Lecture 5/6- Eyelids Part 1: A and B Flashcards
(114 cards)
1
Q
which muscle is the main eyelid protractor, with the primary function of narrowing the palpebral fissure and closing the eye lids. ‘it contracts medially to pump tears toward the ducts. Innervated by CN VII, orbital portion is largest part - wink, preseptal portion is for winking and blinking
A
Orbicularis Oculi
2
Q
What part of the orbicularis oculi is resposible for horizontal movement of eyelid in order to spread tear film and pump tears toward the duct?
A
Pretarsal portion
3
Q
size range of the palpebral fissure
A
12-30 mm
4
Q
name for the crease of the upper lid that represents the cutaneous insertion of fibers of the levator anoneurosis into the preseptal orbicularis oculi, 8-10 mm above lashes
A
Superior palpebral crease
5
Q
What does it mean if there is no superior palpebral crease, here the fibers of the levator palpebrae aponeurosis insert into the preseptal orbicularis oculi
A
No crease = no LP superioris function - as in blepharoptosis
6
Q
name for the crease below the lower lid, 4-5 mm below lower lashes
A
inferior palpebral crease
7
Q
Thin, fibrous, multilayer sheath that separates the eyelids from the orbit - functions as an anatomical barrier to protect orbit from infection, heme, edema
A
orbital septum
8
Q
What is unique to asian populations in terms of crease position and orbital septum anatomy of upper lid
A
Creases in lower position than caucasians
Upper lid orbital septum can be fused to the anoneurosis as it inserts into the tarsus - as high as the superior border of the tarsus, or as low as the lashes line = lower or absent UL crease
9
Q
Term for upper eyelid sin laxity that increases with age, causing a hooding effect - not the same as ptosis, can be severe, causing mechanical ptosis with or without superior visual field defect or entropion
A
Dermatochalasis - can interfere with visual fields if hood droops over the pupil, and entropion i the hood causes the lashes to turn inward against the globe
10
Q
prominent lower lids from orbital fat, malar bags, hypertrophy, or overriding orbicularis oculi, only can be treated by blepharoplasty
A
“Bags” under the eye
11
Q
What could be a secondary condition developed after an elderly person has surgery to remove the excess skin present in dermatochalasis?
A
eye lid could not be able to close - lagophthalmos
12
Q
Retractors of the upper eyelid
A
Levator palpebrae superior and superior tarsal muscle of Muller
13
Q
Lower eye lid retractors
A
capsulopalpebral fascia and inferior tarsal
14
Q
disease with weakness of tarsus elastin fibers
A
Floppy Eyelid syndrome
15
Q
Arteries supplying upper eyelid that branch from the ophthalmic artery, which branches from ICA
A
Lacrimal, Supraorbital, Supratrochlear, Dorsal nasal
16
Q
What artery supplies the superficial arterial system (facial and angular arteries) that supplies the lower lid
A
External Carotid artery
17
Q
Artery supplying lacrimal gland, conjunctiva, lateral upper eyelid, terminates as lateral palpebral artery
A
Lacrimal artery
18
Q
Artery supplying upper eyelid, scalp, forehead, levator muscle, periorbita, diploe of frontal lobe
A
Supraorbital artery
19
Q
Artery supplying skin of superior medial aspect of the orbit, forehead, and scalp
A
Supratrochlear artery
20
Q
Artery supplying nose bridge skin, lacrimal sac, terminates as medial palpebral artery
A
Dorsal nasal artery
21
Q
Eye lid venous drainage review
A
drains through tributaries of ophth vein, and superficially through superficial temporal and angular (superficial frontal and supraorbital and supratrochlear)
22
Q
Vein with dual drainage - deep by superior opth, and superficial by anterior facial vein
A
Angular vein
23
Q
Vein that empties into common facial vein, that empties into external jugular
A
Angular vein
24
Q
Which lymphatic system drains the skin and orbicularis oculi
A
superficial system
25
which lynphatic system drains that tarsi and conjunctiva, upper lid, later half of LL and lateral canthus
Deep system - into the preauricular and deep parotid nodes
26
Nerves of the eyelids
3, 5, 7
27
Viral infections causing skin lesions along a V1 dermatome, and a lesion on the tip of the nose - Hutchison's sighn - with associated kerato uveitis. Typically, involvement of nasociliary nerve is seen.
