The Complete Oculoplastics Exam. Nicole Langelier, MD MBE Oculoplastic Surgery Fellow

Transcription

1 The Complete Oculoplastics Exam Nicole Langelier, MD MBE Oculoplastic Surgery Fellow

2 Goals Review the important components of: 1. Medical history 2. Physical examination 3. Special Testing For common oculoplastics diagnoses: Dermatochalasis Ptosis Ectropion / Entropion Epiphora Eyelid lesion

3 General History Guidelines Referring doctor (send note every visit) PMH: Conditions and Medications For each complaint: A thorough description of the complaint When did it start How does it affect the patient or interfere with daily activities? Does anything make it better or worse? What treatments have they tried?

4 NOPQRST Memory Tool for Complete History (not in the ideal order for flow) Name the problem Onset / Occurs when.... Provoking or palliation Quality of Life Region / Related complaints Name and describe the symptom or problem Symptom ONSET and time course What makes it worse? What makes it better? How does it affect your daily activities? Does it spread? Does it blur the vision? Does it cause any other problems? Severity Pain scale 0-10 Treatments tried Previous medications, surgeries, other techniques to manage the problem

5 Why Thorough Documentation Matters Good documentation is good practice! Better information about the problem = better care. Communication with other care providers Catch vision/life threatening problems Medical/Legal Insurance Approval

6 Physical Examination Visual acuity at EVERY VISIT If not 20/20, why? Pinhole If there is >2 lines drop in vision, this must be evaluated Pressure Pupils Extraocular motility (any diplopia?) Confrontation VF Color Vision (orbit problems, proptosis, decreased vision) Special Testing

7 Case 1

8 Diagnosis? Bilateral Upper Eyelid Dermatochalasis

9 Dermatochalasis: Chief Complaint My eyelids are heavy I have to hold my eyelids up The extra skin gets in the way My doctor said I need a lid lift

10 NOPQRST: Dermatochalasis Name the problem Onset/Occurs when.... Provoking or palliation Quality of Life Region / related complaints Severity Treatments tried Heavy upper eyelids First noticed many years ago and getting worse. Heaviest first thing in the morning. I have to tape my eyelids up. My eyes get tired when I m reading, watching TV, doing crafts. Peripheral vision decreased when I m driving. I don t like the way it looks. My eyelids get itchy from sweat when I work outside. Taping my eyelids is giving me a rash (Should not cause pain) Pain scale is part of every encounter. Surgery for this problem 15 years ago helped by now it s back.

11 Exam: Dermatochalasis Vision Pressure Pupils EOM CVF Every visit New patient, most visits* New patient, most visits* Every new plastics patient Every new plastics patient Color Vision For any complaint of poor vision Abnormal pupils Special Testing MRD1 Ptosis Visual Field External Photography * Post op visits: Visual acuity check alone may be sufficient

12 MRD1 for Dermatochalasis Margin to Reflex Distance MRD1 = 1 MRD1 = 0.5

13 Eyelid Visual Field Testing Focuses on superior visual field Before Tape: Chin neutral Relaxed brows After Tape Shows potential postoperative improvement

14 Case 2

15 Dermatochalasis External Photos Band Elevate Skin (shows true MRD 1) Full Face Tips Chin neutral Relax brows Use flash (one full face flash off) Neutral or bored facial expression Side Right Side Left

16 Post-Operative Follow Up History: Any problems? Any improvement in vision Exam Visual acuity Pressure: if on topical steroids or history of elevated IOP Common Post-Op Complaints: Discomfort Itching Blurry Vision Post Op Photos Allergy to ointment

17 Diagnosis? Bilateral Upper Eyelid Ptosis

18 Ptosis: Chief Complaint? My eyelids are heavy I have to hold my eyelids up People say my eyes look drunk My doctor said I need a lid lift

19 NOPQRST: Ptosis Name the problem Onset/Occurs when.... Provoking or palliation Quality of Life Region / related complaints Severity Treatments tried Droopy upper eyelids Ptosis First noticed 1 year ago, no sudden onset!!!: Sudden onset, complete eyelid closure, large fluctuation in lid height Constant or fluctuation in droopiness? Eye fatigue, headaches, lift chin to see, difficulty reading, driving, watching TV!!!: Double vision, severe headaches, pain (Should not cause pain) Pain scale is part of every encounter. Previous surgeries?

