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OCULAR DISEASE DIAGNOSIS AND MANAGEMENT I LID DISEASES AND DISORDERS

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Management: surgical excision of excess skin Cicatricial entropion Cicatrix = scar Cicatricial entropion caused by scar on tarsal conjunctiva with contraction of ... – PowerPoint PPT presentation

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Title: OCULAR DISEASE DIAGNOSIS AND MANAGEMENT I LID DISEASES AND DISORDERS


1
OCULAR DISEASE DIAGNOSIS AND MANAGEMENT ILID
DISEASES AND DISORDERS
  • Judy Tong, O.D., F.A.A.O.
  • Associate Professor
  • Director of Residency Programs
  • Southern California College of Optometry

2
Mite I hang on the Jungle Gym
3
Goals for Today
  • Review Lid Anatomy
  • Muscles
  • Tissue
  • Lashes
  • Blood Supply
  • Lymphatics
  • Nerves
  • Bacteria and other
  • Congenital Ptosis
  • Entropion
  • Ectropion
  • Lagophthalmos
  • Blepharospasm
  • Blepharoclonus

4
Dear Dr. Optometrist Prime
  • We have a 2 year old beautiful baby boy who was
    born with the eyelid presentation as seen in the
    photograph below.
  • We would like a second opinion from you as to
    what ails our son (diagnosis)?
  • We are financially strapped and have no medical
    or eye insurance.
  • If we let it alone, will it get better on its
    own?
  • What would be the worse possible outcome?
  • If we opted to just obtain an evaluation from you
    today, what would this entail?
  • Signed
  • Concerned Mother

5
REVIEW OF LID ANATOMY
  • Functions of Eyelids
  • Protect globe from injury or excess light
  • Form a mechanical barrier
  • Maintain optical clarity by resurfacing tears
  • Assist immune system
  • Part of native immunity when acting as a
    barrier
  • Remove pathogens in tears
  • Replenish immunological substances which inhibit
    bacterial growth
  • Lysozyme, lactoferrin, beta lysin
  • Immunoglobulins

6
Muscles
  • Levator (LPS)
  • Functions
  • Raises upper eyelid
  • Works with orbicularis in both involuntary
    blinking and forced lid closure
  • Innervated by cranial nerve III
  • Starts at superior part of orbital apex and
    attaches to the front of the superior tarsal
    plate

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  • Dysfunction of levator causes ptosis
  • Mechanical ptosis heavy lid, usually from lid
    mass (chalazion)
  • Myogenic ptosis age-related or inherited
    levator deterioration
  • Neurogenic ptosis due to CN III lesion causing
    poor levator function (diabetic stroke)

9
  • Muellers muscle
  • Functions
  • Maintains tonus of elevated upper lid
  • Maintains tonus of opened lower lid
  • Innervated by sympathetic nervous system
  • Originates on underside of levator and attaches
    to upper border of superior tarsal plate
  • Dysfunction of Muellers muscle gt slight ptosis,
    inverse ptosis (1-3mm)
  • Slide 3a

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  • Orbicularis
  • Functions
  • Closes lids
  • Involuntary regular blinking
  • Forced voluntary blinking
  • Maintains apposition of lacrimal drainage
    apparatus against globe
  • Innervated by cranial nerve VII (which also
    innervates muscles of cheeks and mouth)

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  • Muscles is elliptically shaped
  • Attached to nasal and temporal edges of orbit by
    medial and lateral palpebral ligaments
  • Palpebral portion in lid only responsible for
    involuntary blinking
  • Orbital portion in forehead, temples, and
    cheeks responsible for forced lid closure

15
  • Dysfunction of orbicularis
  • Lesion of CN VII causes paresis or paralysis of
    orbicularis and also some facial muscles
  • Bells palsy
  • Lagophthalmos
  • Loss of tonus of orbicularis and its ligaments
    allows puncta to fall away with resulting
    epiphora
  • Entropion resulting from forced lid closure due
    to reduced tonus of lower orbicularis with
    inability to return lower lid margin to its
    normal position

16
Tissue
  • Skin
  • Thinnest skin in the body
  • 10 times more clinically sensitive to allergens
    than elsewhere in the body
  • Very loose, stretchy skin allows for considerable
    expansion of lid contents
  • Recurrent edema and aging can cause loss of
    elasticity of the skin
  • Areolar tissue
  • Connective tissue
  • Soft, loose, spongy
  • Easily distended

17
Eyelashes
  • Derived from hair follicles at lid margin
  • Highly sensitive
  • Glands located near lash follicle
  • Glands of Moll (sweat)
  • Glands of Zeis (sebaceous)

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19
Tarsal Plate
  • Fibrous skeleton of lids
  • Give shape and firmness to eyelids
  • Meibomian glands located deep in tarsal plates
  • Provide oily top layer of tears
  • Secrete oil layer which acts as a barrier
    preventing spillover of tears onto lid

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21
Blood Vessels
  • Arteries
  • Ophthalmic artery branches
  • Lacrimal artery branches
  • Empty into the veins of the forehead and temple

