OPHTHALMOLOGY Lecturer: Dr.

Aquino-Alegre
S3-06: Eyelid, Lacrimal & Orbital Disorders Date: 03-31-2021

OUTLINE 📣
💡 Audio from lecture recording
I. Surgical Anatomy
II.Anatomic Deformities of the Lids ⭐️ Nice-to-Know

❗️ Important
TG Notes
a.Entropion
i. Involutional
ii. Cicatricial
☑️ Revised/Corrected from previous trans

iii. Congenital
📣
I. SURGICAL ANATOMY
iv. Epiblepharon ● The lids are the ones that protect the delicate
v. Trichiasis structures of the eye. It has 6 essential layers.
vi. Distichiasis ○ Skin
vii. Management ○ Orbicularis muscle
b.Ectropion ○ Levator aponeurosis
i. Treatment ○ Superior tarsal muscle (Müller muscle)
c. Coloboma ○ Tarsus
d.Epicanthus
i. Epicanthus tarsalis
ii. Epicanthus inversus
● 📣
○ Conjunctiva
It is important to know the structures when
performing surgeries. Every part of the lid is
iii. Epicanthus palpebralis important because each has its own specific
iv. Epicanthus supraciliaris function.
e.Telecanthus
III. Dermatochalasis
IV. Benign Tumors of the Lids
a.Nevus
b.Papilloma
c. Xanthelasma
V. Primary Malignant Tumors of the Lids
a.Basal Cell Carcinoma
b.Squamous Cell Carcinoma
c. Sebaceous Gland Carcinoma
VI. Diseases and Disorders of the Orbit
a.Inflammatory
i. Graves Ophthalmopathy
b.Orbital Infections
i. Orbital Cellulitis Fig 1.1 Layers of the eyelids
VII. Primary Orbital Tumors
a.Capillary Hemangioma ● 📣 The lid margins are supported by the different
structures like the tarsal plate, tarsus, rigid
i. Treatment
b.Rhabdomyosarcoma fibrinous plates, which are connected to the orbital
c. Imaging rim, supported by the medial and lateral frontal
VIII.Cystic Lesions involving the Orbit
a.Imaging ● 📣
tendons.
Orbital septum
○ Originates from the orbital rim that attaches to
b.Epidermoid Cyst
c. Dermolipoma the levator aponeurosis and is joined by the
IX. Vascular Abnormalities Involving the Orbit tarsus.
a.Arterio-Venous Malformation ○ In the lower lid, it joins the inferior border of the
b.Carotid Artery-Cavernous Sinus Fistula tarsus.
i. High Flow Shunt ○ This is very important because it serves as a
ii. Low Flow Shunt barrier between the eyelids and the orbit.
X. Lacrimal System ○ Behind this lies the preaponeurotic orbital fat
a.Congenital Nasolacrimal Duct Obstruction which is an important surgical landmark.
b.Dacryocystitis
XI. Post Quiz

References: Lecture Recording and Powerpoint

Presentation

📖
Legend
Reference textbook

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○ Epiblepharon
○ Trichiasis
○ Distichiasis
● Ectropion
○ Involutional
○ Cicatricial
● Coloboma
● Epicanthus
○ Epicanthus tarsalis
○ Epicanthus inversus
● Telecanthus
● Blepharochalasis
● Dermatochalasis
● Blepharospasm
● Blepharoptosis

ENTROPION
● Turning inward of the lid causing lashes to turn
inwards also
Fig 1.2 Parts of the eyelids
● It can be involutional, cicatracial or congenital.

■ 📣
○ Involutional
may be spastic or senile
○ Cicatracial
○ Congenital

📣
Fig 1.3 Parts of the eyelids Fig 2.1 Entropion

● 📣 The eyelid is divided into 3 parts:

○ Orbital
Lashes are turned inward so there are misdirection of the
lashes since the lids are not in the normal position

■ Circular pattern of fibers INVOLUTIONAL ENTROPION

■ Function: Forceable closure of the lids ● Most common
■ No temporal insertion ● By definition, it is actually the result of aging
○ Preseptal ● Most of the time it affects the lower lid
■ Has 2 heads: superficial and deep ● Result of laxity of the lower lid retractors
○ Pretarsal ● Upward migration of the preseptal orbicularis
muscle

● ☑️
● Buckling of the upper tarsal border
Physical findings:
○ Horizontal lid laxity- sagging of skin

● ☑️
○ Canthal tendon laxity
Pathophysiology:
○ Overriding of preseptal over pretarsal orbicularis
during lid closure
○ Weakness of lower lid retractors

Fig 1.4 Orbital Muscles

II. ANATOMIC DEFORMITIES OF THE LIDS

● Entropion
○ Involutional
○ Cicatricial
○ Congenital

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Fig 2.4 Congenital Entropion

EPIBLEPHARON
● Pretarsal skin and muscle cause the lashes to

Fig 2.2 Left. Physical findings Right. Pathogenesis of Involutional

Entropion
●
●
📣
rotate around the tarsal border.

