LIDS LACRIMAL LIDS LACRIMAL SYSTEM AND ORBITSYSTEM AND ORBIT

DR. GEETA LALDR. GEETA LAL

Eyelid diseasesEyelid diseases

MalpositionsMalpositions InflammationInflammation InfectionsInfections Tumours Tumours

Eyelid malposit ionEyelid malposit ion

EntropionEntropion EctropionEctropion PtosisPtosis Lid retractionLid retraction LagophthalmosLagophthalmos

EntropionEntropion

Definition:Definition:– An inward turning of the upper or lower eyelidAn inward turning of the upper or lower eyelid

Aetiology:Aetiology:– InvolutionalInvolutional: most common form; results from age related : most common form; results from age related

changes and laxity in the lower lid.changes and laxity in the lower lid.– CicatricialCicatricial: seen in trachoma, Steven Johnson syndrome, : seen in trachoma, Steven Johnson syndrome,

ocular pemphigoid, chemical burns and trauma. Caused ocular pemphigoid, chemical burns and trauma. Caused by scarring and contraction of lid.by scarring and contraction of lid.

– SpasticSpastic: caused by spasm of orbicularis secondary to : caused by spasm of orbicularis secondary to ocular irritation.ocular irritation.

– CongenitalCongenital: very rare.: very rare.

EntropionEntropion

Symptoms and sequelae:Symptoms and sequelae:– Ocular irritation, discomfortOcular irritation, discomfort– Reflex wateringReflex watering– Corneal abrasion with lashesCorneal abrasion with lashes– Infected corneal ulcer if severeInfected corneal ulcer if severe– Corneal scarringCorneal scarring

Treatment:Treatment:– Short term – Lubricants , taping of lidsShort term – Lubricants , taping of lids– Long term – Surgical correctionLong term – Surgical correction

EctropionEctropion

Definition:Definition:– An outward turning of the lower lid. If severe and An outward turning of the lower lid. If severe and

prolonged may cause conjunctival keratinisation.prolonged may cause conjunctival keratinisation.

Aetiology:Aetiology:– InvolutionalInvolutional : due to age related tissue laxity : due to age related tissue laxity– CicatricialCicatricial: scarring resulting from burns or surgery: scarring resulting from burns or surgery– MechanicalMechanical : excessive lid weight by lid mass, e.g. tumour : excessive lid weight by lid mass, e.g. tumour– ParalyticParalytic : associated with facial nerve palsy : associated with facial nerve palsy– CongenitalCongenital : rare : rare

EctropionEctropion

Symptoms:Symptoms:– WateringWatering– IrritationIrritation– GrittinessGrittiness– RednessRedness

Treatment:Treatment:– Short term – Lubricants , taping of lidsShort term – Lubricants , taping of lids– Long term – Surgical correction Long term – Surgical correction

EctropionEctropion

Eversion of lower lid with conjunctival keratinisation

EctropionEctropion

Lower lid ectropion

TrichiasisTrichiasis

Definition:Definition: Abnormal inturned eyelashes which rub against the eye Abnormal inturned eyelashes which rub against the eye Can cause corneal abrasion – infection – scarringCan cause corneal abrasion – infection – scarring

CausesCauses:: Staphylococcal blepharitisStaphylococcal blepharitis Trauma to the lidsTrauma to the lids Conjunctival scarring diseasesConjunctival scarring diseases

TreatmentTreatment : : EpilationEpilation CryotherapyCryotherapy ElectrolysisElectrolysis

PtosisPtosis

Definition:Definition:- Drooping of the upper eyelidDrooping of the upper eyelid

Can be unilateral or bilateralCan be unilateral or bilateral

PtosisPtosis

PtosisPtosis

AetiologyAetiology CongenitalCongenital

– Caused by weakness of the levator muscle Caused by weakness of the levator muscle – can be unilateral or bilateralcan be unilateral or bilateral– surgical correction is indicated for visual or cosmetic reasonssurgical correction is indicated for visual or cosmetic reasons

