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Home , Entropion, Oculoplastics, Ptosis (eyelid)

The Complete Exam

Nicole Langelier, MD MBE Oculoplastic Fellow Goals • Review the important components of: 1. Medical history 2. Physical examination 3. Special Testing

• For common oculoplastics diagnoses: – – – / – – lesion 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? NOPQRST Memory Tool for Complete History (not in the ideal order for flow)

Name the problem Name and describe the symptom or problem Onset / Occurs when. . . . Symptom ONSET and time course Provoking or palliation What makes it worse? What makes it better? Quality of Life How does it affect your daily activities? Region / Related Does it spread? Does it blur the vision? Does it complaints cause any other problems?

Severity scale 0-10

Treatments tried Previous medications, , other techniques to manage the problem 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 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 • • Extraocular motility (any ?) • Confrontation VF • Color Vision ( problems, proptosis, decreased vision) • Special Testing Case 1 Diagnosis?

Bilateral Upper Eyelid Dermatochalasis Dermatochalasis: Chief Complaint • My are heavy • I have to hold my eyelids up • The extra skin gets in the way • My doctor said I need a lid lift NOPQRST: Dermatochalasis Name the problem Heavy upper eyelids Onset/Occurs when. . . . First noticed many years ago and getting worse. Provoking or palliation Heaviest first thing in the morning. I have to tape my eyelids up. Quality of Life My 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. Region / related complaints My eyelids get itchy from sweat when I work outside. Taping my eyelids is giving me a rash Severity (Should not cause pain) Pain scale is part of every encounter. Treatments tried Surgery for this problem 15 years ago helped by now it’s back. Exam: Dermatochalasis Vision Every visit Pressure New patient, most visits* Pupils New patient, most visits* EOM Every new plastics patient CVF 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 MRD1 for Dermatochalasis “Margin to Reflex Distance”

MRD1 = 1

MRD1 = 0.5 Eyelid Visual Field Testing

Focuses on superior visual field

Before Tape: • Chin neutral • Relaxed brows

After Tape • Shows potential post- operative improvement Case 2 Dermatochalasis External Photos

Band Elevate Skin (shows true MRD 1)

Full Face Tips • Chin neutral • Relax brows Side Left • Use flash (one full face flash off) Side Right • Neutral or bored facial expression Post-Operative Follow Up

• History: Common Post-Op – Any problems? Complaints: – Any improvement in vision • Discomfort • Itching • Exam • Blurry Vision – Visual acuity – Pressure: if on topical steroids or history of elevated IOP

• Post Op Photos

Allergy to ointment Diagnosis?

Bilateral Upper Eyelid Ptosis 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 NOPQRST: Ptosis Name the problem Droopy upper eyelids Ptosis Onset/Occurs when. . . . First noticed 1 year ago, no sudden onset !!!: Sudden onset, complete eyelid closure, large fluctuation in lid height Provoking or palliation Constant or fluctuation in droopiness? Quality of Life , , lift chin to see, difficulty reading, driving, watching TV Region / related !!!: Double vision, severe headaches, pain complaints

Severity (Should not cause pain) Pain scale is part of every encounter. Treatments tried Previous surgeries? Exam: Ptosis Vision Every patient, every visit

Pressure Droopy eyelid + high pressure can be an orbit problem Pupils !!! Notify MD of asymmetric pupils • Horners, 3rd palsy EOM !!! Notify MD of double vision or decreased motility • 3rd nerve palsy, , CVF 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 MRD1 for Ptosis

MRD1 = 3

MRD1 = 2

MRD1 = 0.5

MRD1 = 0 Eyelid Visual Field Testing

Focuses on superior visual field

Before Tape: • Chin neutral • Relaxed brows

After Tape • Shows potential post- operative improvement Ptosis External Photos (pt has dermatochlasis too)

Band Elevate Skin (shows true MRD 1)

