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Anterior Segment Disease > 3: Eyelids- Malpositions and Twitching > Flashcards

3: Eyelids- Malpositions and Twitching Flashcards

1
Q

dermatochalasis

A

lax and redundant upper > lower eyelid skin

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2
Q

dermatochalasis etiology

A

degeneration of connective tissue most commonly the result of aging

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3
Q

dermatochalasis demographics

A
  • most commonly presents in the elderly

- sometimes with extreme weight loss or chronic blepharochalasis

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4
Q

dermatochalasis laterality

A

bilateral

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5
Q

dermatochalasis symptoms

A
  • asymptomatic
  • droopy eyelids
  • heavy eyelids
  • obstruction of superior visual field
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6
Q

dermatochalasis signs

A
  • upper eyelid skin laxity and redundancy
  • excessive skin –> “puffy” appearance
  • decreased MRD-1
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7
Q

dermatochalasis management

A
  • none if asymptomatic
  • if symptomatic/cosmesis, refer out for blepharoplasty (BLUB- bilateral upper lid blepharoplasty); prior to referral, perform a VF with lids taped vs untaped, preferably super 36 aka a “ptosis VF”; if there is improvement in the VF with the lids taped, higher likelihood insurance will consider the surgery medically necessary; otherwise, patient may pursue blepharoplasty as elective cosmesis “out of pocket” procedure
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8
Q

dermatochalasis clinical pearls:

  • BULB can be performed _____
  • never perform BULB ______
A

in office or in outpatient center;

right before intraocular surgery, the speculum will “stretch” the eyelid skin, better cosmetic outcome

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9
Q

ptosis

A

droopy upper eyelid

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10
Q

ptosis etiology

A

most commonly: aponeurotic; levator aponeurosis stretching or dehiscence due to aging, repetitive eye rubbing

less commonly:

  • mechanical (e.g., eyelid tumor, severe eyelid edema)
  • myogenic (e.g., muscular dystrophy, chronic progressive external ophthalmoplegia)
  • neurologic (e.g., CN III palsy, Horner syndrome, myasthenia gravis, multiple sclerosis)
  • congenital
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11
Q

ptosis demographics

A

depends on etiology

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12
Q

ptosis laterality

A

unilateral > bilateral

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13
Q

ptosis symptoms

A
  • asymptomatic, cosmesis
  • droopy eyelid
  • obstruction of the superior visual field
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14
Q

ptosis signs

A
  • drooping eyelid; UL is most commonly affected; if LL is affected, called a reverse ptosis
  • decreased MRD-1 and possibly MRD-2
  • signs of underlying cause (e.g., chalazion, EOM restriction, anisocoria, diplopia, high or absent eyelid crease if aponeurotic or congenital)
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15
Q

ptosis management

A
  • determine and treat the underlying condition

- if no resolution or congenital, consider referral for ptosis surgery, which involves resecting the levator aponeurosis

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16
Q

ptosis clinical pearls:

-differentiate from ______

A

pseudoptosis; ex: dermatochalasis, brow ptosis, enophthalmos, microphthalmia, corneal protective mechanisms, contralateral eyelid retraction

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17
Q

entropion

A

eyelid turns inwards/towards the globe

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18
Q

entropion etiology

A

most commonly age-related; horizontal eyelid laxity, retractor disinsertion, and orbicularis override

less commonly:

  • cicatricial (e.g., conjunctival scarring in trauma, burn injury, trachoma, OCP, SJS)
  • spastic (e.g., sustained orbicularis contraction due to surgical trauma, ocular irritation, or blepharospasm)
  • congenital
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19
Q

entropion demographics

A

most commonly presents in the elderly

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20
Q

entropion laterality

A

unilateral or bilateral

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21
Q

entropion symptoms

A
  • asymptomatic
  • ocular redness
  • ocular irritation (e.g., burning, FBS, pain)
  • tearing
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22
Q

entropion signs

A
  • inversion of the eyelid

- signs of underlying cause (e.g., conjunctival scarring, spastic contraction of the orbicularis muscle)

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23
Q

entropion complications

A

trichiasis (lash bending inwards) –> ocular surface damage (conjunctival injection, SPK, pannus, corneal ulceration and scarring)

