Lagophthalmos

Anatomy & Function of the Facial Nerve

The facial nerve (CNVII) has two major divisions and controls the muscles of facial expression, including the frontalis muscle (raises the eyebrows), the orbicularis oculi muscle (closes the eyes), the zygomaticus muscles (raises the angle of the mouth)

Greater petrosal nerve - provides parasympathetic innervation to lacrimal gland, sphenoid sinus, frontal sinus, maxillary sinus, ethmoid sinus, nasal cavity, as well as special sensory taste fibers to the palate via the Vidian nerve.

Nerve to stapedius - provides motor innervation for stapedius muscle in middle ear

Chorda tympani - provides parasympathetic innervation to submandibular gland and sublingual gland and special sensory taste fibers for the anterior 2/3 of the tongue.



Etiologies

  • Paresis of the orbicularis oculi muscle leads to a diminished blink, incomplete eyelid closure (Lagophthalmos), impairment of the nasolacrimal pumping system
    • The blink reflex and lid position are critical to maintain the ocular surface
    • Each blink spreads the tear film over the ocular surface and allows for a continuous layer of moisture.
  • Congenital
    • Moebius' Syndrome
  • Acquired
    • Bell's Palsy
    • vascular lesions
  • Tumors Trauma
    • Acoustic Neuroma
    • Parotid gland
    • temporal bone tumor

Symptoms Tearing, atonic eyelid




Eyelid Anatomy
  • thinnest in body, no subcutaneous fat
  • upper lid crease (fold) = levator . attachment to pretarsal orbicularis and skin; located at level of sup border of tarsus
  • upper puntca is more medial
  • mucocutaneous border is post to meibomian gland level
  • gray line = muscle of Riolan (superficial orbicularis)
  • Zeis, sebaceous glands (holocrine) with cilia
  • Moll glands (only apocrine gland on lid) with skin
  • 100 lashes on upper lid, 50 on lower
  • Blood supply
    • extensive anastamosis between supraorbital, lacrimal branches of ophthalmic a. (from internal carotid) and angular and temporal a. (from ext carotid)
    • venous drainage: pretarsal, poatarsal
    • NO lymphatics for the orbit except in conjunctiva
    • eyelid medial lymphatics drain to submandibular nodes and laterally to preauricular nodes
  • Subcutaneous tissue
    • no fat, loose connective tissue holds fluid in preseptal > pretarsal area b/c less firmly attached
  • Orbicularis Muscle
    • main protractor
    • supplied by Cranial Nerve VII, narrows PF, helps lacrimal pumporbital
    • voluntary sphincter (wink, blepharospasm)
    • origin at medial canthal tendon and corrugator supercilius muscle
    • palpebral (pretarsal & preseptal)
    • reflex blink and involuntary
    • pretarsal origin at post lacrimal crest (most important to keep lid apposed to globe to let punctum lie in tear lake ) & ant limb of med canthal tendon; deep head of pretarsal m. (Horner’s tensor tarsi) encircles canaliculi to facilitate tear drainage
    • upper & lower segments of pretarsal orb m. fuse to become lateral canthal tendon
    • pretarsal muscle firmly adherent
    • pretarsal muscle of Riolan = gray line = superficial orbicularis
  • Septum
    • extension of periosteum
    • in non-Asians, upper lid septum fuses w/levator aponeurosis. 2-5 mm above sup tarsal border; in lower lid it fuses w/capsulopalpebral fascia at or just below inf tarsal border
    • passes medially in front of trochlea
    • barrier to hemorrhage and infection between lid and orbit
    • orb fat can herniate through septum into lids causing bags
    • central orb fat pad lies behind septum, in front of levator aponeurosis.
  • Tarus
    • dense connective tissue, attach med & lat to periosteum
    • 1 x 29 x 11 mm upper lids, 4 mm vertical height in lower lids
    • meibomian glands are modified holocrine glands
    • in upper lid marginal arcade lies 2 mm sup to lid margin, ant to tarsus
    • peripheral art arcade is sup to tarsus, between levator aponeurosis, Muller’s


Treatment

Medical

Goal: Maintaining a normal corneal epithelium

Temporary: Lubrication, moisture chamber
Used at varying intervals
Ointments are more effective in corneal protection; however, they often substantially blur vision. If this is not effective or if the paralysis is expected to persist, more permanent therapy would include procedures which narrow the palpebral fissure such as tarrsorhaphy (see below)
- Blinkeze™ External Lid Weights provide an immediate, voluntary blink mechanism for treating ocular exposure associated with temporary facial paralysis such as Bell's palsy.


