Ocular Disease 1: Lids

Front 1

Levator (LPS)

Back 1

-CN III
-Fxn: raises upper eyelid, works w/ orbicularis in involunatry blinking & forced lid closure

Front 2

Dysfxn of LPS causes

Back 2

PTOSIS! (more than 3mm)

1. Mechanical: heavy lid, from lid mass (chalazion)

2. Myogenic: aging changes or inherited levator deterioration

3. Neurogenic: CN III lesion, stroke/aneurysms

Front 3

Mueller's muscle

Back 3

-Sympathetic NS
-Fxn: maintain tonus of elevated upper lid and opened lower lid

Front 4

Dysfxn of Mueller's causes

Back 4

-Slight ptosis (1-3mm)
-Inverse ptosis

Front 5

Orbicularis

Back 5

-CN VII
-Fxn: involuntary & forced blinking, maintains apposition of lacrimal puncta to globe

Front 6

Components of orbicularis

Back 6

1. Palpebral (lid only): involuntary blinking

2. Orbital (forehead, temples, cheeks): forced lid closure

Front 7

Dysfxn of orbicularis

Back 7

1. Lesion of CN VII can cause paresis or paralysis
a. Bell's Palsy: unilateral, viral, decreased tonus on affected side
b. Lagophthalmos: 1-3mm opening of the eye that leads to dessication problems

2. Epiphora (over tearing): puncta not in good apposition to globe b/c of loss of tonus

3. Entropion (eyelid rolls inward fr forced lid closure): esp in lower eyelid

Front 8

Lymphatics fr ____ drains into the pre-auricular lymph nodes.

Back 8

Lateral 2/3 of top
Lateral 1/3 of bottom

Front 9

Lymphatics fr ____ drains into the submandibular lymph nodes.

Back 9

Medial 1/3 of top
Medial 2/3 of bottom

*Note: check lymph nodes in red eyes

Front 10

Most common bacteria in pts

Back 10

S. epidermidis

(2nd most common is combination of S. epidermidis, S. aureus and diphtheroids)

Front 11

Least common bacteria in pts

Back 11

Diphtheroids

Front 12

Most common anaerobe

Back 12

Propionibacterium acnes

Front 13

Congenital ptosis (background)

Back 13

-Onset: @ birth or before 6 months old

-Exam includes:
~~Hx (when parents first noticed it)
~~FAT scans (old photos)
~~Superior lid sulcus is absent (KEY SIGN in non-asians)

-Not usually accompanied by neurological dz (except neonatal myasthenia gravis pts who are too sick to see us)

Front 14

Significance of congenital ptosis

Back 14

1. Occlusion amblyopia
-Get surgical consult w/ pediatric ophthalmologist

Front 15

Types of congenital ptosis

1. Autosomal dominant

Back 15

-70%
-Check family members
-Look for other congenital anomalies

Front 16

Types of congenital ptosis

2. SR palsy w/ LPS palsy

Back 16

-Isolated SR palsy congenital is very RARE
-Look for vertical tropia in primary position w/ ptosis

Front 17

Types of congenital ptosis

3. Paradoxical CN III innervation

Back 17

-Marcus Gunn jaw winking: CN II misconnected to levator & jaw (pterygoid) muscle --> eyelids pop open when open mouth to sing/chew/etc

-Amblyopia secondary to ptosis in 20% of cases

-Surgery for ptosis = impt

-Acquired --> pseudo von Graefe sign (no thyroid dz, when pt looks down lid doesn't follow at same rate)

Front 18

Types of congenital ptosis

4. Congenital Horners syndrome

Back 18

-Heterochromia irides (suggests onset before age 2)

-Iris color = different tones w/in same eye

Front 19

Types of congenital ptosis

5. Birth trauma

6. Neonatal myasthenia gravis

Back 19

5. Not common b/c don't use plungers/calipers anymore

6. Very sick pts, not at our service

Front 20

Ankyloblepharon (background)

Back 20

-Adhesion b/n upper and lower eyelids along the lid margin (usually lateral canthus)

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