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Home , Canthus, Eyelid, Madarosis, Meibomian gland, Poliosis

10/6/2016

Disclosure

Don’t • Consultant – ALCON Vision Care Overlook – Allergan – Novabay the Lids – Valeant • President – EyePrint Prosthetics Christine W Sindt OD FAAO Director, Contact Service • I have no financial interest in any of the Associate Professor of Clinical product mentioned in this lecture University of Iowa

Function

• The have 2 main functions: – Protection of the

– Secretion, distribution and drainage of

Eyelid Layers in the Eyelids

• The layers of the • The glands of the eyelid are: are: i) meibomian glands –in the i) tarsal plate. Their secretion ii)loose subcutaneous forms the oily part of the tear tissue film. ii) glands of Zeis – sebaceous iii)muscle layer glands that open into the iv)loose connective tissue follicles of the . iii)glands of Moll – modified layer under the muscle sweat glands that also open v)fibrous tissue layer into the follicles. vi)smooth muscle layer iv)glands of Wolfring –these are accessory lacrimal or tear vii). glands.

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Meibomian Evaluation

Issipiated Normal Blunted

From: The International Workshop on Dysfunction: Report of the Diagnosis Subcommittee From: The International Workshop on Meibomian Gland Dysfunction: Report of the Diagnosis Subcommittee Invest. Ophthalmol. Vis. Sci.. 2011;52(4):2006‐2049. doi:10.1167/iovs.10‐6997f Invest. Ophthalmol. Vis. Sci.. 2011;52(4):2006‐2049. doi:10.1167/iovs.10‐6997f

Figure Legend: Figure Legend: Advanced meibomian gland dysfunction: epithelial ridging extending between opacified meibomian gland orifices (courtesy of A. Cicatricial meibomian gland dysfunction: All meibomian orifices open onto the marginal conjunctiva, with some exposure of Bron). terminal ducts (arrows) (courtesy of A. Bron).

Date of download: 4/9/2016 The Association for Research in Vision and Ophthalmology Copyright © 2016. All rights reserved. Date of download: 4/9/2016 The Association for Research in Vision and Ophthalmology Copyright © 2016. All rights reserved.

Innervation Innervation sensory motor

– upper eyelids Upper lids • infratrochlear, supratrochlear, supraorbital and the V1 lacrimal nerves from the ophthalmic branch (V1) of the CN VII Orbicularis oculi (CN V). ‐shuts – The skin of the lower eyelid: Lower lids • infratrochlear at the medial angle V2 • the rest is supplied by branches of the infraorbital CN III nerve of the maxillary branch (V2) of the trigeminal levator/ tarsal plate nerve. ‐Opens eye

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Position Movement‐ Vertical

• When the eye is open the upper lid covers 1/6 of the and the lower lid should just touch the limbus • Enlarged aperture – Thyroid – Space occupying lesion

Movement‐ Horizontal

Innervation Innervation

• Marcus‐Gunn • 7th Nerve Palsy Winking – Bell’s Palsy • Aberrant connection of – Idiopathic, unilateral the oculomotor nerve • Self limiting (CN III)fibers that • <1% bilateral innervate the levator – DDx • brain tumor and the trigeminal • Stroke nerve fibers of the • myasthenia gravis • Lyme disease. – Inability to close eye

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Innervation Innervation

• Inability to Open Lid • Inability to open lid – Horner’s Syndrome – 3rd Nerve Palsy • Look for small • dilated, poorly reactive pupil • Mild • reduced ocular • Impaired innervation of movements sympathetic to muellers • ocular misalignment muscle – Pupil sparing • Ischemic cranial • Stroke neuropathy (DM, HTN) • Aneurysm – Pupil affecting • Tumor • Compressive lesion • Aneurysm

