Eyelid & Lacrimal System Abnormalities

Oculoplastics | Lisa A. Mansueto, M.D.

  1. Ptosis
    1. Eyebrow Ptosis – heavy brows can weigh on eyelids, accentuating the amount of upper eyelid skin
    2. Eyelid Ptosis
      1. Dermatochalasis – excess eyelid skin
      2. True levator muscle ptosis – problems with the elevating muscle of the eyelid called the levator muscle
        1. Levator aponeurosis dehiscence – most common cause of ptosis in adults due to stretching of muscle
        2. 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
        3. 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
        1. Contralateral asymmetric eyelid retraction from Graves’ disease – opposite eyelid is “too open” or retracted
        2. Enophthalmos – sinking in of an eye
        3. Vertical strabismus – misalignment of eye due to eye muscle problems – not lid
        4. Hemifacial spasm or blepharospasm – spastic conditions cause eyelid to spasm shut
  2. Ectropion – Lid margin rotates outward or falls away from the globe
    1. Symptoms – tearing, redness, dryness, ocular irritation
    2. Involutional – most common cause; due to laxity of medial and/or lateral canthal ligaments
    3. Cicatricial – due to skin contracting from sun exposure, chemical burns, or radiation; scarring of the septum from trauma or prior surgery
    4. Mechanical – skin cancers or scars
    5. Paralytic – facial nerve palsy; heavy atonic lower lid tissue stretches tarsal ligaments
    6. Surgery – aimed at eliminating the laxity, excising scars, or addressing the exact etiology of the lid deformity
  3. Entropion – Lid margin rotates inwards, causing lashes to contact globe
    1. Symptoms – ocular irritation, tearing, foreign body sensation
    2. Involutional – due to laxity of medial and lateral canthal ligaments
      1. Treatment- surgically tighten canthal ligaments
    3. 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
    4. Congenital – exceedingly rare; may be associated with dehiscence or detachment of retractor layer or lower eyelids