1 Q What does the term Entropion mean
- Slides: 96
1 Q What does the term Entropion mean? Ectropion
2 A What does the term Entropion mean? It means the eyelid margin is turning inward Ectropion
3 Q What does the term Entropion mean? It means the eyelid margin is turning inward What does the term Ectropion mean?
4 A What does the term Entropion mean? It means the eyelid margin is turning inward What does the term Ectropion mean? It means the eyelid margin is turning outward
5 Q The Plastics book identifies six general causes of entropion and/or ectropion. What are they? (Note that while most apply to both entropion and ectropion, a few apply only to one or the other. ) Entropion Categories ? ? ? Ectropion
6 A The Plastics book identifies six general causes of entropion and/or ectropion. What are they? (Note that while most apply to both entropion and ectropion, a few apply only to one or the other. ) Entropion Categories Congenital Involutional Paralytic Cicatricial Mechanical Acute Spastic Ectropion
7 Q Of the six, which can result in entropion? Entropion Categories ? Congenital ? Involutional ? Paralytic ? Cicatricial ? Mechanical ? Acute Spastic Ectropion
8 A Of the six, which can result in entropion? Entropion Categories Congenital Involutional Paralytic Cicatricial Mechanical Acute Spastic Ectropion
9 Q Of the six, which can result in ectropion? Entropion Categories Ectropion Congenital ? Involutional ? Paralytic ? Cicatricial ? Mechanical ? Acute Spastic ? Cicatricial Acute Spastic
10 A Of the six, which can result in ectropion? Entropion Categories Ectropion Congenital Involutional Paralytic Cicatricial Mechanical Cicatricial Acute Spastic
11 Entropion Categories Ectropion Congenital Involutional Let’s look at paralytic ectropion in more detail… Paralytic Cicatricial Acute Spastic Paralytic Cicatricial Mechanical Acute Spastic
12 Q Paralytic Ectropion What is the typical setting/cause of paralytic ectropion?
13 A Paralytic Ectropion What is the typical setting/cause of paralytic ectropion? A facial nerve (CN 7) palsy
14 Q Paralytic Ectropion What is the typical setting/cause of paralytic ectropion? A facial nerve (CN 7) palsy Upon leaving the skull, CN 7 immediately enters the substance of a large gland. Which one? The parotid While in the parotid gland, CN 7 splits into branches. How many branches does it (usually) have? Five
15 A Paralytic Ectropion What is the typical setting/cause of paralytic ectropion? A facial nerve (CN 7) palsy Upon leaving the skull, CN 7 immediately enters the substance of a large gland. Which one? The parotid While in the parotid gland, CN 7 splits into branches. How many branches does it (usually) have? Five
16 Q Paralytic Ectropion What is the typical setting/cause of paralytic ectropion? A facial nerve (CN 7) palsy Upon leaving the skull, CN 7 immediately enters the substance of a large gland. Which one? The parotid While in the parotid gland, CN 7 splits into branches. How many branches does it (usually) have? Five
17 A Paralytic Ectropion What is the typical setting/cause of paralytic ectropion? A facial nerve (CN 7) palsy Upon leaving the skull, CN 7 immediately enters the substance of a large gland. Which one? The parotid While in the parotid gland, CN 7 splits into branches. How many branches does it (usually) have? Five
18 Paralytic Ectropion Facial nerve branching within the parotid gland
19 Q Paralytic Ectropion What is the typical setting/cause of paralytic ectropion? A facial nerve (CN 7) palsy Because of their anatomic relationship, inflammation involving the parotid gland Upon leaving the skull, CN 7 immediately enters the can produce CN 7 palsy. Speaking of, there is a classic syndrome involving substance of a large gland. Which one? (along with uveitis and fever). What is the eponymous parotitis and CN 7 palsy name of this syndrome? The parotid Heerfordt syndrome While in the parotid gland, CN 7 splits into branches. What is the underlying cause of inflammation in Heefordt syndrome? How many branches does it (usually) have? Sarcoidosis Five
20 A Paralytic Ectropion What is the typical setting/cause of paralytic ectropion? A facial nerve (CN 7) palsy Because of their anatomic relationship, inflammation involving the parotid gland Upon leaving the skull, CN 7 immediately enters the can produce CN 7 palsy. Speaking of, there is a classic syndrome involving substance of a large gland. Which one? (along with uveitis and fever). What is the eponymous parotitis and CN 7 palsy name of this syndrome? The parotid Heerfordt syndrome While in the parotid gland, CN 7 splits into branches. What is the underlying cause of inflammation in Heefordt syndrome? How many branches does it (usually) have? Sarcoidosis Five
21 Q Paralytic Ectropion What is the typical setting/cause of paralytic ectropion? A facial nerve (CN 7) palsy Because of their anatomic relationship, inflammation involving the parotid gland Upon leaving the skull, CN 7 immediately enters the can produce CN 7 palsy. Speaking of, there is a classic syndrome involving substance of a large gland. Which one? (along with uveitis and fever). What is the eponymous parotitis and CN 7 palsy name of this syndrome? The parotid Heerfordt syndrome While in the parotid gland, CN 7 splits into branches. What is the underlying cause of inflammation in Heerfordt syndrome? How many branches does it (usually) have? Sarcoidosis Five
22 A Paralytic Ectropion What is the typical setting/cause of paralytic ectropion? A facial nerve (CN 7) palsy Because of their anatomic relationship, inflammation involving the parotid gland Upon leaving the skull, CN 7 immediately enters the can produce CN 7 palsy. Speaking of, there is a classic syndrome involving substance of a large gland. Which one? (along with uveitis and fever). What is the eponymous parotitis and CN 7 palsy name of this syndrome? The parotid Heerfordt syndrome While in the parotid gland, CN 7 splits into branches. What is the underlying cause of inflammation in Heerfordt syndrome? How many branches does it (usually) have? Sarcoidosis Five
23 Paralytic Ectropion What is the typical setting/cause of paralytic ectropion? A facial nerve (CN 7) palsy Because of their anatomic relationship, inflammation involving the parotid gland Upon leaving the skull, CN 7 immediately enters the can produce CN 7 palsy. Speaking of, there is a classic syndrome involving substance of a large gland. and Which parotitis CN 7 one? palsy (along with uveitis and fever). What is the eponymous name of this syndrome? The parotid Heerfordt syndrome While in the parotid gland, CN 7 splits into branches. What is the underlying cause of inflammation in Heerfordt syndrome? How many branches does it (usually) have? Sarcoidosis In case you’re wondering, this is not useless trivia! Five You may well see Heerfordt syndrome on the hoof (I have), and it’s definitely in play on the OKAPs, WQEs and Boards. In the back of your mind, file an image of someone with chipmunk-looking cheeks (that’s the parotitis), facial palsy and uveitis under the headings ‘Heerfordt’ and ‘sarcoidosis. ’ Trust me on this one.
