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Eyes Wide (And) Shut
Elyse Chaglasian OD FAAOAssociate Professor
Illinois College of OptometryIllinois Eye Institute
2/22/15
No financial disclosures
Eyelids
I. Function
II. Anatomy
III. Conditions
IV. Eyelash Conditions
V. Infection / Inflammation
VI. Makeup
Eyelids
I. Function
II. Anatomy
III. Conditions
IV. Eyelash conditions
V. Infection / Inflammation
VI. Makeup
Eyelids: Function
I. Protection of ocular surface
From environmental factors, light, trauma
Via lid closure
Gentle or forced
From dessication and infection
Via tear production & distribution
Evaluate blinking
“RIB”
Eyelashes are first line of defense
Eyelids: Function
II. Tear film maintenance
Proper balance of components
Via evaporation prevention
Meibomian glands, Zeiss and Moll
III. Tear flow
Via proper apposition of lids to ocular surface
Into puncta
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Eyelids
I. Function
II. Anatomy
III. Conditions
IV. Eyelash conditions
V. Infection / Inflammation
VI. Makeup
Eyelids: Anatomy
Tarsal Plate
Muscles
Orbital Septum
Eyelids: Anatomy‐Tarsal Plate
Provides structural support
Superior plate ~10 mm
Inferior plate ~5 mm
Conj on outside, skin inside
Meibomian glands, eyelashes
Eyelids: Anatomy‐Muscles
I. Orbicularis Oculi
II. Levator palpebrae
III. Mullers
Eyelids: Anatomy‐Muscles: Upper Lid
Raises the lid/opens the eye
Levator palpebrae muscle
Mullers (superior tarsal) muscle
Lowers the lid/closes the eye
Obicularis Oculi muscle
Eyelids: Anatomy‐Muscles: Lower Lid
Inferior Tarsal
Capsulopalpebral fascia (CPF)
Incorporates IR & IO muscles
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Eyelids: Anatomy: Orbital Septum
Barrier between orbit & lid tissues
Fuses with the levator in upper lid & CPF in lower lid
Prevents fat protrusion, edema, hemorrhage
Orbicularis Oculi
Ringlike band of muscle
Anatagonist to levator muscle
1. Orbital portion Forced closure (squeezing, winking)
2. Palpebral portion
(E) Preseptal section Involuntary, gentle closure blinking, sleeping
(F) Pretarsal section Draws eyelids medially (aids in tear drainage )
: CN VII (facial) innervation
Eyelids: Innervation
Innervated by 3 Cranial Nerves:
III: Motor innervation to Levator
V: Sensory innervation to upper & lower lids
VII: Motor innervation to Obicularis Oculi
Eyelid Margin
Cilia arise from hair follicles
Upper lid: 100‐150
Lower lid: 50‐75
Each follicle contain (sebaceous) glands of Zeiss
(Sweat) glands of Moll close by
Levator Palpebrae
Skeletal muscle
Elevates & retracts upper eyelid
Levator aponeurosis is a tendon that attaches the muscle to the tarsal plate
Antagonist to palpebral portion of the orbicularis oculi
CN III (oculomotor) innervation
MullersMuscle
Smooth muscle
Elevates & retracts upper eyelid
Sympathetic nerve innervation
Phenylephrine test
Increased tone => Graves
Diminished tone => Horners
miosis, anhidrosis, heterochromia
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Eyelid creases
Superior palpebral F: 10 mm: M: 8 mm
Absence = lack of levator function Congenital blepharoptosis
Increased= Levator dehisence Involutional ptosis
Inferior palpebral Marks inferior edge of the tarsus
& the insertions of the lower lid
retractor muscles.
Nasojugal
Malar Junction of the orbicularis muscle
& the malar fat pad
Review
So…. Problem with Obicularis Oculi results in….? Lagophthalmos Exposure, dryness
And…Problem with upper lid retractors results in….? Ptosis
And…Problem with lower lid retractors results in…..? Ectropion Entropion
Eyelids
I. Function
II. Anatomy
III. Conditions
IV. Eyelash conditions
V. Infection / Inflammation
VI. Makeup
Eyelid Conditions
a. Ptosis
b. Lagophthalmos
c. Entropion
d. Ectropion
e. Graves Ophthalmopathy
f. Floppy Eyelid Syndrome
Ptosis
Congenital
Weakness of levator
M‐G Jaw Winking, bleparophimosis
Mechanical
Tumor
Edema
Aponeurotic
Weakness of levator aponeurosis ( w/normal muscle function)
Senile, post‐op, blepharochalasis
Congenital Ptosis
Fibrous tissue in levator
Capillary hemangioma/neurofibromas
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Ptosis
CL related
Traumatic
Damage to levator
Post operative
Myogenic Disease
Dysfunction of levator
Myasthenia Gravis, CPEO, Myotonic Dystrophy
Neurogenic Disease
Damage to 3rd (levator => severe) or sympathetic (Mullers => mild) nerves
Ptosis History
Monocular or Binocular? Onset? Worsening throughout day? Consider MG
Trauma? Pain, malaise, muscle weakness? History of ocular/lid surgery? Medical history? Medications? Contact lens wear?
