Eyelid

• The eyelids are thin moveable folds of tissue that covers the
eyes anteriorly.

• The eyelids are split into upper and lower portions, which
meet at the medial and lateral canthi of the eye.

• The eyelid consists of five main layers (superficial to deep):

• 1-Skin and subcutaneous tissue
• 2-Orbicularis oculi
• 3-Tarsal plates
• 4-Levator apparatus
• 5-Conjunctiva
• Skin and Subcutaneous Tissue:
• -The skin and subcutaneous tissue form the most superficial
layer of the eyelid.

• The layer of skin is among the thinnest in the human body.

• In the subcutaneous layer, there is loose connective tissue but
no subcutaneous fat. Subsequently, the eyelids are readily
distended by edema or blood.

• The eyelashes are attached here with their accompanying

modified sweat glands – the ciliary glands of Moll. There are
also sebaceous glands located in this layer, known as the
glands of Zeis.
• Orbicularis Oculi:
• The orbicularis oculi muscle has three distinct parts – palpebral, lacrimal
and orbital.

• Attachments – Originates from the medial orbital margin, the medial

palpebral ligament, and the lacrimal bone. It then inserts into the skin
around the margin of the orbit, and the superior and inferior tarsal
plates.
• Actions:
• Palpebral part – gently closes the eyelids.
• Lacrimal part – involved in the drainage of tears.
• Orbital part – tightly closes the eyelids.

• Innervation – Facial nerve (CN VII, temporal and zygomatic branches)

• Tarsal Plates:
• The tarsal plates are located deep to the palpebral region of the
orbicularis oculi muscle. There are two plates: the superior tarsus
(upper eyelid) and inferior tarsus (lower eyelid).

• They form the scaffolding of the eyelid and are composed of

dense connective tissue. The superior tarsus also acts as the
attachment site of the levator palpebrae superioris.

• In the tarsal plates lie the Meibomian glands (also known as tarsal
glands). These are a specialized type of sebaceous gland that
secretes an oily substance onto the eye to slow the evaporation of
the eye’s tear film. The oily substance also prevents the eyelids
from sticking together when closed.
• Levator Apparatus
• It’s composed of two muscles: The levator palpebrae superioris and
superior tarsal muscles and they both act to open the eyelid. They are
only present in the upper eyelid.

• Levator Palpebrae Superioris: It opens the eyelid and is innervated by the

superior branch of the oculomotor nerve (CN III)
• Superior Tarsal Muscle: It assists the levator palpebrae superioris in
opening the eyelid and is innervated by sympathetic fibres from the
superior cervical ganglion.

• Conjunctiva
• The palpebral conjunctiva forms the deepest layer of the eyelid.

• It is a thin mucous membrane, which is reflected onto the sclera of the

eyeball (bulbar conjunctiva).
• Innervation:
• Sensory innervation to the eyelids is supplied by branches of the
trigeminal nerve:
• Ophthalmic nerve (V1) – upper eyelid.
• Supraorbital, supratrochlear, infratrochlear and lacrimal branches.
• Maxillary nerve (V2) – lower eyelid.
• Infraorbital and zygomaticofacial branches.

• Blood supply:
• Ophthalmic artery – lacrimal, medial palpebral, supraorbital, dorsal
nasal and supratrochlear arteries.
• Facial artery – angular branch.
• Superficial temporal artery – transverse facial artery branch.
• Function of the eyelids:

• Protection: protect the eyeball from light and

injuries
• Spread the tear film over the conjunctiva and
cornea with each blink.
• Contain the meibomian oil gland which provide
the lipid component of the tear film.
• Prevent dryness of the eyes.
• Contain the puncta through which the tears flow
into the lacrimal drainage system.
Ptosis (Blepharoptosis)
• This is an abnormally low position of the upper eyelid. (drooping
of the upper eyelid margin)
• PATHOGENESIS
• caused by:
• 1-Mechanical factors:
• (a) Large lid lesions pulling down the lid.
• (b) Lid oedema.
• (c) Tethering of the lid by conjunctival scarring.
• (d) Structural abnormalities including a disinsertion of the
aponeurosis of the levator muscle, usually in elderly patients.
• 2-Neurological factors:
• (a)Third nerve palsy
• (b)Horner’s syndrome: happens due to disruption of the sympathetic pathway
• (c)Marcus–Gunn jaw-winking syndrome: (known also as Trigemino-oculomotor
Synkinesis) where there’s a relation between the movement of the lower jaw and the
upper lid, and ptosis is usually unilateral.
• 3.Myogenic factors:
• (A)Myasthenia gravis: neuromuscular disease that leads to skeletal muscle weakness
• -Ptosis occurs due to the involvement of the levator palpebrae superioris (LPS) complex.
• -could be unilateral or bilateral.
• (B)Some forms of muscular dystrophy.
• -Example : OPMD (Oculopharyngeal muscular dystrophy)
• (C)Chronic external ophthalmoplegia
• - Paralysis of the extraocular muscles.
• -Example: mitochondrial disease like Kearns-Sayre syndrome
• Symptoms:
• Drooping eyelids.
• Difficulty closing the eye or blinking.
• Tearing.
• Eye fatigue.
• Double vision.

