2/13/2016

Just Hanging Around: When Purpose of the Eyelids Your Eyelids Get In The Way ! a. protect the eye ( globe ): b. eyelashes ( cilia ) c. secretions of the eyelids d. glands e. movement of the eyelids: a. open b. close

Layers Of The Eyelids

AIR 3. Orbicularis oculi: 1. Skin: thinnest skin of Innervation: CN VII the body Function: Loose & elastic a. closes the eyelids b. when eye closes, Allows extreme swelling causes lacrimal secretions to be pumped from the 2. Superficial fascia lacrimal gland

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4. tarsal plate: 5. Conjunctiva * dense, fibrous tissue often mistaken as cartilage. • Palpebral (tarsal a. made of collagen conjunctiva) : Lines the eyelids b. lined posteriorly by conjunctiva • Bulbar (ocular conjunctiva): c. upper lid: 29mm long,10-12mm Covers the eye; over the wide, 1mm thick anterior sclera. This lower lid: 29mm long, 5-6 wide, conjunctiva is wrapped tightly 1mm thick to the sclera by Tenon's capsule and moves with the eye. * each tarsus has meibomian (sebaceous) glands * Fornix conjunctiva : Forms the junction between the bulbar and upper: 30 - 40 palpebral conjunctivas. Very loose and flexible, allowing the eye to freely move. lower: 20 - 30 studyblue.com

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Frontalis Muscle

Also known as the “eyebrow muscle”. 6. Levator palpebrae: It lifts the eyebrow out of the way and Innervation: CN III allows for facial animation. It starts at the top of the head and attaches to Function: opens the the eyebrow skin. There is one for each brow. It can lift eye with help from the eyelid in a secondary fashion and muscle) can compensate for eyelid muscles Muller’s Muscle to a certain degree. With aging, the brow begins to lower with gravity. This pair of muscles may have to work "overtime“ to keep redundant skin off the eyelid.

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Palpebral Fissure

Normal Adult: You can measure one eye, or 27 – 30 mm long both eyes, to see if they are 8 – 11mm wide proptotic by using an exophthalmeter. * Edge of the upper lid covers the limbus The eyelids get their shape from the tarsal from 10- 2 plates. * Widening of the fissure causes retraction of the lids making the eye look exophthalmic… as in Graves Disease.

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• The exophthalmeter allows measurement of the forward distance of the lateral orbital rim to the front of the cornea. • Measurement is taken from the bony lateral orbital rim to the corneal apex. It is NOT measured from the lateral canthus ! • The normal range is 12–21 mm. • A difference greater than 2 mm between the

eyes is significant

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2 2/13/2016

Movements of the Eyelids

A. Elevation: Blepharospasm (benign 1. Levator is the chief muscle that essential blepharospasm): Extreme squeezing of the opens the eye eyelids – spasm. Essential 2. When eyelids are open it is means that the cause is because of contraction of the unknown. Sometimes the twitching levator muscle. Lid can be raised is chronic and persistent. This is relatively rare but the symptoms up to 10mm against gravity can be severe enough to result in B. Closure: functional blindness. 1. (3) distinctive types of closure: a. blinking: People with blepharospasm 1. reflex: strong light, loud noise, touching cornea have a number of issues: * cosmetically unappealing 2. spontaneous: occurs normally at frequent intervals * can increase IOP * very tiring

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Additional Movements of the Eyelid Function Problems: Eyelids Entropion Bell’s Phenomenon: Entropion: cornea will roll up under the Rolling inward of the lower eyelid eyelid when asleep to protect Causing the eyelashes to rub on the the cornea eye (trichiasis). Trichiasis can cause “Jaw Winking” scratching of the eye by the Marcus – Gunn. When a patient chews, eyelashes. Trichiasis causes watery eyes, corneal they will close the eye irritation and, if severe or prolonged, corneal ulcers . on the same side of the Symptoms also include: crusting of the lashes, increased face as they are chewing. ophthalmologynetwork.blogspot.com mucous, and eye irritation. Usually occurs due to aging (common to people over 60 years of age ) or trauma.

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Eyelid Function Problems: Causes of Entropion Ectropion • Scarring :Cicatricial Entropion is the pulling of the upper Ectropion: or lower eyelid away from the eye. Usually “Sagging” lower eyelid that caused by scar formation or a shortage of the leaves the eye dry and exposed anterior lamella of the eyelid. due to lack of muscle tone in • It is easily distinguished from involutional entropion the lid. Increased tearing - but by the inability to temporarily induce a normal eyelid when the patient wipes the tears position by rolling the eyelid outward. The majority of patients with recurrent trichiasis continually, it causes the lid to have cicatricial entropion. sag MORE. Most common in Worldwide the most common cause of people over 60. Patient cicatricial entropion is Trachoma. complains of gritty sensation, • Spasm burning and red eye.

optometrist.com. webeye.ophth.uiowa.edu stlukeseye.com

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Causes of Ectropion What is Ptosis ?