📖Usually bilateral; Very common among Asians

The condition usually improves as the patient
ages and the face grows
CICATRICIAL ENTROPION
● Involves the upper or lower lid

●
●
📣
● Result of conjunctival and tarsal scar formation

📣 Cicatricial means scarring

Most often found with chronic inflammatory
diseases such as patients with trachoma that
usually affects the upper lids that causes

● ☑️
inflammation then resulting to entropion
Pathophysiology:
○ Severe scarring of palpebral conjunctiva which
pulls lid margin towards globe Fig 2.5 Epiblepharon
○ May affect lower or upper eyelid
○ Most common causes include cicatrizing TRICHIASIS

○ 📣
conjunctivitis, trachoma and chemical burns
Anything that causes chronic inflammation
can cause cicatrizing entropion
●
●
📣
● Abnormally positioned eyelashes

📣 Impingement of the lashes unto the cornea

May be due to either entropion or abnormally
positioned eye lashes
● Since lashes are turned inward, it causes corneal

● 📣
irritation & ulceration
Usually patients with this condition are
complaining of foreign body sensation or redness
of eyes then later on develop into ulceration and
infection since it creates a long term irritation to

● 📣
the eyes
Chronic inflammatory lid diseases or infection
due to position of lashes can cause blepharitis
then causes scarring in lash follicles. Later on, it

● 📣
creates misdirection to the growth.
What to do: Get rid of the lashes causing
mechanical irritation to protect the cornea

Fig 2.3 Pathogenesis of Cicatricial Entropion

CONGENITAL ENTROPION

● 📣
● Lid margin is rotated toward the cornea
Not that common and is rare; but it is important

📣
that it should not be confused with epiblepharon Fig 2.6 Trichiasis
● Actually due to dysgenesis of lower lid

📣
retractors or developmental abnormality in the DISTICHIASIS
tarsal plate causing the lid margin to turn into the ● Condition manifested by the accessory

● 📣
globe
More severe
eyelashes often growing from the orifice of the
Meibomian glands
● 2 rows of eyelashes

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● Inflammatory metaplastic changes in the glands of ■ 2-3 weeks lashes will grow back

● 📣
eyelid margin
Since eyelashes are also turned inward,
patients may complain of foreign body sensation
○ 📣
● Electrolysis, laser, or cryosurgery
Temporary relief

● 📣
as well
Can also be congenital
ECTROPION
● Sagging and eversion of the lower lid
● Caused by relaxation of the orbicularis oculi

○ 📣
muscle
Can be caused by aging or other diseases
such as nerve palsy

○ 📣
● Tearing and irritation
Tearing due to non-full closure of the lids
● Exposure keratitis

○
○
📣
● Same as entropion, ectropion has involutional type

📣 Affects the lower lid most of the time

Chronic conjunctival inflammation ->
📣 Fig 2.7 Distichiasis
Whitish part in the cornea are corneal filaments due to chronic
irritation
Thickening on the affected area

TREATMENT
MANAGEMENT ● Involutional
○ Horizontal thickening of the lid

📣 Fig 2.9 Involutional Ectropion

This one shows unilateral ectropion secondary to traumatic
scarring. Scarring in the lower lid -> Ectropion

● Cicatricial
○ Contracture of the anterior lamellae of the lid
○ Surgical revision of the scar and skin grafting
Fig 2.8 Entropion Surgery
Cut and release the lateral canthal tendon (as stated in the image ■ More complex
above). Small structures inside are very important for oculoplastic ○ When you say cicatricial, maybe caused by
surgeons. Shortening the inferior tarsal plate (in the image above) mechanical problem of the cornea or previous
to tighten. trauma or ectropion
○
○
📣
● Surgery