24 Paralytic Ectropion Heerfordt syndrome
25 Q Paralytic Ectropion What is the typical setting/cause of paralytic ectropion? A facial nerve (CN 7) palsy Paralysis of what facial muscle leads to ectropion?
26 A Paralytic Ectropion What is the typical setting/cause of paralytic ectropion? A facial nerve (CN 7) palsy Paralysis of what facial muscle leads to ectropion? The orbicularis oculi
27 Paralytic Ectropion What is the typical setting/cause of paralytic ectropion? A facial nerve (CN 7) palsy Paralysis of what facial muscle leads to ectropion? The orbicularis oculi Let’s take a moment to review the anatomy of the orbicularis muscle
28 Q Paralytic Ectropion What is the typical setting/cause of paralytic ectropion? A facial nerve (CN 7) palsy Paralysis of what facial muscle leads to ectropion? The orbicularis oculi What is the basic arrangement of the fibers of the orbicularis? As multiple concentric bands encircling all or part of the orbital aperture The ‘multiple bands’ are organized into two basic portions—what are they? How are they defined? The palpebral portion is further subdivided into two parts— what are they? How are they defined? --?
29 A Paralytic Ectropion What is the typical setting/cause of paralytic ectropion? A facial nerve (CN 7) palsy Paralysis of what facial muscle leads to ectropion? The orbicularis oculi What is the basic arrangement of the fibers of the orbicularis? As multiple concentric bands encircling all or part of the orbital aperture The ‘multiple bands’ are organized into two basic portions—what are they? How are they defined? The palpebral portion is further subdivided into two parts— what are they? How are they defined? --Orbital --Palpebral
30 Q Paralytic Ectropion What is the typical setting/cause of paralytic ectropion? A facial nerve (CN 7) palsy Paralysis of what facial muscle leads to ectropion? The orbicularis oculi What is the basic arrangement of the fibers of the orbicularis? As multiple concentric bands encircling all or part of the orbital aperture The ‘multiple bands’ are organized into two basic portions—what are they? How are they defined? The palpebral portion is further subdivided into two parts— what are they? There’s How are they defined? a fundamental functional distinction between the orbital and --Orbital palpebral portions. What is it? --Palpebral The palpebral portion is responsible for normal blinking, whereas the orbital portion comes into play only during effortful/voluntary eye closure
31 A Paralytic Ectropion What is the typical setting/cause of paralytic ectropion? A facial nerve (CN 7) palsy Paralysis of what facial muscle leads to ectropion? The orbicularis oculi What is the basic arrangement of the fibers of the orbicularis? As multiple concentric bands encircling all or part of the orbital aperture The ‘multiple bands’ are organized into two basic portions—what are they? How are they defined? The palpebral portion is further subdivided into two parts— what are they? There’s How are they defined? a fundamental functional distinction between the orbital and --Orbital palpebral portions. What is it? --Palpebral The palpebral portion is responsible for normal blinking, whereas the orbital portion comes into play only during effortful/voluntary eye closure
32 Q Paralytic Ectropion What is the typical setting/cause of paralytic ectropion? A facial nerve (CN 7) palsy Paralysis of what facial muscle leads to ectropion? The orbicularis oculi What is the basic arrangement of the fibers of the orbicularis? As multiple concentric bands encircling all or part of the orbital aperture The ‘multiple bands’ are organized into two basic portions—what are they? How are they defined? The palpebral portion is further subdivided into two parts— what are they? How are they defined? --Orbital: ? --Palpebral: ?