Full Face

Tips • Chin neutral • Relax brows Side Right Side Left • Use flash (one full face flash off) • Neutral or bored facial expression Surgical Treatment: Ptosis Repair Post-Operative Follow Up • History: Post-Op Complaints: • – Any problems? Dryness • Incomplete lid – Any improvement? closure • Blurry vision • Exam • Pain – Visual acuity – Pressure (+/-)

• Post Op Photos

Lagophthalmos Case 3 + 4 Diagnosis? (lower lids)

Ectropion Diagnosis? (lower lids)

Entropion Ectropion: Chief Complaint? • My eyes hurt • My eyes are always dry • My eyes always look red • I have mucous and tearing Entropion: Chief Complaint? • My eyes hurt • My eyes are dry • My eyes always look red • I have mucous and tearing • My scratch my eyes NOPQRST: Lower Lid Malposition Name the problem Ectropion/Entropion/Lid Malposition/Dry Eyes Onset/Occurs when. . . . ”It started years ago” It started after my lower eyelid It started after my cheek cancer reconstruction My eyelid rolls in when I squint in the sun Provoking or palliation Eyes feels worse in wind Quality of Life Irritation, pain, dry eyes, watering eyes, objectionable appearance ”I scare my grandkids” Region / related complaints Dry eyes Watering eyes Skin lesions (cancer) Severity Pain scale is part of every encounter.

Treatments tried Nothing Tear drops (important to insurance) Previous surgeries Punctal plugs Exam: Lower Lid Malposition

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

MRD 1 MRD 2

MRD 2 = 9 Inferior Inf Scleral Show = 3 Scleral Show External Photos Ectropion Entropion

Important to show Important to show • Scleral Show • Lashes rubbing ocular surface • (if visible) • Injected eye (if visible) • Injected eye (if visible) Surgical Treatment Ectropion Entropion

Lateral tarsal strip (horizontal lid tightening) Lateral tarsal strip (horizontal lid tightening) Skin graft Entropion repair via suture Conjunctivoplasty Entropion repair via thermocautery Post-Operative Follow Up • History: – Any problems? – Any improvement in symptoms?

• Exam – Visual acuity – Pressure +/-

• Post Op Photos Post-Operative Photos Ectropion Entropion

Before Before

After Repair After Repair (LTS and FTSG OD; Kenalog OS) (Wheeler Halving) Case 5 Diagnosis?

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

Vision Every patient, every visit Pressure First visit, if on steroids, if a history of abnormal IOP • Tearing is a sign of congenital in children Pupils Part of initial evaluation EOM Part of initial evaluation CVF 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 Dacryocystitis: Google Fail Probing and Irrigation: Is there an obstruction? Treatment Treatment Depends on the Cause of Tearing Post-Operative Follow Up Post-Op Complaints: • History: • Tube discomfort – Any problems? • Pain – Any improvement? • Nose bleed

• Exam – Visual acuity – Pressure (+/-) Case 6 Diagnosis?

Eyelid Lesion “ of Uncertain Behavior” (Often need biopsy for certain diagnosis) Eyelid Lesions: Chief Complaint? • Bump on my eyelid

• Present due to concern for – Cancer – Infection – Pain/ Irritation – Ugly Benign Eyelid Lesions

Hidrocystoma Xanthalasma Papilloma

Amelanotic Sebhorreic Nevus Keratosis Malignant Eyelid Lesions

Basal Cell Squamous Cell Sebaceous Carcinoma Carcinoma Carcinoma NOPQRST: Eyelid Lesions Describe the problem Eyelid lesion on left lower eyelid Onset/Over time ”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 Provoking or palliation None Quality of Life 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 Region / related complaints Any history of previous skin cancer? History of sun exposure? Severity Pain scale is part of every encounter. Most skin cancers DO NOT cause pain Treatments tried Nothing Vaseline Topical Medication Surgery Exam: Eyelid Lesions

Vision Every patient, every visit Pressure First visit, if on steroids, if a history of abnormal IOP Pupils Every patient, every visit EOM !!!: Skin cancer can travel to the orbit to cause double vision or motility restriction CVF 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) 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 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 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 Thank You!

• Questions?