• A sagging, or “drooping”, of the upper eyelid that Congenital: upper or can cause a visual field reduction when the lower lid(s) eyelid either partially, or completely blocks, the pupil. Patients that have ptosis often have difficulty keeping • Aging: Involutional their eyelid(s) open. To compensate, they will often raise their eyebrows in an effort to raise the • Scarring: Cicatricial drooping eyelids with their Frontalis muscle • (“forehead muscle”). Mechanical : lesion pulling lid down Children with ptosis can develop • Paralytic: VII nerve facial palsy amblyopia (“lazy eye”) or even a developmental delay from this limitation of their vision. emedicine.medscape.com

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Ptosis Tidbits What Can Cause Ptosis ?

• Occurs when the muscles that raise the eyelid (levator There are many causes including age related weakening and/or Muller’s muscles) are not strong enough. * One eye or both eyes of the muscle, congenital weakness, trauma, or • More common in older patients, sometimes neurologic disease. As we age, the tendon but you can be born with a ptosis. that attaches the levator muscle can stretch and cause * Congenital ptosis is not always the eyelid to fall. Ptosis can also happen after routine hereditary LASIK or cataract surgery due to stretching of the • Ptosis may be caused by damage/trauma to the muscle that muscle or tendon during the surgery. raises the eyelid, or damage to the III cranial nerve (Oculomotor nerve) . Such damage could be caused an underlying disease like DM, brain tumor, or diseases that cause weakness in the muscles, like myasthenia gravis.

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Anatomical Causes of Ptosis Types of Ptosis

Ptosis can be classified as: • Neurogenic ptosis : III nerve • Neurogenic ptosis: when the nerves attached to palsy, Horner’s Syndrome, the muscle are affected Marcus Gunn jaw winking • Myogenic ptosis: sagging of the lid because of a • Myogenic ptosis: myasthenia gravis, myotonic dystrophy, problem with the levator muscle ocular myopathy, simple congenital ptosis • Aponeurotic ptosis: the stretching and weakening • Aponeurotic ptosis can be of the tendon responsible for raising the eyelid involutional (dehiscence of the • Mechanical ptosis: the tendon of the levator muscle weight of the eyelid(s) is or post-operative). too much for the muscles • Mechanical ptosis occurs to lift due to edema or tumors of the upper lid

neurofibromatosis 1. eyesbybrown.com 2. aapos.org

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• Pseudoptosis: “false Natural Causes (Getting Older) blepharoptosis” Anyone can get droopy • Hypotropia eyelids, but it’s more common in older adults because of Eyelid lowering because the other eye's the aging process. A tendon muscles not working well attaches the levator muscle . • Dermatochalasis As you age, that muscle can stretch and, as a thinning and stretching of upper eyelid skin result, cause the eyelid(s) begin to fall. Sometimes the exact cause is unknown, but other causing redundant upper eyelid skin times it may be due to trauma.

Factors That Increase Chances Lid Fields for Ptosis • Aging • Family history of ptosis • Birth injury • Eye surgery such as cataract surgery • Paralysis of nerve fibers in eyelids • Diabetes

Cranial nerve III controls the movement of four of htforum.nl the six eye muscles. These muscles move the eye in, up and down, and also rotate the eye. Cranial nerve III also controls constriction of the pupil, and the position of the upper eyelid. A complete third nerve palsy causes a totally closed eyelid and an eye muscle defect with the eye pointing out and down. Aapos.org ssc.education.ed.ac.uk

Taped/Untaped Fields

As your can see here, Taped/untaped the patient’s normal visual field is very fields are done restricted in the one eye at a time, superior range. When without correction, the upper lid is taped up, patient’s field of vision and always before appreciably improves. This dilation. The Neosynephrine eyedrop will alerts the doctor that if cause the eyelid to slightly rise after it is the redundant skin was instilled, thereby giving a false reading on removed, or the ptosis was the true visual field. adjusted, the patient’s field of vision would greatly improve. webeye.com

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Congenital Ptosis

What the patient might see with ptosis….. Ptosis is a real problem in babies and children. If a child’s droopy eyelid is left untreated, and is severe enough, he/she may develop amblyopia (“lazy eye”). pediatricophthalmologypa.com slideshare.net

Congenital Ptosis Treatment Repair Surgically

In most cases, the treatment for childhood ptosis is surgery. During ptosis surgery, the levator is tightened. In severe If amblyopia is present, treatment with eyeglasses, or eye ptosis, where the levator is extremely weak, the lid can be drops, may be necessary as well . Other factors that attached, or suspended, from under the eyebrow so that the also should be considered are: forehead muscles can do the lifting. Mild or moderate ptosis usually • The child's age does not require surgery early in life. • Whether one or both eyelids are Children that have ptosis, whether they involved have had surgery or not, need to be • The eyelid height and obstruction examined regularly by an ophthalmologist potential for amblyopia, refractive disorders and • The eyelid's lifting and closing muscle other eye concerns conditions. strength • The eye's movements

