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  • 7/26/2019 Ophtha Lec Appearance 2 Lec

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    AudioRecording...

    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

    2 Appearance 2 Page 4