Presentation on theme: "Orbit, Lid and Lacrimal disorders"— Presentation transcript:
1 Orbit, Lid and Lacrimal disorders Dr Mahmood Fauzi Ansari ASSIST PROF OPHTHALMOLOGY AL MAAREFA COLLEGE
2 ObjectivesReview the clinical anatomy and physiology of Eyelids and AdenexaDescribe disorders of eyelids (infections, malposition, tumors and congenital conditions)Describe disorders of lacrimal system (obstruction ,infection)Enumerate causes and management of Epiphora and Dry eyeOutline Diagnosis and management of orbital infectionCompare between pre-septal and septal cellulitisDevelop the Differential diagnoses of Orbital Inflammatory Disease
3 The orbit Function Anatomy protection to the globe attachments which stabilize the ocular movement;transmission of nerves and blood vessels.
6 The orbit Clinical features of orbital disease Eyelid and conjunctival changesReduced visual acuityPainProptosisEnophthalmosDiplopia
7 Proptosis (exopthalmos) Protrusion of the eye caused by a space-occupying lesionMeasured with an exophthalmometer.3 mm difference between the two eyes is significant.Direction of proptosisTransient proptosis (orbital varices)Fast onset proptosis (malignant, inflammatory)Slow onset proptosis (benign)Pain associated with proptosis ( orbital cellulitis)
8 Thyroid ophthalmopathy Clinical featuresPathogenesisProptosis (most common cause in adults)Lid retraction (characteristic stare)Lid lagDouble visionRed painful eye (exposure)Reduced visual acuity (optic nerve)Disorders of the thyroid gland can be associated with an infiltration of the extraocular muscles with lymphocytes and the deposition of Glycosaminoglycans.An immunological process is suspected but not fully determined.
9 Grading system for thyroid associated ophthalmopathy Pneumonic NO SPECS N: no signs O: only sign = upper lid retraction; Dalrymple S: soft tissue involvement (edema, chemosis, lagophthalmos) P: proptosis E: EOM involvement C: corneal involvement (SPK) S: sight loss (optic nerve compression)
12 Thyroid ophthalmopathy Treatment of associated ocular emergencies (optic nerve compression and corneal exposure)1- systemic steroid2- radiotherapy3- orbital decompression4- heavy lubricationLong term treatmentOnly after stabilization, muscle and lid surgery
13 Diplopia (Muscle pathology) Thyroid ophthalmopathy (Graves’ ophthalmopathy)Idiopathic Orbital Inflammatory Disease( orbital pseudotumor)
14 EnophthalmosCongenital (small eye)After trauma ( blow out fracture)
15 Orbital tumors Lacrimal gland tumors Optic nerve gliomas Meningiomas LymphomasRhabdomyosarcoma (most common orbital malignancy in childhood)Metastasis from other systemic cancers (neuroblastomas in children, the breast, Lung, prostate or gastrointestinal tract in the adult).
16 The orbital septumThe orbital septum is the fascia behind that portion of the orbicularis muscle that lies between the orbital rim and the tarsus; it serves as a barrier between the lid and the orbit. The superior orbital septum blends with the tendon of the levator palpabrae superioris and the superior tarsus; the inferior orbital septum blends with the inferior tarsus.
17 Disorders of the Orbit- infections Pre-septal Cellulitis (Periorbital cellulitis)Post-septal Cellulitis (Orbital cellulitis)
20 ORBITAL INFLAMMATORY DISEASE(OID) Idiopathic/non specific orbital inflammatory disease - inflammation of the orbital tissues of unknown cause resulting in orbital pain, diplopia and proptosisOrbital myositis - inflammation of extraocular muscles, most commonly the superior or lateral rectus, causing orbital pain on movement of affected muscles, diplopia, proptosisDacryoadenitis - inflammation of the lacrimal gland causing painful swollen lacrimal gland and reduced tear production; may be isolated or as part of diffuse idiopathic orbital inflammatory diseaseWegener's granulomatosis - systemic small-vessel vasculitis characterised by necrotising granulomatous inflammation; c-ANCA positive in most cases; ocular involvement can include conjunctivitis, episcleritis, uveitis, retinal artery occlusion, nasolacrimal duct occlusion and optic nerve vasculitis.
21 (d) Tumour in region of the lacrimal gland, note S-shaped ptosis. The differential diagnosis of OID includes infection, inflammation, and tumor.Orbital cellulitis in patient who presented with acute onset orbital inflammation post-foreign body.(b) Idiopathic OID in patient who presented with acute onset of orbital inflammation.(c) Thyroid orbitopathy in patient who presented with a several months history of increasing proptosis.(d) Tumour in region of the lacrimal gland, note S-shaped ptosis.
22 Anatomy and Physiology of the Eyelids and Adnexa The eyelids are composed of several layers of tissue which protect the anterior eyeball.From superficial to deep, they are the skin layer, a layer of striated muscle (orbicularis oculi), areolar tissue, fibrous tissue (tarsal plates), and a layer of mucous membrane (palpebral conjunctiva).The main supporting structure of the eyelids is a dense fibrous tissue layer, called the tarsal plate. The palpebral conjunctiva is the mucous membrane which adheres firmly to the tarsal plates and lines the posterior eyelids. The sensory nerve supply to the eyelids is derived from the first and second divisions of the trigeminal nerve (V).The blood supply to the lids is derived from the lacrimal and ophthalmic arteries by their lateral and medial palpebral branches.