• Patients present because:

• they object to the cosmetic effect.
• vision may be impaired.
• there are symptoms and signs associated with the underlying cause
• (e.g. Horner’s syndrome ; miosis, diplopia caused by third nerve palsy
leads to reduced eye movements).
Treatment
• It is important to exclude an underlying cause
whose treatment could resolve the problem (e.g.
myasthenia gravis). Ptosis otherwise requires
surgical correction to prevent the onset of lazy eye
(amblyopia).
Entropion
• It is an inturning, usually of the lower lid towards the globe.
• Patients present with irritation caused by eyelashes rubbing
on the cornea.
• More common in elderly, because eyelid supports weaken
with age allowing the eyelid muscles to turn the eyelids in.
• It may also be caused by Conjuctival scarring distorting the lid
(cicatrical entropion)
• Treatment:
• Short term: include the application of lubricants to the eye or
taping of the eyelid.
• Permanent: surgery (eyelid tightening)
 Ectropion
• Eversion of the lid away from the globe (eyelid turns outwards).
• Causes:
• -Age related orbicularis muscle laxity.
• Ageing is associated with a slowing of muscle contraction and relaxation.
• -Facial nerve palsy.
• -Scarring of periorbital skin.
• Symptoms :
• - Complaining of watery eye.
• *Punctum : opening of a tear duct, which collects tears
• -Mal position of the lids, everts the puncta and prevents drainage of the tears leading to epiphora
• (overflow of the tears over the cheeks )
• -Exposure the conjunctiva leading to irritable eye.
• -Treatment: Lubricating eye drops / Taping the eyelid
• Surgical: lateral tarsal strip procedure.
Trichiasis
• Definition : abnormally positioned eyelashes which grow back toward the eye, touching the cornea or conjunctiva..
• - It is distinct from entropion.
• Causes:
• Eye infection (trachoma ).
• Inflammation (swelling) of the eyelid.
• Autoimmune conditions.
• Trauma.
• Symptoms:
• 1-Irritation and abrasion due to rubbing of lashes against the cornea.
• 2-Sometimes pain when exposed to light.
• 3-Associated with blindness due to scarring of the cornea.

• Treatment:
• -Epilation of the offending lashes.
• - Recurrence can be treated with cryotherapy or electrolysis
Distichiasis
• Definition: a condition where you have two rows of eyelashes.
• Causes:
• Distichiasis may be congenital, associated with lymphoedema distichiasis syndrome
(LDS).
• Acquired distichiasis: more common than the congenital form.
• -Seen with chronic inflammatory conditions such as blepharitis, staphylococcal
hypersensitivity, meibomian gland dysfunction.

• Symptoms of distichiasis may include:

• Decrease of vision.
• Pain in eyes.
• Redness.
• Irritation.
• Foreign body sensation.
• Diagnosis: slit lamp examination.

• Treatment :
• Medical therapy:
• *Patients without symptoms or keratopathy do not require any treatment.
• Lubricating eye drops and ointment: symptomatic relief.
• Soft contact lenses: protect the cornea in cases of corneal epithelial
breakdown.

• Surgical therapy:
• Epilation with electrolysis: It is useful in treating small numbers of isolated
or focal areas of distichiasis.
• Cryosurgery.
• Laser thermoablation.
Inflammation + lump+ tumor
of eyelid
Blepharitis
 Chronic Inflammation or infection of the eyelid margins

 Sometime it may be associated with systemic diseases > rosacea, atopy, and seborrheic
dermatitis
as well as ocular conditions >> dry eye syndromes, conjunctivitis, and keratitis.
 Common symptoms associated with blepharitis are
 burning sensation
 irritation,
 red eyes
 tearing, Crusting of the lid margin.
Classified into: anterior and posterior
Anterior blepharitis:
• Is when the inflammation is
located around the skin,
eyelashes, and lash follicles
with squamous debris
• Signs :
 Redness and scaling of the
lid margin.
 Reduction in the number of
eyelashes.
 Lash bases may ulcerate-
sign of staphylococcal
infection
Posterior blepharitis:
• Inflammation involves the
meibomian gland orifices,
meibomian glands, tarsal
plate, and blepharo-
conjunctival junction
• Signs :
• Obstruction and plugging of
the meibomian orifices.
• Thickened , cloudy,
expressed meibomian
secretion
Complications:
• Lid :
 Tylosis = hypertrophy of the lid margin

 Scars
 Madarosis
 Trichiasis
• Cornea:
 In severe diseases > blepharokeratitis
 marginal corneal ulcer due to immune complex response to staphylococcal exotoxins .

• Conjunctiva: • Chalazion
• Meibomian Cyst
 recurrent chronic conjunctivitis
Treatment:
• Cleaning with a cotton bud wetted with bicarbonate or
diluted baby shampoo to remove squamous debris
from lash line.
• Hot compressors and lid massage.
• Anterior blepharitis:
• Topical steroid: used infrequently.
• Topical (fusidic acid) +- systemic antibiotic in
staphylococcal lid disease .
posterior blepharitis:
• Oral tetracycline.
• Artificial tears to prevent dryness.
Lid Lumps
• An infectious painful swelling of the eyelid due to obstruction of the duct of sebaceous gland by
S.aureus
•
 acute suppurative infection
 acute suppurative infection of the of the meibomien gland
zeis gland

Treatment :
• Usually is self-limited improving in 1-2 w - analgesia
• Topical antibiotic
In stye >> if it centered around lash follicle the lash can be pulled out
to improve drainage
 Chalazion
• Non-infectious lipo-granulomatous inflammation
due to the obstruction of meibomian gland orifices .
• Risk factors:
 more common in people with inflammatory conditions
like seborrhea, acne, rosacea, chronic blepharitis.
• Treatment:
• can go away without treatment.
• Home care: apply a warm compress.
• Medical treatment: topical steroid
• if persist >>Surgical: Incision and drainage
MALIGNANT LUMPS OF
THE EYELID
 Basal Cell Carcinoma
• The most common malignant
tumor of the eye lids, Prognosis:
mainly in the
lower lid Very good but deep invasive tumors are
difficult to treat.