Herpes Zoster Ophthalmicos
28
glands at the coruncula and within eyebrow hars, associated with periocular skin vellus - thin hairs
Sebaceous - holocrine glands
29
modified sebaceous glands at tarsal plate, each has a central duct with multiple acini to synthesize lipids for outer layer of tear film
Meibomian glands
30
modified apocrine sweat glands - open into a lash follicle, are more in lower lid
Moll Glands
31
Modified sebaceous glands associated with Lash follicles
Zeiss glands
32
glands at eyelid skin, not confined to lid margin, unlike apocrine glands
Eccrine sweat glands
33
units that comprise hair follicles together with their sebaceous glands
Pilosebaceous units
34
Thickening of the keratin layer appearing as white flaky skin, can be a feature of benign and malignant epithelial tumors
Hyperkeratosis
35
thickening of the squamous cell layer
acanthosis
36
Alteration of the size, morphology, and organization of cellular components of a tissue. increased cell growth and change in histological features
Dysplasia
37
Keratinization other than on the surface
Dyskeratosis
38
Retention of nuclei into the keratin layer
Parakeratosis
39
dysplastic changes throughout the thickness of the epidermis and marked hyperkeratosis
Carcinoma in Situ
40
Epicanthal folds that are symmetrically distributed between upper and lower lids, most common type in caucasions
Palebralis
41
epicanthal folds that originate in the medial aspect of the upper lids and extends medially, most common in orientals
Tarsalis
42
epicanthal folds that start in lower lids and extends upwards to the medial canthal areas, associated with blepharophimosis
Inversus
43
Epicanthal fold that arise above the brow and extends downwards to the lateral aspect of the nose
Superciliaris
44
Wide distance between the medial canthi due to long medial canthus tendons - not hypertelorism which is wide separation of orbits
Telecanthus- associated with Waadenburg, Mobious, Treacher-Collens, Rubinstein - Taybi, Turner Syndromes
45
A patient comes in with epicanthal folds starting at the lower lids and extending to medial canthus, and long medial canthus tendons, short palpebral aperture, barely any nasal bridge, poor levator function, and lateral extropion of LL. Patient also has Amblyopia. Diagnose, Treat, How does it occur?
1. Blepharophimosis Syndrome
2. Surgery for epicanthus inversus and telecanthus, then bilateral frontalis suspensions
3. Rare Autosomal Dominant, caused by mutations in FOXL2 gene on chromosome 3
46
Extra horizontal fold of skin that stretches across the anterior lid margin, vertically directed lashes. not a congenital entropion, and common in orientals. Diagnose and Treat
Epiblepharon
| No treatment, spontaneous resolution with age
47
A patient with microphthalmos is having an eyelid turn inward and the lashes are touching the cornea. What does he have?
Upper lid entropion - secondary to echanical effects of micro, causing upper lid inversion
48
A patient with improper development of the inferior retractor aponeurosis is having an eyelid turn inward and the lashes are touching the cornea. What does he have?