📣 More definite treatment than the rest

Since lids are turned inward, so we need to
○ In minor degrees of ectropion, they do
electrocautery on the conjunctiva
■ 4-5 mm from the lid margin
○ 📣
evert the lids
Everting the lids is the actual effective in all
■ Contracture happens in the area -> relieves
ectropion
○ 📣
kinds of entropion
More definite treatment

○ 📣
● Tape the lower lid to the cheek
To release tension

○
○
📣
● Injection of botulinum toxin

📣 To relax lower lid muscles

It is only temporary
■ Maximum effect: 6 months
■ Inject again before 6 months for full effect
(usually 4th month) Fig 2.10 Cicatricial Ectropion

📣
● Trichiasis without entropion Bilateral ectropion due to severe dermatitis. Dermatitis -> Chronic
inflammation -> Ectropion
○ Epilation - plucking the lashes (may be

○ 📣
uncomfortable because plucking can be painful)
Remove all eyelashes causing irritation to the
COLOBOMA
○ 📣
conjunctiva and sclera
It is only temporary

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● Result of the incomplete fusion of fetal maxillary

○ 📣
processes
Mid-margin cleft is produced
● Medial aspect of the lower lid is most often
involved
● Associated dermoid tumor

○
○
📣
● Management is Surgical reconstruction

📣 Can be delayed
If cornea is affected or severe exposure
keratitis, surgical reconstruction at an earlier
time

Fig 2.12 Types of Epicanthus. Important to note only E. Tarsalis

and E. Inversus.

Fig 2.11 Coloboma. Full thickness eyelid defect. Medial aspect of

the lid is usually affected

EPICANTHUS
● Characterized by vertical folds of skin over the
medial canthi
● Typical in Asians

○
○
📣
● Pseudoesotropia

📣 Usual presentation
False “duling”; mukhang duling pero hindi

○ 📣
naman
Duling because skinfold is large enough to
cover part of the nasal sclera
● Most common cause:
○ Vertical shortening of the skin between the
canthus and the nose
● Treatment
Fig 2.13 Types of Epicanthus in actual patients
○ Surgery: Vertical lengthening and horizontal
shortening
TELECANTHUS
EPICANTHUS TARSALIS ● Normal distance between medial canthal area of
● More common
● Superior lid fold is continuous medially with the
○ 📣
each eye
Intercanthal distance should be equal to the
epicanthal fold
📣
length of each palpebral fissure
■ Approx 30 mm in adults
● Wide intercanthal distance may be the result of
EPICANTHUS INVERSUS traumatic disinsertion or congenital craniofacial
● Skinfold blends into the lower lid dysgenesis

☑️
EPICANTHUS PALPEBRALIS
● Usually affected is the upper part of the lid near
the skin fold and medial aspect

☑️
EPICANTHUS SUPRACILIARIS
● Usually in the skin fold and few millimeters from
the medial part

Fig 2.14 Normal Anatomical Distance of External Eye Features

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○
○
📣
● Blepharophimosis syndrome

📣 Minor degrees of telecanthus

May be corrected with skin and soft tissue
surgery

○ 📣
● Crouzon’s disease

📣 Very wide intercanthal distance

○
○ 📣 Orbits may also have a problem
Managed by major reconstruction

Fig 3.1 Redundant skin foldings secondary to aging due to

loss of elasticity

Fig 2.15 Crouzon’s Disease

Fig 3.2 Schematic diagram showing before (left) and after

IV. 📣 (right) blepharoplasty

BENIGN TUMORS OF THE LIDS
● These are very common and cases increases with
Fig 2.16 Post-traumatic Telecanthus. Ptosis in the left eye due to aging
affectation of the upper lid. Total reconstruction is the management.
● They can be distinguished clinically
● Treatment with these types of tumors is usually
III. DERMATOCHALASIS
excision in general
● Eyelid skin redundancy ● Since benign there is no need to do surgery but
○ 📣
● Loss of elasticity
Due to aging
● Treatment
due to cosmetic reasons surgery is done
○ Excision biopsy
■ Lesion is sent to histopath
■📣
○ Blepharoplasty
Upper incision to the lid that is affected or
● There are some lesions that looks benign but
really not that is why it is important to do excisional
■📣 can also be lower incision site.
There is excess fat and causes protrusion
due to loss of elasticity; this is removed along
biopsy in all surgeries
■ Sometimes the characteristics may be benign
but sometimes may actually be malignant
with excess skin to tighten the lid
○ Pulsed CO2 and erbium lasers effective in
NEVUS
● 📣 lightening periocular skin
Weakness in the area of the orbital septum, that ● Melanocytic nevi