20 Vision Exam: Ptosis Every patient, every visit Pressure Pupils EOM CVF Droopy eyelid + high pressure can be an orbit problem!!! Notify MD of asymmetric pupils Horners, 3 rd nerve palsy!!! Notify MD of double vision or decreased motility 3 rd nerve palsy, Myasthenia Gravis, Orbital tumor can cause ptosis and decreased VF Color Vision For any complaint of poor vision Abnormal pupils Special Testing MRD1 Ptosis Visual Field External Photography Ice test for myasthenia gravis

21 MRD1 for Ptosis MRD1 = 3 MRD1 = 2 MRD1 = 0.5 MRD1 = 0

22 Eyelid Visual Field Testing Focuses on superior visual field Before Tape: Chin neutral Relaxed brows After Tape Shows potential postoperative improvement

23 Ptosis External Photos (pt has dermatochlasis too) Band Elevate Skin (shows true MRD 1) Full Face Tips Chin neutral Relax brows Side Right Use flash (one full face flash off) Neutral or bored facial expression Side Left

24 Surgical Treatment: Ptosis Repair

25 Post-Operative Follow Up History: Any problems? Any improvement? Exam Visual acuity Pressure (+/-) Post-Op Complaints: Dryness Incomplete lid closure Blurry vision Pain Post Op Photos Lagophthalmos

26 Case 3 + 4

27 Diagnosis? (lower lids) Ectropion

28 Diagnosis? (lower lids) Entropion

29 Ectropion: Chief Complaint? My eyes hurt My eyes are always dry My eyes always look red I have mucous and tearing

30 Entropion: Chief Complaint? My eyes hurt My eyes are dry My eyes always look red I have mucous and tearing My eyelashes scratch my eyes

31 NOPQRST: Lower Lid Malposition Name the problem Onset/Occurs when.... Provoking or palliation Quality of Life Region / related complaints Severity Treatments tried (important to insurance) Ectropion/Entropion/Lid Malposition/Dry Eyes It started years ago It started after my lower eyelid blepharoplasty It started after my cheek cancer reconstruction My eyelid rolls in when I squint in the sun Eyes feels worse in wind Irritation, pain, dry eyes, watering eyes, objectionable appearance I scare my grandkids Dry eyes Watering eyes Skin lesions (cancer) Pain scale is part of every encounter. Nothing Tear drops Previous surgeries Punctal plugs

32 Exam: Lower Lid Malposition Vision Pressure Pupils EOM CVF Every patient, every visit First visit, if on steroids, if a history of abnormal IOP Every patient, every visit Part of initial evaluation Part of initial evaluation Color Vision For any complaint of poor vision Abnormal pupils Special Testing MRD2 Inferior Scleral Show External Photography

33 MRD2 and Inferior Scleral Show MRD 1 MRD 2 Inferior Scleral Show MRD 2 = 9 Inf Scleral Show = 3

34 External Photos Ectropion Entropion Important to show Scleral Show Inflammation (if visible) Injected eye (if visible) Important to show Lashes rubbing ocular surface Injected eye (if visible)

35 Ectropion Surgical Treatment Entropion Lateral tarsal strip (horizontal lid tightening) Skin graft Conjunctivoplasty Lateral tarsal strip (horizontal lid tightening) Entropion repair via suture Entropion repair via thermocautery

36 Post-Operative Follow Up History: Any problems? Any improvement in symptoms? Exam Visual acuity Pressure +/- Post Op Photos

37 Ectropion Post-Operative Photos Entropion Before Before After Repair (LTS and FTSG OD; Kenalog OS) After Repair (Wheeler Halving)

38 Case 5

39 Diagnosis? Epiphora (due to insufficient drainage)

40 Epiphora (Tearing): Chief Complaint Eyes water Tearing My eyes are wet and it makes it hard to see (Often carry a tissue and dab at eyes during visit)

41 NOPQRST: Tearing Name the problem Onset/Occurs when.... Provoking or palliation Quality of Life Region / related complaints Severity Treatments tried Tearing Years ago After my punctal plugs Worse when I m outside. Worse during allergy season. Have to dab tears with tissues Blurry vision makes it hard to read and drive. People think I m crying. Smears my makeup. Tears irritate my skin. Skin lesions or bumps in medial canthus (cancer) Dacryocystitis (infection of nasolacrimal sac) Bloody tears Pain scale is part of every encounter. Previous surgeries? Artificial tears? Anti-allergy drops?