Lower Lid Entropion
49
How do you treat congenital (or any other ) entropions
Surgery
50
Symmetrical enlargement of the palpebral fissure with malposition of lateral canthus and ectropion. If severe, lagophthalmos and exposure keratopathy are present. Associated to lateral displacement of lacrimal drainage system, double row of meibomian orifices, telechanthus, strabismus. Diagnose and Treat
Euryblepharon
| Tarsorrhaphy - lateral canthal tightening
51
SMall eyelids, vertical shortening of eyelids, opften associated with anophthalmos
Microblepharon
52
Deficiency of the anterior lamellae of eye lids, systemic anomalie syndrome characteried by fish like mouth, ear and genital anomalies, and redundant skin. Diagnose and treat
Ablepharon - Ablepharon-macrostomia syndrome
Reconstructive skin grafting
53
Uncommon, unilateral/bilateral, partial/full thickness eyelid defect on upper or lower lid. occurs when eyelid development is incomplete due to failure of lid ectoderm to fuse with lid folds, or to mechanical forces like amniotic bands
Eyelid Coloboma
54
Upper lid colobomas at middle and inner thirds are associated with what syndrome causing unlateral face deformities of ear, chin, corner of mouth, and benign dermoid cysts, and possible a missing eye
Goldenhar Syndrome
55
lower lid colobomas at middle and outer thirds are associated with what syndrome causing underdeveloped cheek bones, small jaw/ chin, cleft palate, hearing loss, eyes slant downwards
Treacher Collins - lower lid colobomas can also be associated with amniotic band syndrome
56
Rare congenital anomaly where skin is continuous over eyeball with absence of eyelids - lids are completely replaced by a layer of skin that is fused with a microphthalmos
Cryptophthalmos - complete when lids completely replaced by layer of skin
57
What syndrome is associated with incomplete cryptophthalmos with microphthalmos, rudimentary lids, syndactyly, urogenital anomalies, malformed upper airway, craniofacial structures, mental handicap
Fraser syndrome - AD, caused by mutations in FRAS-1 and FRAS-2 genes on chromosome 13
58
Rare condition more frequently seen in black infants with down syndrome and collodion skin disease, bilateral and symmetrical, may resolve spontaneously with conservative tx or require surgery
Congenital upper lid eversion
59
common acquired condition, posterior midirection of lashes from normal origin sites, cause trauma to cornealcan be due to scarring of lid margin from chronic blepharitis, herpes zoster, or others.
Trichiasis
60
Ways to treat Trichiasis - remove, shock, freeze, laser, surgery
1. Epilation every 4 to 6 weeks
2. electrolysis with needle electrocutes root
3. cryotherapy but lots of complications, removes many at once
4. Argon laser ablation - cures after 1 or 2 sessions
5. surgery with full-thickness wedge resection or anterior lamellar excision
61
Partial or complete second row of lashes emerging at or behind meibomian gland orifices, aberrant lashes tend to be thinner and shorter and directed posteriorly
Distichiasis
62
Downward sagging of upper eyelid lashes, idiopathic or associated with floppy eyelid syndrome, dermatochalasis with anterior lamellar slip or long- standing facial palsy
Eyelash Ptosis
63
Curling and increased growth with lengthening and rigidity of eyelashes, can be caused by prostaglandis, ciclosporins, phenytoin, AIDS, hypothyroid, malnutrition, lots of syndromes
Trichomegalia
64
loss of eyelashes, local : blepharitis, Skin disorder: alopecia or psoriasis, systemic disease: lupus, syphilis, leprosy, After removal: trichiasis treatment, trichotilomania - pt pulls them out
Madarosis
65
Premature localized whitening of hair, which may involve lashes and eyebrows, caused by blepharitis, vitiligo, marfan, waardenburg, tuberous sclerosis etc
Poliosis
66
congenital or acquired low position of the upper eyelid, associated with HA, neck pain, motility changes, diplopia, anisocoria, benign etiologies - Rule out Horner, 3rd nerve palsy, Myasthenia gravis, malignancy
Ptosis
67
Type of ptosis due to an innervation defect - Horner, 3rd nerve palsy, marcus gunn jaw winking syndrome, ophthalmoplegic migraine, multiple sclerosis
Neurogenic Ptosis
68