Acquired:Acquired:– Neurogenic – 3Neurogenic – 3 rdrd nerve palsy, Horners syndrome nerve palsy, Horners syndrome– Aponeurotic – dehiscence of levator palpebrae superioris , could be age related Aponeurotic – dehiscence of levator palpebrae superioris , could be age related

(senile), traumatic or post operative(senile), traumatic or post operative– Myogenic - myasthenia gravis, myotonic dystrophy, ocular myopathiesMyogenic - myasthenia gravis, myotonic dystrophy, ocular myopathies– Mechanical - due to inflammation, tumour, vascular abnormality of upper lidMechanical - due to inflammation, tumour, vascular abnormality of upper lid

Management:Management: Treat the underlying conditionTreat the underlying condition Surgical correctionSurgical correction

Other l id abnormalit iesOther l id abnormalit ies Lid retractionLid retraction

– may be unilateral or bilateral and is almost invariably due to may be unilateral or bilateral and is almost invariably due to thyroid diseasethyroid disease

LagophthalmosLagophthalmos– incomplete closure of the eyelids due to 7incomplete closure of the eyelids due to 7 thth nerve palsy nerve palsy– results in exposure keratitisresults in exposure keratitis– Treatment - lubricants, taping of lids, lateral tarsorraphyTreatment - lubricants, taping of lids, lateral tarsorraphy

BlepharospasmBlepharospasm– involuntary spasm of orbicularis muscle causing lid closureinvoluntary spasm of orbicularis muscle causing lid closure– Causes: idiopathic, Parkinsons disease, PsycogenicCauses: idiopathic, Parkinsons disease, Psycogenic– Treatment – Botox injectionTreatment – Botox injection

Lid retractionLid retraction

Lid inflammationLid inflammation BlepharitisBlepharitis- Chronic inflammation of the lid marginsChronic inflammation of the lid margins- Bilateral, symmetricalBilateral, symmetrical

TypesTypes- StaphylococcalStaphylococcal- SeborrheicSeborrheic

CausesCauses - Staphylococcal chronic infection- Staphylococcal chronic infection - Meibomian gland dysfunction- Meibomian gland dysfunction - Acne Rosacea associated- Acne Rosacea associated

Blepharit isBlepharit is Symptoms:Symptoms: - - Grittiness, burning and rednessGrittiness, burning and redness - Stickiness and crusting of lids- Stickiness and crusting of lids

SignsSigns:: - Erythema and telengiectasia of lid margin- Erythema and telengiectasia of lid margin - Meibomianitis/ styes/ chalazia- Meibomianitis/ styes/ chalazia - Scaling around lash roots- Scaling around lash roots - Tear film dysfunction- Tear film dysfunction - Punctate epithelial erosions, marginal keratitis- Punctate epithelial erosions, marginal keratitis

TreatmentTreatment:: - Lid margin hygiene using baby shampoo- Lid margin hygiene using baby shampoo - Lubricants- Lubricants - Topical antibiotics (eg, fusidic acid, chloramphenicol)- Topical antibiotics (eg, fusidic acid, chloramphenicol) - Systemic antibiotics (tetracycline)- Systemic antibiotics (tetracycline)

Blepharit isBlepharit is

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Blepharit isBlepharit is

Non neoplastic l id Non neoplastic l id lesionslesions Meibomian cyst (chalazion)Meibomian cyst (chalazion) External hordeolum (stye)External hordeolum (stye) Cysts of Zeis and MollCysts of Zeis and Moll Molluscum contagiosumMolluscum contagiosum

Meibomian cystMeibomian cyst Inflamed painful lid swelling due to a blocked meibomian ductInflamed painful lid swelling due to a blocked meibomian duct

Very common in patients with blepharitisVery common in patients with blepharitis

Initial treatment is hot compresses and topical antibiotic Initial treatment is hot compresses and topical antibiotic ointment 4 times a day for 2 weeks If the lump persists after 3 ointment 4 times a day for 2 weeks If the lump persists after 3 months, do an incision and curettagemonths, do an incision and curettage

In children commonly associated with localised infective In children commonly associated with localised infective cellulitis (preseptal cellulitis) requiring oral/intravenous cellulitis (preseptal cellulitis) requiring oral/intravenous antibioticsantibiotics

