lecture2 eyelid,orbit,lacrimal

Eyelids, Orbit and Lacrimal System

Hernando L. Cruz Jr., EyeMD

Section of Ophthalmic Plastic, Reconstructive, Lacrimal & Orbital Surgery

Department of Ophthalmology

Eyelids, Orbit and Lacrimal System

Eyelids Basic Anatomy and Physiology Eyelid Lesions Disorders of the Eyelashes Entropion Ectropion Ptosis

Eyelids, Orbit and Lacrimal System

Orbit Applied Anatomy Clinical Evaluation of Orbital Diseases Diagnostic Modalities in Orbital Diseases Graves’ Ophthalmopathy Orbital Infections Orbital Tumors Orbital Fractures

Eyelids, Orbit and Lacrimal System

Lacrimal System Applied Anatomy and Physiology Epiphora and Lacrimation Clinical Evaluations of Tearing Infections of the Lacrimal Passages Treatment of Lacrimal Obstructions Surgical Techniques

Eyelids and Periorbital Structures

Anatomy & Physiology

Eyelids Globe Protection

• 1. Screening and Sensing action of the Cilia

• 2. Secretion of the glands of the Eyelids

• 3. Movements of the Lids

Anatomy & Physiology

Cilia “Eyelashes” first line of Defense 2 rows of about 100 - 150 in the upper and 50 -

75 in the lower lid nerve plexuses in each follicle glands in each follicle

Anatomy & Physiology

Secretion of the Glands of the Eyelids Oily layer of the meibomian glands Forms the superficial element of the precorneal

tear film which prevents tear evaporation

Eyelid Margin Anatomy

Anatomy & Physiology

Movements of the Lids 3rd and most important element levator palpebrae superioris, orbicularis oculi

and Muller’s muscle

Anatomy & Physiology

7 structural layers of the eyelid1. Skin and Subcutaneous Tissue

2.Muscle of Protraction

3.Orbital Septum

4. Orbital Fat

5. Muscle of retraction

6. Tarsus

7.Conjunctiva

Upper Eyelid Anatomy

Lower Eyelid Anatomy

Anatomy & Physiology

I. Skin and Subcutaneous Tissue thinnest of the body no subcutaneous fat Upper lid crease

Anatomy & Physiology

II. Muscles of protraction orbicularis oculi CN VII Pre-tarsal, Pre-septal, Orbital parts

Orbicularis Oculi Muscle

Anatomy & Physiology

III. Orbital Septum multilayered sheet of fibrous tissue fuses with the aponeurosis to form the lid

crease serves as a barrier between the eyelid and the

orbit

Anatomy & Physiology

IV. Orbital Fat lies posterior the orbital septum and anterior the

levator aponeurosis with age-related attenuation - “eyebag”

Anatomy & Physiology

V. Muscles of Retraction Upper Eyelid

• Levator Muscle and its Aponeurosis

• Muller’s Muscle Lower Eyelid

• Capsulopalberal Fascia

• Inferior Tarsal Muscle

Anatomy & Physiology

Levator Palpebrae Superioris muscular portion 40 mm aponeurosis 14-20 mm whitnall’s ligament - functions as a suspensory

support of the upper eyelid innervated by CN III

Whitnalls ligament

Anatomy & Physiology

Muller’s Muscle originates at the undersurface of the

aponeurosis sympathetically innervated provides app. 2 mm of eyelid elevation

Anatomy & Physiology

Lower lid retractors Capsulopalpebral Fascia - analogous to levator

aponeurosis Lockwood’s ligament - analogous to whitnall’s

ligament Inferior tarsal Muscle- analogous to Muller’s

muscle

Lower Eyelid Anatomy

Anatomy & Physiology

Tarsus firm, dense plate skeleton of the eyelid

Conjunctiva non-keratinizing squamous epithelium contains goblet cells & acc. Lacrimal glands

Anatomy & Physiology

Vascular SupplyArterial Supply

ICA - supraorbital and lacrimal artery ECA - angular and temporal artery

Venous Drainage Pretarsal - angular vein (medially); superficial

temporal vein (laterally) Posttarsal - orbital vein

Anatomy & Physiology

Nerve Supply Sensory

• Supraorbital Nerve (V1)- innervates the forehead and lateral periocular area

• Maxillary Nerve (V2)- innervates lower eyelid and Cheek

Motor• CN III

• CN VII

• Sympathetic Nerves

Eyelid Lesions

Benign Eyelid Lesions Chalazion Hordeolum Miscellaneous

Malignant Lesions BCCa SCCa

Cross section of the Eyelid Margin

Benign Eyelid Lesions

Chalazion - chronic granulomatous inflammation of the meibomian glands.

It is a painless round lesion within the tarsal plate

Benign Eyelid Lesions

External Hordeolum- infection of the glands of Moll and Zeiss. Usually caused by staphylococcus.