Type of ptosis with levator muscle myopathy, impairment of impulses transmission to the muscle - Myasthenia Gravis, mytonic dystrophy, progressive ophthalmoplegia
Myogenic Ptosis
69
Type of ptosis with defect in the levator palpebra aponeurosis
Anoneurotic Ptosis
70
Type of ptosis due to gravity caused by a mass or scarring
Mechanical Ptosis
71
congenital causes of ptosis
blepharophimosis, incomplete lavator differentiation, thiamine deficiency
72
"Ptosis" caused by Lack of support: orbital volume deficit
| Contralateral lid retraction, Isilateral hyoptropia, Brow Ptosis, dermatochalasis
Pseudoptosis
73
Measurement for ptosis- distance between upper lid margin and corneal reflection in primary gaze ptosis - graded as mild - 2 mm, moderate - 3 mm, severe - 4 mm
Margin-reflex distance
74
Distance between upper and lower lid margins - ptosis measurement
Palpebral fissure height
75
pt looks down with your thumb against eyebrow, ask to look up as far as possible, excursion is measured with a ruler - normal 15 or less, good is 12 to 14, fair is 5 to 11, poor is 4 or less - ptosis measurement
Levator Function
76
vertical distance between the lid margin and the lid crease looking downward - ptosis measurement, females 10 mm, males 8 mm
Upper lid crease
77
distance between lid margin and skin fold with the eyes in primary gaze position
Pretarsal show
78
associated sign of ptosis where the levator of the contralateral eye is over stimulated resulting in lid retraction
Increased innervation
79
Associated sign of ptosis where pt looks up for 30 seconds, progressive drooping of one or both eyelids or inability to sustain upward gaze suggests myasthenia gravis
Fatigability
80
Check superior rectus in patients with congenital ptosis, correction if ipsilateral hypotropia improves ptosis
Ocular motility defects
81
Associated sign of ptosis involving winking with chewing, in 5% of congenital ptosis, mandibular branch of CN5 is midirected to LP, pt learn to mask it, surgery is option
Jaw winking phenomenon- marcus gunn jaw winking syndrome
82
Globe rotation when eyes close - associated sign of ptosis
Bell Phenomenon
83
Ptosis most likely due to failure of neuronal migration or failure of muscular development, minority is hereditary, ABSENT UPPER LID CREASE AND POOR LEVATOR function, lid lag while looking down, SR weakness
Simple Congenital ptosis
84
syndrome that frequently follows an acquired CN 3 nerve palsy, or abberrant facial nerve regeneration, Bizarre movements of upper lid with eye movements - treat with brown suspensions and LP disinsertion
3rd CN misdirection syndrome
85
Syndrom marked by Retraction of lid on R gaze - pseudo Von Graefe sign
Left Brown's Syndrome
86
Type of ptosis related to age and desinsertion or stretching of aponeurosis of LP, ptosis due to fatigue of muller muscle during the day, can be confused with MG, bilateral, Tx with LP resection, reinsertion and repair
Involutional Ptosis
87
Type of ptosis, result of impaired mobility of the UL caused by dermatochalasis, tumors, heavy scar tissue, severe edema
Mechanical ptosis
88
When working up a ptosis patient, give the reason for testing for EOMS, Pupils, History
1. EOMs to rule out CN3 Palsy
2. Pupilsto rule out Horners or parasypathetic denervation in CN3 palsy
3. History to see if congenital, with lid lag, or if variable ptosis - MG suspect
89
3 signs of Horners
Miosis, ptosis (enophthalmus from muller muscle paralysis can contribute to the appearance of ptosis), anhidrosis
90
Effect of cocaine in a Horner Pupil
NO DILATION
91
Effect of apraclonidine on a Horners pupil
SUPER DILATION
92
Effect of hydroxyamphetamine in a Horners Pupil - Interpretation
Dilates - Pre-ganglionic
| No Dilation- Post gangionic
93
when is ptosis an indication for surgery in children?
amblyopia risk
abnormal head posture
furrowed eye brow
94
test for assessing fatigue in ptosis patients with possible MG
Ice pack test - levator function test
95
outward turning of the eyelid margin - tearing, irritation, corneal exposure, conjunctival injection, thickening. Due to laxity or dinsertion
Ectropion
96
Patient with glaucoma is presenting sings of ectropion. you notice the presence of scarring on the inner lid. you ask the patient what medication he is taking, what would you suspect his answer might be, how would you treat it ?
