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65 Cards in this Set
- Front
- Back
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Medial Canthal Tendon
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Tendon anchoring lids to bone
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Lateral Canthal Tendon
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Tendon anchoring lids to bone
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Upper Tarsus (Tarsal Plate)
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Stiffening element (like cartilage)
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Lower Tarsus (Tarsal Plate)
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Stiffening element (like cartilage)
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Levator Muscle (cut off at tendon)
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Main opening muscle of upper lid
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Superior Oblique Tendon
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Tendon of muscle moving eyeball
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Inferior Oblique Muscle
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Muscle moving eyeball
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Lacrimal Gland (Tear Gland)
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Gland that produces watery tears
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Lacrimal Sac (Tear Sac)
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Part of tear drainage system
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Fat
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Orbital fat extending into eyelids
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Orbital Rim
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Rim of socket bone
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Ectropion
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Definition – an abnormal eversion (outward turning) of the lower lid margin away from the globe.
ICD-9 code: 374.1 Usually involves the lower lid |
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Subjective symptoms of Ectropion
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Tearing
Eye or eyelid irritation Constantly wiping eyes (exacerbates problem) History of burns, surgery or trauma around lids Concurrent Bell’s Palsy Asymptomatic |
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Objective symptoms of Ectropion
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Outward turning of the eyelid margin
May also note (the company it keeps): Punctate Epithelial Erosions (PEE) Exposure keratopathy Conjunctival injection Keratinization (2’ to conj drying) |
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PEE
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Punctate Epithelial Erosions
Fine, scattered areas of corneal epithelium loss. The lesions appear punctate Caused by a variety of conditions (ex. tear abnormalities, exposure, etc) |
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Conjunctival injection
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Dilated blood vessels, which give a red appearance to the conjunctiva/sclera
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Exposure keratopathy
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Inflammation of the cornea caused by irritation due to the inability to close the eyelids (legopthalmos)
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legopthalmos
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inability to close the eyelids
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Causes of Ectropion
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Congenital (born that way)
Acquired Involutional (lid laxity --> age) Paralytic (nerve issues) Cicatricial (due to scarring) Mechanical (Something is pushing or causing it) Allergy (swelling) |
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Congenital Ectropion
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Rare and rarely an isolated anomaly
may be associated with: Blepharophimosis syndrome Microphthalmos Buphthalmos Orbital cysts Down syndrome Occasionally congenital ectropion has a paralytic cause |
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Blepharophimosis syndrome
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Abnormal narrowness of the palpebral fissure in the horizontal direction caused by the lateral displacement of the medial canthi
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Microphthalmos
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Congenital or developmental anomaly where the globe is abnormally small
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Buphthalmos
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Enlarged globe resulting from increased IOP; seen in pts w/ congenital glaucoma
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Orbital cysts
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Cyst around the orbit, can cause pseudo-ptosis or other issues
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Involutional
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The most common form of ectropion
A major factor is horizontal lid laxity Usually due to age-related weakness Most patients are elderly Laxity-related ectropion typically begins medially With time, the central lid margin and the lateral lid may evert |
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Ectropion can be decribed as: (4)
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Punctal
If you can see the puncta without manipulation, this is punctal ectropion Medial Can see an everted medial aspect of the lid Lateral Can see an everted lateral aspect of the lid Tarsal (complete) Can see the entire lower lid everted |
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Lower lid margin laxity are gauged by: (2)
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The lid distraction test
how far the lid margin can be pulled away from the globe > 8mm = lid margin laxity OR The snap test How quickly the lid margin snaps back against the globe after it has been pulled away from it > 1-2 seconds indicates lid margin laxity |
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Paralytic Ectropion is caused by:
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Caused by a Seventh-nerve palsy (ex. Bell’s Palsy)
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Ectropion in pts with suspected facial nerve palsy Orbicularis dysfunction can be tested by:
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Asking the pt to show their teeth rather than smile
Compare the elevation of the angles of the lips -Ptosis of the lateral lip on the affected side is often present |
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Cause of Cicatricial Ectropion
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Chemical burn, surgery, eyelid laceration scar, or others
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Mechanical Ectropion
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Due to herniated orbital fat, eyelid tumor and others
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Allergic Ectropion
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Contact dermatitis
Swelling pushes eyelid forward |
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Ectropion DDx
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Differentials:
Basal Cell Carcinoma Squamous Cell Carcinoma Bell’s Palsy Floppy Eyelid Syndrome Ichthyosis |
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Ichthyosis
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Uncommon group of skin disorders characterized by excessive amounts of dry surface scales
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Ectropion Assessment
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Take careful history
Slit-lamp exam – check for SPK, exposure keratopathy, etc. Treatment is based on cause and severity |
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Tx for mild ectropion
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Lubrication and moisture shields are helpful if significant corneal exposure exists
--Pts w/ corneal or conj drying are reevaluated in 1-2 wks to evaluate the efficacy of therapy --If conjunctiva is markedly keratinized, a lubricating ointment should be used several days or weeks prior to ectropion repair In some cases, taping the lids provides temporary relief Especially in patients with new-onset seventh nerve palsy Pts should be instructed to wipe the eyelids up and in (toward the nose) |
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Surgical Treatment for ectropion
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The correct surgical treatment of ectropion depends on the etiology.
