Lacrimal gland prolapse

• Ectropion

• Aponeurotic ptosis

Floppy eyelid syndrome Tx

• Lubrication

• Surgery

• Tape/sleeping mask