Bernard A. Milstein, M.D.

Da-Thuy Van, D.O.

Allan H. Fradkin, M.D.

GalvestonTexas City

League City

Cataract and Premium IOLsBlepharoplastyLid SurgeryBotox and Facial FillersLaser Refractive Surgery

PterygiumDry EyesDiabeticGlaucomaClinical Studies

Pterygium

Ectropion

Entropion

PTERYGIUM

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

Pterygium Symptoms

Yellow-white flat or slightly raised conjunctival lesion

Usually in the interpalpebral fissure, nasal to the limbus

Not involving the cornea

Pingueculum Signs

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

Pterygium Signs

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

Other Signs

Conjunctival intraepithelial neoplasia (CIN)◦ Unilateral jelly-like, velvety, leukoplakic (white)

mass◦ Often elevated, vascularized, and not wing-

shaped

Pterygium Differential Diagnosis

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)

Pterygium Differential Diagnosis

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

Pterygium Differential Diagnosis

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

Pterygium Pathogenesis

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

Pterygium Treatment

Protect eye from sun – wear sunglasses Mild - topical lubricants Moderate - topical

antihistamine/vasoconstrictor Mod. to severe - topical corticosteroid

Pterygium Treatment - Conservative

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

approach

Pterygium Treatment - Surgery

Pre- and post- 1 month

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

Pterygium Treatment – Surgery

Topical antibiotic and steroid Watch IOP

Pterygium Treatment – post op

http://www.youtube.com/watch?v=A7m61oVDytc

Video of pterygium surgery

ECTROPION

ECTROPION

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

ECTROPION

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

Ectropion symptoms

Congenital ◦ Rare◦ May be associated with other orbital

abnormalities Blepharophimosis Microphthalmos Buphthalmos Down syndrome

Ectropion Etiology

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

Ectropion Etiology

Most common Horizontal lid laxity – age related

Ectropion - Involutional

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

Ectropion - Paralytic

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

Ectropion - Cicatricial

Lid tumors

Ectropion - Mechanical

Lubrication Wipe only superiorly and nasally to avoid

conjunctival irritation Antibiotic ointment, especially at night

Ectropion -Treatment - Medical

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

Ectropion -Treatment – Surgical

Conjunctival and corneal exposure – keratinization and perforation

Retrobulbar hemorrhage, hematoma, infection, wound dehiscence, poor positioning of tarsal strip, and rounded lateral canthus

Ectropion - Complications

ENTROPION

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

ENTROPION

Red and irritated eye Foreign body sensation Blurred vision

Entropion Symptoms

Congenital Acute spastic Involutional Cicatricial

Entropion Etiology

Rare Pediatric epiblepharon – no symptoms

Entropion - Congenital

Result of ocular irritants – infection, inflammatory, trauma

Entropion - Acute spastic

Horizontal lower lid laxity of medial and /or lateral canthal tendons

Snap test Tight squeeze test

Entropion - Involutional

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

Snap test is difficult

Entropion - Cicatricial

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

Entropion Differential Diagnosis

Lubrication Lid hygiene Antibiotic/steroid Taping of lower lid

Entropion Treatment - Medical

Quickert sutures◦ Temporary fix◦ Good for spastic entropion

Tarsal wedge resection◦ Successful◦ In-office procedure

Horizontal or vertical lid shortening

Entropion Treatment - Surgical

Retrobulbar hemorrhage Wound dehiscence Infection Corneal injury Recurrence Consecutive ectropion

Surgical Complications

THANK YOU !!