Dorzolamide - trusopt or brimonidine - alphagan
Discontinue use of Glaucoma meds, try something else for glaucoma
97
A patient with ectropion comes in, and upon evaluation of the frontalis muscle, you notice that the eyebrows cannot be raised and the corners of the mouth curl slope downward and cannot be lifted. Mom says he has been like this since birth, What is the likely diagnosis? what if it was acquired?
congenital :Moebius syndrome, if acquired: bells palsy, vascular lesion, tumor, trauma
98
Cause of facial nerve paralysis where the upper and lower facial muscles are equally affected in voluntary and emotional movements
Peripheral Lesions
99
Cause of facial nerve paralysis where only voluntary movements of the forehead and orbicularis oculi are affected to a small degree because of bilateral cortical innervation, emotional movements are unimpaired
Supranuclear Lesions
100
Flattening of the entire face with loss of forehead wrinkles, infraorbital fold, nasolabial fold, eyebrow drooping, elevated upper eyelid, ptosis, ectropion of lower lid, epiphora, lagophthalmos, exposure keratopathy
Paralytic Ectropion
101
How to treat paralytic ectropion
topical lubrication - antibiotic if a lot of exposure
taping eyelids closed at bed time- mask
temporary suture or botulin toxin into LP
102
Condition caused by seventh nerve palsy, cerebellopontine angle tumors, herpes zoster oticus, infiltration of tumors of parotid gland, bells, trauma, vascular lesions, moebius syndrome
Paralytic ectropion
103
Test for ectropion - if mild, lid in normal position, but when pulled out it returns slowly, if advanced, lid is not in apposition with globe,
Snap-Back test: positive if no brisk return
104
Inward turning of an eyelid caused by disinsertion of lower lid retractors or secondary to inflammation, trauma, scarring, or congenital malformation of lower lid retractors
Entropion
105
How to treat entropion
epilation, lubricant, taping, BCL, antibiotics if severe
106
Soft, rubbery easily everted lid, unilateral or bilateral, ovese middle aged men who sleep face down, lids get everted by pillow, leads to keratoconjunctivitis, loss of tarsal integrity, decrease in elastin in tatus, elongation of tarsal plate
Floppy Eyelid Syndrome
107
problems associated with floppy eyelid syndrome
keratoconus, skin elasticity, joint hypermotility-people who can push their eyes outward, sleep apnea
108
how to treat floppy eyelid syndrome
lid taping, night mask, not sleeping face down, lubricants, antibiotics, weight control
109
Eyelids midirected, causing conj hyperemia, corneal staining, FB sensation, Irritation, due to age, disease, trauma. treated with epilation, lubricant, BCL, antibiotics, if severe - laser/cryo/electro tx
Trichiasis
110
Uncommon condition characterized by cagarette paper skin from multiple episodes of edema, onset around puberty, orbital fat herniation/absorption, can result in ptosis, lacrimal gland can prolapse, Diagnose with drug induced urticaria, angioedema, TX blepharoplasty and ptosis correction
Blepharochalasis
111
Disease characterized by eyelid twitching - spontaneous contractions of the orbicularis muscle, caused by hyper firing of nerve fibers - irritation - can be provoded by stress, caffeine, smoking, alcohol, eye strain
Orbicularis Myokemia
112
Patient comes in with complains about their eye appearing to jump periodically. How do you treat?
1. Education
2. If persistent...
3. If unresolved after topical tx
4. if still unresolved
Orbicularis Myokemia
1. discontinue caffeine, smoking, drinking, manage stress, sleep more, correct refractive error
2. Topical antihistamines - Emadine
3. Add Oral H1 blocker like phenergan or benadryl
4. Refer for botox
113
idiopathic, Involuntary Eyelid closure - hyper-contractions of orbicularis muscle, causing uncontrollable lid closure, corrugator, frontalis, procerus may be involved. More common in females in their 50's - 60's , abnormal levels of neurtotransmitters, What needs ruled out? how do you treat? If persists?
Essential Blepharospasm
Rule out Anti-dopamine and SSRI meds
Oral histamine - zyrtex, sedative at bedtime - benadryl or phenergan
If persists - botox
114
incomplete lid closure - physiologic or nocturnal, can be orbital - protposis, paralytic- 7th nerve palsy, mechanical - lid scarring, or tumor - neuroma or parotid gland, How to treat?
Lagophthalmos
Mild - lubricant and artificial tears, lid taping
Moderate- Severe: antibiotic, sugery, implants
