EYELIDS, ORBIT, AND Eyelid

LACRIMAL SYSTEM  composed of 7 layers:

(Hernando L. Cruz Jr., MD) o skin and subcutaneous tissue
o muscle of protraction
EYELIDS o orbital septum
o orbital fat
Function o muscle of retraction
o tarsus
 Cilia – screening and sensing action
o conjunctiva
 Glands of Eyelids – secretion
 Eyelids – movement

Cilia (Eyelashes)
 first line of defense
 2 rows of 100 – 150 (upper) and
50 – 75 (lower)
 each follicle has nerve plexuses
 each follicle has glands
 Glands of the Eyelids
o Meibomian glands
 modified sebaceous glands
 its secretion forms the Upper Eyelid

superficial element of the

precorneal tear film
 oil layer prevents tear
evaporation

Lower Eyelid

Skin and Subcutaneous Tissue

 thinnest skin of the body
 no subcutaneous fat
 upper lid crease

Muscles of Protraction
 Orbicularis oculi muscle
 motor supplied by CN VII (facial nerve)
 pre-tarsal, pre-septal, orbital parts
 Movement of the Eyelid
rd
o 3 most important element
o movement is made possible by
three muscles
 levator palpebrae superioris
 opens the eyelid
 orbicularis oculi
 closes the eyelid
 Muller’s muscle

Orbicularis oris muscle

OPHTHALMOLOGY | Eyelids, Orbit, and Lacrimal System 1

Orbital Septum Vascular Supply
 multi-layered sheet of fibrous tissue  Arterial Supply
 fuses with the aponeurosis to form the lid o Internal Carotid Artery
crease  Supraorbital artery
 serves as a barrier between the eyelid and  Lacrimal artery
the orbit o External Carotid Artery
 Angular artery
Orbital Fat  Temporal artery
 lies posterior the orbital septum and anterior  Venous Drainage
the levator aponeurosis o Pretarsal portion
 eyebag is an age-related attenuation  Angular vein (medially)
 Superficial temporal vein
Muscles of Retraction (laterally)
 Upper eyelid o Posttarsal portion
o Levator Muscle and aponeurosis  Orbital vein
 40 mm muscular part
 20 mm aponeurosis Nerve Supply
 innervated by CN III  Sensory
(occulomotor nerve) o Supraorbital Nerve
o Whitnall’s ligament  CN V1
 functions as a suspensory  innervates forehead and
support of the upper eyelid lateral periocular area
o Muller’s muscle o Maxillary Nerve
 originates at the  CN V2
undersurface of the  innervates lower eyelid and
aponeurosis cheek
 sympathetically innervated  Motor
 provides 2 mm of eyelid o CN III (occulomotor nerve)
elevation o CN VII (facial nerve)
 Lower eyelid o Sympathetic nerves
o Capsulopalpebral fascia
 analogous to levator Lesions of the Eyelid
aponeurosis  Benign lesions
o Lockwood’s ligament o Chalazion
 analogous to Whitnall’s o Hordeolum
ligament o Miscellaneous lesions
o Inferior tarsal muscle  Malignant lesions
 analogous to Muller’s o Basal cell CA
muscle o Squamous cell CA

Tarsus
 firm, dense plate
 serves as the skeleton of the eyelid

Conjunctiva
 non-keratinizing squamous epithelium
 contains goblet cells and accessory lacrimal
glands

Cross section of a normal eyelid margin

OPHTHALMOLOGY | Eyelids, Orbit, and Lacrimal System 2

Chalazion Treatment for Benign Eyelid Lesions
 chronic granulomatous inflammation of the  oral antibiotics
Meibomian glands  topical antibiotics
 painless, round lesion within the tarsal plate  warm compress
 if severe, surgical  incision and curettage

Miscellaneous Eyelid Lesions

Molluscum Contagiosum
 caused by Pox virus
 painless umbilicated nodule

Chalazion

External Hodeolum
 infection of the glands of Moll and Zeiss
 usually caused by Staphylococcus sp.
 tender, inflamed swelling in the eyelid
margin

Molluscum contagiosum

Strawberry Nevus
 flat, red lesion within 6 months of birth
 involutes spontaneously
 increases in size during straining or crying
 no pulsation or bruit

External hordeolum

Internal Hordeolum
 acute staphylococcal infection of the
Meibomian glands
 tender, inflamed swelling within the tarsal
plate
 usually precedes chalazion

