Palpebra Dan Jaringan Orbita Fix
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Transcript of Palpebra Dan Jaringan Orbita Fix
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Kelainan Palpebra dan Jaringan
Orbita
Dr.Irvan
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Anatomy• Consists of :
– Skin :• the thinnest• loose• no subcutaneus fat
– Muscle of protraction :• M.orbicularis oculi
– Orbital septum, orbital fat – Muscle of retraction :
• M. levator
– Tarsus – Conjunctiva
– Cilia – Glands :
• Zeis• Moll• Meibom
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• Tarsus :
– firm, dense connective tissue--> skeleton of the eye lid
– upper eye lid tarsal plate :10-12 mm
– lower eye lid tarsal plate
:4,5 mm
– width : 29 mm
• Vascularization :
– A/V ophthalmic
– A/V lacrimalis
• Sensoric Inervation : N V
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• Muscles : – Orbicularis oculi muscle
• circular
• function : to close the lids
• inervation : N VII
– Levator palebra muscle :• attached to upper border
of the tarsus and middle
portion of the skin• function : to open the lids
• inervation : N III
– Muller’s muscle : • smooth muscle
• insertion : at the proximaledge of the tarsus
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• The function of palpebra :
– To protect the eye ball from external physic or
chemist injuries and trauma
– To keep the eye ball surface wet and slippery
with well distributing tears and glands secretion
productions
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Eyelid Diseases
• Infection – Hordeolum
• Suppurative acute infection at
eyelids gland caused by
Staphylococcus – Hordeolum internum : at meibom
gland
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– Hordeolum eksternum : at zeis, mole
gland
• Therapy :
– Systemic & local antibiotics
– Incision :
» mostly common on hordeolum
externum
» Skin incision : margo
» Conjuctival incision : margo
• Complication : eyelids abscess
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• Chalazion
– Chronic lipogranulomatous inflammation of themeibom gland
– red-purple painless nodule at the conjunctiva
– Therapy : incision
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• eyelids abscess (abses palpebra)
– originates from hordeolum or severe eyebrow
infections
– Therapy :
• Local and systemic antibiotics
• incision skin line
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• Blepharitis
– chronic infection margin of the eye lid
– Squamous blepharitis (seborrhea) :
• signs : itching, burning, squamous seborrhoic at the lash
• Th/ : - Cleaning with wet cotton
- Topical steroid: used infrequently.
- Topical (fusidic acid) +- systemic antibiotic staphylococcal liddisease .
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– Ulcerated blepharitis :
• margo infection caused by
staphylococci at children with bad general condition
• clinical signs : red palpebra,
squamous seborrhoic,
ulceration along margo covered
by crust,
• loss of eye lashes, margo
distortion (if chronic and
severe)
• Th/ : improving generalcondition, clean the crust with
wet cotton, antibiotic ointment
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• Herpes Zoster Ophtalmica
– E/ : herpes zoster viral
– clinical signs : very pain and burning (caused
by disturbances of the first branch of nervus V)
– Th/ : analgetic, antiviral (acyclovir), antibiotic
(to prevent from secondary infection) and localcorticosteroid
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• ALERGY – Clinical signs : eye lids edema
– Type :• anaphylactic and atopy (urticaria and angioneurotic
edema)
• contact allergy (cosmetic)
– Th/ :
• eliminate etiological agent• local and systemic steroid ( depend on the E/)
• Antihistamin
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• Tumor – Benign :
• naevus
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• verucca
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• xanthelasma : – yellowing plaque, irregular esp.. at
medial
– Th/ : excision (for cosmetic reason)
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• milium : – small and white papil (lenticular )
– caused by retention of sebacea gland
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• Haemangiom (vascular tumor)
– Cavernous haemangiom :» consists of the big branch of vein at
subcutan» blueing
» change at vaso dilatation --> bigger if crying (Valsava test +)
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– Capilary haemangiom :» superficial
» consist of widing capillary
» red – Th/ :
» cryocoagulation (if big and disturbing)
» steroid injection
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• Neurofibromatosis (von Recklinghausendisease)
» usually occur at temporal
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– Malignant• Basal Cell Ca at geriatric
» the most common eye lid malignancy (90-95%) on lower eye lid (near medial cantus)
» clinical signs : ulcerative node, irregular, pigmentation,metastation rare
» Th/ : excision and radio th/
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Squamous Cell Ca (Epithelioma)
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– Squamous Cell Ca (Epithelioma)
» at geriatric
» esp. at superior palpebra
» metastation to preauricular nodesthrough lymphatic system
» Th/ : wide excision
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– Malignant Melanoma» associated with conjuntival melanoma
» Th/ : radical operation --> excenteration
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– Sebaceous Cell Ca» at gland. Meibom
» recurrent Chalazion
» multifocal
» metastation : rare
» Th/ : wide excision
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Eye Lid Malposition
• Entropion
– turning in of the eye lid margin --> the lashes
touch the cornea (Trichiasis) --> corneal
irritation --> corneal ulcer
– unilateral or bilateral
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• Congenital entropion
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– Senile Entropion
• Th/ : blepharoplasty (reconstruction)
– Acute spastic• ocular inflamation
• ocular irritation
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– Cicatricial entropion
• caused by cicatrix/shortening of the tarsus
• E/ :
