Disorders of eyelids, lachrymal

system and Orbit

Fisseha Admassu, MD
Assist prof in ophthalmology
University of Gondar
EYELID DISORDERS
 Congenital anomalies of the eyelids
1. Blepharophimosis syndrome
- AD
- telecanthus, epicanthus inversus, severe ptosis
2. Congenital ptosis
3. Epiblepharon
- pretarsal muscle and skin ride above the lower eyelid
margin => vertical position cilia
- Asian children
- disappear with maturation of the facial bones
4. Congeital coloboma
- medial upper eyelid
 Blepharitis

 Inflammation of the eyelid margins.

 It is a chronic disease.
 Symptoms:
- tired, itchy, sore eye, worse in the morning.
- Crusting of the lid margin.
 Classified into: anterior and posterior .
 Both forms are strongly associated with seborrhea
dermatitis, atopic eczema and acne rosacea.
 Anterior Blepharitis
 Is when the inflammation is located in the outside surface the
lid margin, specifically in lash line.
 Signs are:
-Redness and scaling of the lid margin.
-Debris in the form of a collarets around the eyelashes.
-Reduction in the number of eyelashes.
-Some lash bases may ulcerated- sign of staphylococcal infection.
 In severe diseases the cornea is affected (blepharokeratitis)
 Small infiltrate ulcers may form in the peripheral cornea
(marginal keratitis)due to immune complex response to
staphylococcal exotoxins .
 Posterior blepharitis

 Have another name which is meibomian gland

dysunction.
 Signs are:
- Obstruction and plugging of the meibomian
orifices.
- Thickened , cloudy, expressed meibomian
secretion.
- Injection of the lid margin and conjuctiva.
- Tear film abnormalities and punctate keratitis.
 Treatment

Anterior blepharitis:
• Cleaning with a cotton bud wetted with bicarbonate or diluted baby
shampoo to remove squamous debris from lash line .
• Topical steroid: used infrequently.
• Topical +/- systemic antibiotic in staphylococcal lid disease .
Posterior blepharitis:
• Hot compressors and lid massage.
• Oral tetracycline.
• Artificial tears to prevent dryness
LID LUMPS
 Chalazion
 -It is a granuloma
within the tarsal plate
caused by obstructed
meibomian gland.

 -Painless.

 -Symptoms are
unsightly lid swelling
which resolve within
six months if the lesion
persist we remove it
surgically
 Internal hordeolum

 an abscess in
meibomian gland.

 -Painful.

 -May respond to
topical antibiotics
but incision by be
necessary.
 External Hordeolum (Stye)
 - It is an abscess in
eyelash follicle.
 painful
 -Most cases are self
limiting .

 -Treatment requires
the removal of the
associated eyelash
and application of
hot compresses.
 Molluscum Contagiosum
 -Is a viral infection of
the skin or the mucous
membranes, caused by pox
virus.

 -Can be presented with

umbilicated lesion found on
the lid margin.

 -Cause irritation, redness,

follicular conjuctivitis(small
elevation of lymphoid tissue
found on tarsal conjunctiva)

 -Treatment requires excision

of the lid lesion.
 Xanthelasma
 - Lipid containing
bilateral lesions.

 - Usually
associated with
hyperlipidemia .

 - Removed for
cosmetic reasons.
Eyelid neoplasm
1. Basal cell carcinoma:
- the most common eyelid malignancy
- lower eyelid margin ( 50-60 %)
- risk: fair-skinned
middle age
sun exposure
smoking
- firm, raised, pearly nodule with central ulceration
- Management: incisional biopsy: confirm diagnosis
excisional biopsy
Basal Cell
 Squamous Cell
• 40x less common than
BCC
• More aggressive
– perineural invasion
• Most arise from pre-
existing lesions
• Variable presentation
Sebaceous adenocarcinoma
• Highly malignant
• 2x more common in upper lid
• carcinoma of seabaceous glands
• nodule lesion and later causes loss
of eyelashes
• women > 50 years
• upper lid ( more meibomian glands )
• DDx. chalazion, chronic blepharitis,
BCC, SCC
• Management: - full-thickness punch
biopsy of the tarsus
• wide surgical excision
•
Malignant melanoma:
- risk: sunlight exposure, genetic, environmental mutagen
- rare
- Management: wide surgical excision
ABNORMALITIES OF LID POSITION
 ptosis

 This is an abnormally low position of the upper eyelid.