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Other Causes Of Ptosis Horner’s Syndrome

• Stroke Horner’s Syndrome is a condition that affects • Horner’s Syndrome the Sympathetic nervous system. It causes a triad of ptosis, miosis and anhydrosis. It can • Head or eyelid trauma occur due to by injury, strokes, tumors, • Brain tumor disruption of the main artery of the neck, or as an accidental complication of surgery. Rarely it • Muscular dystrophy may be congenital. • Myasthenia Gravis ptosis

miosis

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Myasthenia Gravis

Myasthenia Gravis is an autoimmune, neurological disorder that affects the eyes, or the body, or the eyes & body together. It causes diplopia, ptosis, and muscle weakness. Medications can be used to treat generalized myasthenia gravis, but it is not clear whether they are effective in treating ocular symptoms. Myasthenia can affect various muscle groups in the body as well, including muscles in the face, the neck, and the extremities causing weakness, immobility and difficulty with breathing.

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Ocular Myasthenia Gravis

Symptoms of myasthenia gravis can include: In approximately 15% of people with • Muscle fatigue, myasthenia gravis, the only muscles to the point of affected are those in the eyes. immobility Some of the first signs of ocular • Double Vision myasthenia gravis include a drooping • Ptosis eyelid and • Fatigue double vision. • Voice changes neuronext.org thoughtyoumayask.com

Benign Eyelid Lesions Benign Tumors of the Eyelids

Hordeolum: “sty” a. “horns” : skin tags. Squamous hxbenefit.com painful..essentially an papillomas abscess b. xanthelasma: cholesterol. Chalazion: accumulation commonly non painful..swelling..meibomian or Zeis in the medial canthal area. gland inflammation. If cholesterol checked – Blepharitis : “ dandruff of the eyelids ” in most cases it is normal ! Itching, burning, irritation of the c. Nevus :”freckle” lash lines d. Veruccae: “warts” caused Staph = rosettes by viruses. Molluscum: usually associated with Seborrheic = “scurf” the eyelid margin

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Primary Malignant Tumors

• Nevus of Ota: a blue spot a. Carcinoma: that occurs on the face or Basal cell and squamous cell are the sclera of the eye most common with 95% of lid • Nevus: sharply carcinomas being basal cell. Basal cell grows slowly and are circumscribed studyblue.com locally invasive. Does not spread to lymph glands. and chronic lesions of the Squamous cell spreads through the lymphatic skin. Commonly called system. Slow moving and painless in the beginning. birthmarks or moles. By As the tumor grows, invades the sensory nerves and definition, nevi are benign. can become very painful.

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Basal Cell Carcinoma

* Most common malignant tumor of the eyelids. * Usually involves the lower lid and medial canthal area. * Exposure to sunlight Basal Cell Squamous Cell is thought to be an

Diabeticretinopathy.org.uk important factor

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Squamous Cell Carcinoma

• Accounts for over 90% • Second most common malignant eyelid neoplasm of all cancerous lid lesions. • Seen mostly in elderly, fair skinned people with a • Often, tumor is discovered history of chronic sun exposure. Patients present with a rough, scaly patch of tissue on or near the during routine slit lamp evaluation. lid margin or in the canthal region. • Usually no associated pain or discomfort. • The area is usually red, elevated and nodular, crusted • More common in older, fair-skinned individuals and/or bloody margins. Often, patients describe this • Lower lid = 50% of the time lesion as “a non-healing scab.”. • Medial Canthus = 25% of the time • In its early stages is easily confused • Locally invasive , slow growing – almost never with a number of other eyelid metastasizes lesions, both malignant and benign.

bombayoculoplastics.com chicagoeyelids.com

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Potentially invasive • UV radiation is a substantial risk factor. This is supported by the fact that the majority of tumor derived from squamous cell tumors occur on the lower lid epithelium skin. In margin and medial canthus, the two periocular areas most susceptible to sunlight exposure. the early stages, the normal epithelial • Aging and northern European descent are two cells are replaced by atypical squamous other commonly associated factors in patients cells throughout the epidermis, resulting with squamous cell carcinoma. in a loss of normal growth. Lower eyelid moreso than the upper lid guidelines-management-cutaneous.org

• Squamous cell carcinoma = 5 % of all eyelid malignancies. • Will invade local tissues and metastasize to other systems, but is not a particularly aggressive tumor. Rate of development is quite slow, and metastasis is exceedingly rare. • Early biopsy is often the key to diagnosis. Suspicious lid lesions, showing irregular growth, changes in color or appearance, or discharge should be biopsied to rule out cancerous entities.

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Malignant Melanoma

• Rare cancer of the eyelid = 1% of all eyelid malignancies. • A cutaneous melanoma that appears pigmented, shows growth and has changes in borders with time. Growth of atypical melanocytes in [email protected] the epithelium

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