Temporary fixes: Tarsorrhaphy Electrocautery “Permanent” Fixes: Involutional ectropion Most surgeons elect to shorten and tighten the lower lid – called a Tarsal Strip Usually only a few stitches that are often removed 7 to 14 days later Almost immediate resolution of the condition There may be mild bruising and swelling following the procedure. This should resolve within about two weeks. |
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Tarsorrhaphy
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lids partially sewn together
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Electrocautery
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at the junction of conjunctiva and lower margin of the tarsus
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Tx - Cicatricial ectropion following trauma or lid surgery
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digital massage may help stretch the scar
Skin grafts are another option May be obtained from the upper lid if dermatochalasis (discussed later) is present Preauricular or postauricular skin is another alternative |
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Ectropion- VII nerve palsy Tx
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External paste-on upper lid weights are available and can be matched approximately for different skin colors.
A double-sided tape is used to apply the lid weight |
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Surgery for paralytic ectropion
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Paralytic ectropion (cont)
Surgery is delayed for 3-6 mos, as ectropian may resolve spontaneously A tarsal strip procedure is often helpful. Upper lid gold weight implantation is a helpful adjunct for patients with lagophthalmos Usually, a 1.0-1.2 g weight is implanted superior to the tarsus and inferior to the orbicularis |
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Ectropion Summary
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Outward turning of eyelid
Pts can come in with tearing, red eyes or no problems at all Different causes (age, scarring, etc), which deserve different treatments Treatment ranges from pt ed to lubes to surgery |
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Entropion
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Definition: Inward turning of the eyelid margin
ICD-9 code: 374.0 |
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Subjective Sx of entropion
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Ocular irritation
Foreign-Body sensation (FB sensation) Tearing Red-eye Light sensitivity (photophobia) Possible decreased vision |
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Objective Sx of entropion
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Objective
The eyelid is turned in! SPK (from lashes contacting the globe) Foreign body tracking Conj injection Corneal ulcer Decreased corneal sensation Corneal scarring if long-term |
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Causes of entropion (3)
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Involutional
Acute Spastic Congenital |
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Involutional entropion
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May be due to numerous problems
-- The patient may exhibit horizontal laxity of the medial and/or lateral canthal tendons. -- Patients usually have an involution of the posterior eyelid retractors, with the eyelid in-turning in much the same manner as with spastic entropion |
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Acute spastic entropion
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Usually occurs as a result of ocular irritation
May be due to an infectious, inflammatory, or traumatic (eg, surgical) processes Orbicularis oculi muscle overwhelms the oppositional action of the lower eyelid retractors Most of these patients often have an involutional component as well. |
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Congenital entropion
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Usually in the lower eyelid
Very rare It may arise due to a number of underlying developmental abnormalities Dysgenesis of the lower eyelid retractors Paucity of tissue vertically in the posterior lamella of the eyelid Tarsal kink syndrome Distortion of the tarsal plate that may result in the in- or out-turning of the lid |
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Cicatricial entropion
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Result of scaring of the palpebral conjunctiva
A consequent inward rotation of the lid margin Digital eversion of the eyelid margin is difficult in cases of cicatricial entropion Examination of the tarsus and palpebral conjunctiva usually will point to the diagnosis in these cases Scar tissue of the conjunctiva is usually a result of: Trauma Infections Chemical burns Stevens-Johnson syndrome A severe form of allergic reaction that most often results from a medication Can be sight threatening |
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Differential Diagnoses for entropion
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Trichiasis – will soon discuss
Distichiasis – lashes that are growing out of the meibomian glands (2nd row of lashes) Trachoma - chronic keratoconjunctivitis caused by the obligate intracellular bacterium Chlamydia trachomatis |