Innervation Lash Ptosis

• Myasthenia gravis • Anatomical changes – 20/100,000 people within the eyelid – Reduction is acetylcholine receptor sites – Orbicularis oculi • Common symptoms can include: – Riolan muscle – A drooping eyelid • Loss of muscle elasticity = – Blurred or double vision loss of follicle support – Slurred speech – Tarsal plate – Difficulty chewing and swallowing • Deficiency of elastin – Weakness in the and legs – Chronic muscle fatigue • Surgical correction for – Difficulty breathing blepharoptosis

Lash Ptosis in Congenital and Acquired Blepharoptosis Arch Ophthalmol. 2007;125(12):1613‐1615

Position Position

• Ptosis‐ Congenital • Ptosis‐Congenital – Present at birth – up head position is bilateral – Gender: males=females – Nocturnal lagophthalmos – Etiology: levator – Lid crease poorly formed development abnormal – 16% have abnormal • Resulting in fibrosis and fatty infiltration of muscle superior rectus function as well – concern • When to do surgery depends on amblyopia risk

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Position Floppy Eyelid Syndrome

• Ptosis‐ Acquired • Note the lash ptosis OS – Floppy Eye Lid Syndrome • GPC • Chronic rubbing

• In obese patients with floppy lids and – think Sleep apnea

Ptosis‐ Acquired Ptosis VF Testing

• Levator dehiscence At least 20 degrees of VF loss for Medicare payment for repair from wear • Aging

Ptosis‐ Acquired Position

• Neoplasmic Symptoms • Neurofibromas • Redness and pain around the eye • Cicatricial • Sensitivity to light and wind • Sagging skin around the eye • • Decreased vision, especially if the cornea is damaged

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Position Position

Entropion Causes • Muscle weakness. • Congenital – age – eyelid can begin to droop and turn outward. • Aging creating loose skin • Facial paralysis. – Bell's Palsy and stretched and loose – tumors ligaments and muscles. • – facial burns • – Trauma‐ dog bite or lacerations Scarring • Eyelid growths – Trauma – Benign or cancerous • – • Radiation – For • Spasm – cosmetic laser skin resurfacing • Congenital ectropion – Have patients squeeze lids – Down syndrome. • Steven‐ Johnson Syndrome

Congenital Distichiasis

• Growth of lashes in meibomian glands Disorders Of – epithelial germ cells failure to differentiate completely to meibomian glands the Lashes • Congenital – dominantly inherited with complete penetrance – isolated or associated with ptosis, , congenital heart defect • Acquired – Lower lid – Pigmented or non‐pigmented – Chronic

Madarosis

– Decrease or loss of • Associated Disease lashes – Alopecia – Long standing Anterior • Hereditary • autoimmune – Atopic – Tumor • Scratching/ rubbing – Thermal burns – Systemic Lupus – • Early loss • Breakage • Scarred follicles – Ichthyosis

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Hypertrichosis Poliosis

• Excess lashes or • Premature whitening of abnormally long lashes the , lashes and – Congenital – Drug induced – • latanoprost – • heterochromia • White forelock –

Normal Flora

• Staphylococcus epidermidis (95.8%)* • Propronibacterium acnes (92.8%)* • Corynebacterium sp. (76.8%)* • Acinetobacter sp. (11.4%) • Staphylococcus aureus (10.5%)

* More heavily colonized in people with blepharitis

Infection

• POST‐SURGICAL DUE TO • Staphlococcal – Normal Bacterial Flora blepharitis – MOST COMMON IS COAGULASE ( MOST COMMON IS COAGULASE (‐) STAPHYLOCOCCUS – INCIDENCE ~ 1 PER 750 SURGERIES – Increased 2.5 to 6x for Clear Corneal Extractions • BABY SHAMPOO NOT ANTIBACTERIAL 10:1 dilution – Harsh on tender eyelid skin • ANTIBACTERIAL SOAPS CONTAIN BAK or EtOH – Not good for use around the eye

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Infection Infection

• Posterior Blepharitis • Angular Blepharitis – Meibomian Gland Dysfunction

Infection Infection

• Hordeolum/ • Molluscum Contagiosum – Demodicosis more • Age: children/ young prevalent than in adults controlgroup (69.2% vs • Etiology: viral lesions 20.3%) – Contact with others – D Brevis more common • Single or multiple than D Folliculorum • Pearly white with central (2.82:1) keratin plug – 33% recurrence • Follicular • Regress spontaneously/ frozen

Am J Ophthalmol. 2014 Feb;157(2):342‐348

What is Demodex?