• It’s a sun related cancer. (rodent ulcer)

• . Characteristics:
• - Painless lesion
• - Slowly growing
• - Locally invasive
• - No metastasis
 Squamous Cell Carcinoma

• - Rare
• - More in males , age > 50 years,
Caucasians mainly
• - UV light is a risk factor for both Squamous
cell and Basal cell carcinoma.
• - More common on the lower eyelid

• . Characteristics:
• - Hard nodule or scaly patch.
 Sebaceous Cell Carcinoma
• Very Rare
• Carcinoma of the Meibomian and Zeis glands
• F > M , more often in the seventh decade of life .
• Usually on the upper lid margin
• . Characteristics:
• - Highly invasive
• - Metastasize
• - May mimic either a recurrent chalazion or chronic blepharitis

• . Treatment:
• - By surgical excision .
• - Lymph node evaluation is necessary to evaluate metastasis.

• Prognosis:
• Is good with no metastasis, However, sebaceous lesions have a high incidence of recurrence and metastasis.
The Orbit
• The orbital cavity is the protective bony socket for the
globe with the optic nerve, ocular muscles, nerves,
blood vessels, and lacrimal gland. These structures are
surrounded by orbital fatty tissue.

• The orbital cavity is shaped like a pyramid whose base

opens to the face and apex opens towards the back .

• The six ocular muscles originate at the apex of the

funnel around the optic nerve and insert into the globe.
The orbit functions
• The orbit functions to protect, support, and
maximize function of the eye

• The orbit holds the eye in the correct position.

• The orbit also protects the eye because the bones

surrounding the eye “stick out” further than the
eye, objects tend to hit the orbit and not the eye.

• Transmission of nerves and blood vessels.

Contents of the Orbit
1.Eyeball
2.Orbital Septum
3.Extraocular Muscles
4.Nerves (C.N II, III, IV, V, VI)
5.Blood Vessels
6.Extraocular Fat
7.Lacrimal gland, Lacrimal sac, Nasolacrimal duct
8.Eyelids
9.Ligaments
10.Conjunctiva
11.Trochlea
12.Ciliary ganglion
Orbital Bony Socket
 Bony socket: This consists of seven bones:
Frontal.
Ethmoid.
Lacrimal.
Sphenoid.
Maxillary.
Palatine.
Zygomatic.

• The bony rim of the orbital cavity forms a strong ring

Orbital Bony Socket – The Base
The base of the funnel, which opens in the face, has
four borders which consist of the following bones:

• Superior margin: frontal bone

• Inferior margin: maxilla and zygomatic
• Medial margin: frontal, lacrimal and maxilla
• Lateral margin: zygomatic and frontal
Orbital Bony Socket – The Apex
• The apex lies near the medial end of superior orbital fissure and contains the optic canal which communicates with middle cranial
fossa.

• The Apex (Posterior area) of the socket consists of:

1. The Roof: formed by the frontal and sphenoid (lesser wing).

2. The Floor: maxilla, Zygomatic & palatine.

3. The Lateral Wall: Zygomatic & sphenoid ( greater wing).

4. The Medial Wall: maxilla, orbital plate of the Ethmoid, lacrimal & sphenoid (small part of the body of the sphenoid)

5. The optic foramen: which contains the optic nerve and the large ophthalmic artery, is at the nasal side of the apex,
while a larger entry, the superior orbital fissure, through which veins, motor nerves, and non-visual sensory nerves (e.g., those for pain),
among other fissures.
Orbital openings
The orbit has 5 openings:

1.Optic Foramen (C.N II & ophthalmic artery)

2.Superior Orbital Fissure (C.N III, C.N IV, C.N V1, C.N
VI, ophthalmic vein & sympathetic fibers)
3.Inferior Orbital Fissure (C.N V2 , infraorbital vessels
and ascending branches from sphenopalatine
ganglion)
4.Supraorbital Foramen (supraorbital nerve,
supraorbital vessels)
5.Lacrimal Fossa (lacrimal gland)
The Extra-Ocular Muscles
Levator palpebrae superioris: innervated by the
oculomotor nerve and smooth muscle fibers are
innervated by sup. Cervical Sympathetic ganglion
originated from carotid plexus.
The recti:
 superior rectus -superior medially
 medial rectus- medially
 inferior rectus-inferior medially
 lateral rectus-laterally

 Superior oblique -inferior laterally

 Inferior oblique -superior laterally
The Orbital Septum
The orbital septum (palpebral
ligament) is a membranous sheet
that acts as the anterior boundary
of the orbit. It extends from the
orbital rims to the eyelids. It forms
the fibrous portion of the eyelids.