○📣
is why the orbital fat protrudes causing sagging
Parang herniation sa preaponeurotic fat pads; ○ 📣
○ Common benign tumors
Same pathologic structure as nevus that is

○📣 parang bulging sa upper or lower lid

Parang mga eybags ang effect but in reality
this is actually preaponeurotic fat pads that are
bulging at the lids. Kaya nagkakaroon ng bulging
○ 📣
found elsewhere in the body
May initially be non pigmented and later on
increase in size or pigmentation through time
○ Sometimes may also resemble benign papilloma

○ 📣
because of loss of elasticity
The bags sa mismong preseptal region of the ○
○
📣
● Shave excision

📣 Since it is close to the lid

We do it without touching or doing any harm
lower lids yun yung mismong herniated orbital
fat to the lid itself

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● Treatment

○ 📣
○ Excision, cauterization, laser surgery
Is more of cosmetic purposes since this is not

○ 📣
pathologic and is only benign
Despite surgery this may still recur

Fig 4.4 Xanthelasma with characteristic yellow plaques on

eyelid skin
Fig 4.1 Non pigmented nevus
V. 📣 PRIMARY MALIGNANT TUMORS OF THE LIDS

❗️
PAPILLOMA
● More common malignant ocular tumors:
● Most common benign eyelid tumors ○ Basal cell carcinoma
● Types: ○ Squamous cell carcinoma
○ Squamous cell papilloma ● More common among patients with fair
● 📣
○ Seborrheic keratoses
For both types, fibrovascular cores are
thickened sa mismong surface epithelium giving it
● ❗️
complexion and have exposure to UV or sunlight
95% of patients would be more on basal cell
papillomatous appearance ● ❗️
carcinoma
5% cases are squamous cell carcinoma or
○📣
● Seborrheic keratoses
Commonly affects middle aged and older
sebaceous gland carcinoma
● Sebaceous gland carcinoma
📣individuals ○ Rare

📣📣
○ Very friable lesion
○ Verrucous surface and often pigmented
● Management is excision biopsy
○ Very aggressive
● Usually with these patients we do complete
excision with frozen section
○ Biopsy is required to be able to establish the
correct diagnosis for the right management
○ There must be no remaining malignant cells

BASAL CELL CARCINOMA

● Nodule grows slowly and painlessly
● Ulcerated

○ 📣
● Sclerosing or morphea basal cell carcinoma
Less common type but commonly extends to
other adjacent structures
● Depending on the location of the basal cell
carcinoma it may produce: Ectropion, entropion,
lid notching or retraction, dimpling of the overlying
Fig 4.2 Squamous cell papilloma skin, or loss of lashes
● Treatment
○ Frozen section, radiotherapy or cryotherapy with

● 📣 liquid nitrogen
While it may slowly invade the other structures,
it rarely metastasize

Fig 4.3 Seborrheic keratoses

XANTHELASMA
● Anterior surface of the eyelid
● Bilaterally near the inner angle of the eye
● Yellow plaques within the eyelid skin
● Commonly in elderly Fig 5.1 Basal cell carcinoma. At first impression, may look
● Collections of lipid containing histiocytes in the benign but is actually basal cell carcinoma, thus highlights
dermis of the eyelid importance of doing excision biopsy

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Fig 5.4 Sebaceous gland Carcinoma

Fig 5.2 Basal cell carcinoma with ulcerated appearance
VI. DISEASES AND DISORDERS OF THE ORBIT
SQUAMOUS CELL CARCINOMA

📣
● Grow slowly and painlessly INFLAMMATORY
○ Usually patients may ignore it for a few years ● Grave’s Ophthalmopathy
since it looks benign ● Pseudotumor
● Often starts as Hyperkeratotic nodule that may

● 📣
become ulcerated
Benign inflammatory tumors such as
keratoacanthomas may resemble squamous cell
GRAVES’ OPHTHALMOPATHY
● Dysthyroid ophthalmopathy
● Dysthyroid eye disease
carcinoma ● Most common cause of unilateral or bilateral