Tender inflamed swelling in the lid margin

Benign Eyelid Lesions

Internal Hordeolum- acute staphylococcal infection of the meibomian glands.

Tender inflamed swelling within the tarsal plate

Benign Eyelid Lesions

Treatment Oral Antibiotics Topical Antibiotics Warm compress Surgical: I & C

Benign Eyelid Lesions

Miscellaneous Eyelid Lesions

Molluscum contagiosum - pox virus; painless umbilicated nodule

Miscellaneous Eyelid Lesions

Strawberry Nevus – flat red lesion within 6 months of birth; involute spontaneously

Inc. in size during straining or crying but no pulsation and bruit

Miscellaneous Eyelid Lesions

Port Wine Stain - nevus flammeus; well demarcated pink patch that darkens with age

45% incidence of glaucoma

5% sturge weber syndrome

Miscellaneous Eyelid Lesions

Miscellaneous Eyelid Lesions

Xanthelasma

Malignant Eyelid Lesions

Basal cell Carcinoma most common human malignancy 90% of cases occur in head and neck, 10% of

these involved the eyelid most common eyelid malignancy(90% of cases) predilection: lower lid, medial canthus, upper lid,

lateral canthus SLOW GROWING, LOCALLY INVASIVE

BUT NON-METASTASIZING

Basal Cell Carcinoma

Basal Cell Carcinoma

Malignant Eyelid Tumors

Squamous Cell Carcinoma hard nodule or a scaly patch which develops

crusting erosions and fissures over a few months.

clinically, it may be indistinguishable from BCCa but it is important to differentiate the two in view of its metastatic potential of SCC

Squamous Cell Carcinoma

Malignant Eyelid Lesions

Treatment: complete excision is a must!

Malignant Eyelid Lesion

Treatment: Surgical Excision - complete removal of the entire

tumor• Fresh frozen section

• MOH’s technique

• Eyelid reconstruction Exenteration Radiotherapy Cryotherapy

Disorders of Eyelashes

TrichiasisDistichiasis

Disorders of Eyelashes

Trichiasis posterior misdirection of previously normal

lashes usually associated with trachoma and severe

chronic staph. Blepharitis

Disorders of Eyelashes

Trichiasis

Disorders of Eyelashes

Distichiasis - abnormal row of lashes

Disorders of Eyelashes

Treatment Epilation Electrolysis Cryotherapy Laser thermoablation

Entropion

Inversion of the Eyelid4 Types

Involutional

Cicatricial

Congenital

Acute Spastic

Entropion

Involutional entropion most common and affects only the lower lid

Pathogenesis 1. Overriding of the orbicularis muscle 2. Horizontal lid laxity 3. Weakness of the lower lid retractors

Entropion

Involutional Entropion

Entropion

Treatment1. Cautery 2. Transverse Lid-everting sutures3. Weiss procedure

Entropion

Entropion

Entropion

Entropion

Cicatricial entropion - usually caused by scarring of the palpebral

conjunctiva, which pulls the lid margin towards the globe

causes: cicatricial pemphigoid, SJ syndromes, trachoma, & chemical burns

Cicatricial Entropion

Entropion

Treatment contact lenses, epilation surgical correction

Entropion

Congenital entropion due to improper development of the retractor

aponeurosis into the inferior border of the tarsal plate

inward turning of the entire lower eyelid and lashes

absence of lower lid crease DDX: Congenital epiblepharon

Entropion

Ectropion

outward turning of the eyelidusually associated with epiphora and

conjunctivitisTypes

Involutional Cicatricial Congenital Paralytic

Ectropion

Pathogenesis Involutional (Senile) - excessive eyelid length;

weakness of the pretarsal orbicularis; laxity of the medial and canthal ligaments

Cicatricial - caused by scarring and contracture of skin and underlying tissues; e.g. trauma, burns, tumors

Ectropion

Pathogenesis Paralytic Ectropion - facial nerve palsy

Ectropion

TreatmentInvolutional Ectropion

determined by the position and amount of Horizontal lid Laxity.

Ectropion

Ectropion

TreatmentMild Medial Ectropion

Medial Canthoplasty

Severe Medial Ectropion Lazy T- procedure

Extensive Ectropion Bick procedure Kuhnt-Szymanowski procedure

Ptosis

Drooping of the eyelidsTypes (My NAMe)

Neurogenic Aponeurotic

• Involutional

• Post-operative Mechanical Myogenic

Ptosis

Neurogenic Ptosis - caused by acquired or congenital innervation defect.

Horner’s syndrome Marcus Gunn jaw winking syndrome Misdirection of CN III

Neurogenic Ptosis

Isolated CN III Paralysis

Ptosis

Aponeurotic Ptosis - defect in the levator aponeurosis. It could be due to disinsertion or stretching.