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24
Q

entropion management

A
  • determine and treat the underlying condition; if no resolution, refer out for entropion surgery for definitive treatment
  • supportive management for trichiasis and resulting ocular surface damage; lash epilation, electrolysis, cryotherapy, or radiofrequency epilation; aggressive topical lubrication; BCL or scleral contact lens
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25
Q

entropion clinical pearls:

-trichiasis without entropion is typically _____

A

idiopathic and only involves a few lashes; can cause irritation of the ocular surface; epilate lashes in office

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26
Q

ectropion

A

eyelid turns out/away from the globe

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27
Q

ectropion etiology

A

most commonly age-related; horizontal eyelid laxity

less commonly:

  • mechanical (e.g., eyelid tumor)
  • cicatricial (e.g., shortening of the anterior lamella from trauma, burn injury, actinic damage, chronic inflammation, atopic dermatitis)
  • neurologic (e.g., CN VII palsy)
  • congenital
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28
Q

ectropion demographics

A

most commonly presents in the elderly

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29
Q

ectropion laterality

A

unilateral or bilateral

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30
Q

ectropion symptoms

A
  • asymptomatic
  • ocular redness
  • ocular irritation (e.g., burning, FBS, pain)
  • tearing
31
Q

ectropion signs

A
  • eversion of the eyelid; LL is most commonly affected

- signs of underlying cause (e.g., eyelid tumor, eyelid scarring, paralysis of the facial muscles)

32
Q

ectropion complications

A

lagophthalmos –> exposure keratopathy; more common in paralytic cases (ex: Bell’s palsy)

33
Q

ectropion management

A
  • determine and treat the underlying condition; if no resolution, refer out for surgery for definitive treatment
  • supportive management for exposure keratopathy; aggressive topical lubrication
  • BCL, but lens may fall out due to lid positioning
34
Q

eyelid retraction

A

excessive elevation of the eyelid

35
Q

eyelid retraction etiology

A

most commonly due to thyroid eye disease; increased sympathetic tone acting on Muller’s muscle, contraction of the levator, proptosis, and/or scarring between the lacrimal gland and levator

less commonly:

  • mechanical (e.g., surgical overcorrection of ptosis)
  • cicatricial (e.g., scarring of the levator and/or Muller’s muscle)
  • neurologic (e.g., dorsal midbrain syndrome)
  • pharmacological (e.g., sympathomimetic drops, like phenylephrine)
  • congenital (rare)
36
Q

eyelid retraction demographics

A

women > men

37
Q

eyelid retraction laterality

A

unilateral or bilateral

38
Q

eyelid retraction symptoms

A
  • asymptomatic
  • ocular redness
  • ocular irritation (e.g., burning, FBS)
39
Q

eyelid retraction signs

A
  • excessive elevation of the eyelid; UL is most commonly affected; in general, eyelid position is abnormal if superior sclera is exposed in primary gaze
  • increased MRD-1 and/or MRD-2
  • signs of underlying cause (e.g., proptosis, deficiency of upward gaze, UL retraction and pupillary constriction on down gaze or adduction, dilated pupil)
40
Q

eyelid retraction complications

A

lagopthalmos –> exposure keratopathy

41
Q

eyelid retraction management

A
  • determine and treat the underlying condition; if no resolution, refer out for surgery for definitive treatment
  • supportive management for exposure keratopathy
42
Q

eyelid retraction clinical pearls:

-lower eyelid retraction can be ____

A

a normal anatomic variant

43
Q

floppy eyelid syndrome (FES)

A

flaccid/loose upper eyelids due to a lax tarsal plate

44
Q

floppy eyelid syndrome (FES) etiology

A
  • unknown etiology

- commonly associated with obstructive sleep apnea

45
Q

floppy eyelid syndrome (FES) demographics

A
  • typically presents between the ages of 45-65. years

- men (obese) > women

46
Q

floppy eyelid syndrome (FES) laterality

A

bilateral

47
Q

floppy eyelid syndrome (FES) symptoms

A
  • asymptomatic
  • ocular redness
  • ocular irritation (e.g., burning, FBS, itching)
  • mild mucous discharge
  • symptoms are typically unilateral (side that the patient sleeps) and worse upon waking (due to eyelid eversion during the night)
48
Q