BENEFITS

Effective non-surgical eyelid closure treatment Superior patient comfort and ease of use

  • Simplifies supportive eye care
  • Enhanced patient satisfaction


Surgical (usually wait several months)

Goal: Closure of the eyelids to narrow the palpebral fissure and decrease evaporation.

  • Horizontal Closure
    • Permanent: lateral tarsorraphy Tarsorrhaphy has been the standard method of managing exposure keratitis and is often effective if large enough.
      large tarsorrhaphies may be disfiguring and limit peripheral vision.
      Medial tarsorrhaphies
    • more disfiguring
    • generally used as a last resort in managing surface exposure.
  • Vertical Closure
  • Lower-lid elevation with spacers
  • fascia lata or silicone sling to lower eyelid
  • Hard palate or Alloderm implant
  • Midface lift
  • Upper eyelid lowering
    gold weight (e.g. Lid Load) insertion a light (1 mg weight ) manufactured by various companies in weights from 0.6 to 1.6 grams may be fixed to pretarsal space of the upper eyelid.
    The weight allows the eyelid to close more easily.
    The weights may be taped to the pretarsal portion of the upper lid to determine which size will be needed to reduce the Lagophthalmos. Excess weight may cause Ptosis.
    Implantation involves an incision at the upper lid crease which exposes the anterior surface of the tarsal plate. The weight is then secured in position
Procedures
Anophthalmos
- Anophthalmia is a medical term used to describe the absence of the globe and ocular tissue from the orbit. - This was first reported more than 400 years ago, yet it is only recently that significant reconstructive options became available. - There are many reasons why one might lose an eye. - Surgeries which result in anophthalmos
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Blepharoplasty
What is Blepharoplasty?
- Your eyes including your eyelids, are perhaps one of the first things people notice in you. This makes your eyes and eyelids one of the most important components for an appealing facial expression and aesthetic appearance. Any visible change in the shape or size of the orbital or periorbital region can spoil the look of your face.
- As you age and grow older, your eyelids may become ‘droopy’ or ‘baggy’ due to the stretching of your eyelid skin and gradually decreasing tone of your eyelid muscles. Your droopy eyelids and brow together cut a sorry figure for your face making you look tired, sleepy and haggard, further leading to eyelid or brow straining or both. In extreme cases, your saggy, baggy eyelids can even obstruct your vision, particularly peripheral vision causing difficulty in reading or driving.
- Blepharoplasty ensures cosmetic or functional corrections to the area around your eyes to enhance your look or to correct any abnormalities in function.
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Blepharospasm
- Blepharospasm is defined as an abnormal, involuntary, sustained and forceful closure or twitching of the eyelids. It is derived from the Greek word ‘blepharon’ which means eyelid, and ‘spasm’ which is an uncontrolled muscle contraction. Blepharospasm is usually associated with headache, eyebrow strain and occasionally loss of vision.
- Isolated blepharospasm is rare and represents a minority of patients presenting with blepharospasm. Blepharospasm is commonly associated with lower facial spasms as part of a syndrome or disease complex. Some examples are:
   - Meige Syndrome: Characterized by spasm of the eyelids and midface.
    - Brueghel’s Syndrome: Presents with blepharospasm and marked spasms in the lower face and neck.
    - Segmental Cranial Dystonia: In addition to the usual spasms of the eyelids and facial muscles it is associated with spasms along distribution of various cranial nerves, most frequently involving the Facial Nerve.
    - Generalized Dystonia: Presents with spasms across various body parts in addition to blepharospasm and facial spasms.
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Brow Lift
A forehead lift, also known as a browlift or browplasty, is a cosmetic surgery procedure used to elevate a drooping eyebrow that may obstruct vision and/or to remove the deep worry lines that run across the forehead and may portray to others anger, sternness, hostility, fatigue or other unintended emotions
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Congenital
Congenital anomolies include :
- Eyelid Disorders
- Orbital Disorders
- Congenital Ptosis
- Congenital Nasolacrimal Duct Obstruction

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Dry Eye
What is Dry Eye?
- Dry eye is a reduction in your eye’s ability to produce sufficient natural tears.
- Insufficient tear production can lead to irritation and pain, and even scarring of the cornea (the transparent part of the eye that covers the pupil and iris).
- Many people will experience dry eye symptoms at some point in their lives.
- Often due to environmental factors such as indoor heating or air conditioning, it can also be caused by occupational factors such as prolonged computer use.
- Dry eye symptoms can affect anyone.
- Some of the symptoms of dry eye include a burning sensation or gritty feeling in the eyes. You may also experience decreased tolerance to contact lens wear or sensitivity to light.
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Eyelid Laxity
- Eyelids protect your eyes from any foreign bodies while keeping them lubricated throughout. Any alteration in the shape, position or function of your eyelids can predispose your eyes to a plethora of ailments or interfere with our vision.
Our eyelid is a complex structure consisting of three theoretical layers:
   - Anterior Layer contains the skin and orbicularis muscle
   - Middle Layer contains the orbital septum and eyelid retractors
   - Posterior Layer contains tarsus and conjunctiva.

