Download (And) Shut - Illinois Eye Institute

2/17/2015
 No financial disclosures
Eyes Wide (And) Shut
Elyse Chaglasian OD FAAO
Associate Professor
Illinois College of Optometry
Illinois Eye Institute
2/22/15
Eyelids
Eyelids
I. Function
II. Anatomy
III. Conditions
IV. Eyelash Conditions
V. Infection / Inflammation
VI. Makeup
I. Function
II. Anatomy
III. Conditions
IV. Eyelash conditions
V. Infection / Inflammation
VI. Makeup
Eyelids: Function
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
 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
Eyelids: Anatomy‐Muscles
 Provides structural support
I. Orbicularis Oculi
II. Levator palpebrae
III. Mullers
 Superior plate ~10 mm  Inferior plate ~5 mm
 Conj on outside, skin inside
 Meibomian glands, eyelashes
Eyelids: Anatomy‐Muscles: Upper Lid
Eyelids: Anatomy‐Muscles: Lower Lid
 Raises the lid/opens the eye
 Inferior Tarsal
 Levator palpebrae muscle
 Mullers (superior tarsal) muscle
 Capsulopalpebral fascia (CPF)
 Incorporates IR & IO muscles
 Lowers the lid/closes the eye
 Obicularis Oculi muscle
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Eyelids: Anatomy: Orbital Septum
Orbicularis Oculi  Barrier between orbit & lid tissues
 Ringlike band of muscle
 Anatagonist to levator muscle  1. Orbital portion
 Fuses with the levator in upper lid & CPF in lower lid
 Prevents fat protrusion, edema, hemorrhage
 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
Mullers Muscle
 Skeletal muscle
 Smooth 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
 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
Review
 So…. Problem with Obicularis Oculi results in….?
 Lagophthalmos
 Exposure, dryness
 And…Problem with upper lid retractors results in….?
 Ptosis
& the insertions of the lower lid retractor muscles.  Nasojugal
 Malar  And…Problem with lower lid retractors results in…..?
 Ectropion
 Entropion
 Junction of the orbicularis muscle & the malar fat pad
Eyelids
Eyelid Conditions
I. Function
II. Anatomy
III. Conditions
IV. Eyelash conditions
V. Infection / Inflammation
VI. Makeup
a. Ptosis
b. Lagophthalmos
c. Entropion
d. Ectropion
e. Graves Ophthalmopathy
f. Floppy Eyelid Syndrome
Ptosis
 Congenital
 Weakness of levator
Congenital Ptosis
 Fibrous tissue in levator
 Capillary hemangioma/neurofibromas
 M‐G Jaw Winking, bleparophimosis
 Mechanical
 Tumor
 Edema
 Aponeurotic
 Weakness of levator aponeurosis ( w/normal muscle function)
 Senile, post‐op, blepharochalasis
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Ptosis
Ptosis History
 CL related
 Monocular or Binocular?
 Onset?
 Worsening throughout day?
 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 => 





 Consider MG
Trauma?
Pain, malaise, muscle weakness?
History of ocular/lid surgery?
Medical history?
Medications?
Contact lens wear?
mild) nerves
Ptosis Evaluation
 Observe
 Forehead wrinkles, scars
 Dermatochalasis, chalazion
 Chin elevation
 Ocular motilities
 Uni‐ or bilateral
Ptosis Evaluation
 Measure
 MRD1
 Fissure width
 Lid excursion (levator function measure)
 Lid crease  Pupil involvement
 3rd n palsy
 Horner’s
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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Ptosis Classification
Levator function / Lid excursion
Amount of Ptosis
Classification
1-2 mm
Mild
3-4 mm
Moderate
>/= 4mm
Severe
The difference in eyelid margin
position in upgaze & downgaze
(while holding the eyebrow to prevent frontalis activity)
www.plasticsurgery4u.com
Levator excursion measures
Ptosis management
 Visual field testing
Levator Muscle Excursion
Classification
13-17 mm
Normal
8-12 mm
Good
5-7mm
Fair
</= to 4mm
Poor
Surgical Management – Mild Ptosis
 Medically necessary?
 Ptosis crutch or tape
 Surgery
Surgical Management – Moderate & Severe Ptosis
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Lagophthalmos
Lagophthalmos ‐ causes
 Inferior PEK
 Paresis of orbicularis  Assess blink
 Ulceration