PATHOGENESIS
It may be caused by:
Mechanical factors:
 (a) Large lid lesions pulling down the lid.
 (b) Lid edema.
 (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, due to a sympathetic nerve
lesion
 (c)Marcus–Gunn jaw-winking syndrome.
3.Myogenic factors:
 (a)Myasthenia gravis
 (b)Some forms of muscular dystrophy.
 (c)Chronic external ophthalmoplegia.
 MANAGMENT

• It is important to exclude an underlying cause

whose treatment could resolve the problem
(e.g. myasthenia gravis). Ptosis otherwise
requires surgical correction

• In very young children this is usually deferred

but may be expedited if pupil cover threatens
to induce amblyopia.
•
 Myogenic ptosis
• Congenital
– Dysgenesis of levator
• Acquired
– Localized or diffuse
disease
– Muscular dystrophy
– CPEO
– MG
– Oculopharyngeal
dystrophy
Aponeurotic
• Most common form of
ptosis
• Congenital and acquired
forms
• High lid crease with
normal levator function
 Neurogenic
• Acquired and congenital
forms
• Acquired:
– 3rd nerve palsy**
– Horner syndrome
– Myasthenia gravis
Dermatochalasis
Brow ptosis

Brow ptosis
 Marcus Gunn Jaw-Winking syndrome

- Also called Trigemino-oculomotor Synkineses

- Autosomal dominant
- In this congenital ptosis there is miswiring of the nerve
supply to the pterygoid muscle of the jaw and the
levator of the eye so that the eyelid moves in
conjugation with movements of the jaw.
Treatment
 Treatment is usually unnecessary but in severe cases,
surgery with a bilateral levator excision and frontalis
brow suspension may be used.
Periocular malpositions and involutional change
Entropion : inversion of eyelid margin
1. Congenital entropion:
- rare
- cause: - lower eyelid retraction dysgenesis
- tarsal plate defect
- shortening of posterior lamella
2. Acute spastic entropion:
- ocular irritation or inflammation
Periocular malpositions and involutional change
Entropion :
3. Involutional entropion:
- lower lid
- cause: - horizontal laxity
- disinsertion of eyelid retraction
- overriding of the preseptal orbicularis
4. Cicatricial entropion:
- vertical tarsoconjunctival contraction
- cause: autoimmune,inflammation,infection,surgery
and trauma
- Management: eliminate chronic ocular irritation
Periocular malpositions and involutional change
Ectropion : eversion of eyelid margin
Congenital ectropion:
- rare
- often associated blepharophimosis
- vertical insufficiancy of anterior lamella of eyelid
- Management: mild form : no treatment
severe form : surgery
Involutional ectropion:
- tissue relaxation with horizontal eyelid laxity
- lower lid ( gravity )
- Management: surgery
Type of ectropion
Periocular malpositions and involutional change
Trichiasis :
- acquired misdirection of the eyelashes
- Management: - mechanical epilation
- electrolysis
- surgery
Lacrimal system
 Abnormal Eyelid Movements
• Blepharospasm
• Hemifacial spasm
• 7th nerve palsy
– Blepharospasm
• Involuntary tonic, spasmodic contraction of orbicularis
 Hemifacial Spasm
• Intermittent
contractions of the
entire side of face
• Present during sleep
• Compression of 7th
nerve at the level of the
brain stem
• MRI evaluation
 7 nerve palsy
th

• Location of lesion:
– Supranuclear, brain
stem, peripheral
• Cause of paralysis:
– Bell’s
– Infection
– Infarct
– Demyelination
– Neoplasm
– Trauma
– Miscellaneous
Lachrymal system disorders
 Lacrimal system
1. Congenital nasolacrimal obstruction
- membraneous block of the valve of Hasner
- 50% of newborn
- spontaneously resolved 4-6 weeks after birth
- Management: - conservative treatment with topical antibiotic
- Crigler massage
- probing ( after 6 months )
2. Acquire nasolacrimal obstruction
- involutional stenosis
- women:men = 2:1
- epiphora
- Management: Dacryocystorhinostomy (DCR)
 Lacrimal system
3. Dacryocystitis:
- cause : nasolacrimal duct obstruction
- clinical finding: - edema and erythema below the medial
canthal tendon with distension of lacrimal
sac
- Management: - Topical and oral antibiotic ( gram+ bacteria)
- Dacryocystorhinostomy
Dacryocystitis
Disorders of ORBIT
 Evaluation
• 7 P’s
– Pain
– Proptosis
– Progression
– Palpation
– Pulsation
– Periorbital changes
– Past medical history
 Imaging options
• Plain films
• CT scan
• MRI
• Ultrasound
 Plain films
• Quick
• R/o foreign bodies
• Infrequently used Caldwell’s view

