Lower Eyelid Malposition

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1 Oculoplastic Surgeon s DDX for the Red Eye Geeta Belsare Been,MD The Center for Facial Plastic Surgery Barrington, IL Lower Eyelid Malposition Ectropion Involutional Cicatricial Paralytic Entropion Involutional Cicatricial Oculoplastic Surgeon s DDX for the Red Eye Eyelid Malposition Photos Disorders of lacrimal drainage Lacrimal set including irrigation Exposure Orbital Disease Color vision, Hertel Possible Visual Field Masquerade Syndrome Involutional Ectropion Majority of cases Horizontal eyelid laxity Loss of eyelid apposition and eversion 1

2 Involutional Ectropion Conjunctival inflammation and keratinization Main Issue: Horizontal Laxity Treatment: Lateral Tarsal Strip Lateral Canthal resuspension Cicatricial Ectropion Caused by chemical burns, trauma, actinic skin damage or chronic inflammation Complication of cosmetic surgery Cicatricial Ectropion Classic lateral tarsal strip was described by Dr. Anderson in 1979 Fashioning a strip of lower lid tarsus Trimming it so that it can be reattached to the lateral orbital rim Acne Rosacea with chalazion 2

3 Cicatricial Ectropion Paralytic Ectropion CN 7 innervates Orbicularis Oculi which is the main protractor of the eyelid Pretarsal, preseptal and orbital parts Involuntary (blink): pretarsal and preseptal Voluntary (Wink): Orbital Cicatricial Ectropion Paralytic Ectropion Concomitant upper eyelid lagopthalmos Treatments: Skin Grafts Midface Lifts Horizontal eyelid tightening Paralytic Ectropion Poor blink and eyelid closure 3

4 Paralytic Ectropion Results in chronic inferior corneal exposure Also poor tear film distribution and replenishment Involutional Entropion Horizontal laxity and disinsertion of retractors White subconjunctival line several mm below inferior tarsal border Deep inferior fornix Decreased mvmt of lower lid on downgaze Dx: Snapback test: >6mm of laxity Combination of treatments Mainly horizontal tightening and repair of the retractors Paralytic Ectropion Involutional Entropion Treatment Options: Lubricating drops & ointments Temporary and permanent tarsorrhaphies Gold weight and horizontal tightening procedure Lashes directly on globe Inferior Scleral Show Involutional Entropion Treatment options: Temporizing measures: Tape Quickert sutures 4

5 Cicatricial Entropion Cicatricial Entropion Cicatricial Entropion Trichiasis Dx: Vertical tarsoconjunctival contracture DDx: Autoimmune (OCP), Inflammatory (SJS), Infectious (Herpes or Trachoma), Surgical (Enucleation), Traumatic (Chemical burn) Cicatricial Entropion Trichiasis Treatment: 1. Mechanical Epilation 2. Radiofrequency epilation (>6wks later) 5

6 Upper Eyelid Malposition Entropion Floppy Eyelid Syndrome Floppy Eyelid Syndrome Entropion Upper Eyelid Floppy Eyelid Syndrome Chronic Papillary conjunctivitis Patching or Shield Surgical correction with horizontal tightening or wedge resections Floppy Eyelid Syndrome Disorders of Lacrimal Drainage Nasolacrimal Duct Obstruction Dacryocystitis Cannaliculitis 6

7 Lacrimal Drainage System Dacryocystitis NLD Obstruction Dacryocystitis Acquired: Present with redness, tearing or infection Etiology: Involutional changes of NLD, trauma or surgical hx Hx of crusting in the mornings Dacryocystitis Stasis of fluid in sac with infection Acute onset of pain and swelling Considerations: Orbital cellulitis Lacrimal sac tumor Imaging Treatment: Systemic antibiotics Warm compresses Possible incision and drainage if abscess DCR Surgery (Dacryocystorhinostomy) Drainage procedure to bypass site of NLDO Required in all patients with chronic epiphora or daycryocystitis due to NLDO 7

8 DCR Surgery Endoscopic DCR Surgery Anastomosis of lacrimal sac to nasal mucosal flaps External DCR Surgery Canaliculitis Rare infection Bacterial or fungal Etiology: Any abnormality in the lacrimal system can lead to concretion formation and a chronic infection Lacrimal Stent Canaliculitis Erythematous Pouting punctum Dilated punctum Tender to palpation 8

9 Canaliculitis Expression of pus with pressure Exposure Keratopathy Upper lid retraction Lower lid retraction Proptosis Facial nerve palsy Canaliculitis Upper lid retraction Defined as exposed sclera between limbus and lid margin Canaliculitis Lower lid Retraction Treatment: Warm compresses, topical and systemic antibiotics Incision and drainage can be required to remove concretions 9

10 Lid Retraction Grave s most common cause Recession of vertical rectus muscles Overly aggressive skin excision Contralateral ptosis overcompensation Hering s law Tumor Facial Nerve Palsy Proptosis Treatment of Lid Retraction Treat the underlying cause Topical treatment After atleast 6mths: Mullerectomy Levator Aponeurosis recession Skin grafts Lateral Tarsorrhaphy Proptosis Red Eye secondary to lymphoma: Importance of scanning Proptosis Proptosis 10

11 Facial Nerve Palsy Facial Nerve Palsy Facial Nerve Palsy Orbital Disease Graves Disease Cellulitis Orbital Inflammatory Disease Carotid Cavernous Fistula Facial Nerve Palsy Graves Disease 11

12 Graves Disease Carotid Cavernous Fistula Abnormal communication due to: Trauma Degeneration Orbital Cellulitis Carotid Cavernous Fistula Orbital Cellulitis Carotid Cavernous Fistula Erythema, swelling, chemosis, restricted EOM, pain on eye movement and proptosis Treatment: Immediate broad-spectrum antibiotics, imaging and careful monitoring. 12

13 Mascarade Syndrome Sebaceous cell carcinoma of the conjunctiva Sebaceous adenocarcinoma Arises from Meibomian glands, Zeis glands or sebaceous glands of caruncle, face or brow Most common in females Twice as likely to be seen in the upper lid Increased number of glands Multicentric origin with pagetoid spread Sebaceous Cell Carcinoma Sebaceous Cell Carcinoma Sebaceous Cell Carcinoma Special Thank you to Dr. John McCann, Dr. Rick Anderson and Dr. Gary Churchill 13

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