Eyes Wide (And) Shut 2/17/2015. Eyelids. Eyelids. Eyelids: Function

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1 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 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 2

3 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 Eyelid Margin Innervated by 3 Cranial Nerves: III: Motor innervation to Levator V: Sensory innervation to upper & lower lids VII: Motor innervation to Obicularis Oculi Cilia arise from hair follicles Upper lid: Lower lid: 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 Mullers Muscle Smooth muscle Elevates & retracts upper eyelid Sympathetic nerve innervation Phenylephrine test Increased tone => Graves Diminished tone => Horners miosis, anhidrosis, heterochromia 3

4 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 4

5 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 3 rd 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 5

6 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) Levator excursion measures Levator Muscle Excursion Classification mm Normal Ptosis management Visual field testing Medically necessary? Ptosis crutch or tape Surgery 8-12 mm Good 5-7mm Fair </= to 4mm Poor Surgical Management Mild Ptosis Surgical Management Moderate & Severe Ptosis 6

7 Lagophthalmos Lagophthalmos causes Inferior PEK Assess blink Ulceration Epiphora Nocturnal Dryness upon awakening? Korb Blackie Light Test Shut, not sealed 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 Blinkeze External Lid Weights Lubrication Nighttime taping Sleep mask/goggles/ Tranquileyes External lid weights Tarsorrhaphy temporary/permanent Surgery: Is upper or lower lid affected? Upper lid? Retraction => levator repair Gold weight implantation Lower lid? Lid tightening & elevation lateral tarsal strip 4 skin tone colors Pack of 100 adhesive strips Tantalum g, in 0.2g increments Gold weight implants 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

8 Ectropion Complications Ectropion Epiphora Redness Dryness Irritation Corneal involvement Infection 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 Ectropion treatment 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 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 palpebral conjunctiva 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 8

9 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 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 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 Thyroid Eye Disease Treatment 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: 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 9

10 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 Trichiasis causes a. Trichiasis b. Distichiasis c. Madarosis d. Poliosis Aging changes Trauma Trachoma OCP Stevens Johnson Leprosy 10

11 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 Madarosis causes Observation if asymptomatic If symptomatic Epilation Cryotherapy Trephination Wedge resection Microhyfrecation Lid splitting procedure with cryotherapy 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 Poliosis Latisse Treat underlying cause Discontinue offending agent 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

12 Eyelids Infection/Inflammation I. Function II. Anatomy III. Eyelid conditions IV. Eyelash conditions V. Infection / Inflammation VI. Makeup 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 Epidermis, aureus Younger Collarettes Madarosis Waxes and wanes Strep Seborrheic Older Nonobstructive Greasy, soft scales Chronic Associated with dandruff Anterior Bleph treatment BlephEx 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 In office procedure Removes biofilm, scurf 6 8 minutes, q4 6 months Not covered by insurance 12

13 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, Minimal signs=>> Pt education, lid hygiene Stage 2: Mild sx s=>add Lubrications, orals Stage 3: Moderate signs & sx s Orals, ung qhs, Restasis, steroid Stage 4: Severe signs & sx s Steroids added Plus Disease: Coexisting OSD ie rosacea Posterior Blepharitis treatment Maskin MG Probing Compresses In office expression Soothe XP, Systane Balance 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 2 or 4 mm stainless steel 76 μmprobe 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 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) 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 77 13

14 Demodex Folliculorum Eyelids 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 I. Function II. Anatomy III. Eyelid conditions IV. Eyelash conditions V. Infection / Inflammation VI. Makeup Eyelids and cosmetics Makeup complications Global market $170 BILLION Mascara: ~4 BILLION Application & removal issues Adverse reactions 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 14

15 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 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 15