Base view Waters’ view

 CT Scan
• Strengths
– spatial resolution
– bone
• fractures
• bone destruction
• calcification
– quick- emergencies
• trauma
– cheaper
 CT Scan
• Weakness
– radiation: 1-2 cGy
– soft tissue definition
– contrast iodinated
• allergy
– may need MRI anyway
• (not cheaper)
• Protocols
– axial and coronal
– +/- contrast
 MRI
• Strengths
– Tissue
• T1anatomy
• T2pathology
– No radiation
• Weaknesses
– magnetic
• pacemakers, surgical clips
– claustrophobia
 MRI
• Protocols
– Axial/coronal/sagittal
– Gadolinium contrast
• non-iodinated
• allergies RARE
– orbital lesions
• fat suppression
Orbital Echography
• Dynamic
• Less expensive +/-
• Availability variable
 Proptosis
• Infection
• Inflammation
• Congenital
• Vascular
• Neural
• Mesenchymal
• Lymphoid
• Secondary
• Lacrimal gland
Infection
• Preseptal Cellulitis
– Vision, motility, pupils, VF, disc are
WNL
– globe itself is not proptotic
• Orbital Cellulitis
– 90% secondary to sinus disease
– high risk of morbidity and mortality
• orbital abscess
• brain abscess
• cavernous sinus thrombosis
 Inflammation
• Graves disease
– Most common cause of
unilateral or bilateral
proptosis
– May occur with any thyroid
status
– Eye disease not controlled by
thyroid ablation
– Treatment options
• steroids
• radiation
• optic nerve decompression
Inflammation
• Idiopathic orbital
inflammation
– orbital pseudotumor
– myositis
– prompt response to steroids
– OU or systemicthink
vasculitis (*except in kids)
• Sarcoidosis
– lacrimal gland
• Vasculitis
– GCA, PAN, SLE, Wegener’s
granulomatosis
 Congenital
• Dermoid cysts
– Most common orbital
tumors in kids
– Usually presents at a
suture junction
– Posterior forms may
present in adulthood
– Surgical excision keeping
the cyst wall intact
Vascular
• Hemangioma
– Capillary (kids)
• Strawberry or deep blue
– Cavernous (adults)
• Intraconal location
• most common benign
tumor in adults
• Lymphangiomas, AVMs,
varices
• CCF, dural-sinus fistula
 Neural
• Optic nerve glioma
– Kids in 1st decade
– 25-50% associated with NF-1
• Malignant glioma- rare
• Meningioma
– Adults
– ON sheath or intracranial
– Calcification and hyperostosis
Rhabdomyosarcoma
• Most common primary
orbital malginancy of
childhood
• Average age: 7-8
• Sudden onset and rapid
evolution of unilateral
proptosis
• 4 cellular types
• 90% survival
 Lymphoproliferative Disorders
• Lymphoid hyperplasia and
lymphoma
– 20% of all orbital mass lesions
– salmon patch appearance
– molds to orbital structures
– 50% arise in lacrimal fossa
– 17% bilateral
• Plasma cell tumors
• Histiocytic disorders
– macrophage based d/o
 Secondary Malignancies
• Local primary
– eye, eyelid, sinus
• Metastasis
– Children:
• Neuroblastoma
• ALL (Leukemia)
• AML (Chloroma)
– Adults:
• Breast
• lung
• prostate
 Lacrimal Gland Tumors
• Inflammatory
– Sarcoidosis
– Orbital Pseudotumor
– Vasculitis
• Non-inflammatory
– Lymphoproliferative
– Epithelial neoplasms

Pleomorphic adenoma
 VASCULAR ORBITAL DISORDERS

1. Orbital venous anomalies (varices)

• Isolated orbital varices
• Combined orbital and external varices

2. Carotid-cavernous fistula

• Direct
• Indirect
Orbital venous anomalies (varices)

• Congenital enlargements of pre-existing venous

channels
• Usually unilateral
• May bleed or become thrombosed
 Isolated orbital varices
Intermittent proptosis

Non-pulsatile, without Precipitated or

a bruit accentuated by
Valsalva manoeuvre
Combined orbital and external varices
Conjunctival varices

Eyelid varices

Precipitated or accentuated by Valsalva manoeuvre

Direct carotid-cavernous fistula
• Defect in intracavernous part of internal carotid
• Rapid flow shunt

Causes
• Head trauma - most common
• Spontaneous rupture - in hypertensive females

• Ptosis, chemosis and conjunctival injection

• Ophthalmoplegia
• Raised intraocular pressure
 Direct carotid-cavernous fistula

• Pulsatile proptosis with bruit • Retinal venous congestion and haemorrhages

and thrill
• Abolished by ipsilateral
carotid compression
Indirect carotid-cavernous fistula (dural shunt)
• Indirect communication between meningeal branches of internal
or external carotids and cavernous sinus
• Slow flow shunt

Causes
• Congenital malformations
• Spontaneous rupture

• Dilated episcleral vessels • Occasional ophthalmoplegia

• Raised intraocular pressure with and mild proptosis
wide pulsation