Involutional Ptosis - degenerative changes in the levator aponeurosis

Post-operative Ptosis - occurs in 5% of patients following intraocular surgery (SR bridle)

Involutional Ptosis

Involutional Ptosis

Ptosis

Mechanical Ptosis physical obstruction

impeding eyelid elevation in the presence of an otherwise normal levator muscle and CN III

E.g. Tumors, deramtochalasis, edema

Ptosis

Myogenic ptosis congenital or acquired myopathy of the

Levator muscle 2 Types Simple congenital Ptosis Blepharophimosis Syndrome

Ptosis

Simple Congenital Ptosis may be unilateral or bilateral during downgaze, the ptotic eyelid is higher

than the normal eyelid weakness of the superior rectus (some cases) head tilt with chin elevation high EOR and astigmatism

Ptosis

Ptosis

Blepharophimosis syndrome Telecanthus Epicanthus Other features: ectropion, poorly developed

nasal bridge, hypoplasia of the superior orbital rims

Amblyopia 50% of cases

Ptosis

Blepharophimosis Syndrome

Ptosis

Clinical Evaluation:

Excellent history taking

Is it a true ptosis or pseudoptosis ?

Ptosis

Causes of Pseudoptosis

1. Decrease vertical fissure height

2. Contralateral lid retraction

3. Ipsilateral hypotropia

4. Dermatochalasis

Ptosis

Parameters1. Marginal Reflex distance

NV 4-5mm; Mild +3 Mod. +2 Severe 0 to -1

2. Vertical Fissure height NV male 7-10mm female 8-12mm

3. Levator Function good 12mm; fair 6-11mm poor 5mm or less

Anatomy and Physiology

Orbit bony cavities : globes, EOM, nerves, fat and

blood vessels pyramidal or conical in shape consists of an apex, a base and 4 sides: roof

floor,medial wall and lateral wall 7 bones: frontal, zygomatic, maxillary,

sphenoid, ethmoid, lacrimal, & palatine

Anatomy and Physiology

The Bony Orbit:

Anatomy and Physiology

Roof of the Orbit frontal bone and lesser wing of the sphenoid located adjacent to anterior cranial fossa and

frontal sinus

Lateral wall of the Orbit zygomatic bone and greater wing of the

sphenoid

Anatomy and Physiology

Orbital Roof

Anatomy and Physiology

Medial Wall ethmoid, lacrimal, maxillary and sphenoid

bones forms the lateral wall of the sphenoid sinus

Floor of the Orbit maxillary, palatine,& zygomatic bones

Anatomy and Physiology

Medial Wall

Anatomy and Physiology

Orbital Apertures1. Optic Canal

Optic Nerve, Ophthalmic Artery, Sympathetic Nerves

2. Superior Orbital Fissure CN III,IV,VI, V1, Sympathetic Nerves

3. Inferior Orbital Fissure CN V2,

Anatomy and Physiology

Clinical Evaluation of Orbital Diseases

6 P’s Pain Proptosis Progression Palpation Pulsation Periorbital Changes

Clinical Evaluation of Orbital Diseases

Proptosis Axial Displacement - retrobulbar lesions like

cavernous hemangioma, glioma, meningioma, AV mal, lesions with in the muscle cone

Clinical Evaluation of Orbital Diseases

Non Axial Displacement - outside the muscle cone

Superior Displacement - maxillary tumor invading the floor of the orbit

Inferomedial displacement - dermoid cyst and lacrimal gland tumor

Bilateral proptosis Grave’s disease and lymphoma, pseudotumor

Clinical Evaluation of Orbital Diseases

Progression Days to weeks - inflammatory diseases.

Infectious diseases, metastatic tumors

Months to years - dermoids, benign mixed tumors, lymphomas

Clinical Evaluation of Orbital Diseases

Palpation superonasal - Mucoceles, neurofibromas dermoids superotemporal - lacrimal gland tumor pseudo

tumor

Pulsations with bruit - CCS Fistula without bruit - meningoencephalocoeles

Diagnostic Modalities in Orbital Diseases

Primary Studies CT scan MRI Ultrasonography Histopathology

Secondary Studies Venography Arteriography

Clinical Evaluation of Orbital Diseases

Clinical Evaluation of Orbital Diseases

CT Scan Good for most orbital

conditions, esp fractures Good view of bone & Ca Degraded image of orbital

apex due to bony artifact Less soft tissue detail Good for metallic foreign

body Less expensive Shorter Scanning time

MRI Better for orbitocranial

lesions No view of bone & Ca Good view of Orbital Apex More soft tissue detail Contraindicated for Metallic