33 A Paralytic Ectropion What is the typical setting/cause of paralytic ectropion? A facial nerve (CN 7) palsy Paralysis of what facial muscle leads to ectropion? The orbicularis oculi What is the basic arrangement of the fibers of the orbicularis? As multiple concentric bands encircling all or part of the orbital aperture The ‘multiple bands’ are organized into two basic portions—what are they? How are they defined? The palpebral portion is further subdivided into two parts— what are they? How are they defined? --Orbital: The portion overlying orbital bone --Palpebral: The portion overlying the lids
34 Q Paralytic Ectropion What is the typical setting/cause of paralytic ectropion? A facial nerve (CN 7) palsy Paralysis of what facial muscle leads to ectropion? The orbicularis oculi What is the basic arrangement of the fibers of the orbicularis? As multiple concentric bands encircling all or part of the orbital aperture The ‘multiple bands’ are organized into two basic portions—what are they? How are they defined? The palpebral portion is further subdivided into two parts— what are they? --Orbital: The portion overlying orbital bone --Palpebral: The portion overlying the lids ----?
35 A Paralytic Ectropion What is the typical setting/cause of paralytic ectropion? A facial nerve (CN 7) palsy Paralysis of what facial muscle leads to ectropion? The orbicularis oculi What is the basic arrangement of the fibers of the orbicularis? As multiple concentric bands encircling all or part of the orbital aperture The ‘multiple bands’ are organized into two basic portions—what are they? How are they defined? The palpebral portion is further subdivided into two parts— what are they? --Orbital: The portion overlying orbital bone --Palpebral: The portion overlying the lids ----Preseptal ----Pretarsal
36 Q Paralytic Ectropion What is the typical setting/cause of paralytic ectropion? A facial nerve (CN 7) palsy Paralysis of what facial muscle leads to ectropion? The orbicularis oculi What is the basic arrangement of the fibers of the orbicularis? As multiple concentric bands encircling all or part of the orbital aperture The ‘multiple bands’ are organized into two basic portions—what are they? How are they defined? The palpebral portion is further subdivided into two parts— what are they? How are they defined? --Orbital: The portion overlying orbital bone --Palpebral: The portion overlying the lids ----Preseptal: ? ----Pretarsal: ?
37 A Paralytic Ectropion What is the typical setting/cause of paralytic ectropion? A facial nerve (CN 7) palsy Paralysis of what facial muscle leads to ectropion? The orbicularis oculi What is the basic arrangement of the fibers of the orbicularis? As multiple concentric bands encircling all or part of the orbital aperture The ‘multiple bands’ are organized into two basic portions—what are they? How are they defined? The palpebral portion is further subdivided into two parts— what are they? How are they defined? --Orbital: The portion overlying orbital bone --Palpebral: The portion overlying the lids ----Preseptal: The part overlying the orbital septum ----Pretarsal: The part overlying the tarsal plates
38 Paralytic Ectropion Orbicularis oculi
39 Q Paralytic Ectropion What is the typical setting/cause of paralytic ectropion? A facial nerve (CN 7) palsy Paralysis of what facial muscle leads to ectropion? The orbicularis oculi What is the basic arrangement of the fibers of the orbicularis? As multiple concentric bands encircling all or part of the orbital aperture There is a special slip ofare pretarsal orbicularis located at the surface are they? The ‘multiple bands’ organized into that two isbasic portions—what of the lid margin. What is the eponymous name? How are they defined? The palpebral portion is further subdivided into two parts— The muscle of Riolan what are they? How are they defined? --Orbital: The portion overlying orbital bone What is its appearance-based, non-eponymous name? --Palpebral: The gray line The portion overlying the lids ----Preseptal: The part overlying the orbital septum ----Pretarsal: The part overlying the tarsal plates
40 A Paralytic Ectropion What is the typical setting/cause of paralytic ectropion? A facial nerve (CN 7) palsy Paralysis of what facial muscle leads to ectropion? The orbicularis oculi What is the basic arrangement of the fibers of the orbicularis? As multiple concentric bands encircling all or part of the orbital aperture There is a special slip ofare pretarsal orbicularis located at the surface are they? The ‘multiple bands’ organized into that two isbasic portions—what of the lid margin. What is the eponymous name? How are they defined? The palpebral portion is further subdivided into two parts— The muscle of Riolan what are they? How are they defined? --Orbital: The portion overlying orbital bone What is its appearance-based, non-eponymous name? --Palpebral: The gray line The portion overlying the lids ----Preseptal: The part overlying the orbital septum ----Pretarsal: The part overlying the tarsal plates
41 Q Paralytic Ectropion What is the typical setting/cause of paralytic ectropion? A facial nerve (CN 7) palsy Paralysis of what facial muscle leads to ectropion? The orbicularis oculi What is the basic arrangement of the fibers of the orbicularis? As multiple concentric bands encircling all or part of the orbital aperture There is a special slip ofare pretarsal orbicularis located at the surface are they? The ‘multiple bands’ organized into that two isbasic portions—what of the lid margin. What is the eponymous name? How are they defined? The palpebral portion is further subdivided into two parts— The muscle of Riolan what are they? How are they defined? --Orbital: The portion overlying orbital bone What is its appearance-based, non-eponymous name? --Palpebral: The gray line The portion overlying the lids ----Preseptal: The part overlying the orbital septum ----Pretarsal: The part overlying the tarsal plates
42 A Paralytic Ectropion What is the typical setting/cause of paralytic ectropion? A facial nerve (CN 7) palsy Paralysis of what facial muscle leads to ectropion? The orbicularis oculi What is the basic arrangement of the fibers of the orbicularis? As multiple concentric bands encircling all or part of the orbital aperture There is a special slip ofare pretarsal orbicularis located at the surface are they? The ‘multiple bands’ organized into that two isbasic portions—what of the lid margin. What is the eponymous name? How are they defined? The palpebral portion is further subdivided into two parts— The muscle of Riolan what are they? How are they defined? --Orbital: The portion overlying orbital bone What is its appearance-based, non-eponymous name? --Palpebral: The gray line The portion overlying the lids ----Preseptal: The part overlying the orbital septum ----Pretarsal: The part overlying the tarsal plates
43 Paralytic Ectropion Muscle of Riolan (aka the gray line)
44 Q Paralytic Ectropion What is the typical setting/cause of paralytic ectropion? A facial nerve (CN 7) palsy Paralysis of what facial muscle leads to ectropion? Of its five, which two branches of CN 7 (usually) The orbicularis oculi innervate the orbicularis muscle? The temporal and zygomatic
45 A Paralytic Ectropion What is the typical setting/cause of paralytic ectropion? A facial nerve (CN 7) palsy Paralysis of what facial muscle leads to ectropion? Of its five, which two branches of CN 7 (usually) The orbicularis oculi innervate the orbicularis muscle? The temporal and zygomatic
46 Paralytic Ectropion Orbicularis muscle innervation
47 Q Paralytic Ectropion What is the typical setting/cause of paralytic ectropion? A facial nerve (CN 7) palsy Paralysis of what facial muscle leads to ectropion? The orbicularis oculi Does the ectropion involve the lower lid, the upper, or both?