 Epiphora

 Nocturnal

 Dryness upon awakening?  Korb–Blackie Light Test
 “ Shut, not sealed”

Lagophthalmos ‐ treatment
oculi muscle
FES
Proptosis
 Graves
Congenital
 Moebius Syndrome
 CN 6 & 7
Acquired
 Bell’s Palsy
 Surgery: Is upper or lower lid  4 skin tone colors
 Nighttime taping
affected?
 Upper lid ?
 Retraction => levator
repair
 Gold weight implantation
 Lower lid ?
 Lid tightening & elevation
 lateral tarsal strip
 Pack of 100 adhesive strips
Tranquileyes
 External lid weights
 Tarsorrhaphy
 temporary/permanent
Gold weight implants
 Acoustic neuroma
 Trauma
 Cicatrices
 Post surgical
 Blepharoplasty
 Ptosis
 Neurosurgery
 Infections
 HZO
Blinkeze External Lid Weights
 Lubrication
 Sleep mask/goggles/  Tumors
 Tantalum
 0.6‐1.8g, in 0.2g increments
Eyelid Position Conditions
 Outpatient, local anesthetic
 3 holes, sutured onto tarsal plate
 Don’t work when patient laying down
 Complications:
 Infection
 Extrusion
 Incomplete closure
 Ptosis
 Allergy
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Ectropion Complications
Ectropion
 Epiphora
 Congenital
 Redness
 Dryness
 Irritation
 Corneal involvement
 Infection
 Inflammatory
 Blepharophimosis
 Cicatricial
 Burns, trauma
 Paralytic
 Facial nerve palsy
 Eczema, rosacea, dermatitis
 Mechanical
 Tumor or orbital fat herniation
 Involutional (senile)
 Weakness of pre‐tarsal  Acquired
 Traumatic
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
Entropion
 Congenital
 Trichiasis
 Corneal involvement
 Rare
 Cicatricial
 Scarring of palpebral
 Redness
conjunctiva
 Tearing




Trachoma
OCP
Trauma
Inflammation
 Spastic
 Excess contraction of the  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
palpebral portion of orbicularis = Blepharospasm
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Blepharospasm
Entropion
 Involuntary, tonic, spastic bilateral lid closure
 Botox
 F > M
 Quickert procedure
 60+
 Sutures, in office, local
 Idiopathic, Parkinson’s, psychotropic meds
 High failure rate
 Temporary fix
 Tx: Botox into orbicularis oculi
 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
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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%
Thyroid Eye Disease
 Thyroid “Stare” 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.
eye movements
eyelid retraction
 UPPER ONLY = GRAVES
 Scleral show
 Bilateral proptosis
 Peri‐ocular swelling
 Diplopia
 Reduced vision, color & contrast if CON
Thyroid Eye Disease‐ Treatment
 Control of thyroid 


 Diplopia :17%
 Optic neuropathy: 6%
 Eye pain, esp. with  Upper & lower 
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
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
 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
Eyelids
 Overnight shield
I. Function
II. Anatomy
III. Eyelid conditions
IV. Eyelash conditions
V. Infection / Inflammation
VI. Makeup
 Surgery
 Wedge excision, canthal tendon repair
Eyelash conditions
Trichiasis ‐ causes
a. Trichiasis
b. Distichiasis
c. Madarosis
d. Poliosis
 Aging changes
 Trauma
 Trachoma
 OCP
 Stevens ‐Johnson
 Leprosy
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Trichiasis ‐ treatment
Distichiasis
 Lubrication
 Extra row of lashes in place  Epilation
 4‐6 weeks
 Laser Ablation
 Cryotherapy
 Radiofrequency ablation
 Entropion repair
Distichiasis ‐ treatment
 Observation if asymptomatic
 If symptomatic
 Epilation
 Cryotherapy
 Trephination
 Wedge resection
 Microhyfrecation
 Lid splitting procedure with cryotherapy
Madarosis ‐ treatment
 Latisse
 Treat underlying cause
 Discontinue offending agent
of meibomian glands
 Most congenital
 Lymphedema‐Distichiasis
(LD) syndrome
 Acquired 




