Taking the history
recent trauma or surgery involving the head/face/eye
past infections e.g. herpes zoster
past symptoms suggestive of thyroid disease or obstructive sleep apnea
Testing the lids and globe
ask patient to look down and gently close both eyes
lagophthalmos is present when a space remains b/w the upper and lower eyelid margins in extreme downgaze
measure this space with a ruler
record the blink rate an the completeness of blink
test cranial nerve function (pay attention to ocular motility and the strength of the orbicularis oculi muscle by evaluating the force generated on attempted eyelid closure)
presence and quality of Bell's phenomenon should be noted (cornea is better protected when the eye rolls upward on attempted closure of the eyelids)
Testing the cornea
test corneal sensitivity by applying soft cotton to the unanesthetized cornea and comparing the blink reaction with that of the fellow eye
describe presence of PEE with NaFl
record TBUT
Etiology
Facial nerve (VII)
- innervates frontalis muscle (raises the eyebrow) and the orbicularis oculi muscle (closes the eyelid)
- loss of function of the VII nihibits eyelid closure, blink reflex, and lacrimal pumping mechanism
- also innervates the muscles of facial expression including the zygomaticus (elevate the cheeks) and corrugator supercilii and procerus (depress the eyebrow) which help facial symmetry
Trauma
- VII is susceptible to blunt trauma or laceration along it's bony course
- fractures to the skull base or mandible can damage the nerve or one of its branches
- neurosurgical procedures
Cerebrovascular accidents
- VII receives its blood supply from the anterior inferior cerebellar artery (susceptible to ischemic damage)
Bell's Palsy
- idiopathic VII palsy thought to be associated with an acute viral infection or reactivation of herpes simplex virus
Tumors
- acoustic neuromas in the cerebellopontine angle and metastatic lesions are most commonly associated with lagophthalmos
- need MRI with gadolinium
Infections, immune-mediated causes
- less common causes: Lyme disease, chickenpox, mumps, polio, Guillain-Barre syndrome, leprosy, diphtheria and botulism
Mobius' syndrome
- rare, congenital condition with CN palsies (esp. VI and VII), motility disturbances, limb anomalies and orofacial defects
Eyelids
damage or degeneration of any of the eyelid tissue structures (skin/subcutaneous tissue, orbicularis oculi muscle, orbital septum, orbital fat, muscles of retraction, tarsus, conjunctiva) may inhibit good eyelid closure
Cicatrices- chemical or thermal burns
- ocular cicatricial pemphigoid
- Stevens-Johnson syndrome
- mechanical trauma
- above may cause scarring of the soft tissues or retractor muscles
- excessive removal of eyelid skin or muscle (blepharoplsty, tumor excision)
- overcorrection in ptosis repair
- exophthalmos in thyroid ophthalmopathy
- aquired causes (orbital blowout fractures, orbital fat atrophy from trauma, infection, inflammation, aging or wasting disease such as linear scleroderma or HIV-AIDS)
- phthisical or prephthisical eye
- scirrhous carcinomas leading to contraction of orbital fat
- result of severe laxity and flexibility of the superior and inferior tarsal plates
- may be associated with obstructive sleep apnea
Symptoms
- FBS and tearing
- pain in AM from increased corneal exposure and dryness during sleep
- blurry vision from unstable TF
Work-up and treatment
- Medical treatment and supportive care for the cornea (non-preserved artifical tears at least QID, ointments QHS/PRN, moisture gogles, methylcellulose)
- Tarsorrhaphy (suturing lateral 1/3 of eyelids, temporary or permanent)
- Gold weight implantation (gold is inert and doesn't show through thin skin of eyelid)
- Uper eyelid retraction and levator recession (for lagophthalmos due to thyroid ophthalmopathy)
- Lower eyelid tightening and elevation (tightenting procedure will improve apposition fo the lower eyelid to teh globe and decrease tearing)
- Ancillary surgical procedures (facial surgery)
Posts
2 comments:
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Ocular cicatricial pemphigoid is an auto immune disease affecting the conjunctiva. You will remember, from the first Patient Information entry on this Web Site, that auto immune diseases result from dysregulation of the patient's immune system, with the white blood cells becoming ""confused"" and beginning to attack not only germs but also part of the patient's own body. In rheumatoid arthritis, for example, the white blood cells become confused and begin to attack tissue in the patient's joints. In pemphigoid, the white blood cells attack skin and mucous membrane, particularly mucous membranes of the mouth, eyes, nose, throat, vagina, and rectum. Patients may or may not have more than one site affected by the disease, but 70% of the patients with cicatricial pemphigoid have eye involvement. And because this is a systemic autoimmune disease, it cannot be successfully treated, long-term, with simple topical (drops) therapy. It must be treated systemically, and typically with strategies that ""cool down"" the immune system, i.e., suppress the immune system sufficiently to stop the autoimmune process. Suppressing the immune system sufficiently to stop the autoimmune process for a short period (one to five years) is usually sufficient to enduce permanent remission of the disease. If this is not done, then continued inflammation, continued scarring, and eventual blindness in both eyes usually occurs.
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- The Ocular Cicatricial Pemphigoid
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