Lagophthalmos

1. Lagophthalmos

3. Causes of Lagophthalmos Contraction of lids due to cicatrization or a congenital deformity Ectropion Paralysis of Orbicularis Proptosis due to exophthalmic goitre, orbital tumour/ inflammmation etc. Laxity of tissue and absence of reflex blinking who are extremely ill.

4. Clinical Picture Symptoms: Inability to close eye(s) Symptoms of dry eye Blurring of vision Foreign body sensation Photophobia

5. Clinical Picture Signs Incomplete closure of lid Exposure of conjunctiva and cornea Dryness, congestion Hazyness of cornea, punctate infiltration Complications 1. Corneal ulcer (Non-healing)

6. Treatment Medical Treatment Lubricating Eye drops Control of infection Protection of ocular surface Surgical Treatment: Tarsorrhaphy (Lateral or paramedian)

7. PTOSIS

8. Ptosis Definition: Drooping of upper lid usually due to paralysis or defective development of the levator palpebrae superioris (LPS)

9. Types Congenital 1. Simple 2. Complicated Acquired 1. Neurogenic 2. Myogenic 3. Aponeurotic 4 Mechanical

10. Types Pseudoptosis – in Phthisis bulbi and anophthalmos Condition may be Unilateral or Bilateral Partial or complete

11. Measurement Normal position of lids Abnormal – Margin Reflex Distance (MRD)- Normal MRD is 4 mm +/- 1 mm Ptosis of less than 2 mm – Mild Ptosis of 3 mm – moderate Ptosis of 4 mm or more – severe

12. Compensatory Mechanism Overaction of frontalis Throwing back the head Assessment of LPS function – Excursion of 8 mm or more – good action Excursion of 5-7 mm – Fair action Excursion of 4 mm or less – poor Look for Bell phenomenon

13. Congenital Ptosis Commonest form of ptosis Usually bilateral / Heriditary Due to defective development of LPS Simple congenital ptosis is an isolated abnormality

14. Congenital Ptosis Complicated – when associated with developmental abnormality of surrounding structures Associated Sup rectus palsy Abnormal synkineses – Marcus Gunn ptosis Dystrophy of the LPS Blepharophimosis syndrome (Ptosis, horizontal shortening of palp aperture, epicanthus inversus, telecanthus lat ectropion of the lower lids)

15. Treatment of Congenital Ptosis Age (3-5 years), early surgery when pupil is covered Fasanella –servat operation (indicated when ptosis is 1.5 – 2 mm – excision of 4-5 mm upper tarsus) LPS resection – 10 mm resection is minimum (resection ranges from 12 – 24 mm) Conjunctival (Blaskovics operation) or skin (Everbusch operation) route for surgery

16. Treatment of Congenital Ptosis Frontalis suspension- intact LPS with poor function (3 mm or less) 4-0 Supramid suture or fascia lata is used Complications associated with this operation

17. Acquired Ptosis Usually unilateral Types Neurogenic – Third nerve paralysis or due to reduced sympathetic innervation (Horner syndrome – ptosis, anhydrosis and miosis) Treatment – of cause, crutch spectacle, surgery – LPS resection/ Frontalis suspension

18. Acquired Ptosis 2. Myogenic – gradual onset, bilateral condition, symmetrical Myotonic dystrophy Chronic progressive exophthalmoplegia Mysthenia gravis ( damage to acetyl-cholin receptor at postsynaptic membrane with presence of antiacetylcholine receptor antibodies)

19. Acquired Ptosis Mysthenia Gravis- Symptoms – variable Signs – bilateral ptosis, increases by prolonged fixation or attempt to look up , external ophthalmoplegia – partial or complete Conformation by prostigmin or edrophonium injection test

20. Acquired Ptosis Aponeurotic Ptosis Is involutional is due to weakness or disinsertion of LPS aponeurosis from ant surface of tarsal plate High lid fold with good LPS function Treatment – reinsertion of LPS and resection of LPS Mechanical Ptosis - Tumour or inflammation weigh down the lid

21. Contusions Black Eye – swelling and ecchymosis of lids and conjunctiva Cryptophthalmos – rare condition characterized by presence of skin passing continuously from brow over the eye to the cheek.