22
Lymphatics
  • Lympathics in posterior lid drain the conjunctiva
    and tarsal glands
  • Lympathics in anterior lid drain the skin and the
    associated skin structures
  • Lateral half of eyelids lympathics drain into the
    preauricular lymph node
  • Medial half of eyelids lymphatics drain into the
    submandibular lymph node

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25
Nerves
  • Motor supply
  • Orbicularis supplied by CN VII
  • Levator supplied by CN III
  • Sensory supply (pg. 79)
  • From first two divisions of trigeminal (CN V)
  • Ophthalmic division of trigeminal (VI)
  • Maxillary division of trigeminal (V2)
  • Upper lid mainly supplied by supraorbital nerve,
    part of frontal division, one of three divisions
    of V1

26
  • Medial side of the upper lid assisted by
  • Supratrochlear, part of the frontal division (one
    of three divisions of V1)
  • Infratrochlear, part of the nasociliary division
    (one of three divisions of V1)
  • Lateral side of the upper lid assisted by
    lacrimal nerve, one of three divisions of V1
  • Lower lid supplied by infraorbital, one of the
    two divisions of V2

27
Indigenous Flora of the Eyelids
  • Bacteria
  • Cultured from normal eyes
  • Species of patients harboring
  • S. epidermidis 37
  • S. aureus 17
  • Diphtheroids 1
  • Combination of above 35
  • Misc. 9
  • Total 99

28
  • Most common anaerobepropionibacterium acnes
  • Non-bacterial flora
  • Pityosporon ovale (orbiculare)
  • Yeast
  • No definitive pathogenic effect is known
  • Demodex folliculorum and D. Brevis (arthropods)
  • D. folliculorum in eyelash follicles
  • D. brevis in sebaceous glands

29
  • Herpes simplex virus periodically excreted in
    tears without being associated with any disease
    process

30
Skip!
  • Self study pages 5 thru 10

31
Congenital ptosis
  • Onset at birth
  • Watch for other congenital anomalies
  • In patient beyond 1 or 2 years of age a ptosis
    will generally be acquired, however, congenital
    ptosis should be considered and ruled out
  • History
  • Superior lid sulcus
    (absent)
  • Old photosFAT scan

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  • Differential diagnosis is very important since
    the congenital form is not usually accompanied by
    ongoing neurological disease (exception is
    neonatal myasthenia gravis)
  • Significance
  • Occlusion amblyopia
  • If significant degree of ptosis, get surgical
    consult to prevent occlusion amblyopia
    (pediatric ophthalmology consult)

34
  • Types
  • Autosomal dominant
  • Approx. 70 are autosomal dominant
  • Check family members
  • Also look for other congenital anomalies
  • If obstructing pupil significantly gt pediatric
    ophthalmology consult for surgical correction of
    ptosis

35
  • SR palsy with LPS palsy
  • Isolated SR palsy congenital is very, rare
  • Look for vertical tropia in primary position with
    ptosis

36
  • Paradoxical CN III innervation
  • Congenital gt Marcus Gunn jaw-winking ptosis
    accompanied by retraction during stimulation of
    ipsilateral pterygoid muscle. Amblyopia
    secondary to ptosis in 20 of these cases
  • Management surgery for ptosis
  • Acquired gt pseudo von Graefe sign

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  • Congenital Horners
  • Look for heterochromia irides (suggests onset
    prior to age 2)
  • Birth trauma
  • Not common at all
  • Neonatal myasthenia gravis

39
  • Tips in diagnosing congenital ptosis
  • History (may be reliable)
  • Old untouched photos (most parents have lots of
    baby pictures)
  • Superior lid sulcus - absent
  • Lid lag (slight) in downgaze due to inelasticity
    of the lid

40
  • Management aspects
  • If significant obstruction of pupil and/or
    apparent reduced acuity or dislike for fixation
    with the eye then consult with pediatric
    ophthalmologist is strongly advised. Ptosis must
    be eliminated to prevent occlusion amblyopia
  • Pediatric neurology (or ophthalmology) consult if
    congenital Horners or suggestion of neonatal
    myasthenia gravis

41
Ankyloblepharon
  • Adhesions between upper and lower eyelids along
    the lid margin
  • Results from significant mucocutaneous disease,
    i.e., ocular pemphigoid or as a congenital
    anomaly
  • Usually at outer canthus (external
    ankyloblepharon). Can be inner canthus
    (internal)
  • Causes pseudostrabismus

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Symblepharon
  • Adhesion of the tarsal conjunctiva to the bulbar
    conjunctiva resulting generally from significant
    inflammatory disease, Stevens-Johnson syndrome,
    pemphigoid, alkali burn
  • Occurs as tarsal conjunctiva and bulbar
    conjunctiva heal
  • Prevention is easier than
    treatment gt BID to QID
    breaking of adhesions with
    glass rod
  • Tx with cyclosporinRestasis

44
Vitiligo
  • Patchy depigmentation of the skin
  • In ocular disease skin of eyelids affected
  • Usually accompanied by depigmentation of lashes gt
    poliosis
  • Alopecia gt along with poliosis, vitiligo
  • R/O Cocaine use