Strawberry nevus

Port Wine Stain

 Nevus flammeus
 well demarcated pink patch that darkens
with age
 45% incidence of glaucoma
 5% is associated with Sturge-Weber
Internal hordeolum
Syndrome

OPHTHALMOLOGY | Eyelids, Orbit, and Lacrimal System 3

 Squamous cell CA

Port Wine stain Treatment of Malignant Eyelid Lesions

 complete excision is a must
Malignant Eyelid Lesions  surgical incision
o complete removal of the entire
Basal Cell Carcinoma tumor
 most common human malignancy  obtain a fresh frozen section
 90% of cases occur in head and neck  MOH’s technique
 10% of head and neck basal cell CA occurs  eyelid reconstruction
in the eyelid  extenteration
 most common eyelid malignancy (90%)  radiotherapy
 predilection:  cryotherapy
o lower lid
o medial canthus
o upper lid Disorders of the Eyelashes
o lateral canthus
 slow growing, locally invasive, not Trichiasis
metastasizing  posterior misdirection of previously normal
lashes
 usually associated with trachoma and
severe chronic staphylococcal blepharitis

Trichiasis

Basal cell CA
Distichiasis
Squamous Cell Carcinoma  abnormal row of lashes
 hard nodule or a scaly patch which develops
crusting erosions and fissures over a few
months
 clinically, indistinguishable from basal cell
carcinoma (but it is important to differentiate
the two in a metastatic potential view point)
 it grows rapidly and highly aggressive
 aggressively metastasizes

Distichiasis

OPHTHALMOLOGY | Eyelids, Orbit, and Lacrimal System 4

Treatment of Eyelash Disorders
 epilation
 electrolysis
 cryotherapy
 laser thermoablation

Abnormal Positions of the Eyelid

Entropion Entropion

 inversion of the eyelid

 four types:
o involutional
o cicatricial
o congenital
o acute spastic
 Involutional entropion
o most common
Congenital entropion
o mostly affects the lower lid
o pathogenesis:
Ectropion
 overriding of orbicularis
 outward turning of the eyelid
muscle
 horizontal lid laxity  usually associated with epiphora and
 weakness of lower lid conjunctivitis
retractors  types:
o treatment o involutional
 cautery o cicatricial
 transverse lid – everting o congenital
sutures o paralytic
 Weiss procedure  Involutional ectropion
 Cicatricial entropion o senile ectropion
o usually caused by scarring of the o excessive eyelid length
palpebral conjunctiva, pulling the lid o weakness of pretarsal orbicularis
margin towards the globe o laxity of the medial and canthal
o causes ligaments
 cicatricial pemphigoid  Cicatricial ectropion
 Steven-Johnson syndrome o caused by scarring and contracture
 trachoma of skin and underlying tissues
 chemical burns o examples are trauma, burns, tumors
o treatment  Paralytic ectropion
 contact lenses o facial nerve palsy
 epilation  treatment
 surgical correction o mild– medial canthoplasty
 Congenital entropion o severe – lazy T procedure
o due to improper development of the o extensive – Bick procedure or
retractor aponeurosis into the Kuhnt-Szymanowski procedure
inferior border of the tarsal plate
o inward turning of the entire lower
eyelid and lashes
o absence of lower lid crease

Ectropion

OPHTHALMOLOGY | Eyelids, Orbit, and Lacrimal System 5

Ptosis
 drooping of the eyelids
 types of ptosis
o myogenic
o neurogenic
o aponeurotic
 involutional
 post-operative
o mechanical
 Neurogenic ptosis
o either acquired or congenital Mechanical ptosis

innervation defect
o Horner’s syndrome  Myogenic ptosis
o Marcus Gunn Jaw Winking o congenital or acquired myopathy of
syndrome the levator muscle
o misdirection of CN III o two types
 simple congenital ptosis
 Blepharophimosis
syndrome
o Simple congenital ptosis
 unilateral or bilateral
 during downgazing, the
ptotic eyelid is higher than
Neurogenic ptosis the normal eyelid
 weakness of the superior
 Aponeurotic ptosis rectus (some cases)
o defect in the levator aponeurosis  head tilt with chin elevation
o it could be due to disinsertion or  high EOR and astigmatism
stretching
 involutional ptosis –
degenerative changes in
levator aponeurosis
 post-operative ptosis –
occurs in 5% of patients
following intraocular surgery
Simple congenital ptosis

o Blepharophimosis syndrome
 telecanthus
 epicanthus
 other features:
 ectroion
 poorly developed
nasal bridge
Aponeurotic ptosis
 hypoplasia of
superior orbital rims
 Mechanical ptosis
 amblyopia in 50% of cases
o physical obstruction impeding eyelid
elevation in the presence of an
otherwise normal levator muscle
and CN III