• 8 legged mite which lives in hair follicles and oil glands. • 65+ species of Demodex, – only 2 live on humans (folliculorum and brevis) – not the same mites which affect pets. • spread either through direct contact or in dust and towels containing eggs. • eat skin cells, hormones and oils in the follicles and glands

• Major cause, if not the cause, of , seborrheic dermatitis and other skin conditions.

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Demodex Species

Brevis Folliculorum • Life span 2‐3 weeks • 0.2mm long • 0.4mm long • Light sensitive – Come out at night to breed • Prevalence: – Acquired shortly after birth – 25% age 25 to near 100% age 70 – Bioload increases with age

Signs Signs

Anterior blepharitis Posterior blepharitis • Studies show nearly 100% if • MGD people with blepharitis • telangectasia have Demodex – Statistically significant correlation • Cylindrical dandruff • “volcano‐like” lash base •

Symptom Symptoms

Dry Eye • Increased Demodex with • Positive correlation to increased OSDI Demodex and conjunctival • Normal shirmer’s with mite papillary changes infestation • Itching • >85% of patients with • DR’s and patients often evaporative dry eye have treat for when demodex (MGD) actually mites • Mite debris and waste elicit inflammatory response

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Associated with other ocular disease Symtoms states 1. Dryness • Salzman nodular 2. Blurred vision degeneration 3. Itching • Ocular rosacea – Stem cell failure 4. FBS/ irritation • Peripheral ulcers 5. Glare – Aka clpu, staph marginal 6. Crusting, redness 7. Many people have lived with their Demodex symptoms for so long that they consider them normal.

Past History How do mites cause symptoms

• Patients may have a history of trying treatments with little to no success • Demodex is colonized with • Drop out of contact lens wear • Decaying mite bodies elicit inflammation • Past treatments may include: • Increasing mite counts – Artificial tears – Cyclosporine • Immune response to mites – Antihistamines • IL‐17 tear concentrations higher in demodex – Doxycycline/ tetracycine colonized patient than non‐colonized patients • Oral • Topical – IL‐17 causes inflammation of ocular surface and lid – Lid hygiene (baby shampoo) margins – –increases mite counts

Looking for Mites Challenges

• Demodex associated with CL drop out/ dry eye – May be a major cause! – I have successfully treated Demodex and patient regained CL wear • Confused with seasonal allergy – Pt self treating allergy • Need better treatment/ awareness – Cliradex – Long time course for improvement‐ months – Need quality patient instructions • No procedure codes for in office diagnosis o treatment • Need more studies

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Treatment Treatment

• Nearly impossible to eradicate • Ivermectin • All members of household should be checked – Antiparasitic • Heat kills mites in bedding – Paralyzes and kills parasites • Scrubbing off debris (baby shampoo very bad) helps – Oral • Tea tree oil? • Single dose 3mg tabs) • Manuka honey? • Based on weight • Colloidal silver? • Call pharmacist • Other Essential oils? – Topical • Hypochlorous acid? • 1% ivermectin • Hard to find for humans. • High patient compliance once they see their own mites • OTC for pets (1.87%)

Treatment EyeLid Hygiene skin‐ not • Permethrin cream 5% • Reasons not to use baby shampoo – BID – Dermatitis – More effective the 0.75% metroidazole • JAMA Ophthalmol. 2014 Mar;132(3):357-9 – Excessive drying – No eye indication – Burning • Eurax cream (crotamiton) 10% – Damage lipid layer • Clin Ophthalmol. 2012; 6: 1689–1698. – Does not effect bacterial colinization of eyelids • Can J Ophthalmol. 2010;45(6):637–641 – Dermatologists won’t use it on their babies!