The orbital septum is an important

landmark in distinguishing
between orbital
cellulitis and periorbital cellulitis.
 Orbital Diseases
• Orbital diseases may be
1. vascular
2. thyroid-related (Graves' disease)
3. infectious
4. inflammatory
5. neoplastic
I. Exophthalmus
It is a protrusion of the eyeball, it may be unilateral
or bilateral.
• Causes are classified into:
1. Intra-conal lesions: the lesion lies within the cone formed by extra-ocular muscles, thus
the eye globe is displaced directly forwards, e.g. most commonly dysthyroid eye disease,
others like Optic nerve sheath meningioma.

1. Extra-conal lesions: the lesion is outside the cone, so the eye is displaced to one side, e.g.
mostly tumors, tumor of the lacrimal gland displaces the globe nasally.
Causes
 The most common cause is Graves disease, it usually causes bilateral proptosis.
 Infections (Orbital cellulitis)
 Orbital Inflammatory disease
 Vasculitis (wegener’s granulomatosis)
 Neoplastic (unilateral): Lacrimal, Lymphoma, Metastatic.
 Orbital vascular disease (orbital varices...causes transient proptosis on valsalva
manouver)
 Trauma

 Pseudoproptosis (pseudoexophthalmos)
 Buphthalmos ( congenital open angle glaucoma)
 Contralateral enophthalmos (posterior displacement of the eye)
 Ipsilateral lid retraction
• History:
• duration, rate of onset.
• associated ocular symptoms (pain, decreased visual acuity or field, diplopia, transient visual
loss).
• complaints of foreign body sensation or dry gritty eyes
• history of trauma
• family history
• Examination:
• Full ophthalmic & systemic examination
• Exophthalmometer: normally 14-21 mm, if > 21 mm or a 2mm difference between the two
eyes is abnormal.
• Treatment :depends on the underlying cause, but if left untreated it could lead to:
1. Failure of the eyelids to close, causing corneal ulcerations and damage.
2. Compression on the optic nerve or ophthalmic artery leading to blindness
3. Restriction of eye movements & squint …
II. Enophthalmos

Definition: Relative recession (backward or downward displacement) of the globe into the
bony orbit.

• Change in the volumetric relationship between the rigid bone cavity, the orbit, and its
contents (predominantly the orbital fat and the eye)

(The three basic structures that determine globe position are the bony orbits, the ligament and
muscle system and the orbital fat)

• Presentation: Presents clinically as a sunken appearance to the eye with pseudoptosis

 Causes
1. Primary enophthalmos indicates a congenital etiology(
Postnatal, inadequate, orbital cavity development)
2. Acquired ( secondary):
- Blow out trauma
- Horner’s Syndrome
- Bone growth arrest (eg, ionizing radiation for
retinoblastoma)
- Postsurgical muscle shortening
This patient has severe displacement of Blow out trauma might lead to
the right eye caused by tumor. enophthalmos
Complications

• Complications :
Long-standing enophthalmos(especially associated with
very extensive orbital trauma) may be associated with
severe orbital scarring, and correction can be very
difficult or impossible.

• Treatment involves reconstruction of the bony orbit

with restoration of bony orbital volume and
repositioning of the globe
Investigation of orbital disease

1. CT
2. MRI
3. Systemic tests depending on the
DDx
Differential diagnosis of orbital
diseases
• Trauma
• Disorders of extra-ocular muscles (Dysthyroid eye disease and
ocular myositis, rhabdomyosacroma)
• Infective disorders (orbital cellulitis and preseptal cellulitis)
• Inflammatory diseases (Sarcoidosis, orbital pseudo-tumors
caused by lymphofibroblastic disorders)
• Vascular abnormalities (Carotico-Cavernous sinus fistula, orbital
varix, capillary hemangioma)
• Orbital tumors (lacrimal gland tumors, meningioma of the optic
nerve, optic nerve glioma, rhabdomyosarcoma)
• Dermoid cysts
Trauma
The Signs of the damged orbit(blow out):
1-emphysema air in the skin
2- a patch paraesthesia below the the orbital rim
(infraorbital neve damage)
3- enopthalamos
4- limitation of eye movement
Dysthyroid Eye Disease
• Autoimmune disorder with orbital involvement frequently associated with thyroid dysfunction.

• Histologic examination reveals inflammatory infiltration of the orbital cavity .

• Dysthyroid eye disease usually occurs in persons with hyperthyroidism.

• The eye symptoms may appear long before the thyroid gland becomes hyperactive, however,
about 10 % of patients with dysthyroid eye disease never develop hyperthyroidism.

• 90% of the patients have hyperthyroidism, 6% normal TFT, 3% Hashimoto, 1% hypothyroidism.

• 90% occurs in smokers .

Epidemiology
• Women are affected eight times as often as men.
Occurs around the age of 30-50 years.
• 60% of all patients have hyperthyroidism.
• 10% of patients with thyroid disorders develop
Graves’ disease during the course of their life.
• Some patients with Graves’ disease never exhibit
any thyroid dysfunction during their entire life.
• Graves’ disease is the most frequent cause of both
unilateral and bilateral Exophthalmos.
Etiology
• The precise etiology of this autoimmune disorder is
not clear. Histologic examination reveals
lymphocytic infiltration of the orbital cavity.
• The ocular muscles are particularly severely
affected. Fibrosis develops after the acute phase.
Symptoms
• The onset of this generally painless disorder is
usually between the ages of 20 and 45.

