Entropion,ectropion, ptosis
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Entropion,ectropion, ptosis

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Entropion,ectropion, ptosis Entropion,ectropion, ptosis Presentation Transcript

  • THE EYELID MUSCLES How the lids are kept in place
  • The palpebral fissure
    • Why do the eyelids not fall outwards?
    • Why do the eyelids not turn inwards?
    • How is the fissure width maintained?
  • The palpebral fissure
    • Why are they apposed to the globe –just so?
    • TARSUS - CANTHAL LIGAMENTS – BONE
  • The palpebral fissure Superior and inferior tarsus Medial and lateral canthal ligaments Lacrimal crests and lateral orbital tubercle
  • Horizontal lid laxity
    • Laxity of canthal ligaments
    • With gravity – ectropion
    • With lid retractor laxity - entropion
  • The palpebral fissure
    • What keeps the upper lid up and the
    • lower lid down?
    THE EYELID RETRACTORS
  • Eyelid retractors
    • Upper lid retractors
        • Levator aponeurosis
        • Superior tarsal muscle (Muller’s)
    • Lower lid retractors
        • Capsulopalpebral fascia
        • Inferior tarsal muscle
    • Orbital septum fuses with the retractors
  • Eyelid retractors
    • Levator aponeurosis
    • Wide insertion
    • Various layers of eyelid
  • Eyelid retractors
    • Levator aponeurosis
    • Insertions
    • Medial horn – posterior lacrimal crest
    • Lateral horn – lateral orbital tubercle
    • Anterior portion – skin
    • Posterior portion – anterior tarsus
    • Conjunctiva
  • Eyelid retractors
    • Muller’s muscle
    • (superior tarsal muscle)
    • Posterior part of levator
    • 2 mm lift to the upper lid
    • Insertion to tarsus and conjunctiva
    • Sympathetic supply
    • Horner’s syndrome – mild ptosis
  • Eyelid retractors
    • Lower lid retractor
    • Capsulopalpebral fascia
    • From inferior rectus terminal fibres
    • Encircles inferior oblique
    • Inserts to inferior conjunctival fornix and inferior tarsal border
  • Eyelid retractors
    • Upper lid retractors
    • rarefaction
    • disinsertion PTOSIS
    • dehiscence
    • Lower lid retractors ECTROPION
    • attenuation ENTROPION
    • Result from imbalance between forces on anterior and posterior lamellae
    Ectropion - Entropion
  • Ectropion - Entropion Initiator of imbalance – horizontal lid laxity Tarsal instability Gravity Ectropion Entropion lower lid retractor weakness
    • Outward turning of eyelid margin
    • Types
            • Congenital
            • Involutional
            • Paralytic
            • Cicatricial
            • Mechanical
    Ectropion
    • Most common type in practice
    • Involutional
    • Primary etiologic factor
    • Horizontal eyelid laxity
    • Clinical test
    • The snap test
    Ectropion
    • Testing lid laxity
    Ectropion
    • Involutional ectropion
    • Lower lid
    • Epiphora
    • Conjunctival
    • hypertrophy
    • Keratinisation
    Ectropion
    • Paralytic ectropion
    Ectropion Facial palsy
    • Cicatricial ectropion
    Ectropion
    • Mechanical ectropion
    Ectropion
    • Inversion of eyelid margin
    • Types
        • Congenital
        • Acute spastic
        • Involutional
        • Cicatricial
    • Lower lid involutional entropion is
    • more common
    Entropion
    • Involutional entropion
    Entropion
    • Involutional entropion
    Entropion
    • Results in
    • Epiphora
    • Corneal abrasions
    • Corneal vascularization
    Entropion
    • Medial
    • conjunctivoplasty/
    • Medial spindle
    • procedure
    Ectropion surgery Lateral canthoplasty/ Lateral tarsal strip procedure
    • Lazy-T procedure
    • Medial
    • Conjunctivoplasty
    • +
    • Full thickness
    • excision
    Ectropion surgery
    • Modified
    • Kuhnt-Szymanowski
    • procedure
    Ectropion Surgery
    • Transverse
    • lid everting suture
    Entropion surgery
    • Weis procedure
    • Lid splitting
    • +
    • marginal rotation
    Entropion surgery
  • What is ptosis?
    • It is an abnormally low position of the upper lid
  • Ptosis
    • How to diagnose mild ptosis?
    • What has caused it?
    • What is the degree of ptosis?
    • Is it an indicator of a serious disease?
    • How to choose the right surgery ?
  • Ptosis
    • Diagnosis
    • Drooping > 2 mm of cornea covered
    • Frontalis overaction – forehead wrinkles
    • Chin elevation in bilateral ptosis
    • Rule out pseudoptosis
  • Ptosis
    • Chin elevation
  • Ptosis
    • Brow elevation
  • Ptosis
    • What has caused it?
