Entropion,ectropion, ptosis

Eyelid musclesEyelid muscles

THE EYELID MUSCLESTHE EYELID MUSCLES

How the lids are kept in placeHow the lids are kept in place

The palpebral fissureThe palpebral fissure

Why do the eyelids not fall outwards?Why do the eyelids not fall outwards?

Why do the eyelids not turn inwards? Why do the eyelids not turn inwards?

How is the fissure width maintained?How is the fissure width maintained?

Why are they apposed to the globe –just so?Why are they apposed to the globe –just so?

TARSUS - CANTHAL LIGAMENTS – BONETARSUS - CANTHAL LIGAMENTS – BONE

Superior and inferior tarsusSuperior and inferior tarsusMedial and lateral canthal ligamentsMedial and lateral canthal ligaments

Lacrimal crests and lateral orbital tubercleLacrimal crests and lateral orbital tubercle

Horizontal lid laxityHorizontal lid laxity

Laxity of canthal ligamentsLaxity of canthal ligaments With gravity – With gravity – ectropionectropion With lid retractor laxity - With lid retractor laxity - entropionentropion

What keeps the upper lid up and the What keeps the upper lid up and the

lower lid down?lower lid down?THE EYELID RETRACTORS

Eyelid retractorsEyelid retractors

Upper lid retractorsUpper lid retractorsLevator aponeurosisLevator aponeurosisSuperior tarsal muscle (Muller’s)Superior tarsal muscle (Muller’s)

Lower lid retractorsLower lid retractorsCapsulopalpebral fasciaCapsulopalpebral fasciaInferior tarsal muscleInferior tarsal muscle

Orbital septum fuses with the retractorsOrbital septum fuses with the retractors

Levator aponeurosisLevator aponeurosis Wide insertion Wide insertion Various layers of eyelidVarious layers of eyelid

Levator aponeurosisLevator aponeurosisInsertionsInsertions1.1. Medial horn – posterior Medial horn – posterior

lacrimal crestlacrimal crest2.2. Lateral horn – lateral Lateral horn – lateral

orbital tubercleorbital tubercle3.3. Anterior portion – skinAnterior portion – skin4.4. Posterior portion – Posterior portion –

anterior tarsusanterior tarsus5.5. ConjunctivaConjunctiva

Muller’s muscleMuller’s muscle

(superior tarsal muscle)(superior tarsal muscle) Posterior part of levatorPosterior part of levator 2 mm lift to the upper lid2 mm lift to the upper lid Insertion to tarsus and Insertion to tarsus and

conjunctivaconjunctiva Sympathetic supplySympathetic supply Horner’s syndrome – mild Horner’s syndrome – mild

ptosisptosis

Lower lid retractor Lower lid retractor Capsulopalpebral fasciaCapsulopalpebral fascia From inferior rectus From inferior rectus

terminal fibresterminal fibres Encircles inferior Encircles inferior

oblique oblique Inserts to inferior Inserts to inferior

conjunctival fornix and conjunctival fornix and inferior tarsal border inferior tarsal border

Upper lid retractorsUpper lid retractorsrarefactionrarefactiondisinsertion disinsertion PTOSISPTOSISdehiscencedehiscence

Lower lid retractorsLower lid retractors ECTROPIONECTROPIONattenuationattenuation ENTROPIONENTROPION

Result from imbalance between forces on Result from imbalance between forces on anterior and posterior lamellaeanterior and posterior lamellae

Ectropion - EntropionEctropion - Entropion

Initiator of imbalance – horizontal lid laxity

Tarsal instability

Gravity

Ectropion Entropion

lower lid retractor weakness

Outward turning of eyelid marginOutward turning of eyelid margin

TypesTypes

1.1. CongenitalCongenital

2.2. InvolutionalInvolutional

3.3. ParalyticParalytic

4.4. CicatricialCicatricial

5.5. MechanicalMechanical

EctropionEctropion

Most common type in practiceMost common type in practiceInvolutionalInvolutional

Primary etiologic factorPrimary etiologic factorHorizontal eyelid laxityHorizontal eyelid laxity