• Patients complain of reddened dry eyes with a

sensation of pressure (symptoms of
keratoconjunctivitis sicca) and of cosmetic
problems.
• Ocular motility is also limited, and patients may
experience double vision.
Diagnostic Considerations

1. Cardinal symptoms include

exophthalmos, which is unilateral in
only 10% of all cases, and eyelid
changes that involve development of a
characteristic eyelid sign.
2. Thickening of the muscles (primarily
the rectus inferior and medialis) and
subsequent fibrosis lead to limited
motility and double vision. Elevation is
impaired; this can lead to false high
values when measuring intraocular
pressure with the gaze elevated.
Signs and Symptoms

• Red & painful eyes

• Blurred vision
• Decreased visual acuity (sometimes associated with optic neuropathy).
• Proptosis
• Retraction of upper eyelid
• Lid lag
• Chemosis (edema of conjunctiva)
• Restriction of eye movements or squint (inferior rectus is the most commonly affected)
• Double vision
Complications
Acute serious complications:
1) Cornea & conjuctival exposure leading ulcers &
perforation.
2) Optic neuropathy leading to visual field loss &
blindness.

Lab & Investigations:

• Biochemical tests for hyperthyroidism (TFT &
antibodies)
• Orbital CT & MRI (to assess the E.O.M
involvement at the orbital apex, which may lead
to blindness)
Management

• *Emergency (corneal problem & pressure of optic nerve) is managed by systemic steroids,
surgical orbital decompression & radiotherapy.

• *The long term management aims to restore E.O.M function & cosmetic.
• The first step is the regulation of thyroid hormones levels
• Artificial tears (prevent corneal drying and ulceration)
• Glasses to correct any double vision (diplopia(
• Guanethidine 5% drops may reduce lid retraction
• Eyelid surgery to overcome lid retraction
• Stop smoking.
Prognosis
• Visual acuity will remain good if treatment is
initiated promptly.
• In the postinflammatory phase, exophthalmos
often persists despite the fact that the underlying
disorder is well controlled.
• Men has a worse prognosis than women.
Orbital Cellulits
Abdallah AlHusan, 5th year MD student
Orbital Cellulits
• Orbital cellulitis is an infection of the soft tissues of the eye socket behind
the orbital septum (Posterior to the orbital septum), a thin tissue which
divides the eyelid from the eye socket.
• It is also sometimes referred to as postseptal cellulitis.
Causes:
• Entry of microorganisms into orbital space;
• Via anatomical perforations into orbital space blood vessels in
paranasal sinuses (e.g. ethmoid)
• Migration from surrounding tissues (e.g. face, eyelids) after local
trauma/surgery
• Inflammatory response cause tissue destruction
Risk Factors
• It can occur at any age; it is more common in children than
adults. Complication of upper respiratory tract infection most
commonly due to bacterial rhinosinusitis and fungal
rhinosinusitis (rare)
The causative organisms of orbital cellulitis are commonly bacterial
but can also be polymicrobial, often including aerobic and
anaerobic bacteria and even fungal or mycobacteria. The most
common bacterial organisms causing orbital cellulitis
are Staphylococcus aureus and Streptococci species and Hemophilus
influenzae. Fungal pathogens causing invasive orbital cellulitis
include Mucorales which causes mucormycosis
and Aspergillus which can cause life-threatening invasive orbital
infections. Other rare reported cause of orbital cellulitis is mycobacteria,
especially Mycobacterium tuberculosis
• Dacryocystitis: lacrimal sac infection
• Chalazion
• Infected mucocele: mucus-containing cystic lesion of salivary
glands erodes into orbit
• Infections involving teeth, middle ear, face
• Direct inoculation: ophthalmic surgical procedures such as
strabismus surgery, blepharoplasty, radial keratotomy and
retinal surgery; orbital trauma with fracture/foreign body
 Signs and Symptoms
• Orbital cellulitis is primarily diagnosed clinically by objective findings on physical
examination combined with presenting signs and symptoms. The most important
distinguishing feature of orbital cellulitis is the presence of ophthalmoplegia
(paralysis of eye muscles) , the presence of pain with eye movement causing limited
ocular movement, and/or proptosis (abnormal displacement of eye). Orbital cellulitis
also typically cause eyelid swelling with or without erythema; however, these findings
are also seen in another less serious condition called preseptal cellulitis.
• Local symptoms includes vision loss , eye pain, double vision, discharge. Red,
swollen eyelids:
• Chemosis (conjunctival edema)
• Diplopia
• Dyschromatopsia
• Impaired visual acuity (red-green color differentiation lost early)
• Preceding sinusitis
• Abnormal pupillary light reflex
• Systemic symptoms are fever, severe headache, vomiting, mental status changes
(intracranial complications)
 Investigations/Diagnostics
• Eye swab (send pus if present
• Full blood count test
• Blood Culture: leukocytosis; +ve blood and tissue fluid cultures
Imaging Studies
Two main imaging tools are available such as a CT and MRI to aid in the diagnosis of orbital
cellulitis. MRI has been found to be superior to CT scan because it can help in following soft
tissue disease progression. However, due to lack of availability of MRI, CT scanning is more
commonly used. Other specific imaging modalities such as MRI or CT venography are used
when complications of orbital cellulitis are suspected. Based on the studies and guidelines it
is recommended that patients with suspected orbital cellulitis with any of the following
features undergo a contrast-enhanced CT scan of the orbits and sinuses:
• Proptosis Findings on Imaging