floppy eyelid syndrome (FES) signs

A
  • upper eyelids that are easily everted without exerting counter pressure
  • rubbery superior tarsal plate
  • eyelid imbrication (UL overrides the LL on closure)
  • conjunctival injection
  • palpebral papillae superior (due to eyelid eversion during sleep and rubbing against bedding)
  • superficial punctate keratitis (SPK)
  • mild mucous discharge
  • ptosis (due to redundancy of skin surrounding tarsal plate)
49
Q

floppy eyelid syndrome (FES) complications

A
  • lagophthalmos (due to eyelid imbrication) –> exposure keratopathy
  • bacterial conjunctivitis (due to eyelid eversion during sleep)
50
Q

floppy eyelid syndrome (FES) management

A
  • supportive management (topical lubricant, eyelid taping or patching qhs with topical lubricant, refrain from sleeping face down)
  • refer out for surgery for definitive treatment
  • if not previously diagnosed, refer to PCP for sleep apnea
51
Q

lagophthalmos

A

incomplete closure of the eyelids

52
Q

lagophthalmos etiology

A
  • mechanical (e.g., eyelid laxity, eyelid tumor, post eyelid surgery, proptosis, FES, severe conjunctival chemosis)
  • cicatricial (e.g., eyelid scarring, eyelid retractor muscle scarring)
  • neurologic (e.g., dorsal midbrain syndrome, CN VII palsy)
  • congenital
53
Q

lagophthalmos demograhpics

A

depends on etiology

54
Q

lagophthalmos laterality

A

unilateral or bilateral

55
Q

lagophthalmos symptoms

A
  • asymptomatic
  • ocular redness
  • ocular irritation (e.g., burning, FBS, pain)
  • tearing
56
Q

lagophthalmos signs

A
  • inadequate blinking or closure of the eyelids
  • signs of underlying cause (e.g., eyelid tumor, proptosis, chemosis, eyelid scarring, restriction in up gaze, paralysis of the facial muscles)
57
Q

lagophthalmos complications

A

exposure keratopathy

58
Q

lagophthalmos management

A
  • determine and treat the underlying condition; if no resolution, refer out for surgery for definitive treatment
  • supportive treatment for exposure keratopathy (aggressive AT regime, topical steroid for SPK, Restasis or Xiidra bid, sleep mask, BCL, scleral lens, AMT with BCL)
59
Q

eyelid myokymia

A

subtle eyelid twitch due to spontaneous contracture of the orbicularis muscle

60
Q

eyelid myokymia etiology

A
  • unknown etiology

- commonly triggered by stress, caffeine, alcohol, ocular irritation, lack of sleep

61
Q

eyelid myokymia demographics

A

no predilection

62
Q

eyelid myokymia laterality

A

unilateral***

63
Q

eyelid myokymia symptoms

A

eyelid twitch

64
Q

eyelid myokymia signs

A

eyelid twitch is typically subtle and difficult to observe

65
Q

eyelid myokymia management

A
  • self-limiting
  • modify/avoid triggers
  • 5-6 oz tonic water (anecdotal); contains quinine which may inhibit nerve impulses
66
Q

eyelid myokymia clinical pearls:

-differentiate from _____

A

hemifacial spasm (unilateral contracture of the entire side of the face; requires brain MRI to rule out tumor)

67
Q

blepharospasm

A

spastic (involuntary muscular contraction) twitching, blinking, or closure of the eyelids due to contraction of the orbicularis muscle

68
Q

blepharospasm etiology

A
  • unknown etiology

- may be associated with Meige’s syndrome

69
Q

blepharospasm demographics

A

women > men

70
Q

blepharospasm laterality

A

bilateral***

71
Q

blepharospasm symptoms

A
  • increased blink rate initially
  • spasmodic eyelid closure as it progresses; disappears during sleep
  • interference with ADLs; may be functionally blind
  • ocular redness
  • ocular irritation (e.g., burning, FBS)
  • tearing
72
Q

blepharospasm signs

A
  • spastic twitching, blinking, or closure of the eyelids
  • conjunctival injection
  • superficial punctate keratitis (SPK)
73
Q

blepharospasm management

A
  • refer out for Botox or surgery; Botox is currently gold standard
  • supportive management for dry eye
  • Meige’s syndrome is characterized by dystonia (movement disorder in which a person’s muscles contract uncontrollably); often of the jaw, tongue, and eyelids

Anterior Segment Disease (22 decks)

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