Cataract and Premium IOLs Blepharoplasty Lid Surgery Botox and Facial Fillers Laser Refractive Surgery Pterygium Dry Eyes Diabetic Glaucoma Clinical Studies

 Irritation, burning, tearing  Foreign body sensation  Redness  Decreased vision  Double vision in advanced cases  May be asymptomatic

 Yellow-white flat or slightly raised conjunctival lesion  Usually in the interpalpebral fissure, nasal to the limbus  Not involving the cornea

 Wing-shaped fold of fibrovascular tissue  Elevated at the interpalpebral fissure of the conjunctiva  Nasal > temporal to the limbus  Can be bilateral, usually asymmetric  Extending onto the cornea – loss of corneal transparency and irregular astigmatism

 May be vascularized and injected  May be associated with superficial punctate keratitis or dellen (thinning of the cornea due to uneven tear pooling and drying)  Stocker’s line (iron line) may be seen on the leading edge of the pterygium on the cornea

 Conjunctival intraepithelial neoplasia (CIN) ◦ Unilateral jelly-like, velvety, leukoplakic (white) mass ◦ Often elevated, vascularized, and not wing-shaped

 Dermoid ◦ Congenital white lesion ◦ Usually inferotemporal limbus ◦ Occasionally associated with deformity of the ear, preauricular skin tags, and/or vertebral skeletal defects (Goldenhar’s syndrome)

 Pannus ◦ Blood vessels growing on to the cornea, often associated with contact lens wear, trachoma, phlyectenular keratitis, atopic disease, blepharitis, ocular rosacea, herpes keratitis, or others

 Elastoid degeneration of collagen and the subepithelial fibrovascular tissue  UV sun, dust, wind… repeated exposure  Chronic irritation – contact lenses, welding  Higher prevalence with proximity to the equator

 Conservative therapy, unless ◦ Reduce vision due to induced astigmatism or encroachment onto the visual axis ◦ Cosmetic ◦ Marked discomfort and irritation, unrelieved by conservative treatment ◦ Restricted ocular motility ◦ Progressive growth toward visual axis

 Protect eye from sun – wear sunglasses  Mild - topical lubricants  Moderate - topical antihistamine/vasoconstrictor  Mod. to severe - topical corticosteroid

 Recurrence rate is very high 10% - 90%  No single approach is universally successful  Recurrence rate is reduced with grafting approach

Temporal Recurrent Pterygium – 5 years

 Excise pterygium – head and body  Clean conjunctiva to bare sclera  Avoid damage of underlying rectus muscle  Polish with diamond burr  Mitomycin C application – antifibroblast  Harvest autograft – limbus to limbus  Tisseel fibrin glue

 Topical antibiotic and steroid  Watch IOP

ytc

 Abnormal eversion or turning out of the lid margin away from the globe.  Usually involves lower lids  Usually has a horizontal lid laxity  Co-morbidity: associated with corneal/conjunctival exposure

 Red and irritated eye with tearing.  Pain, gritty feeling, crusting of lids  Constantly wiping their eyes, exacerbating the lid laxity.  History of chronic eye drop use, especially in glaucoma pts.  History of facial or eye trauma/cancer/surgery.  Facial skin pathology

 Congenital ◦ Rare ◦ May be associated with other orbital abnormalities  Blepharophimosis  Microphthalmos  Buphthalmos  Down syndrome

 Acquired ◦ Involutional – most common ◦ Paralytic ◦ Cicatricial ◦ Mechanical

 Most common  Horizontal lid laxity – age related

 CN VII palsy – Bell palsy, herpes zoster, tumor of parotid gland

 Scarring of anterior lamella ◦ Facial burns ◦ Trauma ◦ Chronic dermatitis ◦ Chronic use of eye drops - glaucoma ◦ Excessive lower lid blepharoplasty

 Lid tumors

 Lubrication  Wipe only superiorly and nasally to avoid conjunctival irritation  Antibiotic ointment, especially at night

 Lateral tarsal strip procedure – for horizontal lid laxity/involutional ectropion  Medial conjunctival spindle procedure – for mild medial ectropion with punctum ectropion  Anterior lamella graft may be necessary in cicatricial ectropion

 Conjunctival and corneal exposure – keratinization and perforation  Retrobulbar hemorrhage, hematoma, infection, wound dehiscence, poor positioning of tarsal strip, and rounded lateral canthus

 Inversion of eyelid margin  Usually lower lid  Lashes rubbing against ocular surface

 Red and irritated eye  Foreign body sensation  Blurred vision

 Congenital  Acute spastic  Involutional  Cicatricial

 Rare  Pediatric epiblepharon – no symptoms

 Result of ocular irritants – infection, inflammatory, trauma

 Horizontal lower lid laxity of medial and /or lateral canthal tendons  Snap test  Tight squeeze test

 Scarring of palpebral conjunctiva – trauma, chemical burns, Stevens-Johnson syndrome, ocular cicatricial pemphigoid, infections, or topical medication  Snap test is difficult

 Epiblepharon – pretarsal orbicularis muscle and skin override the lid margin and push the eyelashes inward. ◦ Asymptomatic ◦ Common in Asians ◦ Spontaneously resolves as face matures  Trichiasis  Distichiasis

 Lubrication  Lid hygiene  Antibiotic/steroid  Taping of lower lid

 Quickert sutures ◦ Temporary fix ◦ Good for spastic entropion  Tarsal wedge resection ◦ Successful ◦ In-office procedure  Horizontal or vertical lid shortening

 Retrobulbar hemorrhage  Wound dehiscence  Infection  Corneal injury  Recurrence  Consecutive ectropion