Blepharophimosis syndrome

OPHTHALMOLOGY | Eyelids, Orbit, and Lacrimal System 6

Psueodoptosis  Orbital Apertures
 should be differentiated from true ptosis in o Optic Canal
the physical examination  Optic nerve
 causes of psueodptosis:  Ophthalmic artery
o decrease vertical fissure height  Sympathetic nerves
o contralateral lid retraction o Superior Orbital Fissure
o ipsilateral hypotropia  CN III
o dermatochalasis  CN IV
 parameters  CN VI
o marginal reflex distance  CN V-1
 NV 4-5 mm  Sympathetic nerves
 mild +3 o Inferior Orbital Fissure
 moderate +2  CN V-2
 severe 0 to -1
o vertical fissure height Clinical Evaluation of Orbital Diseases:
 NV male 7-10 mm  pain
 NV female 8-12 mm  proptosis
o levator function  progression
 good 12 mm  palpation
 fair 6-11 mm  pulsation
 poor 5 mm or less  periorbital changes

Proptosis
ORBIT  Axial displacement
 bony cavity containing globes, extraoccular o retrobulbar lesions
muscles, nerves, fat, and blood vessels  cavernous hemangioma
 pyramidal or conical in shape  glioma
 consists of an apex and a base  meningioma
 4 sides: roof, floor, medial and lateral walls  AV malformation
 7 bones: frontal, zygomatic, maxillary,  Non-axial displacement
sphenoid, ethmoid, lacrimal, and palatine o outside the muscle cone
 Roof  superior displacement
o frontal bone o maxillary tumor invading the floor of
o lesser wing of sphenoid the orbit
o located adjacent to anterior cranial  inferomedial displacement
fossa and frontal sinus o dermoid cyst
 Lateral Wall o lacrimal gland tumor
o zygomatic bone  bilateral proptosis
o greater wing of sphenoid o Grave’s disease
 Medial Wall o lymphoma
o ethmoid bone o psuedotumor
o lacrimal bone
o maxillary bone Progression
o sphenoid bone  days to weeks
o forms the lateral wall of sphenoid o inflammatory diseases
sinus o infectious diseases
 Floor o metastatic tumors
o maxillary bone  months to years
o palatine bone o dermoid cysts
o zygomatic bone o benign mixed tumors
o lymphomas

OPHTHALMOLOGY | Eyelids, Orbit, and Lacrimal System 7

Palpation
 superonasal
o mucocoeles
o neurofibromas
o dermoid cysts
 superotemporal
o lacrimal gland tumor
o pseudotumor

Pulsations
 with bruit
o carotid-cavernous fistula
 without bruit
o meningoencephalocoeles

Diagnostic Modalities in Orbital Diseases

Pathogenesis of exophthalmos in Grave’s disease
 Primary Studies
o CT scan
 main clinical manifestations
o MRI
o eyelid retraction
o ultrasonography
o soft tissue involvement
o histopathology
 conjunctival infection
 Secondary Studies
 chemosis
o venography
 eyelid fullness
o arteriography
o proptosis
o optic neuropathy
CT Scan MRI o restrictive myopathy
Good for most orbital Better for orbitocranial  key points in Grave’s ophthalmology
conditions, especially lesions o eyelid retraction is the most
fractures common feature
Good view of bone and No view of bone and Ca o Grave’s ophthalmology is the most
Ca common cause of eyelid retraction
Degraded image of Good view of orbital o Grave’s ophthalmology is the most
orbital apex due to bony apex common cause of unilateral and
artefact bilateral proptosis
Less soft tissue detail More soft tissue detail o this condition is associated with
Good for metallic Contraindicated for hyperthyroidism in 90% of cases,
foreign body metallic foreign body but 6% are euthyroid
Less expensive More expensive o severity of Grave’s ophthalmology
Shorter scanning time Longer scanning time may not parallel serum levels of T3
and T4
Grave’s Ophthalmology o Grave’s ophthalmology may be
 an autoimmune disorder that is related to asymmetric
excess secretion of thyroid hormone o urgent care may be required for
 10 – 25% occurs in the absence of any optic neuropathy or severe proptosis
thyroid dysfunction o if surgery is needed, the usual order
 female/male ratio = 8:1 of surgery is:
th th
 4 to 5 decades of life  decompression
 most common cause of adult unilateral and  squint surgery
bilateral exophthalmos  eyelid surgery
 pathogenesis:
o hypertrophy of extraocular muscles
o cellular infiltration
o proliferation of orbital fat and
connective tissues

