Trichiasis Trichiasis

TrichiasisTrichiasis

Misdirected eye lashes are called trichiasis.Misdirected eye lashes are called trichiasis.Eyelashes (cilia) emerging normally i.e. from Eyelashes (cilia) emerging normally i.e. from anterior border of lid margin are misdirected anterior border of lid margin are misdirected backward towards the ocular surface backward towards the ocular surface (cornea).(cornea).Tarsal plate remains normal in position.Tarsal plate remains normal in position.Any condition causing entropion Any condition causing entropion (involutional, cicatricial as in Trachoma or (involutional, cicatricial as in Trachoma or spastic entropion) will cause misdirected spastic entropion) will cause misdirected lashes (Trichiasis) to rub against cornea lashes (Trichiasis) to rub against cornea

Causes of Trichiasis Causes of Trichiasis

1.1. Secondary to chronic inflammatory Secondary to chronic inflammatory conditions like Trachoma, Stevens- conditions like Trachoma, Stevens- Jhonson Syndrome, Pemphigus, Jhonson Syndrome, Pemphigus, Blepharitis, traumatic or operative Blepharitis, traumatic or operative scar, blepharitis (Ulcerative) and scar, blepharitis (Ulcerative) and chemical burns chemical burns

2.2. It may be idiopathic It may be idiopathic

Traumatic Scar causing Traumatic Scar causing TrichiasisTrichiasis

Trichiasis in Trachoma Stage Trichiasis in Trachoma Stage IVIV

Trichiasis with Corneal Trichiasis with Corneal OpacityOpacity

Trichiasis associated with Trichiasis associated with Ivolutional Entropion Ivolutional Entropion

Trichiasis associated with Trichiasis associated with spastic entropion spastic entropion

Trichiasis associated with operative Trichiasis associated with operative scarscar

SymptomsSymptoms

►Foreign body sensationForeign body sensation► IrritationIrritation►PainPain►RednessRedness► Inability to open eyes Inability to open eyes ►Watering Watering

Signs Signs

►Misdirected eyelash(s)Misdirected eyelash(s)►Conjunctival congestion Conjunctival congestion ►Lacrimation/ blepharospasm Lacrimation/ blepharospasm ►Recurrent corneal erosions / superficial Recurrent corneal erosions / superficial

corneal opacity(ies) corneal opacity(ies) ►Corneal vascularizationCorneal vascularization►Recurrent corneal ulcer/ Non-healing Recurrent corneal ulcer/ Non-healing

corneal ulcer corneal ulcer

Trichiasis with corneal Trichiasis with corneal abrasion abrasion

Trichiasis Trichiasis

Trichiasis with Stevens Jhonson Trichiasis with Stevens Jhonson SyndromeSyndrome

TreatmentTreatment

1.1. Epilation of affected eyelash, but they grow Epilation of affected eyelash, but they grow in 4- 6 weeksin 4- 6 weeks

2.2. Diathermy: 30 mA current is passed in the Diathermy: 30 mA current is passed in the root of affected eyelash for 10 seconds then root of affected eyelash for 10 seconds then epilated epilated

3.3. Electrolysis: done under local anaesthesia by Electrolysis: done under local anaesthesia by injecting lignocaine along the lid margin to injecting lignocaine along the lid margin to anaesthetize root of eyelashes. Positive pole anaesthetize root of eyelashes. Positive pole is applied temple. Negative pole is is applied temple. Negative pole is introduced in hair follicle and current of 2 introduced in hair follicle and current of 2 mA is used (bubble is seen at root of eyelash mA is used (bubble is seen at root of eyelash then) eyelash is then epilatedthen) eyelash is then epilated

Epilation Forceps Epilation Forceps

Treatment Treatment

4. Cryotherapy: used for treating portion 4. Cryotherapy: used for treating portion of lid. This procedure is done under of lid. This procedure is done under local anaesthesia. Temperature of -20 local anaesthesia. Temperature of -20 deg. C , two cycles then eyelashes are deg. C , two cycles then eyelashes are epilated epilated

Distichiasis Distichiasis

► In this condition there is an extra row of In this condition there is an extra row of eyelashes emerging from the duct of the eyelashes emerging from the duct of the meibomian glands meibomian glands

► It may be a congenital (autosomal It may be a congenital (autosomal dominant) condition or acquired dominant) condition or acquired following chronic inflammatory condition following chronic inflammatory condition of the eyelids, conjunctiva or trauma of the eyelids, conjunctiva or trauma

►Treatment- epilation/ Treatment- epilation/ electrolysis/cryotherapy electrolysis/cryotherapy

TrichiasisTrichiasis

Symblepharon Symblepharon

►Symblepharon is adhesion between Symblepharon is adhesion between the bulbar and palpabral conjunctiva the bulbar and palpabral conjunctiva due to raw opposing surfaces due to raw opposing surfaces