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46
Entropion
  • Condition where the eyelid margin turns inward
    toward the globe - more common in lower lid
  • Significance
  • Can result in trichiasis, but not necessarily

47
  • Types
  • Congenital entropion
  • Usually other developmental anomalies
  • Cause is usually deformity in tarsal plate
    development causing entropion
  • Management is surgical reformation of tarsal
    plate
  • Epiblepharon-horizontal lid skin fold physically
    pushing lashes toward globe (trichiasis).
    Management surgical excision of excess skin

48
  • Cicatricial entropion
  • Cicatrix scar
  • Cicatricial entropion caused by scar on tarsal
    conjunctiva with contraction of scar tissue
    resulting in tractional entropion
  • Usual cause is inflammation of tarsal conjunctiva
    such as trachoma
  • Other causeschemical injuries, lacerations,
    surgical procedures

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  • Spastic entropion
  • Caused by excessive contraction of palpebral
    portion of orbicularis (or very rarely atrophy of
    the lid retractors)
  • Most common cause is blepharospasm due to ocular
    irritation, injury, inflammation (conjunctivitis,
    keratitis, etc.)

51
  • Atonic (involutional, senile) entropion
  • Common in lower lid not in upper lid
  • Occurs in elderly due to age-related lid changes
  • Lower border of lower tarsal plate (in inferior
    lid) rotates outward and superior border rotates
    upward due to
  • Elongation (stretching) of lid structureslaxity
    of tarsal plate orbital septum
  • Lower lid retractors (capsulopalpebral head of
    inferior rectus inferior Mueller muscle)
  • Atrophy of orbital fat with age gt enophthalmos
  • Orbicularis spasm (possibly?)

52
  • Signs and symptoms
  • Trichiasis can cause
  • Discomfort, foreign body sensation, irritation,
    tearing, pain
  • Corneal epithelial defects gt secondary corneal
    infections, ulcers, damage and scarring in
    anterior stroma
  • Vision loss can result from entropion with
    secondary trichiasis

53
  • Management
  • Careful evaluation of anterior segment to
    determine cause of entropion
  • Rule out ongoing anterior segment disease
    foreign body (evert lids inspect very
    carefully) to rule out a cause of spastic
    entropion
  • Rule out scar in palpebral conjunctiva
    (cicatricial entropion)
  • Evaluate laxity of the
    lid for atonic

54
  • Management is most effective if cause can be
    found and eliminated
  • Manage lid disease (eg., trachoma)
  • Epilation of lashes if symptomatic, temporary
    treatment for trichiasis only. Does not treat
    the entropion. Lashes will grow back and
    trichiasis will recur in a few weeks
  • If trichiasis is present with significant
    epithelial defects -gt broad spectrum antibiotic
    (SEE TOPICAL ANTIBIOTIC OINTMENT AND DROP TABLE
    pg 14 and 15) as indicated to prevent keratitis

55
  • Surgical management most successful for atonic
    entropion (blepharoplasty)
  • If surgery is refused by patient could consider
    electrolysis, cautery, argon laser, cryo -gt to
    prevent trichiasis (not treat entropion). Also
    helpful if gt 1/3 of lashes are touching globe
  • Bland ophthalmic ointment is helpful
  • Bandage contact lenses

56
Ectropion
  • Lid margin turned outward away from globe such
    that lid margin is not in contact with globe
  • Inferior tarsal conjunctiva is exposed, possibly
    inferior cornea
  • Usually lower lid, usually in elderly (atonic
    form of ectropion)

57
  • Significance
  • Dessication (keratinization of palpebral
    conjunctiva) of conjunctiva, cornea -gt discomfort
    and tearing, infection
  • Lacrimal puncta not in opposition to globe -gt
    epiphora
  • Patient may complain of an eye that waters all
    the time

58
  • Type
  • Cicatricial ectropion
  • Scarring on skin of lid
  • Can also occur in active dermatitis of lid
  • Past trauma (laceration, burn) of skin

59
  • Paralytic ectropion
  • Post trauma (injury, burn) or surgery
  • CN VII palsy (Bell's palsy)
  • Involutional (atonic, senile)
  • Laxity of lid tissue in lower lid
  • Gravity pulls the lid away from the globe

60
  • Signs and Symptoms (significance)
  • Dessication of lower conjunctiva and cornea
  • Irritation, dry eye symptoms
  • Epiphora
  • Widely opening mouth
  • Cicatricial -gt worse
  • Involutional -gt no change
  • Lid lax, puncta not in apposition to the globe

61
  • Evaluation
  • Symptoms -gt Epiphora
  • Gross observation
  • Pull lid away from globe -gt slow or no return

62
  • Management
  • Goal is to prevent discomfort, tearing, secondary
    keratinization and/or infection
  • Prevent dessication of conjunctiva and discomfort
    by use of lubricant
  • Artificial tears PRN (Q1H or QID recommended)
  • Bland ophthalmic ointments QHS
  • Possible EWCL to protect cornea
  • Broad spectrum antibiotic (TABLES on pages 14 and
    15) if recurrent infection such as blepharitis,
    conjunctivitis or keratitis
  • Tape lid at medial canthus to tighten it
  • Surgical treatment
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