25 The lid margins are divided into the anterior and posterior margins at the mucocutaneous junction. Glands of Zeis and glands of Moll are both found on the anterior margin. Glands of Zeis are small, modified sebaceous glands that open into the hair follicles at the base of the eyelashes; whereas glands of Moll are modified sweat glands that open in a row near the base of the eyelashes.The posterior lid margin is in close contact with the globe, and along this margin are the small orifices of modified sebaceous glands, called meibomian glands.
29 Posterior Blepharitis Involving the meibomian gland orifices (meibomitis)Associated with acne rosaceaSymptoms: similiar to anterior blepharitisSigns: thickening and telangiectasia of lid margins, decreased tear break-up time, rosaceaManagementLid massage after heatTopical antibiotics/steroidsTear film supplementsSystemic tetracyclines in persistent or severe cases
31 Anterior LamellaExternal hordeolum (stye) - acute abscess within lash follicle and its associated glands of Moll or ZeisSigns: tender, warm, swollen, red eyelid lumpManagement - warm compression, topical antibiotic; add oral antibiotic in preseptal cellulitisCyst of Moll - translucent cyst arises from blockage of gland of Moll (apocrine sweat gland)Cyst of Zeis - poorly translucent cyst arises from blockage of gland of Zeis (modified sebaceous gland)Xanthelasma - deposition of lipids within perivascular xanthoid cells which may be idiopathic or associated with hyperlipidaemia, hypothyroidism or primary biliary cirrhosis.
32 Posterior LamellaInternal hordeolum - acute abscess within a meibomian gland resulting in tender lump with inflammationUsually caused by Staphylococcus aureusManagement - warm compression, oral antibiotics in preseptal cellulitisChalazion - chronic lipogranulomatous inflammation of blocked meibomian glands.Often evolving from an internal hordeolumCommon in patients with chronic marginal blepharitis, rosacea, seborrhoeic dermatitis.Management - small chalazion tends to resolve itself; persistent and symptomatic chalazion can be surgically removed by incision and curettage.
33 Ptosis - Abnormally low position of the upper lid EYELID MALPOSITIONEctropion - Abnormal eversion of eyelid (usually the lower) away from the globeEntropion - Abnormal inversion of eyelid (usually lower) towards the globePtosis - Abnormally low position of the upper lidHorner's Syndrome(ptosis+meiosis+anhydrosis+enopthalmos)
34 EctropionAbnormal eversion of eyelid (usually the lower) away from the globe Congenital - rareParalytic - due to orbicularis weakness secondary to seventh cranial nerve palsyInvolutional - due to age-related tissue laxityCicatricial - due to shortened anterior lamella resulting from scarringMechanicalManagementLubricants and artificial tearsTaping lower and upper eyelids together overnightCorrective surgery
35 Entropion Congenital - rare Acute spastic - caused by sustained eyelid orbicularis contraction secondary to ocular irritationInvolutional - due to inferior refractor dysfunction/tissue laxityCicatricial - due to shortened posterior lamella resulting from scarringManagementTaping eyelid to the cheekBotulinum injectionCorrective surgery
36 Ptosis Management Involutional/aponeurotic ptosis – most common form of ptosis; arises from disinsertion, dehiscence or attenuation of levator palpebrae superiorisNeurogenic ptosis - third nerve palsy (dilated pupil, inability to elevate and adduct the globe), Horner's syndrome (constricted pupil; partial ptosis due to weakness of Muller's muscle)Myasthenic ptosis - Myasthenia gravis (fatiguable ptosis)Myopathic ptosis - chronic progressive external ophthalmoplegia, myotonic dystrophyMechanical ptosis - masses, infiltration, oedema of upper lidDermatochalasis (a form of pseudoptosis) - excess skin of upper lidsManagement ConservativeSurgery - depending on the amount and type of ptosis, degree of levator function. There are three main approaches including anterior (transcutaneous/external)posterior (transconjunctival/internal)brow/frontalis suspension surgery
37 Viral Infections Treatment Varicella zoster – Widespread vesicular rash, primarily affecting the head neck and trunk.Reactivation of virus gives rise to shinglesHerpes zoster ophthalmicus(shingles)Occurring in the first division of the trigeminal nerveCharacteristic unilateral maculopapular rash,Associated with marked pain and systemic malaise (1 week prior to the development of the rash)Common in older patient .Hutchinson's sign: cutaneous involvement of the tip of the nose suggests an increased likelihood of ocular complications).TreatmentSystemic Antivirals (eg famciclovir )Management of lid involves cool compresses and topical lubrication ± topical antibiotics for secondary infectionsHerpes simplexprimary infection is usually not clinically apparent unless occurring in the neonate or when associated with immunodeficiency.Secondary infection frequently manifests as a dendritic corneal ulcer
38 Malignant tumours Basal cell carcinoma (rodent ulcer) >90% of all neoplastic eye lesionsFrequently occurs on the lower lidIndurated Plaque ± Lid distortion and Lash Abnormalities.Treatment is with wide local excision.Is Basal Cell Carcinoma Serious? …Yes, Basal Cell Carcinoma can kill if left untreated.