• Limitation of eye movements Common CT findings in orbital cellulitis are inflammation of extraocular
muscles, fat stranding, and anterior displacement of the globe, although this
• Pain with eye movements may be subtle. Evidence of rhinosinusitis, with the most intense, is commonly
seen in ethmoid sinuses. Complications of orbital cellulitis, for example,
• Double vision subperiosteal abscesses and orbital abscesses appear as low-density
collections on CT scan.
• Vision loss
• Edema extending beyond the eyelid margin
• ANC greater than 10,000 cell/microL
• Signs or symptoms of central nervous system (CNS) involvement
• Inability to examine the patient fully (patients less than 1 year of age)
• Patients who do not begin to show improvement within 24 to 48 hours of initiating
 Common CT findings in orbital cellulitis are inflammation of extraocular
muscles, fat stranding, and anterior displacement of the globe, although
Findings on Imaging this may be subtle. Evidence of rhinosinusitis, with the most intense, is
commonly seen in ethmoid sinuses. Complications of orbital cellulitis,
for example, subperiosteal abscesses and orbital abscesses appear as
low-density collections on CT scan.
Treatment
• Empiric IV antibiotic treatment includes vancomycin
PLUS ceftriaxone OR cefotaxime OR ampicillin-
sulbactam OR piperacillin-tazobactam
• In patients with penicillin allergy: vancomycin PLUS
ciprofloxacin OR levofloxacin
• If an intracranial extension is suspected: add
metronidazole
• In case of abscess formation: surgical drainage
Complications
• Subperiosteal or orbital abscess
• Blindness due to involvement of the optic nerve
• Brain abscess
• Other rare complications: cavernous sinus thrombosis
and central retinal artery occlusion
 • An infection of the eyelid and periorbital soft
tissues without involvement of the orbital contents
• Anterior to the orbital septum
Etiology

Preseptal • Complication of upper respiratory tract infection,

most commonly due to bacterial rhinosinusitis

cellulitis • Other causes include:

• Acute dacryocystitis
• Local trauma to the surrounding tissues of
the face and eyelids
• Insect or animal bites
• Ophthalmic surgery
Clinical Features
• Ocular pain
• Eyelid swelling and erythema
• Less commonly, chemosis and fever
Diagnostics
• Primarily a clinical diagnosis
• Laboratory tests: leukocytosis; blood cultures are
generally unnecessary
• CT scan: only eyelid swelling apparent
Treatment
• If mild:
Treat with oral antibiotics (Augmentin or 1st generation
cephalosporins), warm compressors
• If severe:
Patient should be admitted and given IV antibiotics (2 nd or 3rd
generation cephalosporins with or without Clindamycin)
• Improvement should be noted after 2 - 3 days
• Surgery is indicated for eyelid abscess drainage
ORBITAL VASCULAR LESIONS &
DERMOID CYST
CAROTICOCAVERNOUS FISTULA
• This is an abnormal connection between the
carotid artery or dural artery and the CS itself,
causing abnormal arteriovenous shunting within
the cavernous sinus, so the veins are exposed to a
high intravascular pressure.
CAROTICOCAVERNOUS FISTULA

• Etiology
1) Direct : Caused by
communication between
carotid artery branches and
orbital veins.
2) Indirect : communication
between the cavernous sinus
and the branches of the
internal carotid artery,
external carotid artery, or
both significant head trauma
Presentation
The C-C fistula would lead to venous exposure to a high intravascular
pressure:

1. Dilated conjunctival veins & proptosed eyes

2. E.O.M engorgement leading to decreased eye movements
3. Increased pressure in veins draining the eye leading to increased IOP
4. Pulsatile tinnitus
5. Bruit might be heard over the eye

* Diagnosed by: angiography

* Treated by Embolizing and thrombosing the affected vessel using

radiological techniques.
• Gross chemosis in a patient with • Enlargement of the conjunctival
a high-flow carotid-cavernous and episcleral blood vessels in a
fistula patient with a low-flow carotid-
cavernous communication
Orbital Varix

• Dilated orbital veins that causes

intermittent proptosis when the venous
pressure is raised due to a certain
position or maneuver.

• Usually unilateral & painless. The

patient might complain from tightness
across the eye & nose.

• Treatment:
Avoid activities that cause the symptoms.
Surgery is indicated when the symptoms
get
worse by emobilizing the affected vein.
Capillary Hemangiomas
• Capillary hemangiomas are one of the most
common benign orbital tumors of infancy. They are
benign endothelial cell neoplasms that lead to
vessel growth stimulation.

• They are typically absent at birth and

characteristically have rapid growth in infancy with
spontaneous involution in the first 5 years of life.

• Treated by local injections of steroids only when

the size & position obstructs the visual axis risking
the development of Amblyopia.

• Incisional surgical techniques also have had

variable success
DERMIOD CYST
• Caused by overgrowth of ectodermal
tissue beneath the surface.

• Etiology:
congenital defect that occurs during
embryonic development when the
skin layers do not properly grow
together.

• Commonly observed as a painless

mass in the superiotemporal area at
the lateral portion of the eyebrow
• Clinical feature :
• 1) small, often painless
• 2) the lump may be skin-colored or slight
yellow tinged.