Hot Compresses BlephEx TM

• Warm compresses applied to the outer lid must maintain a temp of 113oF in order to reach the MG, 4‐6 minutes. • Cornea temperature increases – Cornea. 2013 Jul;32(7):e146-9 • Moisture help soften collarettes • Last 6‐8 minutes • Repeated every 4‐6 months • Hot water increases evaporation off • Cost $130‐ $250 periorbital skin • S9986 (not medically – Increased drying and discomfort necessary‐ pt aware)

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Current Lid & Lash Cleansers Sterilid

• Linalool •Main function is to act as a “detergent”, removing • A Liquid distilled debris from the lids and lashes – from oils of flowers, spice plants, tea trees. •Current formulations contain many, extraneous – pleasant floral scent and ingredients anti‐microbial. –Such as surfactants, buffers and wetting agents • Effective against Pseudomonas

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Ocusoft Cleansing Oils

• Reduce surfactant induced • OCuSOFT Lid Scrub skin irritation Original is recommended – Polar oils bond with proteins for routine daily eyelid and protect skin – Sunflower oil better than hygiene mineral oil – Int J Cosmet Sci. 2015 Feb • OCuSOFT Lid Scrub PLUS 6. is an extra strength, • Coconut oil has higher leave‐on formula saponification • Improved epidermal barrier recommended for loss and cutaneous moderate to severe inflammation conditions with bacterial – Int J Dermatol. 2014 Jan;53(1):100-8 involvement.

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Coconut oil Coconut oil

• Coconut oil is a polar oil • Clinically: what I have found – J Cosmet Sci. 2001 May-Jun;52(3):169-84 • Antibacterial – Changes bacterial cell membrane activity • Adds oil to the tear film – J Med Food. 2013 Dec;16(12):1079-85 – Severe evap dry eye patients report improved comfort • Anti- candida while using it – J Med Food. 2007 Jun;10(2):384-7 • Lowers lipid peroxide levels • No need to hot soaks to remove scurf • Antioxidant • Reduced collarettes – Skin Pharmacol Physiol. 2010;23(6):290-7 • Reduced lid inflammation • Better long term compliance

Coconut oil regime Coconut oil scrubs

• Apply small amount to lid margin Before After 1 month of treatment • Let soak in about 20 minute – Brush teeth – Get in jammies – Etc… • Wipe off with dry wash cloth or gauze pad – Apply firm but not excessive pressure

• If patient complains of lingering blurred vision: used too much

Before After 1 month of treatment

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Tea Tree Oil Cliradex

• Tea tree treatments • Melaleuca alternifolia with 50% lid scrubs in – a special variety of tea office tree oil • 5‐15% TTO at home • Preservative free • Multiple Properties – Anti‐microbial – Anti‐inflammatory – Anti‐protozoal – Anti‐viral • Toxic to the Ocular surface!

Manuka honey Manuka Honey

• Made in New Zealand by bees • principle antibacterial that pollinate the native components manuka bush. – methylglyoxal and hydrogen peroxide • UMF (Unique Manuka Factor) determines effectiveness. • Manuka honey used is pharmaceutical/medical grade and highly sterilized.

Manuka‐type honeys can eradicate biofilms produced by Staphylococcus aureus strains with diffe PeerJ. 2014 Mar 25;2

Hypochlorous Acid .01% Betadine

• Betadine 5% Ophthalmic •Excellent activity Prep Solution against a broad – Povidone‐Iodine range of pathogens • Normal surgical scrub is •Fast acting onset 10% of activity • Intended for: – Irrigation of cornea, conj. •Effective against pathogens – Periocular antiseptic commonly found • Wide range of bacteria on the lids & lashes – Effective against biofilm – Inhibits release of exotoxins • Possible Treatment for EKC

*Data on file 84

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Lipiflow/Tearscience • “A revolutionary way to treat evaporative dry eye caused by meibomian gland dysfunction.” Lesions • Controlled heat and massage for optimized stimulation of the meibomian glands.