Foreign Body More expensive Longer Scanning time

Graves’ Ophthalmopathy

Autoimmune disorder that is related to excess secretion of thyroid hormone

10-25% occurs in the absence of any thyroid dysfunction

Female/male ratio 8:14th to 5th decades of lifemost common cause of adult unilateral and

bilateral exophthalmos

Graves’ Ophthalmopathy

Pathogenesis

1. Hypertrophy of Extraocular Muscles

2. Cellular Infiltration

3. Proliferation of orbital fat, connective tissue

Graves’ Ophthalmopathy

Main Clinical Manifestation

1. Eyelid retraction

2. Soft Tissue involvement

3. Proptosis

4. Optic Neuropathy

5. Restrictive Myopathy

Graves’ Ophthalmopathy

Eyelid Retraction

Graves’ OphthalmopathySoft Tissue

Involvement

1. Conjunctival Injection

2. Chemosis

3. Eyelid Fullness

Graves’ Ophthalmopathy

Proptosis

Graves’ Ophthalmopathy

Restrictive Myopathy

IR>MR>SR>LR

Graves’ Ophthalmopathy

CT Scan EOM

Hypertrophy with tendon sparing

Key Points in Graves’ Ophthalmopathy

Eyelid retraction is the most common clinical feature; Graves’ ophthalmopathy is the most common cause of eyelid retraction.

Graves’ Ophthalmopathy is the most common cause of unilateral and bilateral proptosis.

Graves’ Ophthalmopathy is 6 more times more common in female than male.

This condition is associated with hyperthyroidism in 90% of cases, but 6% are Euthyroid.

Severity of Ophthalmopathy may not parallel serum levels of T3 or T4. Ophthalmopathy may be asymmetric. Urgent care may be required for optic Neuropathy or severe proptosis If surgery is needed the usual order of surgery is DECOMPRESSION

followed by SQUINT SURGERY followed by EYELID SURGERY

Orbital Infections

Preseptal Cellulitis Infection confined to the eyelids and periorbital

tissues anterior to the orbital septum Globe is uninvolved, Pupillary rxn, VA, & EOM’s are NORMAL no chemosis, no pain

Orbital Infections

Orbital Infections

Orbital Cellulitis active infection posterior to the septum 90% occurs as a 2ndary extension of bacterial

sinusitis fever, proptosis,chemosis, EOM restrictions,

pain on eye movement decrease VA, pupillary abnormalities

Orbital Infections

Orbital Tumors

Vascular capillary hemangioma cavernous

hemangioma lymphangioma

Lacrimal Gland Benign Mixed Tumor Malignant Tumor

Rhabdomyosarcoma

Cystic Lesions dermoid cyst mucocele

Neural optic nerve glioma

MetastaticTumor invasion from

adjacent structures

Capillary Hemangioma

Most common tumor of the orbit in childhood

increase in tumor size during crying and straining

absent bruit and pulsation

involute spontaneously

Cavernous Hemangioma

Most common benign orbital lesion in adults

middle-aged women commonly affected

enhanced well-encapsulated mass on CT scan

Tx: Surgical Excision

Rhabdomyosarcoma

Most common primary orbital malignancy of childhood

age-onset is 7-8 y/o rapid onset of proptosis Tx: Exenteration,

Radiation Therapy combined with systemic chemotherapy

Pleomorphic Adenoma

Most common epithelial tumor of the lacrimal gland

4th -5th decades of life, mostly men

progresssive, painless, downward & inward displacement

Epidermoid / Dermoid Cyst

Dermoid is a benign cystic teratoma

well-encapsulated lined by stratified squamous & contain dermal appendages

Epidermoid - does not contain dermal appendages

Fractures of the Orbit

Orbital floor Fracture Most frequently

involve wall Usually along the

infraorbital canal

Orbital Floor Fracture

Clinical Features Periocular Changes – ecchymosis, edema,

subcutaneous emphysema Enophthalmos Infraorbital nerve anesthesia Diplopia

Fractures of the Orbit

Fractures of the Orbit

Fractures of the Orbit

Fractures of the Orbit

Fractures of the Orbit

Lacrimal System

PunctaAmpullaecanaliculilacrimal sacnasolacrimal duct

Tear Flow Physiology

Evaluation of Tearing

Lacrimation vs EpiphoraLacrimation - reflex over production of

tears from stimulation of CN V by irritation of the cornea and conjunctiva

Epiphora - normal tear production but there is physical obstruction on the drainage system

Infections of Lacrimal Passages

Canaliculits - unilateral epiphora with mucopurulent discharge. “Pouting of the punctum” on slit lamp exam.

Infections of Lacrimal Passages

Dacryocystitis infection of the lacrimal sac. Presents as a painful swelling at the medial canthal area.

Surgical Techniques

External DCREndoscopic Laser-Assisted DCRTranscanalicular Endoscopic DCR

Thank you for your kind attention!