42 Exam: Epiphora Vision Pressure Pupils EOM CVF Every patient, every visit First visit, if on steroids, if a history of abnormal IOP Tearing is a sign of congenital glaucoma in children Part of initial evaluation Part of initial evaluation Part of initial evaluation Color Vision For any complaint of poor vision Abnormal pupils Special Testing Probing and Irrigation External photos if lid position is contributing

43 Dacryocystitis: Google Fail

44 Probing and Irrigation: Is there an obstruction?

45 Treatment Treatment Depends on the Cause of Tearing

46 Post-Operative Follow Up History: Any problems? Any improvement? Exam Visual acuity Pressure (+/-) Post-Op Complaints: Tube discomfort Pain Nose bleed

47 Case 6

48 Diagnosis? Eyelid Lesion Neoplasm of Uncertain Behavior (Often need biopsy for certain diagnosis)

49 Eyelid Lesions: Chief Complaint? Bump on my eyelid Present due to concern for Cancer Infection Pain/ Irritation Ugly

50 Benign Eyelid Lesions Hidrocystoma Xanthalasma Amelanotic Nevus Sebhorreic Keratosis Papilloma Chalazion

51 Malignant Eyelid Lesions Basal Cell Carcinoma Squamous Cell Carcinoma Sebaceous Carcinoma

52 NOPQRST: Eyelid Lesions Describe the problem Onset/Over time Provoking or palliation Quality of Life Region / related complaints Severity Treatments tried Eyelid lesion on left lower eyelid It started years ago as a small bump. In the last three months it has grown bigger. Occasionally scabs, seems like it is healing but opens again None I m afraid it s cancer. It s causing irritation. I can see it in my vision It s ugly and I want it gone Any history of previous skin cancer? History of sun exposure? Pain scale is part of every encounter. Most skin cancers DO NOT cause pain Nothing Vaseline Topical Medication Surgery

53 Exam: Eyelid Lesions Vision Pressure Pupils EOM CVF Every patient, every visit First visit, if on steroids, if a history of abnormal IOP Every patient, every visit!!!: Skin cancer can travel to the orbit to cause double vision or motility restriction Part of initial evaluation Color Vision For any complaint of poor vision Abnormal pupils Special Testing External Photography Biopsy (send a piece to pathology) Excisional biopsy (send the whole thing to pathology)

54 Equipment for Biopsy Before Procedure Photo done? Consent done? Approval obtained? Numb Lidocaine w/ epi, 3cc syringe, 30g needle Prep Betadine swab, fenestrated drape, sterile gloves Biopsy 15 blade scalpel, Westcott scissors, 0.5 forcep, hot temp cautery, 2x2 gauze, cotton tip applicators, suture (sometimes) Path Specimen Specimen cup (fomalin, Michels, fresh/saline) Label: Pt name, MRN, Date, specimen Finish Up Sterile saline on gauze, apply antibiotic ointment, ice pack Patient goes home Review instructions, antibiotic ointment to pharmacy, follow up appointment

55 Pathology Specimen Sheet Not helpful to pathologist: Right lower eyelid lesion Helpful to pathologist: Right lower eyelid lesion present x years but enlarging in size with ulceration and bleeding in patient with history of sun exposure. Clinically most consistent with squamous cell carcinoma. Ask your surgeon what they would like on the pathology slip Label with patient name, MRN, date, and specimen description

56 Post-Operative Follow Up History: Any problems? Physician to review pathology (helpful to copy and paste into encounter) Exam Visual acuity Pressure (+/-) Post Op Photos

57 Thank You! Questions?