    • Classification
      • Congenital / Acquired
      • Lesion at the level of
    • nerve
    • muscle
    • aponeurosis
  • Ptosis
    • Etiology
        • Myogenic
        • Aponeurotic
        • Neurogenic
        • Mechanical
        • Traumatic
  • Ptosis
    • M ost common acquired ptosis
    • Aponeurotic
    • M ost common congenital ptosis
    • Myogenic
  • Ptosis
    • Congenital myogenic ptosis
  • Ptosis
    • Aponeurotic ptosis
  • Ptosis
    • Paralytic ptosis
  • Ptosis
    • Mechanical ptosis
    • Neurofibromatosis
  • Ptosis
    • A poneurotic ptosis
        • Involutional
        • Postoperative
    • Mechanism
        • rarefaction
        • disinsertion
        • dehiscence
  • Ptosis
    • A poneurotic ptosis
    • aging / surgery
    • high upper lid crease
      • normal – 8-10 mm
      • levator attachments to skin
      • thinning of lid
    • near normal levator function
  • Ptosis
    • A poneurotic ptosis
    Brow elevation, high crease, deep sulcus, thinned lid
  • Ptosis
    • C ongenital ptosis
    • Simple
    • developmental dystrophy of levator muscle
    • Absent / weak lid crease
    • reduced levator function
  • Ptosis
    • C ongenital ptosis
    • Simple
    • lid lag in downgaze
    • weakness of superior rectus +/-
    • amblyopia from
    • astigmatism
    • anisometropia
    • occlusion
  • Ptosis
    • C ongenital ptosis
    Obscuring visual axis
  • Ptosis
    • Marcus Gunn jaw-winking syndrome
    C ongenital ptosis
  • Ptosis Congenital Myogenic Mild to severe ptosis Acquired Aponeurotic Mild to severe ptosis Palpebral fissure height
  • Ptosis Congenital Myogenic Weak or absent Acquired Aponeurotic Higher than normal Upper eyelid Crease
  • Ptosis Congenital Myogenic Reduced Acquired Aponeurotic Near normal Levator function
  • Ptosis Congenital Myogenic Eyelid lag Acquired Aponeurotic Eyelid drop On downgaze
  • Ptosis
    • As an indicator of a serious disorder
    • Myasthenia gravis
        • ocular involvement in 90%
        • presenting feature in 60%
        • variable ptosis, bilateral, asymmetric
        • worsens towards evening
        • Tensilon testing
  • Ptosis
    • As an indicator of a serious disorder Myasthenia gravis
    Ptosis RE Ptosis LE, 3 months later
  • Ptosis
    • As an indicator of a serious disorder
    • Neurogenic ptosis
        • oculomotor nerve palsy
          • diabetes / hypertension
          • intracranial aneurysms
        • / tumors / trauma
          • check for III nerve functions
  • Ptosis
    • Pancoast’s tumor / carotid aneurysms / malignant cervical lymph nodes
    Horner’s syndrome before cocaine after cocaine
  • Ptosis
    • As an indicator of a serious disorder
    • N eurogenic ptosis
      • Oculosympathetic palsy
        • (Horner’s syndrome)
        • mild ptosis as a rule
        • miosis
        • normal pupillary reactions
        • Pancoast’s tumor / carotid aneurysms / malignant cervical lymph nodes
  • Ptosis
    • D egree of ptosis
    • Measurements
        • Palpebral fissure height
        • Margin reflex distance
        • Upper eyelid crease
        • Levator function
  • Ptosis
    • D egree of ptosis
    • Measurements
    Poor levator function
  • Ptosis
    • D egree of ptosis
    • Measurements
    Ptosis data sheet
  • Ptosis
    • D egree of ptosis
    • Measurements
    Amount of droop from normal Amount Ptosis Classification less than or equal to 2mm Mild 3mm Moderate greater than or equal to 4mm Severe
  • Ptosis
    • D egree of ptosis
    • Measurements
    Levator function Levator Muscle Excursion Classification 15mm Normal greater than or equal to 8mm Good 5-7mm Fair less than or equal to 4mm Poor
  • Ptosis
    • A dditional tests
      • Ocular motility
      • Lid in downgaze
      • Amblyopia
      • Bell’s phenomenon
      • Pharmacologic testing
  • Ptosis
    • S urgery
    • Dependent on levator function
    Normal function Levator aponeurosis advancement / reinsertion
  • Ptosis
    • S urgery
    • Dependent on levator function
    • For mild ptosis
    Mild ptosis Horner’s Fasanella-Servat procedure (tarsoconjunctival) Muller’s muscle resection
  • Ptosis
    • S urgery
    • Dependent on levator function
    Moderate to severe ptosis Levator resection Amount of resection according to degree of ptosis
  • Ptosis
    • S urgery
    • Dependent on levator function
    Absent function Frontalis suspension Autogenous fascia lata or synthetic materials