48 A Paralytic Ectropion What is the typical setting/cause of paralytic ectropion? A facial nerve (CN 7) palsy Paralysis of what facial muscle leads to ectropion? The orbicularis oculi Does the ectropion involve the lower lid, the upper, or both? The lower only (ectropion is not how orbicularis paralysis manifests in the upper lid)
49 Q Paralytic Ectropion What is the typical setting/cause of paralytic ectropion? A facial nerve (CN 7) palsy Paralysis of what facial muscle leads to ectropion? The orbicularis oculi Does the ectropion involve the lower lid, the upper, or both? The lower only (ectropion is not how orbicularis paralysis manifests in the upper lid) OK then, how does orbicularis paralysis manifest in the upper lid? As lagophthalmos What is lagophthalmos? The inability to completely close the eyelids
50 A Paralytic Ectropion What is the typical setting/cause of paralytic ectropion? A facial nerve (CN 7) palsy Paralysis of what facial muscle leads to ectropion? The orbicularis oculi Does the ectropion involve the lower lid, the upper, or both? The lower only (ectropion is not how orbicularis paralysis manifests in the upper lid) OK then, how does orbicularis paralysis manifest in the upper lid? As lagophthalmos What is lagophthalmos? The inability to completely close the eyelids
51 Q Paralytic Ectropion What is the typical setting/cause of paralytic ectropion? A facial nerve (CN 7) palsy Paralysis of what facial muscle leads to ectropion? The orbicularis oculi Does the ectropion involve the lower lid, the upper, or both? The lower only (ectropion is not how orbicularis paralysis manifests in the upper lid) OK then, how does orbicularis paralysis manifest in the upper lid? As lagophthalmos What is lagophthalmos? The inability to completely close the eyelids
52 A Paralytic Ectropion What is the typical setting/cause of paralytic ectropion? A facial nerve (CN 7) palsy Paralysis of what facial muscle leads to ectropion? The orbicularis oculi Does the ectropion involve the lower lid, the upper, or both? The lower only (ectropion is not how orbicularis paralysis manifests in the upper lid) OK then, how does orbicularis paralysis manifest in the upper lid? As lagophthalmos What is lagophthalmos? The inability to completely close the eyelids
53 Paralytic Ectropion Paralytic lagophthalmos
54 Q l Paralytic Ectropion As for managing paralytic ectropion: The overarching treatment goal is…
55 A l Paralytic Ectropion As for managing paralytic ectropion: The overarching treatment goal is…protect the cornea from exposure damage
56 Paralytic Ectropion Q l As for managing paralytic ectropion: The overarching treatment goal is…protect the cornea from exposure damage ? Two basic levels of paralysis severity ?
57 Paralytic Ectropion A l As for managing paralytic ectropion: The overarching treatment goal is…protect the cornea from exposure damage Mild/temporary Two basic levels of paralysis severity Severe/permanent
58 Paralytic Ectropion l As for managing paralytic ectropion: The overarching treatment goal is…protect the cornea from exposure damage If the paralysis/ ectropion is… Mild/temporary Two basic levels of paralysis severity Severe/permanent
59 Paralytic Ectropion Q l As for managing paralytic ectropion: The overarching treatment goal is…protect the cornea from exposure damage If the paralysis/ ectropion is… Mild/temporary Two basic levels of paralysis severity Severe/permanent ? ? ? …these maneuvers will likely be needed to protect the cornea
60 Paralytic Ectropion A l As for managing paralytic ectropion: The overarching treatment goal is…protect the cornea from exposure damage If the paralysis/ ectropion is… Mild/temporary Two basic levels of paralysis severity Severe/permanent Lubrication Ointment Lid taping Tarsorrhaphy Gold weight placement Lid tightening …these maneuvers will likely be needed to protect the cornea
61 Q l Paralytic Ectropion As for managing paralytic ectropion: The overarching treatment goal is…protect the cornea from exposure damage Permanancy ? If the paralysis/ ectropion is… basic levels of There are two common ways to. Two categorize Mild/temporary paralysis severity tarsorrhaphies. What are they? Lubrication One is categorize them in terms of their Ointment permanency; the other, in terms of their extent Lid taping With respect to… Severe/permanent …these maneuvers will likely be needed to protect the cornea Tarsorrhaphy Gold weight placement Lid tightening With respect to… Extent ?