Clinical testClinical testThe snap testThe snap test

EctropionEctropion

Testing lid laxityTesting lid laxity

EctropionEctropion

Involutional ectropionInvolutional ectropionLower lidLower lidEpiphoraEpiphoraConjunctival Conjunctival

hypertrophyhypertrophyKeratinisationKeratinisation

EctropionEctropion

Paralytic ectropionParalytic ectropion

EctropionEctropion

Facial palsy

Cicatricial ectropionCicatricial ectropion

EctropionEctropion

Mechanical ectropionMechanical ectropion

EctropionEctropion

Inversion of eyelid marginInversion of eyelid margin

TypesTypes

1.1. CongenitalCongenital

2.2. Acute spasticAcute spastic

3.3. InvolutionalInvolutional

4.4. CicatricialCicatricial

Lower lid involutional entropion is Lower lid involutional entropion is

more common more common

EntropionEntropion

Involutional entropionInvolutional entropion

EntropionEntropion

Involutional entropionInvolutional entropion

EntropionEntropion

Results inResults in EpiphoraEpiphora Corneal abrasionsCorneal abrasions Corneal vascularizationCorneal vascularization

EntropionEntropion

MedialMedial

conjunctivoplasty/conjunctivoplasty/

Medial spindle Medial spindle

procedureprocedure

Ectropion surgeryEctropion surgery

Lateral canthoplasty/Lateral tarsal

strip procedure

Lazy-T procedureLazy-T procedure

MedialMedial

ConjunctivoplastyConjunctivoplasty

Full thickness Full thickness

excisionexcision

Ectropion surgeryEctropion surgery

Modified Modified

Kuhnt-Szymanowski Kuhnt-Szymanowski

procedureprocedure

Ectropion SurgeryEctropion Surgery

Transverse Transverse

lid everting suturelid everting suture

Entropion surgeryEntropion surgery

Weis procedureWeis procedure

Lid splitting Lid splitting

marginal rotationmarginal rotation

Entropion surgeryEntropion surgery

What is ptosis?What is ptosis?

It is an abnormally low It is an abnormally low position of the upper lid position of the upper lid

PtosisPtosis

How to How to diagnosediagnose mild ptosis? mild ptosis?What has What has causedcaused it? it?What is the What is the degreedegree of ptosis? of ptosis? Is it an indicator of a Is it an indicator of a seriousserious

disease?disease?How to choose the right How to choose the right

surgery surgery ??

PtosisPtosis

DiagnosisDiagnosisDrooping > 2 mm of cornea Drooping > 2 mm of cornea

coveredcoveredFrontalis overaction – forehead Frontalis overaction – forehead

wrinkleswrinklesChin elevation in bilateral ptosisChin elevation in bilateral ptosisRule out pseudoptosisRule out pseudoptosis

PtosisPtosis

Chin elevationChin elevation

PtosisPtosis

Brow elevationBrow elevation

PtosisPtosis

What has caused it?What has caused it?

ClassificationClassification• Congenital / AcquiredCongenital / Acquired• Lesion at the level ofLesion at the level of

nervenerve

musclemuscle

aponeurosisaponeurosis

PtosisPtosis

EtiologyEtiology

1.1. MyogenicMyogenic

2.2. AponeuroticAponeurotic

3.3. NeurogenicNeurogenic

4.4. MechanicalMechanical

5.5. TraumaticTraumatic

PtosisPtosis

MMost common acquired ptosisost common acquired ptosis

AponeuroticAponeurotic

MMost common congenital ptosisost common congenital ptosis

MyogenicMyogenic

PtosisPtosis

Congenital myogenic ptosisCongenital myogenic ptosis

PtosisPtosis

Aponeurotic ptosisAponeurotic ptosis

PtosisPtosis

Paralytic ptosisParalytic ptosis

PtosisPtosis

Mechanical ptosisMechanical ptosis

NeurofibromatosisNeurofibromatosis

PtosisPtosis

AAponeurotic ptosisponeurotic ptosis

InvolutionalInvolutional

PostoperativePostoperative

MechanismMechanism

rarefactionrarefaction

disinsertiondisinsertion

dehiscencedehiscence

PtosisPtosis

AAponeurotic ptosisponeurotic ptosis aging / surgeryaging / surgery high upper lid creasehigh upper lid crease

normal – 8-10 mmnormal – 8-10 mm

levator attachments to skinlevator attachments to skin

thinning of lidthinning of lid near normalnear normal levator functionlevator function

