Financial disclosures Mythbusters Oculoplastic Edition Jed T. Poll, M.D. Utah Optometric Association June 3, 2016 Myth #1 Seriously…They’re all the same • Causes of “Droopy Eyelids” • Dermatochalasis All droopy • Blepharoptosis • Brow ptosis eyelids are • Pseudoptosis created equal I’m still not convinced… Different kinds-o-ptosis? Most common Usually congenital Dermatochalasis Ptosis Stretched tendon Weak muscle Excess skin problem Eyelid muscle problem High lid crease Absent lid crease Weighs down eyelid Lid margin / lashes low Involutional Myogenic Normal lid function Possible lid dysfunction Uncommon Uncommon Myasthenia / Botox Lesion / Mass Fluctuating Treat mass effect Many patients have both Neurogenic Mechanical 1 So…They’re not all the same Myth #1 • Correct Dx = Correct treatment – Not always surgical • Potential comorbidities All droopy – Droopy lid with… eyelids are • Anisocoria - Horner’s syndrome / CN III palsy • Fluctuations - Myasthenia Gravis created equal Myth #2 Will my insurance cover this? • Most common question for dermato and ptosis • 3 Elements: All eyelid – Complaint of visual impairment that improves with eyelid elevation surgery is – Supported by clinical exam – Documented with clinical photographs and cosmetic taped/untaped visual fields Dermatochalasis Evaluation Ptosis Evaluation • Exam: PF: lid margin to lid margin – “Grading” the amount of dermatochalasis MRD: light reflex to lid margin • 1+ to 4+ scale or mild to severe 1+ 2+ 3+ 4+ Dermatochalasis continuum Barely any Barely seeing 2 Ptosis Evaluation Dermatochalasis: Surgery LF: excursion length of upper eyelid • Intervention: Blepharoplasty Normal: 10+ mm Excess Eyelid Orbital & Subbrow Dermatochalasis: Surgery Dermatochalasis: Surgery Upper Eyelid Blepharoplasty Before After Ptosis: Surgery Ptosis: Surgery • Levator function predicts surgery type Levator Surgery Suspension Surgery – 10+ mm: External levator advancement Low functioning Involutional ptosis – 4-10 mm: External levator advancement + tarsectomy ptosis – 0-4 mm: Frontalis suspension Small incision Uses frontalis muscle Titrate height / contour Height limited ? Addresses weak levator Bypasses weak levator 3 Ptosis: Surgery Myth #3 Contrast Mueller • External Ptosis Repair muscle procedures – Goal: Address weak /stretched levator muscle Levator muscle – All tearing is tendon complex reflexive in nature Why are my eyes watering? Why you Crying? • Tearing common complaint / consult Production • Many / most have tried various drops Lacrimal & Accessory glands • Many / most view recommending drops for tearing as dismissive of their complaint Drainage Punctum Canaliculus Lacrimal sac Nasolacrimal duct Why you Crying? Get the history! • Ask 2 Questions Water always on – “Is the tearing constant or intermittent?” – “Any ocular surface symptoms?” Drain plugged • Burning; itching; sandy; gritty… • I-I & C-C rule: • Intermittent & Irritated favors hypersecretion • Constant & Comfortable favors obstruction 4 Why you Crying? Why you Crying? Hypersecretion Insufficient drainage • Exam: • Lower eyelid position / laxity • Punctum position & patency Dry eye Punctum • Eyelid margin disease Allergy Canaliculus • Tear film stability Blepharitis Lacrimal sac • Corneal & conjunctival signs Trichiasis Nasolacrimal duct • Further evaluation: Conjunctivitis Eyelid pump • Dye disappearance test (Jones) Lid malposition – Helps with functional obstruction Trauma • Canalicular probing & irrigation Why you Crying? Why you Crying? • Canalicular probing & irrigation • A: Likely hypersecretion – Detects structural NLDO • Treat eyelids and surface disease • NOT physiologic • B: Likely obstruction – Diagnostic • Refer to ophthalmology • NOT therapeutic – 3 Outcomes: • C: I dunno! • Eyelid hygiene Immediate passage; no reflux Normal • Trial of scheduled tears & lube qHS ® ® Immediate reflux; no passage NLDO • Other gtts: Azasite ; low potency steroids; Restasis Delayed passage; some reflux Stenosis Why you Crying? Myth #4 Source of Obstruction Treatment Punctum Entropion & Stenosis Punctoplasty Eversion Ectropion repair Ectropion are the Canaliculus cDCR w/ Jones tube Nasolacrimal duct DCR Eyelid pump Lid tightening same &%^$ thing 5 Ectropion & Entropion Ectropion & Entropion • Both very common & underdiagnosed • Evaluation: • Both can present with irritation / tearing – Evaluate canthal angle • Horizontal laxity = eyelid instability • Round • Sharp – Assess horizontal laxity • Distraction test • Snap back test Rotate inward Rotate outward Entropion Ectropion Ectropion & Entropion Ectropion • Evaluation: – Evaluate lower lid skin • “Short” anterior lamella Midface descent • Lack of wrinkles Involutional Paralytic • Scarring / previous surgery No wrinkles! – Punctum position / patency Everted punctum Cicatricial Mechanical Entropion Ectropion • Intervention: Ectropion repair – Lateral Tarsal Strip • Gold standard • Lateral canthus incision Involutional Cicatricial • Tightens lower eyelid • Normalizes punctum position Can combine with midface lift Spastic Epiblepharon 6 Entropion Entropion: Surgery • Intervention: • Intervention: Entropion repair 1. Surgery • Lateral tarsal strip • Retractor reinsertion 2. Conservative management • Aggressive lubrication • Lash epilation • Quickert sutures Myth #5 Bumps, lumps & chumps • 2 types of bump consults: Chalazion or Cancer • Many other Dx Eyelid bumps are • Not everything needs Biopsy / excision either chalazia Cancer or cancer Yes Maybe No Bumps, lumps & chumps Name that bump Common Uncommon Chalazia Eyelid CA Chalazion Papilloma / tag Eyelid cyst Skin tags Basal cell Papilloma Squamous cell Nevi Sebaceous cell Keratosis Melanoma Cyst Xanthelasma Basal Cell Sebaceous Cell Inclusion Dermoid Xanthelasma Carcinoma Carcinoma Sebaceous Keratoacanthoma 7 Myth #6 TBx or not TBx • GCA is a Seasonal Disease - Increase in frequency after educational meetings All headaches need a temporal artery biopsy TBx or not TBx TBx or not TBx • GCA Rules: • Being Committed… – Age appropriate – 55+ – Appropriate symptoms: claudication; tenderness Order • Committed to – Ocular findings: vision loss, APD, disc Consultation edema/heme, diplopia ESR / CRP Start PO • Committed to steroids Biopsy TBx or not TBx • Decision for Biopsy determined by outside Mythbusters recommendation – Try not to convince pt for or against Oculoplastic Edition • Critical: Biopsy does NOT impact vision • TAB chosen because it is accessible and redundant Jed T. Poll, M.D. • 10:1 ratio of negative to positive – Why? Ramifications of missing Dx and AION Utah Optometric Association June 3, 2016 8 .