Eye Lids and Lacrimal System

Anatomy• Consists of :

– Very thin , loose, fatty less, skin – muscles, artery & veins, lymph, nerve,

glands tied up by tissues which being compact in the posterior area, called Tarsus

– deeper layer : conjunctiva tarsal– Cilia (2-3 lines) found at the margo, that– Glands :

• Zeis : Fat• Moll : Sweat• Meibom :

– 20 - 25 glands– big– narrow straight-line– at tarsus– producing fat

• Tarsus :– build eyelids structure– superior ( height : 10 mm) is bigger

than inferior ( height : 4,5 mm)– width : 29 mm

• Vascularization :– A/V ophthalmic– A/V lacrimalis

• Sensoric Inervation : from N V

• Muscles :– Orbicular oculli muscle :

• circular• function : to open or close

the lids• inervation from N III

– Levator palebra muscle :• attached to upper border

of the tarsus and middle portion of the skin

• inervation from N III– Muller’s muscle :

• smooth muscle• insertion : at the proximal

edge of the tarsus• symphatic nerve ?

• The function of palpebra :– To protect the eye ball from external physic or

chemist injuries/trauma– To keep the eye ball surface wet and slippery

with well distributing tears and glands secretion productions

Eyelid Diseases

• Infection– Hordeolum

• Suppurative acute infection at eyelids gland caused by Staphylococcus

– Hordeolum internum : at meibom gland

– 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

• Kalazion– Chronic lipogranulomal inflammation at the

meibom gland– red-purple painless nodule at the conjunctiva– Therapy : incision

• eyelids abscess– originates from hordeolum or severe eyebrow

infections– Therapy :

• Local and systemic antibiotics

• incision skin line

• Blepharitis– bilateral– chronic infection at the edge of the eye lid– Squamous blepharitis (seborrhea) :

• clinical signs : itching, burning, Squamous seborroic at the lash

• Th/ : cleaning with wet cotton, corticosteroid ointment

– Ulcerate blepharitis :• margo infection caused by

staphylococci at children with bad general condition

• clinical signs : red palpebra, Squamous sebhorroic, ulceration along margo covered by crust,

• lose of lash, margo distortion (if chronic and severe)

• Th/ : improving general condition, clean the crust with wet cotton, antibiotic ointment

• 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 local corticosteroid

• ALERGY– Clinical signs : oedema of palpebra– Type :

• anaphilactic and atopy (urticaria and angioneurotic edema)

• contact allergy (cosmetic)– Th/ :

• eliminate etiological agent• local and systemic steroid ( depend on the E/)

• Tumor– Benign :

• naevus

• verucca

• xanthelasma : – yellowing plaque, irregular esp.. at

medial– Th/ : excision (for cosmetic reason)

• milium :– small and white papil (lenticular)– caused by retention of sebacea gland

• Haemangiom (vascular tumor)– Cavernous haemangiom :

» consists of the big branch of vein at subcutan

» blueing» change at vaso dilatation --> bigger if

crying

– Capilary haemangiom :» consist of widing capillary» red

– Th/ :» cryoangulation (if big and disturbing)» steroid injection

– Malignant• Basal Cell Ca (Rodent Ulcer) ~ 95%

» at geriatric» most common occur on inferior palpebra (esp. at medial

cantus of margo)» clinical signs : ulcerative node, irregular, pigmentation,

metastation rare» Th/ : excision and radio th/

– Squamous Cell Ca (Epithelioma)» at geriatric» esp. at superior palpebra» metastation to preauricular nodes

through lymphatic system» Th/ : wide excision

– Malignant Melanoma» comes from the metastation of conjuntival melanoma» Th/ : radical operation --> exenterating

– Sebaceous Cell Ca» at gland. Meibom » similar with Kalazion --> repeat growing » multifocal» metastation : rare» Th/ : wide excision

Palpebra Position Anomaly

• Entropion – eyelids margo directing into the eye ball --> the

lash touch the cornea (Trichiasis) --> irritation at cornea --> corneal ulcer

– cicatrical Entropion• caused by cicatrix at tarsal conjunctive and tarsus

• E/ : trauma and trachoma (SBL tarsotomic th/ - Sie Boen Lian)

– Senile Entropion• Th/ : blepharoplasty (reconstruction)

• Ektropion– eyelids margo directing outside --> conjunctive is not well

covering --> thick, red, like chronic conjunctivitis

– Senile Ectropion :• caused by loosing of muscle• at inferior palpebra

– Paralytic Ectropion :• caused by paralyze of M.orbicularis oculi

– Cicatric Ectropion

– Th/ : blepharoplasty/reconstruction

• Simblepharon– the condition of attachment of palpebra and eye

ball (usually with cornea or bulbic conjunctive)– Th/ : leave the condition alone (if small) and

simblepharectomy

• Lagophthalmus– the condition which is eyelids aperture can not

close perfectly– E/ : paralyze of N.VII, cicatrix, proptosis,

tumor– complication : xerosis (drying)

• Ptosis– the condition which is superior palpebra can not open perfectly– unilateral/bilateral– congenital ptosis– acquired ptosis

• senile• myogenic• neurogenic (paralyze of N.III)• traumatic• mechanic (tumor)

– Th/ :• fasanela servat

– if some and the function of levator still good• shorting levator

– from skin and conjunctive

APPARATUS LACRIMALIS

• Built of :– Secretion section -->

tears production• orbital gland

• eyelids gland

• gland. Krause

– Excretion section --> draining the tears into the cavum nasal

• Tear– rather alcalyc– containing NaCl, such a lyzozym enzyme that

bacteriostatic – Normal : tear dampened the eye ball --> the

excesses are evaporates and drainating to lachrymal punctum caused by eye blinking

– measure with Schirmer Test

Clinical features of lachrymal system disturbances

• Dry eye– caused by decrease of producing tear – occur at :

• conjunctival cicatrix caused by trachoma/trauma• Sjorgen syndrome• Steven Johnson syndrome

• deficiency of Vit A• lagophthalmous

• Epiphora– the disturbance of tear excretion– Occur on :

• lachrymal punctum position disturbance

• paralyze of M. orbicularis --> weaking the canaliculi suction effect

• obstruction of nasolacrimal duct and sac

Determining a lachrymal system disturbances

• punctum inspection

• palpation at sac area– push --> the secret come out

• testanel

• probing with probe from Bowman

• dacryosistograph with contrast

• dacryoskintilograph, sophisticated, with radioactive

The congenital disturbances of nasolacrimal system

• Nasolacrimal duct obstruction– often– temporary/permanent characteristic– Th/ :

• antibiotic drop

• massage of lachrymal sac

• irrigation probing

• Punctum anomaly– no punctum– punctum evertion

• loose palpebra -----> facial paralysis

• cicatrix -----> old age

– Th/ : reconstruction

Nasolacrimal system infection• Acute dacrioadenitis

– signs : lachrymal gland red, edema, pain, blepharoptosis (sometime)

– E/ :• adult : gonorrhoica• children : with another disease --> parotitis

• Chronic dacrioadenitis– slow edema– not pain– often at TB, leukemia, trachoma– Th/ : depend on the etiological agent

• Chronic dacriosistitis– caused by the obstruction of nasolacrimal duct– children and adult– signs :

• epiphore• push at sac area --> yellow thick fluid from the punctum

– Th/ : • topical and systemic antibiotic• if obstruction --> dacriosistorinostomi

• Lacrimal sac tumor– benign

• squamous papiloma– malignant

• epidermoid Ca– Th/

• operation (cystectomy)• radiation