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 Lens Service • I have no financial interest in any of the Associate Professor of Clinical Ophthalmology product mentioned in this lecture University of Iowa Function • The eyelids have 2 main functions: Anatomy – Protection of the globe – Secretion, distribution and drainage of tears Eyelid Layers Glands in the Eyelids • The layers of the eyelid • The glands of the eyelid are: are: i) meibomian glands –in the i) skin 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 eyelashes. iii)glands of Moll – modified layer under the muscle sweat glands that also open v)fibrous tissue layer into the eyelash follicles. vi)smooth muscle layer iv)glands of Wolfring –these are accessory lacrimal or tear vii)conjunctiva. glands. 1 10/6/2016 Meibomian Gland Evaluation Issipiated Normal Blunted From: The International Workshop on Meibomian Gland 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 trigeminal nerve (CN V). ‐shuts eye – 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 Oculomotor nerve levator/ tarsal plate nerve. ‐Opens eye 2 10/6/2016 Position Movement‐ Vertical • When the eye is open the upper lid covers 1/6 of the cornea and the lower lid should just touch the limbus • Enlarged aperture – Thyroid eye disease – Space occupying lesion Movement‐ Horizontal Lagophthalmos Innervation Innervation • Marcus‐Gunn Jaw • 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 muscles of mastication • Lyme disease. – Inability to close eye 3 10/6/2016 Innervation Innervation • Inability to Open Lid • Inability to open lid – Horner’s Syndrome – 3rd Nerve Palsy • Look for small pupil • dilated, poorly reactive pupil • Mild ptosis • 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 arms 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 – Chin 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 – Amblyopia concern • When to do surgery depends on amblyopia risk 4 10/6/2016 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 keratoconus – think Sleep apnea Ptosis‐ Acquired Ptosis VF Testing • Levator dehiscence At least 20 degrees of VF loss for Medicare payment for repair from contact lens wear • Aging Ptosis‐ Acquired Position • Neoplasmic Entropion Symptoms • Neurofibromas • Redness and pain around the eye • Cicatricial • Sensitivity to light and wind • Sagging skin around the eye • Epiphora • Decreased vision, especially if the cornea is damaged 5 10/6/2016 Position Position Entropion Causes Ectropion • 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. • Scars – facial burns • – Trauma‐ dog bite or lacerations Scarring • Eyelid growths – Trauma – Benign or cancerous • Blepharoplasty – Trachoma • Radiation – For neoplasm • 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, strabismus, congenital heart defect • Acquired – Lower lid – Pigmented or non‐pigmented – Chronic inflammation Madarosis Madarosis – Decrease or loss of • Associated Disease lashes – Alopecia – Long standing Anterior • Hereditary • Blepharitis autoimmune – Atopic dermatitis – Tumor • Scratching/ rubbing – Thermal burns – Systemic Lupus – Trichotillomania • Early loss • Breakage • Scarred follicles – Ichthyosis 6 10/6/2016 Hypertrichosis Poliosis • Excess lashes or • Premature whitening of abnormally long lashes the hair, lashes and eyebrows – Congenital – Drug induced – Vitiligo • latanoprost – Waardenburg syndrome • Iris heterochromia • White forelock – Demodex Normal Flora • Staphylococcus epidermidis (95.8%)* Infection • 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 ENDOPHTHALMITIS 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 Cataract 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 7 10/6/2016 Infection Infection • Posterior Blepharitis • Angular Blepharitis – Meibomian Gland Dysfunction Infection Infection • Hordeolum/Chalazion • 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 conjunctivitis • 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 rosacea, seborrheic dermatitis and other skin conditions. 8 10/6/2016 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 • folliculitis Symptom Symptoms Dry Eye Allergy • 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 allergies when demodex (MGD) actually mites • Mite debris and waste elicit inflammatory response 9 10/6/2016 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 keratitis 7. Many people