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Oculoplastic Surgeon’s DDX for the Red Eye

Geeta Belsare Been,MD

The Center for Facial Plastic Surgery

Barrington, IL

Oculoplastic Surgeon’s DDX for the Red Eye

Eyelid Malposition

Photos

Disorders of lacrimal drainage

Lacrimal set including irrigation

Exposure

Orbital Disease

Color vision, Hertel

Possible Visual Field

Masquerade Syndrome

Lower Eyelid Malposition Ectropion

Involutional

Cicatricial

Paralytic

Entropion

Involutional

Cicatricial 

Involutional Ectropion• Majority of cases

• Horizontal eyelid laxity

• Loss of eyelid apposition and eversion

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Involutional Ectropion

•Conjunctival inflammation and keratinization

•Main Issue:• Horizontal Laxity

•Treatment:•Lateral Tarsal Strip •Lateral Canthal resuspension

•Classic lateral tarsal strip was described by Dr. Anderson in 1979•Fashioning a strip of lower lid tarsus•Trimming it so that it can be reattached to the lateral orbital rim

Cicatricial Ectropion• Caused by chemical burns, trauma, actinic skin damage or chronic inflammation

• Complication of cosmetic surgery

Cicatricial Ectropion

•Acne Rosacea with chalazion

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Cicatricial Ectropion

Cicatricial Ectropion

•Treatments:•Skin Grafts•Midface Lifts•Horizontal eyelid tightening

Paralytic Ectropion

•CN 7 innervates Orbicularis Oculi which is the main protractor of the eyelid•Pretarsal, preseptal and orbital parts•Involuntary (blink): pretarsal and preseptal•Voluntary (Wink): Orbital

Paralytic Ectropion

•Concomitant upper eyelid lagopthalmos

Paralytic Ectropion

•Poor blink and eyelid closure

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Paralytic Ectropion

•Results in chronic inferior corneal exposure•Also poor tear film distribution and replenishment

Paralytic Ectropion

•Treatment Options: •Lubricating drops & ointments•Temporary and permanent tarsorrhaphies•Gold weight and horizontal tightening procedure

Involutional Entropion Horizontal laxity and disinsertion of retractors

White subconjunctival line several mm below inferior tarsal border

Deep inferior fornix

Decreased mvmt of lower lid on downgaze

Dx: Snapback test: >6mm of laxity

Combination of treatments Mainly horizontal tightening and repair of the retractors

Involutional Entropion

•Lashes directly on globe

•Inferior Scleral Show

Involutional Entropion

Treatment options:•Temporizing measures:

•Tape •Quickert sutures

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Cicatricial Entropion

Cicatricial Entropion

Dx: Vertical tarsoconjunctival contracture

DDx: Autoimmune (OCP), Inflammatory (SJS), Infectious (Herpes or Trachoma), Surgical (Enucleation), Traumatic (Chemical burn)

Cicatricial Entropion

Cicatricial Entropion

Trichiasis

Trichiasis

Treatment:1. Mechanical

Epilation2. Radiofrequency

epilation(>6wks later)

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Upper Eyelid Malposition Entropion

Floppy Eyelid Syndrome

Entropion Upper Eyelid

Floppy Eyelid Syndrome

Floppy Eyelid Syndrome

Floppy Eyelid Syndrome

•Chronic Papillary conjunctivitis

•Patching or Shield

•Surgical correction with horizontal tightening or wedge resections

Disorders of Lacrimal Drainage Nasolacrimal Duct Obstruction

Dacryocystitis

Cannaliculitis

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Lacrimal Drainage System

NLD Obstruction

•Acquired:•Present with redness, tearing or infection

•Etiology:•Involutional changes of NLD, trauma or surgical hx

•Hx of “crusting” in the mornings

Dacryocystitis•Stasis of fluid in sac with infection•Acute onset of pain and swelling•Considerations:

•Orbital cellulitis•Lacrimal sac tumor

•Imaging•Treatment:

•Systemic antibiotics•Warm compresses•Possible incision and drainage if abscess

Dacryocystitis

Dacryocystitis

DCR Surgery(Dacryocystorhinostomy)

•Drainage procedure to bypass site of NLDO

•Required in all patients with chronic epiphora or daycryocystitis due to NLDO

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DCR Surgery

•Anastomosis of lacrimal sac to nasal mucosal flaps

External DCR Surgery

Lacrimal Stent

Endoscopic DCR Surgery

Canaliculitis

•Rare infection •Bacterial or fungal

•Etiology: •Any abnormality in the lacrimal system can lead to concretion formation and a chronic infection

Canaliculitis

•Erythematous•Pouting punctum•Dilated punctum•Tender to palpation

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Canaliculitis

•Expression of pus with pressure

Canaliculitis

Canaliculitis

•Treatment: •Warm compresses, topical and systemic antibiotics

•Incision and drainage can be required to remove concretions

Exposure Keratopathy Upper lid retraction

Lower lid retraction

Proptosis

Facial nerve palsy

Upper lid retraction

•Defined as exposed sclera between limbus and lid margin

Lower lid Retraction

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Lid Retraction Grave’s – most common cause

Recession of vertical rectus muscles

Overly aggressive skin excision 

Contralateral ptosis overcompensation

Hering’s law

Tumor

Facial Nerve Palsy

Treatment of Lid Retraction Treat the underlying cause

Topical treatment

After atleast 6mths:

Mullerectomy

Levator Aponeurosis recession

Skin grafts

Lateral Tarsorrhaphy

Proptosis

Proptosis

Proptosis

•Red Eye secondary to lymphoma:

•Importance of scanning

Proptosis

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Facial Nerve Palsy

Facial Nerve Palsy

Facial Nerve Palsy

Facial Nerve Palsy

Orbital Disease Graves Disease

Cellulitis

Orbital Inflammatory Disease

Carotid Cavernous Fistula

Graves Disease

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Graves Disease

Orbital Cellulitis

Orbital Cellulitis

•Erythema, swelling, chemosis, restricted EOM, pain on eye movement and proptosis•Treatment:

•Immediate broad-spectrum antibiotics, imaging and careful monitoring.

Carotid Cavernous Fistula

•Abnormal communication due to:

•Trauma•Degeneration

Carotid Cavernous Fistula

Carotid Cavernous Fistula

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Mascarade Syndrome Sebaceous cell carcinoma of the conjunctiva

Sebaceous Cell Carcinoma

Sebaceous Cell Carcinoma

Sebaceous adenocarcinoma Arises from Meibomian glands, Zeis glands or sebaceous glands of caruncle, face or brow

Most common in females

Twice as likely to be seen in the upper lid  Increased number of glands

Multicentric origin with pagetoid spread

Sebaceous Cell Carcinoma

Special Thank you to Dr. John McCann, Dr. Rick Anderson and Dr. Gary Churchill