PtosisPtosis

AAponeurotic ptosisponeurotic ptosis

Brow elevation, high crease,

deep sulcus, thinned lid

PtosisPtosisCCongenital ptosisongenital ptosisSimpleSimple developmental dystrophy of developmental dystrophy of

levator musclelevator muscle Absent / weak lid creaseAbsent / weak lid crease reduced levator functionreduced levator function

PtosisPtosis

CCongenital ptosisongenital ptosis

SimpleSimple lid lag in downgazelid lag in downgaze weakness of superior rectus weakness of superior rectus

+/-+/- amblyopia from amblyopia from

astigmatismastigmatism

anisometropiaanisometropia

occlusionocclusion

PtosisPtosis

Obscuring visual axis

PtosisPtosis

Marcus Gunn jaw-winking syndromeMarcus Gunn jaw-winking syndrome

PtosisPtosis

Congenital Congenital

MyogenicMyogenic

Mild to severeMild to severe

ptosisptosis

Acquired Acquired

Mild to severeMild to severe

ptosisptosis

PalpebralPalpebral

fissure heightfissure height

PtosisPtosis

MyogenicMyogenic

Weak orWeak or

absentabsent

Acquired Acquired

Higher thanHigher than

normalnormal

Upper eyelidUpper eyelid

CreaseCrease

PtosisPtosis

MyogenicMyogenic

ReducedReduced

Acquired Acquired

Near normalNear normalLevatorLevator

functionfunction

PtosisPtosis

MyogenicMyogenic

Eyelid lagEyelid lag

Acquired Acquired

Eyelid dropEyelid dropOn downgazeOn downgaze

PtosisPtosis

AsAs an indicator of a serious disorder an indicator of a serious disorder

Myasthenia gravisMyasthenia gravis ocular involvement in 90%ocular involvement in 90% presenting feature in 60%presenting feature in 60% variable ptosis, bilateral, variable ptosis, bilateral,

asymmetricasymmetric worsens towards eveningworsens towards evening Tensilon testing Tensilon testing

PtosisPtosis

AsAs an indicator of a serious disorder an indicator of a serious disorder Myasthenia gravisMyasthenia gravis

Ptosis RE Ptosis LE, 3 months later

PtosisPtosis

Neurogenic ptosisNeurogenic ptosis oculomotor nerve palsyoculomotor nerve palsy

diabetes / diabetes / hypertensionhypertension

intracranial intracranial aneurysmsaneurysms

/ tumors / trauma/ tumors / trauma check for III nerve functionscheck for III nerve functions

PtosisPtosis

Pancoast’sPancoast’s tumor / carotid aneurysms / malignant tumor / carotid aneurysms / malignant cervical lymph nodes cervical lymph nodes

Horner’s syndrome

before cocaine after cocaine

PtosisPtosis

NNeurogenic ptosiseurogenic ptosis• Oculosympathetic palsyOculosympathetic palsy

(Horner’s syndrome)(Horner’s syndrome) mild ptosis as a rulemild ptosis as a rule miosismiosis normal pupillary reactionsnormal pupillary reactions Pancoast’s tumor / carotid Pancoast’s tumor / carotid

aneurysms / malignant cervical aneurysms / malignant cervical lymph nodeslymph nodes

PtosisPtosis

DDegree of ptosisegree of ptosis

MeasurementsMeasurements• Palpebral fissure heightPalpebral fissure height• Margin reflex distanceMargin reflex distance• Upper eyelid creaseUpper eyelid crease• Levator functionLevator function

