Lagophthalmos The palpebral aperture cannot be closed properly when the eyes are shut Bell’s palsy Cicatricial ectropion Proptosis Thyrotoxicosis

PTOSIS Definition: Ptosis is the drooping of the upper eyelid that normally covers the upper 1/6 of the cornea.

Classification of ptosis 1. Neurogenic ptosis Third nerve palsy Horner syndrome Marcus Gunn jaw-winking syndrome Third nerve misdirection 2. Myogenic ptosis Myasthenia gravis Myotonic dystrophy Ocular myopathy Simple congenital Blepharophimosis syndrome 3. Aponeurotic ptosis Involutional postoperative 4. Mechanical ptosis

Evaluation of ptosis N.B. pseudoptosis: occurs with loss of support e.g. enophthalmos and atrophia bulbi 1. Clinical history 2. Exclude pseudoptosis 3. Unilateral ptosis can be determined by comparing the vertical dimension of the palpepral aperture of two sides.

4. Bilateral ptosis a. Measuring the amount of cornea covered b 4. Bilateral ptosis a. Measuring the amount of cornea covered b. Action of LPS 5. Presence of Bell’s phenomenon 6. Action of superior rectus 7. jaw-winking phenomenon 8. Abnormal tear film and corneal sensitivity

Tumours of the lids A. Benign tumour B. Malignant 1. Naevus 1. Carcinoma 2. Heamangioma 2. Sarcoma 3. Xanthelasma 3. M.M. 4. Molluscum contagiosum 5. Neurofiboromatosis

Naevus Either from skin or conjunctiva. Rarely under go malignant transformation Haemangioma Either capillary or cavernous Sometime associated with Haemangiomata of choroid and leptomeninges and hydrophthalmos ( sturge – Weber syndrome)

Xanthelasma: Subcutaneous deposits of cholesterol on the medial canthus region. It is seen in diabetics and in patients with hypercholesterolemia.

Molluscum contagiosum Small, flat, umbilicated growth along the lid margin, caused by a large size poxvirus Neurofibromatosis Is a generalized disease may involve the lid and cause mechanical ptosis

Cacinoma of the lid More common than other tumours and most frequent in men over 50 years 1. Squamous cell carcinoma ( epithelioma) shows predilection for the lid margin. Started as small nodule which ulcerates and later resulting in fungating growth. It grows slowly and painlessly with lymph glands enlargement

2. Basal cell carcinoma ( rodent ulcer ) Is much more common in lower lid, locally invasive and does not spread to lymph nodes. Started as small pimple which ulcerates. The ulcer has a raised nodular border and indurated base it spread very slowly and eventually erodes the surrounding structures. The tumor is radiosensitive

THE LACRIMAL SYSTEM Anatomy of the lacrimal system Secretory system Darainage system

The lacrimal Secretory system The lacrimal secretory system is formed of The main lacrimal gland. The accessory lacrimal glands of krause and Wolfring. Conjunctival goblet cells.

Nerve supply: Blood supply: Lymphatic drainage: Sensory: lacrimal nerve Sympathetic: vasoconstrictor to the blood vessels. Parasympathetic: parasympathetic secretory to the lacrimal gland (from the facial nerve). Blood supply: Lacrimal artery Lymphatic drainage: Preauricular lymph nodes

Precorneal tear film: It is formed of 3 layers Outer lipid layer: secreted by the meibomian glands. Function: Prevent rapid evaporation of tears Lubricates the eyelids over the globe. 2. Middle aqueous layer: secreted by the lacrimal gland Supplies oxygen to the corneal epithelium. Antibacterial as it contains lysozymes. 3. Inner mucinous layer: secreted by the goblet cells. Function: makes the corneal epithelium hydrophilic.

The Lacrimal Drainage System Two puncti Two canaliculi Lacrimal sac Nasolacrimal duct Nose

Tear Drainage Evaporation: 25% of tears Excretion: a. Passive: Gravity and capillarity. b. Active: Lacrimal pump through the action of the lacrimal portion of orbicularis muscle (Horner’s muscle).

DRY EYE Etiology: Congenital absence of the lacrimal gland. Inflammation of lacrimal gland Tumors of lacrimal gland Keratoconjunctivitis sicca Conjunctival scarring

WATERY EYE 1. Lacrimation Lacrimation is over secretion of tears 2. Epiphora Epiphora is overflow of tears onto the cheek due to inadequate drainage, Which may be due to lacrimal pump failure or obstruction of the lacrimal passages.

Etiology of Epiphora: LACRIMAL PUMP FAILURE OBSTRUCTIVE EPIPHORA Puncti Canaliculi Lacrimal sac Nasolacrimal duct nose

CLINICAL EVALUATION AND INVESTIGATIONS OF EPIPHORA History: Exclude lacrimation as a cause Bilateral watering: is usually due to lacrimation. Unilateral watering: is usually due to epiphora. Examination: Eyelid: exclude the presence of ectropion and trichiasis. Lacrimal sac swelling and dacryocystitis. Nose: polypi, deviated septum

Investigations: Regurgitation test A +ve regurge. A –ve regurge. Jones test Type I test. Type II test. 3. Dacryocystography 4. Plain X ray 5. Tuberculin

LACRIMAL SAC DISORDERS ACUTE DACRYOCYSTITIS Definition: acute suppurative inflammation of the lacrimal sac. Etiology: Predisposing factor: nasolacrimal duct obstruction. Causative agent: pneumococci, Staphylococci and Streptococci.

CHRONIC DACRYOCYSTITIS Definition: A chronic inflammation of lacrimal sac secondary to obstruction of the naso-lacrimal duct. It is the commonest lacrimal sac disorder. Etiology: Predisposing factor: nasolacrimal duct obstruction . Causative agent: Pneumococci in 80% Staphylococci, Streptococci, trachoma, and fungi TB and Syphilis

Treatment of congenital dacryocystitis Antibiotics: systemic and topical (drop and ointment ) Hydrostatic Massage: The mother is instructed to press on lacrimal sac in a downward direction. This may help to remove any remnants of epithelium or to open Hasner’s valve. This is tried for a long period up to 6 months. Probing: is successful if done carefully as the lacrimal passages are still elastic and can be stretched on the probe. Irrigation: repeated syringing with saline may cure the condition. Dacryocystorhinostomy.

Treatment of acquired dacryocystitis Treatment of the cause of obstruction : e.g. relive congestion, removal of a nasal polyp. Dacryocystorhinostomy : operation of choice. Dacryocystectomy : in neglected cases.

Dacryocystorhinostomy (DCR) Principle: The idea is to create surgical opening between the lacrimal sac and the nasal mucosa of the middle meatus. allowing drainage of tears directly into the nose bypassing the obstructed naso-lacrimal duct. Indication: Chronic dacryocystitis. Mucocele of lacrimal sac Lacrimal fistula (DCR and fistulectomy)

Dacryocystectomy Contraindications: Bad lacrimal sac : extensive adhesion and neglected cases. Bad nasal mucosa : atrophic rhinitis and polyp. T.B and tumors of the sac. Hypopyon ulcer. Dacryocystectomy removal of the lacrimal sac. Indication: indicated in cases where DCR cannot be done.