Ptosis Evaluation
Observe
Forehead wrinkles, scars
Dermatochalasis, chalazion
Chin elevation
Ocular motilities
Uni‐ or bilateral
Pupil involvement
3rd n palsy
Horner’s
Ptosis Evaluation
Measure
MRD1
Fissure width
Lid excursion (levator function measure)
Lid crease
Margin Reflex Distance (MRD)
Measure from corneal reflex to lid margin
MRD 1: to upper lid margin: ~4‐5 mm
MRD 2: to lower lid margin: ~5 mm
Ptosis & MRD 1
Unilateral: MRD between ptotic & non‐ptotic lid
Bilateral: MRD of average normal (~4.5 mm) minus MRD of ptosis
Non ptotic Ptotic
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Amount of Ptosis Classification
1-2 mm Mild
3-4 mm Moderate
>/= 4mm Severe
Ptosis Classification Levator function / Lid excursion
www.plasticsurgery4u.com
The difference in eyelid marginposition in upgaze & downgaze(while holding the eyebrow to prevent frontalis activity)
Levator excursion measures
Levator Muscle Excursion Classification
13-17 mm Normal
8-12 mm Good
5-7mm Fair
</= to 4mm Poor
Ptosismanagement
Visual field testing
Medically necessary?
Ptosis crutch or tape
Surgery
Surgical Management –Mild Ptosis Surgical Management –Moderate & Severe Ptosis
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Lagophthalmos
Inferior PEK
Assess blink
Ulceration
Epiphora
Nocturnal
Dryness upon awakening?
Korb–Blackie Light Test
“ Shut, not sealed”
Lagophthalmos ‐ causes
Paresis of orbicularis oculi muscle
FES
Proptosis
Graves
Congenital
Moebius Syndrome
CN 6 & 7
Acquired
Bell’s Palsy
Tumors
Acoustic neuroma
Trauma
Cicatrices
Post surgical
Blepharoplasty
Ptosis
Neurosurgery
Infections
HZO
Lagophthalmos ‐ treatment
Lubrication
Nighttime taping
Sleep mask/goggles/ Tranquileyes
External lid weights
Tarsorrhaphy
temporary/permanent
Surgery: Is upper or lower lid affected?
Upper lid ?
Retraction => levatorrepair
Gold weight implantation
Lower lid ?
Lid tightening & elevation
lateral tarsal strip
Blinkeze External Lid Weights
4 skin tone colors
Pack of 100 adhesive strips
Tantalum
0.6‐1.8g, in 0.2g increments
Gold weight implants
Outpatient, local anesthetic
3 holes, sutured onto tarsal plate
Don’t work when patient laying down
Complications:
Infection
Extrusion
Incomplete closure
Ptosis
Allergy
Eyelid Position Conditions
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Ectropion Complications
Epiphora
Redness
Dryness
Irritation
Corneal involvement
Infection
Ectropion
Congenital
Blepharophimosis
Cicatricial
Burns, trauma
Paralytic
Facial nerve palsy
Acquired
Traumatic
Inflammatory Eczema, rosacea, dermatitis
Mechanical Tumor or orbital fat herniation
Involutional (senile) Weakness of pre‐tarsal orbicularis
Laxity of canthal ligaments Punctal malposition
Snap back test
• Grade 0 ‐ normal lid returns to position immediately
• Grade I ~ 2‐3 sec
• Grade II ~ 4‐5 sec
• Grade III >5 sec but returns to position with blinking
• Grade IV ‐ never returns to position; frank ectropion
Ectropion ‐ treatment
Lubrication
Tarsorrhaphy
Surgical horizontal shortening
Full‐thickness temporal eyelid resection
Lateral canthal tendon tightening (canthoplasty)
Lateral tarsal strip procedure
Eyelid retractor reinsertion
Entropion Complications
Trichiasis
Corneal involvement
Redness
Tearing
Entropion
Congenital Rare
Cicatricial
Scarring of palpebralconjunctiva Trachoma
OCP
Trauma
Inflammation
Spastic
Excess contraction of the palpebral portion of orbicularis = Blepharospasm
Involutional (senile) Laxity of lower lid retractors
Upward migration of preseptal orbicularis
Excess contraction of the palpebral portion of orbicularis
Horizontal lid laxity due to stretched tendons
Thinning of tarsal plate
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Blepharospasm
Involuntary, tonic, spastic bilateral lid closure
F > M
60+
Idiopathic, Parkinson’s, psychotropic meds
Tx: Botox into orbicularis oculi
Entropion
Botox
Quickert procedure
Sutures, in office, local
High failure rate