62 A l Paralytic Ectropion As for managing paralytic ectropion: The overarching treatment goal is…protect the cornea from exposure damage Permanancy If the paralysis/ ectropion is… basic levels of There are two common ways to. Two categorize Mild/temporary paralysis severity tarsorrhaphies. What are they? Lubrication One is to categorize them in terms of their Ointment permanency; the other, in terms of their extent Lid taping With respect to… Severe/permanent …these maneuvers will likely be needed to protect the cornea Tarsorrhaphy Gold weight placement Lid tightening With respect to… Extent
63 Paralytic Ectropion Q l As for managing paralytic ectropion: The overarching treatment goal is…protect the cornea from exposure damage Permanancy If the paralysis/ ectropion With respect to permanency: What are is… ? the two types of tarsorrhaphy? Mild/temporary Two basic levels of paralysis severity With respect to… ? Severe/permanent Lubrication Ointment Lid taping Tarsorrhaphy Gold weight placement Lid tightening …these maneuvers will likely be needed to protect the cornea With respect to… Extent
64 Paralytic Ectropion A l As for managing paralytic ectropion: The overarching treatment goal is…protect the cornea from exposure damage Permanancy If the paralysis/ ectropion With respect to permanency: What are is… the two types of tarsorrhaphy? Mild/temporary Two basic levels of paralysis severity Temporary With respect to… Permanent Severe/permanent Lubrication Ointment Lid taping Tarsorrhaphy Gold weight placement Lid tightening …these maneuvers will likely be needed to protect the cornea With respect to… Extent
65 Paralytic Ectropion Q l As for managing paralytic ectropion: The overarching treatment goal is…protect the cornea from exposure damage Permanancy If the paralysis/ ectropion is… Mild/temporary Two basic levels of paralysis severity Lubrication Ointment Lid taping With respect to extent: What are the two types of tarsorrhaphy? Temporary With respect to… Permanent Severe/permanent …these maneuvers will likely be needed to protect the cornea Tarsorrhaphy Gold weight placement Lid tightening ? With respect to… Extent ?
66 Paralytic Ectropion A l As for managing paralytic ectropion: The overarching treatment goal is…protect the cornea from exposure damage Permanancy If the paralysis/ ectropion is… Mild/temporary Two basic levels of paralysis severity Lubrication Ointment Lid taping With respect to extent: What are the two types of tarsorrhaphy? Temporary With respect to… Permanent Severe/permanent …these maneuvers will likely be needed to protect the cornea Tarsorrhaphy Gold weight placement Lid tightening Partial With respect to… Extent Complete
67 Paralytic Ectropion Q l As for managing paralytic ectropion: The overarching treatment goal is…protect the cornea from exposure damage Permanancy If and the paralysis/ In terms of technique, temporary permanent tarsorrhaphies differ ectropion in a couple is… With Permanent Temporary respect of key ways. What are they? to… They are 1) the type of suture used, and Two basic levels of 2) how the lid-margin epithelium is handled. Mild/temporary Severe/permanent paralysis severity Lubrication Ointment Lid taping Tarsorrhaphy Gold weight placement Lid tightening Partial …these maneuvers will likely be needed to protect the cornea With respect to… Extent Complete
68 Paralytic Ectropion A l As for managing paralytic ectropion: The overarching treatment goal is…protect the cornea from exposure damage Permanancy If and the paralysis/ In terms of technique, temporary permanent tarsorrhaphies differ ectropion in a couple is… With Permanent Temporary respect of key ways. What are they? to… They are 1) the type of suture used, and Two basic levels of 2) how the lid-margin epithelium is handled. Mild/temporary Severe/permanent paralysis severity Lubrication Ointment Lid taping Tarsorrhaphy Gold weight placement Lid tightening Partial …these maneuvers will likely be needed to protect the cornea With respect to… Extent Complete
69 Paralytic Ectropion Q l As for managing paralytic ectropion: The overarching treatment goal is…protect the cornea from exposure damage Permanancy What sort of suture is used for: paralysis/ If and the In terms of technique, temporary --temporary tars? Nonabsorbable permanent tarsorrhaphies differ ectropion in a couple is… --permanent tars? Absorbable With Permanent Temporary respect of key ways. What are they? to… They are 1) the type of suture used, and Two basic levels of 2) how the lid-margin epithelium is handled. Mild/temporary Severe/permanent paralysis severity Lubrication Ointment Lid taping Tarsorrhaphy Gold weight placement Lid tightening Partial …these maneuvers will likely be needed to protect the cornea With respect to… Extent Complete
70 Paralytic Ectropion A l As for managing paralytic ectropion: The overarching treatment goal is…protect the cornea from exposure damage Permanancy What sort of suture is used for: paralysis/ If and the In terms of technique, temporary --temporary tars? Nonabsorbable permanent tarsorrhaphies differ ectropion in a couple is… --permanent tars? Absorbable With Permanent Temporary respect of key ways. What are they? to… They are 1) the type of suture used, and Two basic levels of 2) how the lid-margin epithelium is handled. Mild/temporary Severe/permanent paralysis severity Lubrication Ointment Lid taping Tarsorrhaphy Gold weight placement Lid tightening Partial …these maneuvers will likely be needed to protect the cornea With respect to… Extent Complete