PtosisPtosis

MeasurementsMeasurements

Poor levator function

PtosisPtosis

Ptosis data sheet

PtosisPtosis

Amount PtosisAmount Ptosis ClassificationClassification

less than or equal to 2mmless than or equal to 2mm MildMild

3mm3mm ModerateModerate

greater than or equal to 4mmgreater than or equal to 4mm SevereSevere

Amount of droop from normal

PtosisPtosis

Levator function

Levator Muscle ExcursionLevator Muscle Excursion ClassificationClassification

15mm15mm NormalNormal

greater than or equal to 8mmgreater than or equal to 8mm GoodGood

5-7mm5-7mm FairFair

less than or equal to 4mmless than or equal to 4mm PoorPoor

PtosisPtosis

AAdditional testsdditional testsOcular motilityOcular motilityLid in downgazeLid in downgazeAmblyopia Amblyopia Bell’s phenomenonBell’s phenomenonPharmacologic testingPharmacologic testing

PtosisPtosis

SSurgeryurgery

Dependent on levator functionDependent on levator function

Normal function

Levator aponeurosis advancement / reinsertion

PtosisPtosis

SSurgeryurgeryDependent on levator functionDependent on levator functionFor mild ptosisFor mild ptosis

Mild ptosisHorner’s

Fasanella-Servat procedure(tarsoconjunctival)Muller’s muscle resection

PtosisPtosisSSurgeryurgery

Moderate tosevere ptosis

Levator resection Amount of resection according to degree of ptosis

PtosisPtosis

SSurgeryurgery

Absent function

Frontalis suspensionAutogenous fascia lata or synthetic materials

Entropion,ectropion, ptosis

Health & Medicine

University of Groningen Paralytic ectropion treatment with ...€¦ · of ectropion. For this purpose, a new photograph-based scoring method [the Ectropion Severity Score (ESS)] was

Ektropion Dan Entropion

OP07lite Entropion and Ectropion Repair€¦ · about entropion and ectropion repair. If you have any questions, you should ask your GP or other relevant health professional. What

Entropion, ectropion, distiquiasis

ENTROPION SIKATRIKS

The entropion

Collie Eye Anomaly Progressive Retinal Atrophy Patella Luxation Elbow Dysplasia Heart Valve Disorders Entropion and Ectropion

Dr.Mazen Khwaira Disorders of the Eyelids. Benign eyelid lesions Malignant eyelid tumours Disorders of eyelashes Entropion Ectropion Ptosis

Affections de l'oeil 02 - atih.sante.fr · entropion et trichiasis de la paupiere h02.1 ectropion palpebral h02.2 lagophtalmie h02.3 blepharochalasis h02.4 ptosis de la paupiere h02.5

Allegato A D.A. 799/2015 Catalogo Unico Regionale Codice incataniaperte.altervista.org/blog/wp-content/uploads/2015/05/Allegat… · RIPARAZIONE DI ENTROPION O ECTROPION CON RESEZIONE

Upper and lower eyelid Blepharoplasty– Entropion Repair Ptosis Repair– Ectropion Repair Brow surgery Brow ptosis repair Tear duct DCR (re-routing

Ectropion w

Entropion/Ectropion Elizabeth J. Rosen, MD Karen H. Calhoun, MD 1/17/02

Chapter 1 Repair of Involutional Ectropion and Entropion

06Ectropion & Entropion

Fisiopatologia dell’epitelio della cornea: recenti ... · (occlusione, entropion, ectropion, sindrome palpebra molle) Tzong-Shyue Liu D et al. Tear dynamics in floppy eye lid syndrome

referat entropion

Normalt öga. Entropion - Svenska Kennelklubben · förklara hur fyra olika typer av entropion uppkommer. Entropion hos shar pei, som orsakas av mucinos, behandlas inte här. Entropion

Breed Associated Eye Diseases - Animal Eyes of NJ...Pigmentary keratitis/exposure keratopathy syndrome Labrador retriever Distichiasis Primary entropion Primary ectropion Iris melanoma

ECTROPION AND ENTROPION - repository-tnmgrmu.ac.in