– trauma thermal, chemical burns and eye lid injury
– infections : trachoma, herpes zoster
• Th/
– eye lid reconstruction
– trachoma --> Sie Boen Lian technique (SBL)
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• Ectropion – turning out of the eye lid margin--> conjunctiva is not well
covering --> thick, red, chronic conjunctivitis
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– Congenital ectropion
– Senile ectropion :• caused by tissue relaxation--> loss of eye lid tone-->evertion
of margin• often seen in the lower eye lid
– Paralytic ectropion :• caused by N.VII palsy--> poor blinking & lagophthalmos
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– Cicatrical ectropion
• Th/ : blepharoplasty/reconstruction
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• Mechanical
– caused by :
» bulky tumor of the eye lid» fluid accumulation
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• Simblepharon
– attachment of the eye lid to the eye ball (usually
with cornea) – Th/ : simblepharectomy
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• Lagophthalmos
– the eyelids aperture can not close perfectly
– E/ : paralyze of N.VII, cicatrix, proptosis,tumor
– complication : xerosis (dry eye)
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• Ptosis – the upper eye lid can not open perfectly
– unilateral/bilateral
– congenital ptosis
– acquired ptosis• senile
• myogenic
• neurogenic (paralyze of N.III)• trauma
• mechanic (tumor)
– Th/ :
• fasanela servat – if some and the function of levator still good
• levator shortening – skin approach or conjunctival approach
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Kelainan Jaringan Orbita
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Clinical Evaluation of Orbital
Diseases• 6 P’s
– Pain
– Proptosis
– Progression
– Palpation
– Pulsation – Periorbital Changes
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Graves’ Ophthalmopathy
• 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
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Graves’ Ophthalmopathy
Pathogenesis
1. Hypertrophy of
Extraocular Muscles
2. Cellular Infiltration
3. Proliferation of
orbital fat,
connective tissue
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Graves’ Ophthalmopathy
Main Clinical Manifestation
1. Eyelid retraction
2. Soft Tissue involvement
3. Proptosis
4. Optic Neuropathy
5. Restrictive Myopathy
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Graves’ Ophthalmopathy
• Eyelid Retraction
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Graves’ Ophthalmopathy
• Soft Tissue
Involvement
1. Conjunctival
Injection
2. Chemosis
3. Eyelid Fullness
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Graves’ Ophthalmopathy
• Proptosis
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Graves’ Ophthalmopathy
Restrictive Myopathy
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Graves’ Ophthalmopathy
CT Scan – EOM
Hypertrophywith tendon
sparing
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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
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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
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Orbital Infections
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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
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Orbital Infections
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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 from
adjacent structures
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Capillary Hemangioma
– Most common
tumor of the orbit in
childhood
– increase in tumor size during crying
and straining
– absent bruit and
pulsation – involute
spontaneously
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Cavernous Hemangioma
• Most common benign
orbital lesion in adults
• middle-aged women
commonly affected
• enhanced well-
encapsulated mass on
CT scan
• Tx: Surgical Excision
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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
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Pleomorphic Adenoma
• Most common
epithelial tumor of the
lacrimal gland
• 4th -5th decades of
life, mostly men
• progresssive, painless,
downward & inwarddisplacement
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Epidermoid / Dermoid Cyst
• Dermoid is a benign
cystic teratoma
•well-encapsulated lined by stratified squamous
& contain dermal
appendages
• Epidermoid - does notcontain dermal
appendages
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Fractures of the Orbit
• Orbital floor
Fracture
– Most frequentlyinvolve wall
– Usually along the
infraorbital canal
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Orbital Floor Fracture
• Clinical Features
– Periocular Changes – ecchymosis, edema,
subcutaneous emphysema – Enophthalmos
– Infraorbital nerve anesthesia
– Diplopia
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Fractures of the Orbit
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Fractures of the Orbit
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Fractures of the Orbit
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Fractures of the Orbit
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Fractures of the Orbit
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Lacrimal System
• Puncta
• Ampullae
• canaliculi
• lacrimal sac
• nasolacrimal duct
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Tear Flow Physiology
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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
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Infections of Lacrimal Passages
• Canaliculits -
unilateral epiphora
with mucopurulent
discharge. “Pouting of
the punctum” on slit
lamp exam.
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Infections of Lacrimal Passages
• Dacryocystitis infection
of the lacrimal sac.
Presents as a painfulswelling at the medial
canthal area.
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Surgical Techniques
• External DCR
• Endoscopic Laser-Assisted DCR
• Transcanalicular Endoscopic DCR
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Thank you for your kind attention!