Lagophthalmos The palpebral aperture cannot be closed properly
when the eyes are shut Bells 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 Bells 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
(Horners 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
ductobstruction . 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 instructedto press on lacrimal sac in a
downward direction. This may help to remove any remnants of
epithelium or to open Hasners 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.
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