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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 1 2/17/2015 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 2 2/17/2015 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 3 2/17/2015 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 4 2/17/2015 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 5 2/17/2015 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 6 2/17/2015 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 7 2/17/2015 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 8 2/17/2015 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 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 9 2/17/2015 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 10 2/17/2015 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) 11 2/17/2015 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 12 2/17/2015 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 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 77 13 2/17/2015 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 14 2/17/2015 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! 15