- Eyelid malpositions include any unnatural or incorrect positioning and orientation of eyelids due to various factors that influence any of the three layers of the eyelids. They may be caused due to ageing, trauma, scarring, birth defects or medical disease involving any or all of the three layers.
- The most common forms of eyelid malposition are eyelid retraction, ptosis, entropion and ectropion.
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Face
The world of cosmetic surgery has advanced tremendously over the last two decades. New procedures have emerged that can make an individual look and feel younger in a matter of a few minutes. Amongst the vast number of cosmetic procedures currently available, the face lift is a commonly performed one that is sought after by both men and women. Here we shall take a look at this procedure in a little more detail.

- What is a face lift?    - A face lift is called a rhytidectomy in the world of medicine. It involves tightening the muscles of the face and smoothening of the skin so that the face appears younger.    - However, it must be remembered that a face-lift is not an anti ageing solution.
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Lacrimal System
- The lacrimal gland produces tears which enter into the "duct" that drain the tears from the eye into the nose. The most common symptoms are If one has a plugged up "tear duct," not only will tears spill over the eyelids and run down the face, but the stagnant tears within the system can become infected.    (1) excess tearing (tears may run down the face) and    (2) mucous discharge - This may lead to recurrent red eyes and infections. - The excessive tearing can also produce secondary skin changes on the lower eyelids.
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Lagophthalmos
Patients with lagophthalmos have an inability to close eyelids. This may occur, for instance, in patients with Thyroid eye disease.
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Latisse
LATISSE® makes lash growth possible because of its active ingredient: bimatoprost. Although the precise mechanism of action is not known, research suggests that the growth of eyelashes occurs by increasing the percent of hairs in, and the duration of, the anagen (or growth) phase. Lashes can grow longer, thicker and darker because bimatoprost can also prolong this growth phase.
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Orbital Tumors
- Orbital Tumor is any tumor that occurs within the orbit of the eye. The orbit is a bony housing in the skull about 2 inches deep that provides protection to the entire eyeball except the front surface. It is lined by the orbital bones and contains the eyeball, its muscles, blood supply, nerve supply, and fat.
- Tumors may develop in any of the tissues surrounding the eyeball and may also invade the orbit from the sinuses, brain, or nasal cavity, or it may metastasize (spread) from other areas of the body. Orbital tumors can affect adults and children. Fortunately, most are benign.
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Ptosis
- Ptosis is an abnormally low position (drooping) of the upper eyelid
- Ptosis occurs when the muscles that raise the eyelid (levator and Müller's muscles) are not strong enough to do so properly.
- It can affect one eye or both eyes and is more common in the elderly, as muscles in the eyelids may begin to deteriorate.
- Compare with dermatochalsis (extra skin and fat)
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Skin Rejuvination
A radiant, smooth, youthful skin is the essence of beauty and trendy looks. Skin care routine highly contributes in the slowing down of rate of aging of the skin. Choosing the right skin care products for your skin type enhances your beauty keeping the skin cleansed, moisturized and well toned. Use of superficial skin resurfacing treatments to counter fine lines and wrinkles, acne scars and blemishes before they deepen ensures skin rejuvenation.
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Skin Tumors
Cancer of the eyelid, like any other cancer, can be a worrying thing. Treatments are variable and depend on the type of cancer. In this article, we shall take a brief look at the different kinds of eyelid tumors.
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Symblepharon
A symblepharon is a fibrous tract that connects bulbar conjunctiva to conjunctiva on the eyelid.
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Thyroid
Graves' disease is an autoimmune disease.
It most commonly affects the thyroid, causing it to grow to twice its size or more (goiter), be overactive, with related hyperthyroid symptoms such as increased heartbeat, muscle weakness, disturbed sleep, and irritability. It can also affect the eyes, causing bulging eyes (exophthalmos).
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Trauma
Eye injuries are extremely common with over 2 million cases reported every year that require medical treatment. Blindness in one eye is most commonly due to cataract and this is followed closely by eye injuries. In addition, in children, injury to the eye is a recognized as the most common cause of blindness in one eye that is not due to a birth defect.
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