Meibomian cystMeibomian cyst

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Non neoplastic l id Non neoplastic l id lesionslesionsExternal hordeolum (stye)External hordeolum (stye) A small abscess of an eye lash follicleA small abscess of an eye lash follicle An acute, painful inflamed swelling on the anterior lid margin, pointing An acute, painful inflamed swelling on the anterior lid margin, pointing

through the skinthrough the skin Rx - Removal of the associated lash, hot bathing, topical antibiotic ointmentRx - Removal of the associated lash, hot bathing, topical antibiotic ointment

Cysts of Zeis and MollCysts of Zeis and Moll A cyst of Zeis is a small, whitish, chronic, painless opaque nodule on the lid A cyst of Zeis is a small, whitish, chronic, painless opaque nodule on the lid

marginmargin A cyst of Moll is similar but translucentA cyst of Moll is similar but translucent Rx - simple excision (usually not necessary)Rx - simple excision (usually not necessary)

Molluscum ContagiosumMolluscum Contagiosum Umbilicated lesion on the lid caused by pox virus Umbilicated lesion on the lid caused by pox virus Usually unilateral associated with follicular conjunctivitisUsually unilateral associated with follicular conjunctivitis Rx – Shave excisionRx – Shave excision

Benign tumours of the Benign tumours of the eyelideyelid Papilloma (viral wart)Papilloma (viral wart) Seborrhoeic keratosesSeborrhoeic keratoses KeratoacanthomaKeratoacanthoma NaeviNaevi Capillary haemangiomaCapillary haemangioma XanthalesmaXanthalesma

Papil loma Papil loma

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Malignant l id tumoursMalignant l id tumoursBasal cell carcinoma:Basal cell carcinoma: - Most common malignant eye lid tumour- Most common malignant eye lid tumour - Lower lid most common site- Lower lid most common site - Invades locally- Invades locally - Does not metastasize- Does not metastasize - Treatment: surgery – local excision- Treatment: surgery – local excision

Squamous cell carcinoma:Squamous cell carcinoma: - Much less common than BCC- Much less common than BCC - Metastasise to lymph nodes- Metastasise to lymph nodes - Rx – excision/ radiotherapy- Rx – excision/ radiotherapy

Meibomian cell carcinoma:Meibomian cell carcinoma: - Rare tumour, may present as recurrent chalazion- Rare tumour, may present as recurrent chalazion - Treatment : excision/ radiotherapy- Treatment : excision/ radiotherapy

Malignant melanoma:Malignant melanoma: - Very rare tumour- Very rare tumour

Basal cell carcinomaBasal cell carcinoma

Lacrimal systemLacrimal system

INSERT PICTURE INSERT PICTURE TO EXPLAIN TO EXPLAIN ANATOMYANATOMY

EXPLAIN TEAR EXPLAIN TEAR PRODUCTION PRODUCTION AND DRAINAGE AND DRAINAGE WITH NARRATIVE WITH NARRATIVE NOT TEXT NOT TEXT

The watering eyeThe watering eye

TearingTearing– Can be due to lacrimation (hypersecretion) or Can be due to lacrimation (hypersecretion) or

epiphora (decreased tear elimination)epiphora (decreased tear elimination)

Causes of lacrimation Causes of lacrimation – Corneal F.B.Corneal F.B.– Corneal irritationCorneal irritation– Ocular surface inflammationOcular surface inflammation

The watering eyeThe watering eye

Causes of epiphoraCauses of epiphora Anatomical - strictures, tumoursAnatomical - strictures, tumours Physiologic dysfunction – orbicularis muscle Physiologic dysfunction – orbicularis muscle

weakness, punctal or eyelid malposition, weakness, punctal or eyelid malposition, nasal obstructionnasal obstruction

The watering eyeThe watering eye

ManagementManagement:: Displaced punctum in entropion and blocked punctum etc can Displaced punctum in entropion and blocked punctum etc can

be diagnosed by careful inspection and the cause removed or be diagnosed by careful inspection and the cause removed or corrected surgically.corrected surgically.

