2/17/2015

1

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)

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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