Papilloma Actinic Keratosis

• Age: middle age/ elderly • Age: rare under 30 • Etiology • Etiology – Viral: HPV – Presumed sun exposer – Non‐viral: UV light – Generally multiple • Skin: – Most common on , trunk – Soft and upper extremities – Skin colored, tan or brown • 20% risk of progression to – Round oval or pedunculated squamous cell carcinoma – Treatment: excision • Lesion start flat, light tan • Conjunctival – Become pigmented, elevated – Differential from and warty over time Squamous cell Carcinoma • Treatment – Treatment: , 40% recur – Biopsy/excision/ cautery

Epidermal Inclusion Sebaceous

• Age: Any • Clinically look like • Males= females epidermal inclusion cysts • Smooth round elevated • Blocked glands of Zeiss, cysts filled with keratin meibomian or • Arising from follicles sebaceous • Ablation of entire cyst • Filled with epithelial walls necessary for cells, keratin, fat and eradication cholesterol crystals • Surgical excision

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Eyelid Nevus Tumor

• Acquired • Sebaceous Cell – Begins in childhood – Arise from glands of Zeis • Basal migrates • 2‐7% of malignant eyelid to the dermis surface tumors – Deeply pigmented to • Diagnosis amelanotic – Recurrent chalazion – Flat or pedunculated – Chronic meibomitis – No lash loss – Blepharoconjunctivitis – 5% malignant • Aggressive transformation – Orbital extension (17%) – Photodocument – Systemic mets (8%)

Sebaceous Cell Carcinoma Tumor

• Clinical Features • Basal Cell – Solitary lid lesion – Most common tumor of the skin – Diffuse lid thickening • Sunlight exposure – Loss of lashes • demodex – Lesion visible through – >400,000 people treated tarsal conjunctiva annually in US – 65% lower lid – Zeis gland‐ lid margin – 15% medial – MG‐ deep in – 15% upper lid – 5% lateral canthus

Basal Cell Tumor

• Pearly, waxy, • Primary Malignant translucent Melanoma – Rolled boarder – Sun exposed areas • Telangiectasia near – Primary lesion or met – 1% of malignant eyelid borders tumors Benign conj nevus • Loss of lashes – Variable pigment mass • Tumor extensions • Can bleed or ulcerate possible but no distant • Check fornices – Histopath proven mets – Prognosis depends on • Mortality <1% mets

Malignant melanoma

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Differential Dx Differential Dx

Both patients shown above presented with unilateral, pigmented lesions of the upper eyelid. 1. What common historical element might be anticipated in both of these patients? The patient on the left noticed the lesion slowly progressing over the last 4‐5 months; the a. Injections of BOTOX™ for cosmetic enhancement patient on the right was referred by her primary care physician due to her “suspicious bruise”. b. with eczema c. Chronic or excessive exposure to ultraviolet radiation d. Elevated serum cholesterol and lipids

Differential Dx Differential Dx

1. The patient on the right is an 88‐year‐old white female who lives in the mid‐western United 1. The patient on the left is a 68‐year‐old woman who vacations frequently in South Florida, States. She has advanced Alzheimer’s disease and cannot give an accurate history. A family where she is an avid golfer and boater. She has noticed the lesion on her left upper lid member claims that the “bruise” on her upper lid was noticed about 2 weeks ago without developing over the last year. Upon inspection, you find similar, smaller lesions on her any known trauma. Which of the following is NOT a red flag for potential malignancy? , and . What is the LEAST likely presumptive diagnosis? a. Associated madarosis a. Actinic keratosis b. Non‐uniform color and shape b. Basal cell carcinoma c. Location on the upper eyelid c. Sebaceous cell carcinoma d. A satellite lesion at the outer canthus d. Seborrheic keratosis

Thank You

Christine‐[email protected]

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