►Causes: opposing surfaces of palpabral Causes: opposing surfaces of palpabral and bulbar conjunctiva becomes raw and bulbar conjunctiva becomes raw and inflamed in cases of:and inflamed in cases of:a. Chemical burn (Alkali / Acid burn)a. Chemical burn (Alkali / Acid burn)b. Stevens- Johnson syndrome b. Stevens- Johnson syndrome c. Pemphigus c. Pemphigus

SymblepharonSymblepharon

Types:Types:

- Anterior- Anterior

- Posterior- Posterior

- Total - Total

Posterior symblepharon in Posterior symblepharon in Stevens Johnson SyndromeStevens Johnson Syndrome

Posterior and Anterior Posterior and Anterior SymblepharonSymblepharon

SymptomsSymptoms

► Irritation, foreign body sensationIrritation, foreign body sensation►Restriction of ocular movements Restriction of ocular movements ►Diplopia Diplopia

TreatmentTreatment

►Prevention: Sweeping of glass rod and Prevention: Sweeping of glass rod and use of topical steroids use of topical steroids

►Treatment: surgical release + mucous Treatment: surgical release + mucous membrane or amniotic membrane membrane or amniotic membrane grafting grafting

LagophthalmosLagophthalmos

LagophthalmosLagophthalmos

Definition : Incomplete closure of the Definition : Incomplete closure of the palpabral aperture when attempt is palpabral aperture when attempt is made to close the eyes. made to close the eyes.

Lagophthalmos in 7Lagophthalmos in 7thth nerve nerve palsypalsy

Lagophthalmos with neuroparalytic Lagophthalmos with neuroparalytic

keratitiskeratitis

Causes of LagophthalmosCauses of Lagophthalmos

►Contraction of lids due to cicatrization or Contraction of lids due to cicatrization or a congenital deformitya congenital deformity

►EctropionEctropion►Paralysis of OrbicularisParalysis of Orbicularis►Proptosis due to exophthalmic goitre, Proptosis due to exophthalmic goitre,

orbital tumour/ inflammmation etc.orbital tumour/ inflammmation etc.►Laxity of tissue and absence of reflex Laxity of tissue and absence of reflex

blinking in patients who are extremely blinking in patients who are extremely ill. ill.

Clinical PictureClinical Picture

Symptoms:Symptoms:

1.1. Inability to close eye(s)Inability to close eye(s)

2.2.Symptoms of dry eyeSymptoms of dry eye

3.3.Blurring of visionBlurring of vision

4.4.Foreign body sensationForeign body sensation

5.5.Photophobia Photophobia

Clinical Picture Clinical Picture

SignsSigns

1.1. Incomplete closure of lidIncomplete closure of lid

2.2.Exposure of conjunctiva and corneaExposure of conjunctiva and cornea

3.3.Dryness, congestionDryness, congestion

4.4.Haziness of cornea, punctate Haziness of cornea, punctate infiltrationinfiltration

ComplicationsComplications

1. Corneal ulcer (Non-healing)1. Corneal ulcer (Non-healing)

TreatmentTreatment

Medical TreatmentMedical Treatment

1.1.Lubricating Eye dropsLubricating Eye drops

2.2.Control of infectionControl of infection

3.3.Protection of ocular surfaceProtection of ocular surface

4.4.Close affected eye and tape upper lid Close affected eye and tape upper lid or application of sutureor application of suture

Surgical Treatment:Surgical Treatment:

Tarsorrhaphy (Lateral or paramedian) Tarsorrhaphy (Lateral or paramedian)

PTOSISPTOSIS

PtosisPtosis

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

TypesTypes

►CongenitalCongenital1. Simple1. Simple2. Complicated2. Complicated

►Acquired Acquired 1. Neurogenic1. Neurogenic2. Myogenic2. Myogenic3. Aponeurotic3. Aponeurotic4 Mechanical4 Mechanical

TypesTypes

►Pseudoptosis – in Phthisis bulbi and Pseudoptosis – in Phthisis bulbi and anophthalmos anophthalmos

►Condition may be Unilateral or Condition may be Unilateral or Bilateral Bilateral

►Partial or complete Partial or complete

Measurement Measurement

►Normal position of lidsNormal position of lids►Abnormal – Margin Reflex Distance Abnormal – Margin Reflex Distance

(MRD)- Normal MRD is 4 mm +/- 1 mm (MRD)- Normal MRD is 4 mm +/- 1 mm ►Ptosis of less than 2 mm – MildPtosis of less than 2 mm – Mild►Ptosis of 3 mm – moderate Ptosis of 3 mm – moderate ►Ptosis of 4 mm or more – severe Ptosis of 4 mm or more – severe

Compensatory Mechanism Compensatory Mechanism

►Overaction of frontalisOveraction of frontalis►Throwing back the headThrowing back the head