OPHTHALMOLOGY | Eyelids, Orbit, and Lacrimal System 8

Orbital Infections  Neural tumor
 Preseptal cellulitis o Optic nerve glioma
o infection confined to the eyelids and  Metastatic tumor
periorbital tissues anterior to the  Tumor invasion from adjacent structures
orbital septum
o globe is uninvolved Capillary Hemangioma
o pupillary reaction, VA, and EOM are  most common tumor of the orbit in childhood
normal  increase in tumor size during crying or
o no chemosis, no pain straining
 absent bruit and pulsation
 involutes spontaneously

Capillary hemangioma

Preseptal cellulitis
 Orbital cellulitis
o active infection posterior to the
septum
o 90% occurs as a secondary
extension of bacterial sinusitis
o fever, proptosis, chemosis, EOM
restrictions, pain on eye movement
o decreased VA, pupillary
abnormalities
Cavernous hemangioma
 most common benign orbital lesion in adults
 middle-aged women commonly affected
 enhanced well-encapsulated mass on CT
scan
 treatment is surgical incision
Rhabdomyosarcoma
 most common primary orbital malignancy of
childhood
 age of onset is 7 – 8 years old
 rapid onset of proptosis
 treatment:
o exenteration
o radiation therapy combined with
systemic chemotherapy

Orbital cellulitis

Orbital Tumors
 Vascular tumors
o Capillary hemangioma
o Cavernous hemangioma
o Lymphangioma
 Lacrimal gland tumor
o Benign mixed tumor
o Malignant tumor Rhabdomyosarcoma (CT scan)
 Rhabdomyosarcoma
 Cystic lesions
o Dermoid cyst
o Mucoceole

OPHTHALMOLOGY | Eyelids, Orbit, and Lacrimal System 9

Pleomorphic Adenoma
 most common epithelial tumor of lacrimal
glands
th th
 4 – 5 decades of life
 mostly men
 progressive, painless, downward and inward
displacement

Fracture at the floor of the orbit

Pleomorphic adenoma

Dermoid / Epidermoid Cyst LACRIMAL SYSTEM

 benign cystic teratoma  puncta
 well-encapsulated line by stratified  ampullae
squamous and dermal appendages  canaliculi
 epidermoid – does not contain dermal  lacrimal sac
appendages  nasolacrimal duct

Dermoid cyst

Fractures of the Orbit

 Orbital Floor Fracture
o most frequently involved wall
o usually along the infraorbital canal
o clinical features
 periocular changes
 ecchymosis
 edema
 subcutaneous The lacrimal system

emphysema
 enophthalmos
 infraorbital nerve anesthesia
 diplopia

Tear flow physiology

OPHTHALMOLOGY | Eyelids, Orbit, and Lacrimal System 10

Evaluation of Tearing
 Lacrimation vs. Epiphora
 Lacrimation
o reflex production of tears from
stimulation of CN V (trigeminal) by
irritation of the cornea and/or
conjunctiva
 Epiphora
o normal tear production but there is
physical obstruction on the drainage
system

Infections of Lacrimal Passages

Dacryocystitis
 Canaliculitis
o Unilateral epiphora with  Surgical techniques
mucopurulent discharge o DCR
o “pouting of the punctum” on slit lamp  dacryocystorhynostomy
exam  to create a new tear drain
between the eye and the
nose
o external DCR
o endoscopic laser-assisted DCR
o transcanalicular edoscopic DCR

Canaliculitis

“Pouting of the punctum” on slit lamp exam

 Dacryocystitis
o infection of the lacrimal sac
o presents as a painful swelling at the
medial canthal area

OPHTHALMOLOGY | Eyelids, Orbit, and Lacrimal System 11