Temporary fix
Horizontal tightening
Lateral tarsal strip procedure
Reattachment of retractors to tarsus
Thyroid Eye Disease
aka Graves' Ophthalmopathy / Orbitopathy (GO), Thyroid Associated Orbitopathy (TAO)
Orbital, auto‐immune condition
Testing:
SLE SLK, staining, injection
Exophthalmometry
Visual fields
Compressive Optic Neuropathy (CON)
Thyroid function tests ( Free T4, TSH)
Orbital CT/MRI
Thyroid Eye Disease
Thyroid “Stare”
Upper & lower eyelid retraction
UPPER ONLY = GRAVES
Scleral show
Bilateral proptosis
Peri‐ocular swelling
Eye pain, esp. with eye movements
Diplopia
Reduced vision, color & contrast if CON
Thyroid Eye Disease
F/M = 6/1
F:Early 40’s or 60’s/M: late 40’s or 60’s
Hyperthyroidism: 90%
Eyelid retraction: 90%
Proptosis: 60%
Restrictive Ophthalmoplegia: 40% Diplopia :17%
Optic neuropathy: 6%
Bartley GB. The epidemiologic characteristics and clinical course of ophthalmology associated autoimmune thyroid disease in Olmstead County, MN. Trans Am Ophthalmol Soc 1994;92:477‐588.
Thyroid Eye Disease‐ Treatment
Control of thyroid hormones
Smoking cessation
Head elevation
Lubrication, lid closure
Prism
Steroids ‐ acute only
Radiation ‐ acute only
Surgery
Orbital decompression
Proptosis & CON
Botox prevents contraction of MR during surgery
Strabismus
Eyelid
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Floppy Eyelid Syndrome
Generalized laxity of lid tissues
Easy superior lid eversion
Papillary reaction
Associated with:
Tear film abnormalities
Lipid deficiency
Reduced TBUT
Eyelash ptosis
Lagophthalmos
Ectropion
Floppy Eyelid Syndrome
Strong association with obstructive sleep apnea syndrome Obesity Male Larger neck girth (>17” M, >16” F) Snoring Alcohol use Keratoconus GLC NA‐AION
Floppy Eyelid Syndrome Treatment
Overnight shield
Surgery
Wedge excision, canthal tendon repair
Eyelids
I. Function
II. Anatomy
III. Eyelid conditions
IV. Eyelash conditions
V. Infection / Inflammation
VI. Makeup
Eyelash conditions
a. Trichiasis
b. Distichiasis
c. Madarosis
d. Poliosis
Trichiasis ‐ causes
Aging changes
Trauma
Trachoma
OCP
Stevens ‐Johnson
Leprosy
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Trichiasis ‐ treatment
Lubrication
Epilation
4‐6 weeks
Laser Ablation
Cryotherapy
Radiofrequency ablation
Entropion repair
Distichiasis
Extra row of lashes in place of meibomian glands
Most congenital Lymphedema‐Distichiasis
(LD) syndrome
Acquired Entropion Chronic blepharitis OCP Stevens ‐ Johnson Burns
Distichiasis ‐ treatment
Observation if asymptomatic
If symptomatic
Epilation
Cryotherapy
Trephination
Wedge resection
Microhyfrecation
Lid splitting procedure with cryotherapy
Madarosis ‐ causes
Chronic inflammation Blepharitis
Allergy
Alopecia, SLE, scleroderma, psoriasis, thyroid
Trauma
Eyelid tumors & treatment
Makeup reaction
Eyelid tattooing
Trichotillomania
Medications
Miotics, cholesterol, anticoags, Botox
HIV/AIDS
Sickle cell
Madarosis ‐ treatment
Latisse
Treat underlying cause
Discontinue offending agent
Poliosis
Most commonly associated with VKH Syndrome(uveitis‐vitiligo‐alopecia‐poliosis) Also: tuberous sclerosis, Marfan’s, sarcoid, bleph, herpes zoster, sympathetic ophthalmia
Medications: post fungal, latanoprost (Report)
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Eyelids
I. Function
II. Anatomy
III. Eyelid conditions
IV. Eyelash conditions
V. Infection / Inflammation
VI. Makeup
Infection/Inflammation
Blepharitis
Anterior
Staph/ Strep
Posterior
Molluscum
Demodex
Blepharitis sequlae
Hordeolum Infection
External = Zeiss or Moll; Internal = Meibomian
Chalazian Sterile, granulomatous inflammation of meibomian gland
Dry eyes
Punctate keratopathy
Staph hypersensitivity keratitis
Phlyctenules
Anterior Blepharitis
Staph Strep
Epidermis, aureus
Younger
Collarettes
Madarosis
Waxes and wanes
Seborrheic
Older
Nonobstructive
Greasy, soft scales
Chronic
Associated with dandruff
Anterior Bleph ‐ treatment
Lid scrubs/foams
Baby shampoo?
