eyelid orbit lacrimal

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Eyelids, Orbit and Lacrimal

System

Hernando L. Cruz Jr., EyeMDSection of Ophthalmic Plastic, Reconstructive,

Lacrimal & Orbital Surgery

Department of Ophthalmology




System

Eyelids

Basic Anatomy and Physiology

Eyelid Lesions

Disorders of the Eyelashes

Entropion

Ectropion

Ptosis




System

Orbit

Applied Anatomy

Clinical Evaluation of Orbital Diseases Diagnostic Modalities in Orbital Diseases

Graves’ Ophthalmopathy

Orbital Infections

Orbital Tumors

Orbital Fractures




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




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




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




Movements of the Lids

3rd and most important element

levator palpebrae superioris, orbicularis oculi

and Muller ’s muscle




7 structural layers of the eyelid

1. 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




I. Skin and Subcutaneous Tissue

thinnest of the body

no subcutaneous fat

Upper lid crease




II. Muscles of protraction

orbicularis oculi

CN VII

Pre-tarsal, Pre-septal, Orbital parts



Orbicularis Oculi Muscle




III. Orbital Septum

multilayered sheet of fibrous tissue

fuses with the aponeurosis to form the lidcrease

serves as a barrier between the eyelid and the

orbit




IV. Orbital Fat

lies posterior the orbital septum and anterior the

levator aponeurosis with age-related attenuation - “eyebag”




V. Muscles of Retraction

Upper Eyelid

• Levator Muscle and its Aponeurosis

• Muller ’s Muscle

Lower Eyelid

• Capsulopalberal Fascia

• Inferior Tarsal Muscle




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




Muller ’s Muscle

originates at the undersurface of the

aponeurosis sympathetically innervated

provides app. 2 mm of eyelid elevation




Lower lid retractors

Capsulopalpebral Fascia - analogous to levator

aponeurosis Lockwood’s ligament - analogous to whitnall’s

ligament

Inferior tarsal Muscle- analogous to Muller ’smuscle



Lower Eyelid Anatomy




Tarsus

firm, dense plate

skeleton of the eyelid

Conjunctiva

non-keratinizing squamous epithelium

contains goblet cells & acc. Lacrimal glands




Vascular Supply

Arterial Supply

ICA - supraorbital and lacrimal artery

ECA - angular and temporal artery

Venous Drainage

Pretarsal - angular vein (medially); superficialtemporal vein (laterally)

Posttarsal - orbital vein




Nerve Supply

Sensory

• Supraorbital Nerve (V1)- innervates the foreheadand 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




Chalazion - chronic

granulomatous

inflammation of themeibomian glands.

It is a painless round

lesion within the

tarsal plate




External Hordeolum-

infection of the

glands of Moll andZeiss. Usually caused

by staphylococcus.

Tender inflamed

swelling in the lidmargin




Internal Hordeolum-

acute staphylococcal

infection of themeibomian glands.

Tender inflamed

swelling within the

tarsal plate




Treatment

Oral Antibiotics

Topical Antibiotics Warm compress

Surgical: I & C



Miscellaneous Eyelid Lesions

Molluscum contagiosum - pox virus;

painless umbilicated nodule




Strawberry Nevus – flat

red lesion within 6

months of birth;involute spontaneously

Inc. in size during

straining or crying butno pulsation and bruit




Port Wine Stain -

nevus flammeus;

well demarcated pink patch that

darkens with age

45% incidence of

glaucoma 5% sturge weber

syndrome



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



Malignant Eyelid Tumors

Squamous Cell Carcinoma

hard nodule or a scaly patch which develops

crusting erosions and fissures over a fewmonths.

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

Trichiasis

Distichiasis




Trichiasis

posterior misdirection of previously normal

lashes usually associated with trachoma and severe

chronic staph. Blepharitis




Trichiasis




Distichiasis

- abnormal row of lashes




Treatment

Epilation

Electrolysis

Cryotherapy

Laser thermoablation



Entropion

Inversion of the Eyelid

4 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

Treatment

1. Cautery

2. Transverse Lid-everting sutures

3. Weiss procedure



Entropion



Entropion

Cicatricial entropion

- usually caused by scarring of the palpebral

conjunctiva, which pulls the lid margin towardsthe 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 thetarsal plate

inward turning of the entire lower eyelid and

lashes

absence of lower lid crease

DDX: Congenital epiblepharon



Entropion



Ectropion

outward turning of the eyelid

usually associated with epiphora and

conjunctivitis Types

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

Treatment

Involutional Ectropion

determined by the position and amount of Horizontal lid Laxity.