Entropion
Chronic blepharitis
OCP
Stevens ‐ Johnson
Burns
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
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
Blepharitis sequlae
Infection/Inflammation
 Blepharitis
 Anterior
 Staph/ Strep
 Posterior
 Molluscum
 Demodex
Anterior Blepharitis
 Hordeolum
 Infection  External = Zeiss or Moll; Internal = Meibomian
 Chalazian
 Sterile, granulomatous inflammation of meibomian gland




Dry eyes
Punctate keratopathy
Staph hypersensitivity keratitis
Phlyctenules
Anterior Bleph ‐ treatment
Staph
 Epidermis, aureus
Strep
 Seborrheic
 Younger
 Older
 Collarettes
 Nonobstructive
 Madarosis
 Waxes and wanes
 Greasy, soft scales
 Chronic
 Associated with dandruff
BlephEx
 Lid scrubs/foams
 Baby shampoo?
 Demodex treatment
 Omega 3 (FSO)
 Azasite
 Antibiotic ointment
 In office procedure
 Removes biofilm, scurf
 6‐8 minutes, q4‐6 months
 Not covered by insurance
 Alodox kit
 Tranquileyes with heat packs
 Ocusoft cleanser/pads
 Doxy 20 mg
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Posterior Blepharitis
Stage 1: Asymptomatic, Minimal
signs=>> Pt education, lid hygiene
 aka Meibomian Gland Dysfunction
Stage 2: Mild sx’s=>add
Lubrications, orals
 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



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Balance or Gel drops, Freshkote
Omega 3’s Azasite
Antibiotic ointment
Restasis
Mild topical steroids
Stage 4: Severe signs & sx’s
Steroids added
Plus Disease: Coexisting OSD
ie rosacea
Maskin MG Probing
Posterior Blepharitis ‐treatment
 Compresses
 In office expression
 Soothe XP, Systane
Stage 3: Moderate signs & sx’s
Orals, ung qhs, Restasis, steroid
 Oral antibiotics
 Doxy/minocycline
 Azithromycin
 Avenova with Neutrox
 iLid cleanser  Gland probing
 Intense Pulsed Light (IPL)
 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
 LipiFlow thermal pulsation
Intense Pulse Light (IPL)
Molluscum contagiosum
 Skin disease caused by MC  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)
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
Eyelids
 More common than you think
I. Function
II. Anatomy
III. Eyelid conditions
IV. Eyelash conditions
V. Infection / Inflammation
VI. Makeup
 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 and cosmetics
 Global market
Makeup ‐ complications
 Allergic Contact Dermatitis
 $170 BILLION
 Preservatives, ingredients,  Mascara: ~4 BILLION
fragrances, glues, tints
 Beware of “natural”, “organic’, “fragrance free”  ~25% of patients have allergy to their own makeup
 Application & removal issues
 Adverse reactions ACD ‐ treatment
Infections
 Cool compresses
 Shared use cosmetics
 OTC antihistamines
 Topical steroids
 Identification of offending agent
 Trauma
 K abrasions
 K ulcers
 Infection
 Dry eye
 Madarosis
 Makeup counters
 Friends and family
 Old makeup
 Breakdown of preservatives
 Frequent replacement
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Permanent makeup
Permanent makeup –why?
 “Blepharopigmentation”
 Cosmetics allergies
 1984‐Angres
 Intradermal injection of pigment onto eyelids, eyebrows
 No FDA regulation
 Convenience
 Time  Unsteady hands
 Poor vision
 Improve appearance
 Longterm cost savings
Permanent makeup complications
Permanent makeup complications
 Infection
 Allergy
 Pigment migration
• Phone survey of 92 patients who reported AE’s to FDA  anticoagulants
 Granulomas
 Keloids
 Procedure complications
 Burn from topical anesthetic
 Improper pigment usage
• 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
Thank you  Blepharitis management
 Makeup – have the conversation!
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