📣
● Treatment proptosis in adults or children

● 📣❗
○ Excision biopsy
Squamous cell carcinoma is less
● It is an autoimmune disease usually seen in
hashimoto’s thyroiditis and may also be associated
common but more aggressive than basal cell
carcinoma ● ☑️📣
with myasthenia gravis
for patients with grave’s you should always
do external eye exam, because there’s always
show scleral show, lid retraction, proptosis and
always check EOMs and ask patients if there is
any restrictions, because usually in thyroid
ophthalmopathy it begins with lymphocytic
infiltration first and then later on edema of the
rectus muscles can occur, and then later on in
time the inflammation in the rectus muscles
become fibrotic, then causing restriction later on
● Clinical findings:

Fig 5.3 Two types of squamous cell carcinoma nodular and

ulcerative. In nodular it is hard and keratotic and may develop
📣
○ Ocular surface discomfort
○ Lid retraction - usually in a normal anatomy
there is no exposure of the upper sclera, but in
crusting and vascularization. In ulcerative base of skin is more grave’s upper sclera is seen
reddish, sharply demarcated borders but sometimes lesion
may be indurated or elevated
○ Proptosis
○ Lagophthalmos - 📣 upper lid happens to have
SEBACEOUS GLAND CARCINOMA
● Arise from the meibomian glands and the glands
lid lag
○ Limitation in EOMs - ☑️📣 usually begins in the
upper field and with time the inferior field is also
of Zeis, sebaceous glands of the eyebrow or
caruncle affected be
● May resemble benign inflammatory lesions such

● ❗️📣
as: Chalazion and chronic blepharitis
More aggressive than SCC
○ Diplopia - ☑️📣
○ Pain on eye movement

already severe
this usually happens when it is

○ Often extends to other structures such as ○ Blurring of vision

○ 📣
orbit and lymphatics
May metastasize
● Treatment

● 📣
○ Sentinel node biopsy
May be rare but once detected aggressive
management must be done

Fig 6.1 patient with grave’s ophthalmopathy

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○ 📣
● Treatment:
Goal is to avoid exposure keratitis - lubricants
such as topical lubricants are given to the
● Clinical signs:
○ Chemosis
○ Proptosis
patients and sometimes ointments or gel types ○ Limitation of eye movement
of lubricants are given because these are more
📣
○ Reduction of vision

○ ☑️📣
viscous
Ocular surface discomfort is very common
in all stages of the disease, sometimes the
● Complications:
patient experiences proptosis associated with
the grave’s disease
● Management:
Fig 6.2 exposure keratitis - severe dry eye with the fluorescent
○ ☑️📣 light
Some patients will complain to have
severe blurring of vision that is why EOMS
should always be checked, and sometimes it
may lead to compressive neuropathy &
○ 📣
proptosis
When there is already compressive optic
neuropathy & proptosis - high dose IV systemic
steroids is given & sometimes when it is more
aggressive, surgical decompression is done
○ these should be managed immediately
because of its severe complications
○ Cavernous sinus thrombosis
○ Subperiosteal abscess
○ Brain abscess
○ Sino-orbital imaging to rule out sinusitis,
subperiosteal abscess or tumor
○ Staphylococcus aureus and streptococci - most
common organisms
○ Distinction between preseptal and postseptal
cellulitis maybe difficult that’s why different
imaging studies are requested
○ All forms of orbital cellulitis are treated
aggressively
○ Lack of improvement within 24 to 48hrs signals
an incorrect diagnosis or ineffective agents
○ Localized subperiosteal infection requires
surgical drainage
○ Consult ENT specialist
○ Immunocompromised host and patients with
DM: strongly consider urgent biopsy to rule out
mucormycosis or other fungal infection
Table 6.1 Preseptal Cellulitis VS Orbital Cellulitis
PRESEPTAL ORBITAL
CELLULITIS CELLULITIS

Painful, swollen lid that Painful, swollen lid that

Fig 6.3 Compressive optic neuropathy - the photo shows you stops at orbital rim extend beyond the
that on the right eye there is already compressive optic orbital rim
neuropathy comparing it on the left one there’s no distinct
margins Normal vision Decreased vision

Full eye motility Restricted eye motility

ORBITAL INFECTIONS
● Orbital Cellulitis White conjunctiva Chemosis
● Preseptal Cellulitis
No proptosis Proptosis
ORBITAL CELLULITIS
● Diffuse bacterial infection of periocular tissues No fever Fever, malaise
● Sources: skin infection, paranasal sinusitis carried
by emissary veins
● Children: ethmoid usual source
● 📣 It is very important to know the anatomy