Ectropion



Ectropion

Treatment

Mild Medial Ectropion

Medial Canthoplasty

Severe Medial Ectropion

Lazy T- procedure

Extensive Ectropion

Bick procedure

Kuhnt-Szymanowski procedure



Ptosis

Drooping of the eyelids

Types (My NAMe )

N eurogenic

A poneurotic

• Involutional

•

Post-operative Me chanical

My ogenic



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



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

Parameters

1. 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




The Bony Orbit:




Roof of the Orbit

frontal bone and lesser wing of the sphenoid

located adjacent to anterior cranial fossa andfrontal sinus

Lateral wall of the Orbit

zygomatic bone and greater wing of thesphenoid




Orbital Roof




Medial Wall

ethmoid, lacrimal, maxillary and sphenoid

bones forms the lateral wall of the sphenoid sinus

Floor of the Orbit

maxillary, palatine,& zygomatic bones




Medial Wall




Orbital Apertures

1. 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,




Clinical Evaluation of Orbital



Diseases

6 P’s

Pain

Proptosis Progression

Palpation

Pulsation Periorbital Changes




Diseases

Proptosis

Axial Displacement - retrobulbar lesions like

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




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 andlymphoma, pseudotumor




Diseases

Progression

Days to weeks - inflammatory diseases.

Infectious diseases, metastatic tumors

Months to years - dermoids, benign mixed

tumors, lymphomas




Diseases

Palpation

superonasal - Mucoceles, neurofibromas dermoids

superotemporal - lacrimal gland tumor pseudotumor

Pulsations

with bruit - CCS Fistula

without bruit - meningoencephalocoeles

Diagnostic Modalities in Orbital



g

Diseases

Primary Studies

CT scan

MRI Ultrasonography

Histopathology

Secondary Studies Venography

Arteriography




Diseases




DiseasesCT 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




Autoimmune disorder that is related to

excess secretion of thyroid hormone

10-25% occurs in the absence of anythyroid dysfunction

Female/male ratio 8:1

4th to 5th decades of life most common cause of adult unilateral and

bilateral exophthalmos




Pathogenesis

1. Hypertrophy of

Extraocular

Muscles

2. Cellular Infiltration

3. Proliferation of

orbital fat,connective tissue




Main Clinical Manifestation

1. Eyelid retraction

2. Soft Tissue involvement

3. Proptosis

4. Optic Neuropathy

5. Restrictive Myopathy




Eyelid Retraction




Soft Tissue

Involvement

1. Conjunctival

Injection

2. Chemosis

3. Eyelid Fullness




Proptosis




Restrictive Myopathy

IR>MR>SR>LR




CT Scan EOM

Hypertrophy

with tendonsparing

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 thanmale.

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 bacterialsinusitis

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

Metastatic

Tumor invasion fromadjacent 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 withsystemic chemotherapy



Pleomorphic Adenoma

Most common

epithelial tumor of the

lacrimal gland

4th -5th decades of

life, mostly men

progresssive, painless,

downward & inwarddisplacement



Epidermoid / Dermoid Cyst

Dermoid is a benign

cystic teratoma

well-encapsulated lined

by stratified squamous

& contain dermal

appendages

Epidermoid - does notcontain dermal

appendages

f h bi



Fractures of the Orbit

Orbital floor

Fracture

Most frequentlyinvolve wall

Usually along the

infraorbital canal

O bi l l



Orbital Floor Fracture

Clinical Features

Periocular Changes – ecchymosis, edema,

subcutaneous emphysema

Enophthalmos

Infraorbital nerve anesthesia

Diplopia

F f h O bi




F f h O bi




F t f th O bit




L i l S t



Lacrimal System

Puncta

Ampullae

canaliculi lacrimal sac

nasolacrimal duct

T Fl Ph i l



Tear Flow Physiology

E l ti f T i



Evaluation of Tearing

Lacrimation vs Epiphora

Lacrimation - reflex over production of

tears from stimulation of CN V byirritation of the cornea and conjunctiva

Epiphora - normal tear production but there

is physical obstruction on the drainagesystem

I f ti f L i l P



Infections of Lacrimal Passages

Canaliculits -

unilateral epiphora

with mucopurulent

discharge. “Pouting of the punctum” on slit

lamp exam.

I f ti f L i l P



Infections of Lacrimal Passages

Dacryocystitis infection

of the lacrimal sac.

Presents as a painfulswelling at the medial

canthal area.

S i l T h i



Surgical Techniques

External DCR

Endoscopic Laser-Assisted DCR

Transcanalicular Endoscopic DCR



Thank you for your kind attention!

eyelid orbit lacrimal

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