Demodex treatment
Omega 3 (FSO)
Azasite
Antibiotic ointment
Alodox kit
Tranquileyes with heat packs
Ocusoft cleanser/pads
Doxy 20 mg
BlephEx
In office procedure
Removes biofilm, scurf
6‐8 minutes, q4‐6 months
Not covered by insurance
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Posterior Blepharitis
aka Meibomian Gland Dysfunction
Lipid film insufficiency
TBUT due to evaporation
Bacterial lipases degrade meibum
67% over age 60
Often co‐exists with anterior bleph
Seen with rosacea, distichiasis, accutane, taxotere usage
Stage 1: Asymptomatic, Minimalsigns=>> Pt education, lid hygiene
Stage 2: Mild sx’s=>addLubrications, orals
Stage 3: Moderate signs & sx’sOrals, ung qhs, Restasis, steroid
Stage 4: Severe signs & sx’sSteroids added
Plus Disease: Coexisting OSDie rosacea
Posterior Blepharitis ‐treatment
Compresses
In office expression
Soothe XP, SystaneBalance or Gel drops, Freshkote
Omega 3’s
Azasite
Antibiotic ointment
Restasis
Mild topical steroids
Oral antibiotics
Doxy/minocycline
Azithromycin
Avenova with Neutrox
iLid cleanser
Gland probing
Intense Pulsed Light (IPL)
LipiFlow thermal pulsation
MaskinMG Probing
2 or 4 mm stainless steel 76 μm probe
24/25 pts had immediate relief & all 25 had relief of by 4 months post‐probing
20/25: didn’t require re‐tx by average follow‐up of 11.2 months
5/25:Re‐tx at an average of 4‐6 months
Intense Pulse Light (IPL)
Brief, powerful light bursts at 500‐800 nm reduce inflammation
Light is absorbed by the oxyhemoglobin in the blood vessels on the skin's surface, generates heat that coagulates blood vessels
Heat melts oil in glands, allows for easer expression
3‐4 treatments (once a month), lasts 6‐12 months
~$400/tx (no insurance coverage)
77
Molluscum contagiosum
Skin disease caused by MC virus
Children
Sexually active adults
Immunocompromised
Skin‐skin contact
Incubation pd 2‐3 mo
Follicular conjunctivitis
Self limiting, excision, cryotherapy, or curettage
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Demodex Folliculorum
More common than you think
84% of the population at age 60 & 100% over the age of 70
Cliradex wipes (4‐terpinol) : qd x 6‐8 weeks for mild to moderate symptoms, or bid x six to eight weeks for moderate to severe
Cliradex Complete Advanced Lid Hygiene Kit: stronger concentration of 4‐terpineol for in‐office application
Eyelids
I. Function
II. Anatomy
III. Eyelid conditions
IV. Eyelash conditions
V. Infection / Inflammation
VI. Makeup
Eyelids and cosmetics
Global market
$170 BILLION
Mascara: ~4 BILLION
Application & removal issues
Adverse reactions
Makeup ‐ complications
Allergic Contact Dermatitis
Preservatives, ingredients, fragrances, glues, tints
Beware of “natural”, “organic’, “fragrance free”
~25% of patients have allergy to their own makeup
Trauma
K abrasions
K ulcers
Infection
Dry eye
Madarosis
ACD ‐ treatment
Cool compresses
OTC antihistamines
Topical steroids
Identification of offending agent
Infections
Shared use cosmetics
Makeup counters
Friends and family
Old makeup
Breakdown of preservatives
Frequent replacement
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Permanent makeup
“Blepharopigmentation”
1984‐Angres
Intradermal injection of pigment onto eyelids, eyebrows
No FDA regulation
Permanent makeup –why?
Cosmetics allergies
Convenience
Time
Unsteady hands
Poor vision
Improve appearance
Longterm cost savings
Permanent makeup complications
Infection
Allergy
Pigment migration
anticoagulants
Granulomas
Keloids
Procedure complications
Burn from topical anesthetic
Improper pigment usage
Permanent makeup complications
• Phone survey of 92 patients who reported AE’s to FDA
• Tenderness (95%)
• Swelling (91%)
• Itching (88%)
• Bumps (83%)
• 68% reported that problems had not completely resolved from 5.5‐36 months
• Patients with self‐reported history of allergy took longer to heal
Take home messages
Eyelids serve important functions & their problems cannot be overlooked
Proper lid position is critical
Lid measurements, photos, fields, referrals
Blepharitis management
Makeup – have the conversation!
Thank you