• If a dermoid cyst was more to the medial

side, a possibility of encephalocele
increases.
• Diagnosis by history & physical
examination

• Treatment includes surgery to remove the

cyst
• Excision is performed for cosmetic reasons
and to avoid traumatic ruptured.
ORBITAL TUMORS
Primary:
• Rhabdomyosarcoma( malignant)
• Optic nerve glioma
• Lacrimal gland tumors
• Meningiomas
• Lymphoma

Secondary (Metastasis)
RHABDOMYOSARCOMA
• Commonest orbital tumor in children (sarcoma)

• Rapidly growing arises from striated muscles.

appears everywhere there is skeletal muscles.

• 40% in the H&N around the eyes (usually found in

the superonasal orbit)

• 90% occurs before the age of 16.

Signs & Symptoms:
Painless visible mass, proptosis,
ptosis.

Diagnosis:
CT Scan; help to show adjacent
bones invasion.
MRI to show if a mass adjacent
or attached to
ocular/orbital muscles.
Complications:
Metastasis to the lungs or brain.

Treatment:
Radiotherapy & chemotherapy, if there is no
recurrence after 3 years then it is controlled.
Surgery might be used but it is difficult because the
tumor is embedded deep in the tissue.

Prognosis depends on the site, type & stage.

OPTIC NERVE GLIOMA
• Most common 1ry neoplasm of the optic nerve.

• Glial cells, These tumors include the astrocytomas,

ependymomas and oligodendrogliomas.

• Occurs before the age of 16 years old.

• Mostly associated with type I Neurofibromatosis

Signs & Symptoms:
1. Proptosis (mainly)
2. Strabismus
3. Decreased vision
4. Ptosis

Diagnosis:
CT Scan, MRI is preferred.

Treatment:
Requires no intervention only observation. They are slowly growing & the
treatment is very difficult.
Surgery, radiation, chemotherapy.
SECONDARY TUMORS
Metastasis to the Orbit from:

• Breast cancer (40%)

• Lung cancer
• Prostate cancer
• Liver cancer
CONJUNCTIVA
Anatomy of the conjunctiva
• conjunctiva is a thin, transparent mucous
membrane which lines the inner part of the
superior and inferior palpebrae and covers a
bit of the bulb of the eye, it’s composed of
stratified columnar epithelium.
 The conjunctiva is typically divided into
three parts:

1- Palpebral or tarsal conjunctiva : lines the

eyelids .

2- Bulbar conjunctiva : covers the eyeball, over

the sclera.

3- Fornix conjunctiva : Forms the junction

between the bulbar and palpebral conjunctivas.
Layers of the conjunctiva
1)The epithelium : is non-keratinized and around five
cell layers deep.
2)The stroma (substantia propria) : consists of richly
vascularized loose connective tissue.
3)Conjunctiva-associated lymphoid tissue (CALT): is
critical in the initiation and regulation of ocular
surface immune responses.
Function of the conjunctiva

The conjunctiva :
1) helps lubricate the eye by producing mucous and
tears.
2) contributes to immune surveillance.
3) helps to prevent the entrance of microbes into the
eye.
Inflammatory diseases of the
conjunctiva
Conjunctivitis is one of the most common causes of an uncomfortable red
eye. conjunctivitis itself has many causes including bacteria, viruses,
chlamydia and allergies.
 BACTERIAL
CONJUNCTIVITIS
Bacterial conjunctivitis is commonly caused by staphylococci,
streptococci, chlamydial organism, and gonocci. Mild
conjunctivitis is usually benign and self-limited and can be
easily treated with antibiotics. Severe conjunctivitis, such as
that caused by gonococci, can cause blindness and can signify
a severe underlying systemic disease.
Signs & Symptoms :
*Bilateral redness of the eyes.
* Discharge (purulent white yellow).
* Ocular irritation.
Eye pain, photophobia or a marked foreign body sensation suggest
corneal involvement
The eye may be difficult to open in the morning because the
discharge sticks the lashes together there may be a history of
contact with a person with similar symptoms. The vision should
be normal after the discharge has been blinked clear of the
cornea.
Treatment :
• This condition is usually self-limiting 10-14 days, although a
broad spectrum antibiotic eye drops 1-3 days will resolve the
condition. Conjunctival swabs for culture are indicated if the
condition fails to resolve.
 OPHTHALMIA NEONATORUM

** which refers to any conjunctivitis that occurs in the

first 28 days of neonatal life. It commonly occurs in
neonates due to maternal vaginal infection.
** neonatal conjunctivitis, with Chlamydia being the
most common infectious agent. Infants may acquire
these infective agents as they pass through the birth
canal during the birth process. Neisseria gonorrhoea
is the most severe and threatens both sight and
health corneal perforation may occur

Present with: Severe purulent discharge and eyelid

edema in a newborn with gonococcal conjunctivitis
(confirmed with Gram stain and culture).
VIRAL CONJUNCTIVITIS

** Viruses are a common cause of conjunctivitis in patients of all ages.

** Adenovirus is by far is the most common cause.

** Patients with viral conjunctivitis may give a history of recent exposure to an individual with red eye
at home, school, or work because it’s highly contagious, or they may have a history of recent
symptoms of an upper respiratory tract infection.

** Viral infection is characterized commonly by an acute follicular conjunctival reaction and

preauricular adenopathy and it may be unilateral or bilateral.

