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Audio recording started: 1:30 PM Wednesday, 8 June 2016

To squint or to look obliquely or askance-

Any ocular misalignment cause by abnormalities in binocular vision or by anomalies of neuromuscular control of

ocular motility

-

Comitant - not paralytic

See double (in elderly)Incomittant - paralytic

Gaze position

Refractive/Non-refractive

AC/A Ratio (when high)

Accommodation

Constant/Monocular

Alternating

Fixation

Congenital - 0-6 months

Usually no diplopia

Acquired - > 6 months

Age of onset

Classification-

Strabismus

-up and out - SR

-up and in - IO

-Down and out - IR

-Down and in - SO

EOM

Eso - medially deviated (convergent)-

Exo - laterally deviated (divergent)-

Prefixes and Suffixes

Tuesday, 7 June 2016 6:35 PM

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Hyper - upward-

Hypo - downward-

Phoria - latent deviation-

Tropia - manifest deviation-

Diagnosis

*Corneal Light reflex / Hirschberg Reflex

Cover-uncover: differentiate phoria from tropia-

Alternating cover: breaks fusion and exposes total deviation; once dissociation is achieved, the amount of

deviation is measured using prisms

-

*Cover tests

Determines amount of deviation using prism in combination with corneal light reflex test-

1 mm deviation = 7 degrees-

*Krimsky method

Correction of refractive errors with spectacle1.

Surgical correction based on amount of deviation2.

Treatment

Muscle resection : shortening of muscle to STRENGTHEN it

Muscle recession : moving the muscle insertion closer to its origin to WEAKEN it.

4mm x 7

degrees = 28

Anatomy

Skin and subcutaneous tissue-

Muscle of protraction-

Orbital septum - boundary of orbit with eyelid-

Orbital fat - 2 inferiorly, 3 superiorly-

*Whitmann's ligament

Levator palpebra superiori - upper lid

Capsulopalpebral fascia - lower lid

Muscle of retraction-

Muller's muscle

Upper lid

Lockwood's ligament

Lower lid

Tarsus-

Conjunctiva-

Eyelid Layers

Drooping or inferior displacement of the upper eyelid-

*eyelid should cover 2 mm of cornea superiorly-

Palpebral Fissure Height

Normal is 3-4 mm(MRD1)

Margin-reflex distance

Insertion/Attachment of levator aponeurosis

Upper Eyelid Crease position - 2-5 mm from lid margin edge

Levator Function

Lagophthalmos - eyelid does not totally close

Evaluation and Examination of Ptosis-

dysgenesis of levator muscle (congenital)

Lid lag, dec. levator fx, lagophthalmos, absent lid crease

Myogenic

Classification-

Ptosis



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High or indistinct upper lid crease

Good upper lid movement

Worse in reading position

Most common cause: aging, post-surgical

Aponeurotic - attachment of levator aponeurosis is gone

Congenital or acquired CN3 palsy(ptosis, dilated pupil, down and out globe), Horner's

syndrome, Marcus Gunn Jaw winking(aberrant cranial nerve 5-mandibular; when you

move your jaw [contralateral], eyelid open)

Neurogenic - problem with CN 3

Traumatic - trauma to levators or its aponeurosis

Hemangioma, large chalazion, BCC, SCC

Mechanical -masses

Surgical reinsertion and resection of levator aponeurosis

Temporizing procedures: tape upper lid, eyelid crutches

Management-

Entropion - inward turning of eyelids

Tarsal plate defects

Dysgenesis of lower lid retractor

Shortening of posterior lamella

Congenital-

Horizontal lid laxity (snapback test) - address by shortening

Overriding of the preseptal orbicularis over the pretarsal orbicularis(forced lid closure)

Attenuation or disinsertion of lid retractors - reattach disinserted retractors

Involutional-

Autoimmune, inflammatory, infectious, surgical traumatic

Cicatricial (sec. to scar)-

Ocular irritation

Inflammation

Sustained orbicularis contraction causing inward rotation of eyelid margin

With unrecognized or mild involutional eyelid changes

Acute Spastic-

*all problems that shorten posterior lamella give rise to an entropion

temporizing procedures-

Horizontal lid tightening, repair of retractors-

Management

Rare

Blepharophimosis syndrome

Vertical insufficiency of anterior lamella

Congenital-

Horizontal lid laxityStretching or disinsertion of canthal tendons

Involutional-

CN7 paralysis or palsy

Lagophthalmos

Poor blinking and lid closure

Tearing

Paralytic-

Scar at anterior lamella

Burns, trauma, chronic actinic skin damage, chronic lid inflammation(rosacea, eczema,

zoster, atopy)

Cicatricial-

Tumors, accumulated fluid, herniated orbital fluid

Mechanical-

Ectropion - problems with anterior lamella

Lubricants-

Tear supplements-

Ointments-

Treatment



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Tape temporal half of eyelid-

Horizontal lid shortening-

Repair of lower lid retractors-

Reattachment of tarsus to canthal tendon-

tarsorrhapies-

Surgical management

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