71 Q l Paralytic Ectropion As for managing paralytic ectropion: The overarching treatment goal is…protect the cornea from exposure damage Permanancy What sort of suture is used for: paralysis/ If and the In terms of technique, temporary --temporary tars? Nonabsorbable permanent tarsorrhaphies differ ectropion in a couple of is… --permanent tars? Absorbable With Permanent Temporary respect key ways. What are they? to… They are 1) the type of suture used, and Two levels of 2) how the lid-margin epithelium is basic handled. Mild/temporary Severe/permanent paralysis severity Lubrication How Ointment is the epithelium handled in: --temporary tars? It is left alone Lid taping --permanent tars? It is denuded …these maneuvers will likely be needed to protect the cornea Tarsorrhaphy Gold weight placement Lid tightening Partial With respect to… Extent Complete
72 A l Paralytic Ectropion As for managing paralytic ectropion: The overarching treatment goal is…protect the cornea from exposure damage Permanancy What sort of suture is used for: paralysis/ If and the In terms of technique, temporary --temporary tars? Nonabsorbable permanent tarsorrhaphies differ ectropion in a couple of is… --permanent tars? Absorbable With Permanent Temporary respect key ways. What are they? to… They are 1) the type of suture used, and Two levels of 2) how the lid-margin epithelium is basic handled. Mild/temporary Severe/permanent paralysis severity Lubrication How Ointment is the epithelium handled in: --temporary tars? It is left alone Lid taping --permanent tars? It is denuded …these maneuvers will likely be needed to protect the cornea Tarsorrhaphy Gold weight placement Lid tightening Partial With respect to… Extent Complete
73 Q l Paralytic Ectropion As for managing paralytic ectropion: The overarching treatment goal is…protect the cornea from exposure damage Permanancy What sort of suture is used for: paralysis/ If and the In terms of technique, temporary --temporary tars? Nonabsorbable permanent tarsorrhaphies differ ectropion in a couple of is… --permanent tars? Absorbable With Permanent Temporary respect key ways. What are they? to… They are 1) the type of suture used, and Two levels of 2) how the lid-margin epithelium is basic handled. Mild/temporary Severe/permanent paralysis severity Lubrication How Ointment is the epithelium handled in: --temporary tars? It is left alone Lid taping --permanent tars? It is denuded Tarsorrhaphy Gold weight placement Lid tightening Partial What’s the purpose of …these denuding themaneuvers lid-margin epithelium? As they heal, raw upper and lower lid margins will fuse, will likely (as beanneeded thereby making the tars permanent aside, this is why absorbable sutures can be used—once thecornea margins fuse, to protect the suture tension is no longer needed to maintain closure) With respect to… Extent Complete
74 A l Paralytic Ectropion As for managing paralytic ectropion: The overarching treatment goal is…protect the cornea from exposure damage Permanancy What sort of suture is used for: paralysis/ If and the In terms of technique, temporary --temporary tars? Nonabsorbable permanent tarsorrhaphies differ ectropion in a couple of is… --permanent tars? Absorbable With Permanent Temporary respect key ways. What are they? to… They are 1) the type of suture used, and Two levels of 2) how the lid-margin epithelium is basic handled. Mild/temporary Severe/permanent paralysis severity Lubrication How Ointment is the epithelium handled in: --temporary tars? It is left alone Lid taping --permanent tars? It is denuded Tarsorrhaphy Gold weight placement Lid tightening Partial What’s the purpose of …these denuding themaneuvers lid-margin epithelium? As they heal, the raw upper and lower lid margins will fuse, will likely (as beanneeded thereby making the tars permanent aside, this is why absorbable sutures can be used—once thecornea margins fuse, to protect the suture tension is no longer needed to maintain lid closure) With respect to… Extent Complete
75 Paralytic Ectropion Q l As for managing paralytic ectropion: The overarching treatment goal is…protect the cornea from exposure damage Permanancy If the paralysis/ ectropion is… Mild/temporary Two basic levels of paralysis severity Temporary With respect to… Permanent Severe/permanent Lubrication Ointment Are partial tarsorrhaphies placed medially, or temporally? Lid taping Per the Orbit BCSC book, either is acceptable. (Although Tarsorrhaphy Gold weight placement Lid tightening IMHO temporal placement is preferred as it is technically Partial easier to perform, has better cosmesis, and does not risk …these maneuvers damaging the lacrimal apparatus. Just my $0. 02. ) will likely be needed to protect the cornea With respect to… Extent Complete
76 Paralytic Ectropion A l As for managing paralytic ectropion: The overarching treatment goal is…protect the cornea from exposure damage Permanancy If the paralysis/ ectropion is… Mild/temporary Two basic levels of paralysis severity Temporary With respect to… Permanent Severe/permanent Lubrication Ointment Are partial tarsorrhaphies placed medially, or temporally? Lid taping Per the Orbit book, either is acceptable. (Although IMHO Tarsorrhaphy Gold weight placement Lid tightening temporal placement is preferred as it is technically easier Partial to perform, has better cosmesis, and does not risk …these maneuvers compromising the lacrimal apparatus. Just my $0. 02. ) will likely be needed to protect the cornea With respect to… Extent Complete