►Assessment of LPS function –Assessment of LPS function –Excursion of 8 mm or more – good Excursion of 8 mm or more – good actionactionExcursion of 5-7 mm – Fair actionExcursion of 5-7 mm – Fair actionExcursion of 4 mm or less – poor Excursion of 4 mm or less – poor

►Look for Bell phenomenon Look for Bell phenomenon

Congenital PtosisCongenital Ptosis

►Commonest form of ptosisCommonest form of ptosis►Usually bilateral / Heriditary Usually bilateral / Heriditary ►Due to defective development of LPSDue to defective development of LPS►Simple congenital ptosis is an isolated Simple congenital ptosis is an isolated

abnormality abnormality

Ptosis of left eyePtosis of left eye

Marcus Gunn Phenomenon Marcus Gunn Phenomenon

Blepharophimosis syndrome Blepharophimosis syndrome

Congenital PtosisCongenital Ptosis

►Complicated – when associated with Complicated – when associated with developmental abnormality of surrounding developmental abnormality of surrounding structures structures Associated Sup rectus palsyAssociated Sup rectus palsyAbnormal synkineses – Marcus Gunn ptosisAbnormal synkineses – Marcus Gunn ptosisDystrophy of the LPS Dystrophy of the LPS Blepharophimosis syndrome (Ptosis, Blepharophimosis syndrome (Ptosis, horizontal shortening of palp aperture, horizontal shortening of palp aperture, epicanthus inversus, telecanthus lat epicanthus inversus, telecanthus lat ectropion of the lower lids)ectropion of the lower lids)

Treatment of Congenital Treatment of Congenital Ptosis Ptosis

►Age (3-5 years), early surgery when pupil Age (3-5 years), early surgery when pupil is coveredis covered

►Fasanella –servat operation (indicated Fasanella –servat operation (indicated when ptosis is 1.5 – 2 mm – excision of 4-when ptosis is 1.5 – 2 mm – excision of 4-5 mm upper tarsus) 5 mm upper tarsus)

►LPS resection – 10 mm resection is LPS resection – 10 mm resection is minimum (resection ranges from 12 – 24 minimum (resection ranges from 12 – 24 mm)mm)

►Conjunctival (Blaskovics operation) or skin Conjunctival (Blaskovics operation) or skin (Everbusch operation) route for surgery (Everbusch operation) route for surgery

Treatment of Congenital Treatment of Congenital Ptosis Ptosis

►Frontalis suspension- intact LPS with Frontalis suspension- intact LPS with poor function (3 mm or less)poor function (3 mm or less)

4-0 Supramid suture or fascia lata is 4-0 Supramid suture or fascia lata is used used

Complications associated with this Complications associated with this operation operation

Acquired PtosisAcquired Ptosis

►Usually unilateral Usually unilateral

Types Types

1.1. Neurogenic – Third nerve paralysis or due to Neurogenic – Third nerve paralysis or due to reduced sympathetic innervation (Horner reduced sympathetic innervation (Horner syndrome – ptosis, anhydrosis and miosis)syndrome – ptosis, anhydrosis and miosis)

Treatment – of cause, crutch spectacle, Treatment – of cause, crutch spectacle, surgery – LPS resection/ Frontalis surgery – LPS resection/ Frontalis suspension suspension

Left Eye 3Left Eye 3rdrd nerve Palsy nerve Palsy

Left Eye 3Left Eye 3rdrd nerve Palsy nerve Palsy

Acquired PtosisAcquired Ptosis

2. Myogenic – gradual onset, bilateral 2. Myogenic – gradual onset, bilateral condition, symmetrical condition, symmetrical

Myotonic dystrophyMyotonic dystrophy

Chronic progressive exophthalmoplegiaChronic progressive exophthalmoplegia

Mysthenia gravis ( damage to acetyl-Mysthenia gravis ( damage to acetyl-cholin receptor at postsynaptic cholin receptor at postsynaptic membrane with presence of membrane with presence of antiacetylcholine receptor antibodies)antiacetylcholine receptor antibodies)

Acquired PtosisAcquired Ptosis

Mysthenia Gravis-Mysthenia Gravis-

Symptoms – variableSymptoms – variable

Signs – bilateral ptosis, increases by Signs – bilateral ptosis, increases by prolonged fixation or attempt to look prolonged fixation or attempt to look up , external ophthalmoplegia – partial up , external ophthalmoplegia – partial or completeor complete

Conformation by prostigmin or Conformation by prostigmin or edrophonium injection test edrophonium injection test

Acquired PtosisAcquired Ptosis

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

ContusionsContusions

►Black Eye – swelling and ecchymosis of Black Eye – swelling and ecchymosis of lids and conjunctiva lids and conjunctiva

►Cryptophthalmos – rare condition Cryptophthalmos – rare condition characterized by presence of skin characterized by presence of skin passing continuously from brow over passing continuously from brow over the eye to the cheek. the eye to the cheek.

CryptophthalmosCryptophthalmos