● 📣Management of preseptal cellulitis is same with

● CAUTION:
○ Rare in immunocompetent adults
○ Suspect: severe sinusitis or immune deficiency
● In elderly and diabetic patients,since they are
immunocompromised, be alert and you may
consider mucormycosis or aspergillosis although
fungal is not that common, life-threatening fungal
infections that require prompt management
because orbital cellulitis is deeper
orbital cellulitis, we give the patient oral antibiotics
but we can send the patients home unlike our
patients with orbital cellulitis, they should be
admitted because IV antibiotics are given
VII. PRIMARY ORBITAL TUMORS

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CAPILLARY HEMANGIOMA VIII. CYSTIC LESIONS INVOLVING THE ORBIT

📣
● Common benign tumor of the eyelids and orbit
● Sometimes described as “strawberry nevus”
● Superficial lesions appear reddish
IMAGING
● Benign choristomas arising from embryonic tissue
● Deeper lesions appear bluish not usually found in the orbit
● 90% become apparent before 6 months ○ Choristoma are microscopically normal tissue
● Enlarge rapidly in the first year of life derived from germ cell layers foreign to that
● Regress slowly in the 6th to 7th year of life

📣
● Lesions within the orbit may cause strabismus,
proptosis, astigmatism, amblyopia ( lazy eye)
○ ⭐️
body site
Sa powerpoint and lecture po chriOstoma.
However, based on references, choristoma is
the correct spelling.

📣
TREATMENT ● Arise from surface ectoderm and often contain
● Small lesions do no generally require treatment, epithelial structures such as keratin, hair, and even
just observe teeth
● However, larger lesions, especially those with
📣
● Cystic and filled with an oily fluid

📣
orbital involvement may be treated with: ● Most of dermoids occur in the superior
○ Intralesional corticosteroids ( first offered)
○ Prolonged compression ● 📣
temporal quadrant of the orbit
May also occur in the bony suture line
● Xray will show a sharp round bony defect which is
○ Systemic corticosteroids
○ Sclerosing agents usually affixed to the periostium (Fig 6.4)
○ Cryotherapy ● 2 Types, epidermoid and dermolipoma
○ Laser surgery
○ Radiation and surgical resection

Fig 7.1 Capillary hemangioma

Fig 8.1 Dermoid

📖
RHABDOMYOSARCOMA
● Rhabdomyosarcoma is a potentially fatal disease

● 📖Age of onset is usually between 5 and 7 years

and can be a primary orbital tumor

● 📖Any child with proptosis that progresses over

days should be urgently evaluated for a possible

● ❗️Most common primary malignant tumor of

rhabdomyosarcoma.

childhood
● Very rapid growth
● Erosion of nearby orbital bone may lead to brain

● 📣
metastases
Important to comanage with pedia-onco always
Fig 8.2 X Ray of Dermoid

EPIDERMOID CYST
● Superficial keratin filled mass (yellowish in color)
● Superior orbital rim
● Congenital or post traumatic

○ 📣
● Treatment is excision
Complete excision may be done

Fig 7.2 Rhabdomyosarcoma

IMAGING
● CT Scan
○ Better for bone
● MRI
○ Better for soft tissue changes

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Fig 8.3 Epidermoid Cyst ● Some resolve spontaneously but its better to still
request for labs
DERMOLIPOMA
● Solid mass of fatty material that occurs below the
conjunctival surface
● Hair growth on the overlying conjunctiva
● Much larger than they appear to be

○ 📣
● Treatment is also excision
May cause considerable damage to the vital
structures since this is deeper so is excision is
limited only.

Fig 9.2 📖 Right carotid-cavernous fistula demonstrating

“corkscrew” conjunctival vessels due to
arterialization of the venous system of the orbit.