77 Paralytic Ectropion Partial tarsorrhaphy
78 Paralytic Ectropion l As for managing paralytic ectropion: The overarching treatment goal is…protect the cornea from exposure damage Permanancy What sort of suture is used for: paralysis/ If and the In terms of technique, temporary --temporary tars? Nonabsorbable permanent tarsorrhaphies differ ectropion in a couple of is… --permanent tars? Absorbable With Permanent Temporary respect key ways. What are they? to… They are 1) the type of suture used, and Two levels of 2) how the lid-margin epithelium is basic handled. Mild/temporary Severe/permanent paralysis severity Lubrication How Ointment is the epithelium handled in: --temporary tars? It is left alone Lid taping --permanent tars? It is denuded Tarsorrhaphy Gold weight placement Lid tightening Partial With respect to… Complete Note that the BCSC Orbitof …these book not a fanepithelium? of the permanent tarsorrhaphy— What’s the purpose denudingisthe lid-margin maneuvers As they heal, the raw upper and lower lid margins will fuse, says it “should be avoided” unless necessary will likely absolutely beanneeded thereby making the tars permanent (as aside, this is why absorbable sutures can be used—once thecornea margins fuse, to protect the suture tension is no longer needed to maintain lid closure) Extent
79 Paralytic Ectropion l As for managing paralytic ectropion: The overarching treatment goal is…protect the cornea from exposure damage If the paralysis/ ectropion is… Mild/temporary Two basic levels of paralysis severity Severe/permanent Lubrication Ointment Lid taping Tarsorrhaphy Gold weight placement Lid tightening Instead, it advocates for gold weight placement in conjunction …these maneuvers with lid tightening will likely be needed to protect the cornea
80 Q l Paralytic Ectropion As for managing paralytic ectropion: The overarching treatment goal is…protect the cornea from exposure damage Permanancy If the paralysis/ ectropion is… Two basic levels of There is an alternative technique that can Mild/temporary paralysis severity be used to create a complete temporary Lubrication tarsorrhaphy without sutures. What is it? Ointment The levator muscle can be paralyzed with Lid taping an injection of botulinum toxin Temporary With respect to… Permanent Severe/permanent Tarsorrhaphy Gold weight placement Lid tightening Partial …these maneuvers will likely be needed to protect the cornea With respect to… Extent Complete
81 Q/A l Paralytic Ectropion As for managing paralytic ectropion: The overarching treatment goal is…protect the cornea from exposure damage Permanancy If the paralysis/ ectropion is… Two basic levels of There is an alternative technique that can Mild/temporary paralysis severity be used to create a complete temporary Lubrication tarsorrhaphy without sutures. What is it? Ointment The levator muscle can be paralyzed tapingof botulinum toxin with an. Lid injection Temporary With respect to… Permanent Severe/permanent Tarsorrhaphy Gold weight placement Lid tightening Partial …these maneuvers will likely be needed to protect the cornea With respect to… Extent Complete
82 A l Paralytic Ectropion As for managing paralytic ectropion: The overarching treatment goal is…protect the cornea from exposure damage Permanancy If the paralysis/ ectropion is… Two basic levels of There is an alternative technique that can Mild/temporary paralysis severity be used to create a complete temporary Lubrication tarsorrhaphy without sutures. What is it? Ointment The levator muscle can be paralyzed tapingof botulinum toxin with an. Lid injection Temporary With respect to… Permanent Severe/permanent Tarsorrhaphy Gold weight placement Lid tightening Partial …these maneuvers will likely be needed to protect the cornea With respect to… Extent Complete
83 Paralytic Ectropion A 10 -year-old female with right meta-herpetic corneal ulcer (top left). Anterior transcutaneous chemodenervation of levator muscle was performed with Botox (top right). One week after chemodenervation demonstrating complete ptosis (bottom left). Patient in upgaze demonstrating preserved superior rectus function (bottom right). Neurotoxin (botulinum) tarsorrhaphy
84 Paralytic Ectropion Q l Also, when managing paralytic ectropion… l Remember: 7 + 5 = ? [Note: Not 12]
85 Paralytic Ectropion A l Also, when managing paralytic ectropion… l Remember: 7 + 5 = Tarsorrhaphy
86 Paralytic Ectropion Q l Also, when managing paralytic ectropion… l Remember: 7 + 5 = Tarsorrhaphy 7 + 5 = tarsorrhaphy? What on earth is that supposed to mean?
87 Q/A l Paralytic Ectropion Also, when managing paralytic ectropion… l Remember: (CN)7 + (CN) 5 = Tarsorrhaphy 7 + 5 = tarsorrhaphy? What on earth is that supposed to mean? It means if a pt has both a CN 7 palsy preventing lid closure and decreased corneal sensation (ie, CN 5 dysfunction), then s/he is at words very high risk for exposuretwokeratopathy , and prophylactic tarsorrhaphy (or similar procedure) should be strongly considered.
88 A l Paralytic Ectropion Also, when managing paralytic ectropion… l Remember: (CN)7 + (CN) 5 = Tarsorrhaphy 7 + 5 = tarsorrhaphy? What on earth is that supposed to mean? It means if a pt has both a CN 7 palsy preventing lid closure and decreased corneal sensation (ie, CN 5 dysfunction), then s/he is at very high risk for exposure keratopathy , and prophylactic tarsorrhaphy (or similar procedure) should be strongly considered.