Canalicular and nasolacrimal obstruction in adult can be Canalicular and nasolacrimal obstruction in adult can be diagnosed by probing and syringing of the lacrimal diagnosed by probing and syringing of the lacrimal canaliculum. This is treated surgically by canaliculum. This is treated surgically by dacryocystorhinostomy (DCR).dacryocystorhinostomy (DCR).

Congenital nasolacrimal duct obstruction – spontaneous cure Congenital nasolacrimal duct obstruction – spontaneous cure by the age of 12-18 months is the rule, aided by regular by the age of 12-18 months is the rule, aided by regular massage over the lacrimal sac. After this age probing of the massage over the lacrimal sac. After this age probing of the nasolacrimal duct carried out under GA. Patency confirmed by nasolacrimal duct carried out under GA. Patency confirmed by syringing.syringing.

Orbital diseasesOrbital diseases

Thyroid eye diseaseThyroid eye disease Aetiology – autoantibodies to both thyroid Aetiology – autoantibodies to both thyroid

and orbital tissue cause inflammation in the and orbital tissue cause inflammation in the orbit. The extraocular muscles are orbit. The extraocular muscles are particularly affected.particularly affected.

Clinical features - the clinical course Clinical features - the clinical course involves an active congestive stage lasting 2 involves an active congestive stage lasting 2 -3 yrs, followed by quiescent stage -3 yrs, followed by quiescent stage characterised by residual restriction of characterised by residual restriction of ocular movements.ocular movements.

Thyroid eye diseaseThyroid eye disease

SymptomsSymptoms Redness, irritation, discomfortRedness, irritation, discomfort Wide - eyed (staring) appearanceWide - eyed (staring) appearance Double visionDouble vision Decreased vision in severe casesDecreased vision in severe cases

SignsSigns Fullness of the eyelidsFullness of the eyelids Conjunctival hyperaemia and chemosisConjunctival hyperaemia and chemosis Proptosis (exophthalmos) may be unilateral or bilateralProptosis (exophthalmos) may be unilateral or bilateral Lid retraction Lid retraction Lid lag Lid lag Restricted eye movementsRestricted eye movements Optic neuropathy – sight threatening complication caused by compression of Optic neuropathy – sight threatening complication caused by compression of

the optic nerve or its blood supply by swollen orbital tissue.the optic nerve or its blood supply by swollen orbital tissue.

ExophthalmosExophthalmos

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Thyroid eye diseaseThyroid eye disease

InvestigationsInvestigations– T3, T4 and TSHT3, T4 and TSH– Thyroid autoantibodies raisedThyroid autoantibodies raised

RadiologyRadiology– CT scan of the orbit – Enlarged extraocular muscles CT scan of the orbit – Enlarged extraocular muscles

(tendons spared) and enlarged soft tissue(tendons spared) and enlarged soft tissue– Optic nerve may be compressed in the canalOptic nerve may be compressed in the canal– Clinical and radiological findings more important than Clinical and radiological findings more important than

biochemical profile in establishing a diagnosis.biochemical profile in establishing a diagnosis.

Thyroid eye diseaseThyroid eye disease

TreatmentTreatment– Lubricants and non steroidal anti inflammatoriesLubricants and non steroidal anti inflammatories– Prisms for double visionPrisms for double vision– Systemic steroids Systemic steroids – Immunosuppressants (Azathioprine, cyclophosphamide)Immunosuppressants (Azathioprine, cyclophosphamide)– Radiotherapy as an adjunctive therapy to steroidsRadiotherapy as an adjunctive therapy to steroids– Surgery: Surgery:

Orbital decompression for acute optic nerve compression not Orbital decompression for acute optic nerve compression not responding to immunosuppression and for cosmesis when responding to immunosuppression and for cosmesis when burnt outburnt out

Strabismus surgery for double visionStrabismus surgery for double vision Surgery to correct lid retractionSurgery to correct lid retraction

Orbital cellul i t isOrbital cellul i t is

DefinitionDefinition– A potentially life threatening acute A potentially life threatening acute

bacterial infection of the soft tissues of bacterial infection of the soft tissues of the orbit the orbit

AetiologyAetiology– Secondary to sinusitis Secondary to sinusitis – Infected chalazion in childrenInfected chalazion in children– Following trauma or surgeryFollowing trauma or surgery