📣
HIGH FLOW SHUNT
●
● 📣 Easily diagnosed
Sometimes occur spontaneously
● Secondary to trauma
● Physical signs
Fig 8.4 X Ray of Dermoid ○ Severe congestion
○ Chemosis
IX. VASCULAR ABNORMALITIES
INVOLVING THE ORBIT 📣
○ Pulsating proptosis
○ Loud bruit ( do auscultation)

ARTERIO-VENOUS MALFORMATION LOW FLOW SHUNT

● Not very common ● Dural carotid cavernous sinus fistula
● May cause intermittent proptosis, pain, and ● More spontaneous
● Request for MRI ( ❗️📣
transient reduction in vision
diagnostic) or a venography
● Most commonly associated with diabetes and
hypertension
○ 📣
● Surgery is the only method of treatment
Procedure is complicated and may cause
permanent damage to other structures
● Physical signs
○ Mild congestion
○ Venous engorgement and arterialization
○ Elevated IOP
○ Mild proptosis
○ Faint bruit

Fig 9.1 AV Malformation in the upper lid, causing mechanical

ptosis. Note the prominent vessels

📖
CAROTID ARTERY-CAVERNOUS SINUS FISTULA
● A carotid-cavernous fistula is a condition that
results in arterialization of the draining vessels of
the orbit due to a direct communication between the
internal or external carotid artery and the cavernous
sinus (Fig 6.8)
● Diagnosis for both high and low flow shunts would
be contrast MRI or subtraction angiography
● Treatment would include selective intra-arterial or
transvenous embolization
Fig 9.3 Physical signs of high and low flow shunts

X. LACRIMAL SYSTEM
● Responsible for production and drainage of tears
● Tear fluid is distributed over the surface of the eye
by the action of the blinking
● Important structures include (Fig 6.9)
○ Lacrimal gland

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○ Canaliculus ● Purulent discharge may be extruded from the lid
○ Lacrimal puncta
○ Nasolacrimal duct ● Treatment
○ Oral or IV antibiotics
○ Criggler massage
○ Lacrimal apparatus irrigation
○ Dacryocystorhinostomy

Fig 10.3 Dacryocystitis

XI. POST QUIZ

1. True of Involutional Entropion EXCEPT?
a. Most common
b. Result of aging
Fig 10.1 Lacrimal system c. Affects both upper and lower lid
d. Laxity of the lower lid retractors
CONGENITAL NASOLACRIMAL DUCT OBSTRUCTION
2. This refers to the deformity of the eyelid wherein
●
● 📣
Occurs before birth or first month of life
30% would have epiphora (excessive tearing)
○ Severe if with concurrent colds or upper
the pretarsal skin and muscle cause the lashes
to rotate around the tarsal border. It is usually
respiratory tract infection bilateral and is very common among Asians.
● Discharge a. Trichiasis
● Matting of lashes b. Epiblepharon
● Management c. Cicatricial
○ Lacrimal sac massage (crigler massage) d. Involutional

📣
○ Nasal probing
■
📣
○ Topical antibiotics
@1yr old if severe tearing
If recurrent and the infant gets dacryocystitis,
3. A wide intercanthal distance in adults is more
than?
you may do nasal probing even though patient a. 25mm
is less than 1 year old b. 30mm
c. 28mm
d. 20mm

4. Treatment for Epicanthus involves:

a. Surgical reconstruction
b. Skin and soft tissue surgery
c. Vertical lengthening and horizontal
shortening
d. Epilation

5. Most common benign eyelid tumor

a. Non pigmented nevus
b. Papilloma
Fig 10.2 Duct Obstruction Findings
c. Xanthelasma
d. All choices are malignant
📣Already discussed
DACRYOCYSTITIS
●
6. Most aggressive primary malignant tumor of the
● Acute inflammation of the lacrimal sac usually eyelid
secondary to a nasolacrimal duct obstruction a. Squamous cell carcinoma
● Reddish, raised erythematous mass, representing b. Basal cell carcinoma
acute inflammation c. Sebaceous gland carcinoma
● Acute - S. aureus or beta hemolytic streptococcus
● Chronic - S. pneumoniae or Candida albicans 7. All of the following clinical manifestations point
● If you touch it, there will be tenderness to orbital cellulitis. EXCEPT
a. fever

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b. decreased vision
c. white conjunctiva
d. chemosis

8. What is the most common organism that causes

orbital cellulitis?
a. Staphylococcus aureus
b. Streptococcus pneumoniae
c. Escherichia coli
d. Klebsiella pneumoniae

9. Solid mass of fatty material that occurs below the

conjunctival surface
a. Epidermoid cyst
b. Dermolipoma
c. Adenoma
d. AV malformation

10. Capillary hemangioma that are superficial

appear
a. Purplish
b. Bluish
c. Reddish
d. Blue to black

Answers: 1.C 2.B 3.B 4.D 5.B 6.C 7.C 8.A 9.B 10.C

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