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


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

Health & Medicine

Entropion,ectropion, ptosis