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Medical Therapy for entropion
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May be warranted for pts who decline surgery
Ocular lubrication and tear preparations Helpful for protecting the ocular surface May break the cycle in pts with spastic entropion 2’ to dry eye syndrome Eyelid hygiene, antibiotics, and steroids Useful for treating blepharitis, which may cause spastic entropion botulinum toxin (BOTOX®) small amounts are quite effective for the treatment of spastic entropion Weakens the pretarsal orbicularis oculi muscle |
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Surgical Therapy for entropion
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Multiple surgical procedures have been described
The most common procedures utilized in the management are as follows: Repair of involutional entropion Repair of the horizontal laxity via medial and/or lateral canthal tightening Small amount of the pretarsal orbicularis oculi can be resected Temporizing Quickert-Rathbun sutures Sutures from the inferior fornix anteriorly toward the lashes - used to torque the eyelid margin away from the globe Cicatricial entropion Depends on the degree and etiology of scarring Mild cases - removal of scar More extensive scarring may require grafts Cautery is another option (temporary) – Poor aesthetics Consultations If pt has pemphigoid - consultation with an internist or hematologist is recommended |
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Entropion Summary
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INWARD turning of the eye lid
Painful, red, tearing can cause scarring Due to multiple causes (age, spasm, scarring, etc) Treatment based upon cause Treatment varies from lubes (protection) to surgery |
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Trichiasis
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Definition: The acquired misdirection of eyelashes toward the globe
ICD-9: 374.05 |
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Subjective sx of trichiasis
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FB sensation
Red eyes Pain Photophobia Tearing |
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Objective sx of trichiasis
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signs of conjunctival scarring
FB tracking on cornea (linear defects) Signs of entropion and horizontal lid laxity Lashes growing from the meibomian gland orifices (distichiasis) Symblepharon formation and fornix scars as seen in OCP or SJS |
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Causes of trichiasis
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Infectious
Blepharitis Herpes zoster Trachoma (chlamydia) Autoimmune - Ocular cicatricial pemphigoid Inflammatory Stevens-Johnson syndrome Vernal keratoconjunctivitis Trauma Postsurgical Floor fracture repair or blepharoplasty After enucleation After ectropion repair Chemical Alkali burns to the eye Medical drops (eg, glaucoma drops) Thermal burns to face/lids |
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Trichasis DDx
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Differentials
Blepharitis Blepharospasm Chemical burns Cicatricial Pemphigoid (OCP) Corneal Abrasion Corneal Foreign Body Distichiasis Entropion Red eye Stevens-Johnson Syndrome (SJS) Trachoma |
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Trichasis Therapy
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Lubricants may decrease the irritant effect of lash rubbing
If a more serious disease (eg, OCP, SJS) is the cause - medical therapy should be geared toward that disease |
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Surgical Therapy for trichasis
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The technique is dependent on the cause of the problem
These procedures can be categorized as lash/follicle destroying or lash/follicle repositioning Lash and follicle destruction surgery Preferred for segmental or focal trichiasis. Epilation – usually temporary Often leaves the lash follicle When lash grows back - often short and irritating Electrolysis Can be effective Often painful for the pt and tedious for the surgeon |
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Eyelid Coloboma
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Definition: a full-thickness defect of the eyelid
Triangular defect Base of the notch directed primarily at the margin It primarily affects upper lid Usually between the inner and middle third of the lid In the lower lid Usually between the middle and outer third of the lid Coloboma is a rare anomoly Primarily congenital, but may be 2’ to trauma |
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Upper lid coloboma is often associated with
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cryptophthalmos – failure of eyelid formation
The eyelid skin grows continuously from the forehead to the cheek, covering the underlying globe |
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cryptophthalmos
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failure of eyelid formation
The eyelid skin grows continuously from the forehead to the cheek, covering the underlying globe |