39 Sebaceous Gland Carcinoma accounts for 5% of all malignant eyelid tumors. can originate from Meibomian glands, Zeis glands or the sebaceous glands of the caruncle.more common in the upper eyelidSquamous cell carcinomaaccounts for ~2-5% of lid malignanciesThe tumour tends to occur on the lower lid at the margin,commonly in fair-skinned elderly people with a history of sun exposure.Plaque-like (rough, scaly erythematous patch), nodular or ulcerating with a sharply defined base and everting borders.It can be aggressive: refer early if you suspect this.
40 Congenital disorders of the lid vertical folds of skin extending from the upper eyelids to the side of the noseThese are NORMAL features in Orientals.Epicanthic foldsColoboma-uncommon condition of a partial or full thickness defect of the lid-associated with systemic conditions such as Treacher Collins' syndrome.-Treatment is surgical.Cryptophthalmos –failure of lid development
49 Nasolacrimal duct obstruction, right eye Nasolacrimal duct obstruction, right eye. Note the build-up of tears and mucous along the lower lid margin.Congenital dacryocystocele of the lacrimal sac in a newborn baby. A dacryocystocele is located just inferior to the medial canthus and presents as a purplish or greyish-blue swelling.
51 These structures are involved in the production and drainage of tears. The lacrimal puncta, canaliculi, and sac, and the nasolacrimal duct form the drainage system, ultimately draining into the nose.The nose is lined by a highly vascular mucosal epithelium; consequently, topically applied medications that pass through this nasolacrimal system have direct access to the systemic circulation. Valve-like folds of the epithelial lining of the duct, called the valve of Hasner tend to resist the retrograde flow of tears and air. When the structure is imperforate, it is the most common cause of congenital nasolacrimal duct obstruction, resulting in epiphora and chronic dacryocystitisThe lacrimal apparatus consists of the lacrimal gland, accessory lacrimal gland, lacrimal puncta, lacrimal canaliculi, lacrimal sac and nasolacrimal duct.These structures are involved in the production and drainage of tears.The blood supply of the lacrimal gland is derived from the lacrimal artery. The lymphatic drainage drain into the pre-auricular lymph nodes.The nerve supply of the lacrimal gland is by the lacrimal nerve (sensory), a branch of the trigeminal first division, the great petrosal nerve (parasympathetic secretory), which comes from the superior salivary nucleus and is a branch of the facial nerve; and sympathetic nerves accompanying the lacrimal artery and the lacrimal nerve.
52 Any abnormality of one of the three layers produces an unstable tear film and the symptoms of dry eyes.A tear Layer frequently affected is the Aqueous Layer, Resulting in Aqueous Tear Deficiency (ATD) or lacrimal hyposecretion.
53 A tearing eye may be a nuisance but usually is not a serious problem. Epiphora- watery eyesA tearing eye may be a nuisance but usually is not a serious problem.Successful management of the tearing patient requires the clinician to determine the underlying cause of the epiphora.Common causes of watery eyes include:Blepharitis(eyelid inflammation)Blocked tear ductCommon coldEctropion (outwardly turned eyelid)Entropion (inwardly turned eyelid)Foreign object in the eyeHay feverInfection of the tear ductIngrown eyelash (trichiasis)Irritation of the cornea (front of the eye)conjunctivitisTrachomasome times, dry eye can be a contributing factorMedications that can cause watery eyes include:Epinephrine , Chemotherapy drugs, Cholinergic agonists, Eyedrops, especially echothiophate iodide (Phospholine Iodide) and pilocarpineManaging the ‘Tearing’ patientDilation,punctoplasty,silicone intubation
54 Dry eyeDry eye syndrome can occur if your eyes do not produce enough tears or your tears evaporate too quicklySymptoms of dry eye:Pain ,Light sensitivity, A gritty sensation, A feeling of a foreign body or sand in the eye,Itching,RednessBlurring of vision (Without tear film, good vision not possible.)What Causes Dry Eyes?The natural aging process, especially menopauseSide effects of certain drugs such as antihistamines and birth control pillsDiseases that affect the ability to make tears, such as Sjogren's syndrome, rheumatoid arthritis, and collagen vascular diseasesStructural problems with the eyelids that don't allow them to close properlyManaging the dry eyeArtificial tear drops and ointments.Temporary punctal occlusionLipiflow. use heat and pressure on the eyelids to unclog blocked glands.Restasis. (Cyclosporine Ophthalmic Emulsion) 0.05% increases eyes’ natural ability to produce tears, in Chronic Dry Eye. RESTASIS® did not increase tear production in patients using anti-inflammatory eye drops or tear duct plugs
55 Useful ResourcesDiagnosis and Management of Eyelids and Lacrimal Abnormalities.External Eye Overview - Lashes, eyelids and lacrimal system.Eyelids, Orbit and Lacrimal System.