89 Q l Paralytic Ectropion Also, when managing paralytic ectropion… l Remember: (CN)7 + (CN) 5 = Tarsorrhaphy 7 + 5 = tarsorrhaphy? What on earth is that supposed to mean? It means if a pt has both a CN 7 palsy preventing lid closure and decreased corneal sensation (ie, CN 5 dysfunction), then s/he is at very high risk for exposure keratopathy , and prophylactic (orthe similar be strongly considered. What doestarsorrhaphy this imply about initial procedure) evaluation ofshould a pt presenting with paralytic ectropion? That it must include assessment of corneal sensation
90 A l Paralytic Ectropion Also, when managing paralytic ectropion… l Remember: (CN)7 + (CN) 5 = Tarsorrhaphy 7 + 5 = tarsorrhaphy? What on earth is that supposed to mean? It means if a pt has both a CN 7 palsy preventing lid closure and decreased corneal sensation (ie, CN 5 dysfunction), then s/he is at very high risk for exposure keratopathy , and prophylactic (orthe similar be strongly considered. What doestarsorrhaphy this imply about initial procedure) evaluation ofshould a pt presenting with paralytic ectropion? That it must include assessment of corneal sensation
91 Q l Paralytic Ectropion Also, when managing paralytic ectropion… l Remember: (CN)7 + (CN) 5 = Tarsorrhaphy 7 + 5 = tarsorrhaphy? What on earth is that supposed to mean? It means if a pt has both a CN 7 palsy preventing lid closure and decreased corneal sensation (ie, CN 5 dysfunction), then s/he is at very high risk for exposure keratopathy , and prophylactic (orthe similar be strongly considered. What doestarsorrhaphy this imply about initial procedure) evaluation ofshould a pt presenting with paralytic ectropion? That it must include assessment of corneal sensation What two broad categories of conditions causing paralytic ectropion are most likely to also result in loss of corneal sensation? CVA, and intracranial surgery
92 Paralytic Ectropion A l Also, when managing paralytic ectropion… l Remember: (CN)7 + (CN) 5 = Tarsorrhaphy 7 + 5 = tarsorrhaphy? What on earth is that supposed to mean? It means if a pt has both a CN 7 palsy preventing lid closure and decreased corneal sensation (ie, CN 5 dysfunction), then s/he is at very high risk for exposure keratopathy , and prophylactic (orthe similar be strongly considered. What doestarsorrhaphy this imply about initial procedure) evaluation ofshould a pt presenting with paralytic ectropion? That it must include assessment of corneal sensation What two broad categories of conditions causing paralytic ectropion are most likely to also result in loss of corneal sensation? CVA, and intracranial surgery
93 Q l Paralytic Ectropion Also, when managing paralytic ectropion… l Remember: (CN)7 + (CN) 5 = Tarsorrhaphy 7 + 5 = tarsorrhaphy? What on earth is that supposed to mean? It means if a pt has both a CN 7 palsy preventing lid closure and decreased corneal sensation (ie, CN 5 dysfunction), then s/he is at very high risk for exposure keratopathy , and prophylactic (orthe similar be strongly considered. What doestarsorrhaphy this imply about initial procedure) evaluation ofshould a pt presenting with paralytic ectropion? That it must include assessment of corneal sensation What two broad categories of conditions causing paralytic ectropion are most likely to also result in loss of corneal sensation? CVA, and intracranial surgery What is the most common cause of simultaneous loss of CNs 5 & 7? Acoustic neuroma resection surgery
94 Q/A l Paralytic Ectropion Also, when managing paralytic ectropion… l Remember: (CN)7 + (CN) 5 = Tarsorrhaphy 7 + 5 = tarsorrhaphy? What on earth is that supposed to mean? It means if a pt has both a CN 7 palsy preventing lid closure and decreased corneal sensation (ie, CN 5 dysfunction), then s/he is at very high risk for exposure keratopathy , and prophylactic (orthe similar be strongly considered. What doestarsorrhaphy this imply about initial procedure) evaluation ofshould a pt presenting with paralytic ectropion? That it must include assessment of corneal sensation What two broad categories of conditions causing paralytic ectropion are most likely to also result in loss of corneal sensation? CVA, and intracranial surgery What is the most common cause of simultaneous loss of CNs 5 & 7? tumor type (two words) Acoustic neuroma resection surgery
95 Paralytic Ectropion A l Also, when managing paralytic ectropion… l Remember: (CN)7 + (CN) 5 = Tarsorrhaphy 7 + 5 = tarsorrhaphy? What on earth is that supposed to mean? It means if a pt has both a CN 7 palsy preventing lid closure and decreased corneal sensation (ie, CN 5 dysfunction), then s/he is at very high risk for exposure keratopathy , and prophylactic (orthe similar be strongly considered. What doestarsorrhaphy this imply about initial procedure) evaluation ofshould a pt presenting with paralytic ectropion? That it must include assessment of corneal sensation What two broad categories of conditions causing paralytic ectropion are most likely to also result in loss of corneal sensation? CVA, and intracranial surgery What is the most common cause of simultaneous loss of CNs 5 & 7? Acoustic neuroma resection surgery
96 Paralytic Ectropion A. A 33 -year-old woman with complete right facial paralysis following resection of a large acoustic neuroma resulting in the loss of the facial nerve at the skull base. B. Lagophthalmos with corneal exposure despite the presence of Bell's phenomenon. C, D. Shortly after the initial tumor surgery, a 1 g gold weight was placed in the upper eyelid, followed by cross facial nerve graft. Three weeks later, full closure is achieved. Paralytic lagophthalmos
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