** Viral conjunctivitis, although it’s usually benign and self-limited, tends to follow a longer course
lasting for approximately 2-4 weeks. antibiotic eyedrops provide symptomatic relief and help
prevent secondary bacterial infection. viral conjunctivitis is extremely contagious and strict
hygiene measures are important for both the patient and the doctor.
** Signs & Symptopms :

- Ocular itching & foreign body sensation .

- Tearing
- Redness
- Clear Discharge
- Lid oedema.
- Photophobia.

** This is distinguished from bacterial conjunctivitis by:

* A watery and limited purulent discharge.
* Presence of follicles*.
* maybe associated with head and neck and pre-auricular
lymphadenopathy
ü Follicles : These are raised,
gelatinous, oval lesions about
1mm in diameter found usually
in the lower tarsal conjunctiva
and upper tarsal border, and
occasionally at the limbus.
Each follicle represents a
lymphoid collection with its
own germinal center. Unlike
papillae, the causes of follicles
are more specific (e.g. viral and
chlamydial infections).
CHLAMYDIAL INFECTIONS

** Chlamydia trachomatis are responsible for two forms of ocular infections:

1- Inclusion keratoconjunctivitis
2- Trachoma

chlamydia may be responsible for a

chronic conjunctivitis and sight
threatening corneal scarring.
1- Inclusion keratoconjunctivitis :

** It’s a sexually transmitted disease, the patient present with mucopurulent follicular
conjunctivitis and develop Micropannus (superficial peripheral corneal vascularisation)
with subepithelium scarring.

** Diagnosis is conformed by detection of chlamydial antigens, using immunofluorescence

or by identification of typical inclusion bodies by Giemsa staining conjunctival swab or
scrape specimens.

** Treated by topical and systemic tetracycline

2- Trachoma

** The commonest infective cause of blindness in the word although it’s uncommon in
developed countries.
** The disease is encouraged by poor hygiene and overcrowding in a dry, hot climate.
** The housefly acts as a vector.
** The hallmark of the disease is subconjunctival fibrosis caused by frequent re-infection
associated with the unhygienic condiotions.
** Blindness may occur due to corneal scarring from recurrent keratitis and trichiasis.
** Trachoma is treated with oral or topical tetracycline or erythromycin.
** Entropion and trichiasis require surgical correction.
scarring of upper eyelid scaring of the cornea
Trachoma
 ALLERGIC CONJUNCTIVITIS

*It’s divided into acute and chronic forms:

1-Acute (hay fever conjunctivitis)*:

acute IgE-mediated reaction to airborne allergen usually pollens.

* Signs & Symptoms include :

>> Itching. The main feature
>> Conjunctival injection and swelling (chemosis).
>> Clear discharge
Acute allergic conjunctivitis
2- Vernal conjunctivitis (spring catarrh) :

Is mediated by IgE, it affects male children with hx of Atopy.

* Signs & Symptoms include :

>> Itching.
>> Photophobia.
>> Lacrimation.
>> papillary conjunctivitis on the upper tarsal plate, papilla may coalesce to form Giant
(cobblestone).
>> limbal follicles and white spots.
>> punctate lesions on the corneal epithelium.
>> an opaque, oval plaque which in severe disease replaces an upper zone of the corneal
epithelium.
** Initial therapy is with antihistamines and mast cell stabilizeres , topical steroids are
required in severe cases but long-term use is avoided if possible because of the
possibility of steroid induced glaucoma or cataract.

** Contact lens wearer may develop an allergic reaction to the lens or to lens cleaning
material leading to giant papillary conjunctivits (GPC)* with mucoid discharge on
the upper tarsal plate ,while this may respond to topical treatment with mast cell
stabilizers it is often necessary to stop lens wear for a period or even
permanently. Some patients are unable to continue contact lens wear due to
recurrence of the symptoms.
Papillae: These are raised lesions on the
upper tarsal conjunctiva, about 1 mm in
diameter with a central vascular core.
They are non-specific signs of chronic
inflammation. They result from fibrous
septa between the conjunctiva and sub
conjunctiva which allow only the
intervening Papillae tissue to swell with
inflammatory infiltrate.
giant papillae, found an allergic eye
disease are formed by the cohesion of
papillae.
 Conjunctival Degeneration- Pterygium & Pinguecula

** Pterygium: a triangular wing

shaped continuous growth of
the degenerative conjunctival
tissue over the limbus toward
the cornea.

* Treatment by surgery if
threatens visual axis.

** Pinguecula: it’s a common benign asymmptomatic

degeneration of the collagen fibers of conjunctival
stroma.

* You notice a small yellow white nodule usually near

the limbus nasally.

*It happens due to excessive exposure to UV light

*No treatment requires, only if inflamed use mild

topical steroids.
 CONJUNCTIVAL TUMOURS
** It’s Rare!
2- Malignant melanoma : The differential diagnosis from
1- Squamous cell CA :irregular raised
benign pigmented lesions (for example a naevus) may be
area of conjunctiva may invade
difficult. Review is necessary to assess whether the lesion is
deeper tissue.
increasing in size.
**Biopsy, to achieve a definitive diagnosis, may be required.
 Foreign Body
Most common cause : “spark metal”

Treatment:

1- Must be removed + evert eyelids

2- Antibiotics

3- Treat as corneal abrasion

4- CT scan if hx suggests a foreign

body in posterior segment of the eye.