Orbital cellul i t isOrbital cellul i t is SymptomsSymptoms

– Acute lid swelling and redness, pain and malaiseAcute lid swelling and redness, pain and malaise

SignsSigns– Reduced visual acuityReduced visual acuity– Lid oedema and erythemaLid oedema and erythema– ChemosisChemosis– ProptosisProptosis– Painful ophthalmoplegiaPainful ophthalmoplegia– Optic disc swellingOptic disc swelling

ComplicationsComplications– Intra cranial infection, cavernous sinus thrombosis and blindnessIntra cranial infection, cavernous sinus thrombosis and blindness

ManagementManagement– Intravenous antibioticsIntravenous antibiotics– Orbital CT, to rule out an abscessOrbital CT, to rule out an abscess– Surgery for abscess drainage or sinus washout.Surgery for abscess drainage or sinus washout.

Orbital tumoursOrbital tumours

Muscle – RhabdomyosarcomaMuscle – Rhabdomyosarcoma Vascular – Capillary haemangiomaVascular – Capillary haemangioma Lacrimal – Carcinoma of lacrimal glandLacrimal – Carcinoma of lacrimal gland Neural – Optic nerve glioma and optic Neural – Optic nerve glioma and optic

nerve sheath meningioma nerve sheath meningioma Metastatic Metastatic

Orbital tumoursOrbital tumours

Rhabdomyosarcoma:Rhabdomyosarcoma:– Rare but aggressive tumourRare but aggressive tumour– Children mainlyChildren mainly– Progressive proptosisProgressive proptosis– Palpable mass may be presentPalpable mass may be present– Management: incisional biopsy to confirm Management: incisional biopsy to confirm

diagnosis followed by radiotherapy and diagnosis followed by radiotherapy and chemotherapychemotherapy

Orbital tumoursOrbital tumours

Capillary haemangiomaCapillary haemangioma– presents in infancy with an anterior orbital presents in infancy with an anterior orbital

swellingswelling– may increase in size when cryingmay increase in size when crying– similar eyelid lesion (strawberry naevus) similar eyelid lesion (strawberry naevus)

may also be presentmay also be present– most of the tumours involute most of the tumours involute

spontaneouslyspontaneously

Orbital tumoursOrbital tumours Neural tumours:Neural tumours:

– Optic nerve glioma: Presents with slowly progressive proptosis Optic nerve glioma: Presents with slowly progressive proptosis and visual lossand visual loss

– Optic nerve sheath meningioma: Typically affects middle aged Optic nerve sheath meningioma: Typically affects middle aged females, causes slowly progressive visual loss followed by females, causes slowly progressive visual loss followed by proptosis.proptosis.

Metastatic:Metastatic:– Bilateral orbital metastases of neuroblastoma to orbit presents Bilateral orbital metastases of neuroblastoma to orbit presents

with bilateral ecchymosis in a 2yr old child.with bilateral ecchymosis in a 2yr old child.

Dermoid cyst:Dermoid cyst:– Presents in children with proptosis and/or palpable massPresents in children with proptosis and/or palpable mass– Rx - excisionRx - excision

Orbital blow out fractureOrbital blow out fracture Blow-out fracture of orbital floor - is typically caused by a sudden increase in the orbital Blow-out fracture of orbital floor - is typically caused by a sudden increase in the orbital

pressure by a striking object which is >5cm in diameter such as a fist or tennis ball.pressure by a striking object which is >5cm in diameter such as a fist or tennis ball.

Clinical features:Clinical features:– Periorbital oedemaPeriorbital oedema– EnophthalmosEnophthalmos– Vertical diplopiaVertical diplopia– Infra orbital anaesthesiaInfra orbital anaesthesia– Subcutaneous emphysemaSubcutaneous emphysema

Investigations Investigations – X- ray orbit and sinusesX- ray orbit and sinuses– CT scan CT scan

Management:Management:– Antibiotics to prevent infection from maxillary sinusAntibiotics to prevent infection from maxillary sinus– Avoid blowing noseAvoid blowing nose– Observation vs. surgery Observation vs. surgery