OCULOPLASTICS

Eyelid & Lacrimal System Abnormalities

Lisa A. Mansueto, M.D.

I. Ptosis

A. Eyebrow Ptosis - heavy brows can weigh on eyelids, accentuating the amount of upper eyelid skin

B. Eyelid Ptosis

   1. Dermatochalasis - excess eyelid skin

   2. True levator muscle ptosis – problems with the elevating muscle of the eyelid called the levator muscle

         a. Levator aponeurosis dehiscence - most common cause of ptosis in adults due to stretching of muscle

         b. Myogenic - congenital or acquired; most common cause of ptosis in children; due to weakness of levator muscle; can be associated with systemic muscular weakening disorders, such as myotonic dystrophy, chronic progressive external ophthalmoplegia, or oculopharyngeal dystrophy

         c. Neurologic – due to poor nerve innervations to levate muscle, Marcus-Gunn Jaw winking, Third nerve palsy, and Horner's syndrome

   3. Mechanical Ptosis - due to increased weight of eyelid from tumor or scars

   4. Pseudoptosis - mimics ptosis but not true ptosis; gives the “appearance” of ptosis

         a. Contralateral asymmetric eyelid retraction from Graves' disease – opposite eyelid is “too open” or retracted

         b. Enophthalmos – sinking in of an eye

         c. Vertical strabismus – misalignment of eye due to eye muscle problems – not lid

         d. Hemifacial spasm or blepharospasm – spastic conditions cause eyelid to spasm shut

II. Ectropion - Lid margin rotates outward or falls away from the globe

A. Symptoms - tearing, redness, dryness, ocular irritation

B. Involutional - most common cause; due to laxity of medial and/or lateral canthal ligaments

C. Cicatricial - due to skin contracting from sun exposure, chemical burns, or radiation; scarring of the septum from trauma or prior surgery

D. Mechanical - skin cancers or scars

E. Paralytic - facial nerve palsy; heavy atonic lower lid tissue stretches tarsal ligaments

F. Surgery - aimed at eliminating the laxity, excising scars, or addressing the exact etiology of the lid deformity

III. Entropion - Lid margin rotates inwards, causing lashes to contact globe

A. Symptoms - ocular irritation, tearing, foreign body sensation

B. Involutional - due to laxity of medial and lateral canthal ligaments

   1. Treatment- surgically tighten canthal ligaments

C. Cicatricial - due to scarring of conjunctiva

   1. Etiologies- chemical burns, trauma, prior cryotherapy treatment, radiation treatment, ocular cicatrical pemphigoid, Stevens-Johnson syndrome, erythema multiforme, trachoma, herpes zoster, chronic allergies, trauma, long-term use of miotic eyedrops

   2. Treatment- often require buccal mucous membrane grafts to re-create a conjunctival lining

D. Congenital - exceedingly rare; may be associated with dehiscence or detachment of retractor layer or lower eyelids