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Oculoplastics overview Dr Ekta Aggarwal

Oculoplastics overview - cdn.auckland.ac.nz · Driving lacrimal pump ... Orbital disorders . 49 . Pre-septal cellulitis Etiology: Trauma, Insect bite, Stye . Features: - Inflamed,

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Oculoplastics overview Dr Ekta Aggarwal

Case Scenario Links Oculoplastics overview • Child with red swelling around one eye (Oph10) • Diplopia (Oph06) • Gradual deterioration in visual acuity over time (Oph07) • Watery eye in an infant (Oph03) • Skin tumours (Derm03)

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EYELIDS

Functions of Eyelids:

Light protection & regulation Keep cornea moist Driving lacrimal pump Mechanical protection of globe

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EYELIDS (surface anatomy)

Upper lid [UL] covers superior 2mm of cornea (10 – 2’o clock)

Lower Lid [LL] margin JUST touches inferior limbus 5

EYELIDS (surface anatomy)

Distance between UL margin & central pupillary reflex is margin reflex distance (MRD1) and normally, is 3.5 mm

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EYELIDS (surface anatomy)

Space between UL & LL is palpebral fissure height (PFH) and normally, it is 10-12 mm.

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EYELIDS (surface anatomy)

A puncta (one in each lid) lies in close apposition to globe

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Levator Palpebrae superioris [LPS]

• LPS action – From extreme down gaze to extreme up gaze, by blocking the Frontalis

• Important while planning surgical management of ptosis

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Presenter
Presentation Notes
Nearly 50mm long, originates above Annulus of Zinn, stays close to orbital roof. Travels forward and close to superior orbital rim, it changes its antero-posterior direction to vertical and inserts down at various levels close to tarsus. This direction change is marked by Whitnall’s ligament, which marks the end of muscular part and beginning of aponeurotic LPS. Its insertion into lid skin makes lid crease

To summarize- Normal parameters for lid position evaluation:

MRD1 – 3.5 – 4.0 mm PFH – 10 -11mm LPA – <4mm – poor 5-7mm – fair > 7-8mm – good Lid crease height – 10 mm in females 8-10 mm in males Inferior scleral show – Nil Lagophthalmos (inability to close eyes) – Nil Bell’s phenomenon (globe movement on eye closure) – Up and out

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Eyelid muscular and nervous control

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Presenter
Presentation Notes
Protractor muscle, i.e. Orbicularis Oculi, closes the eyelid and is supplied by 7th cranial nerve. Retractors of the eyelid are Levator Palpebrae Superioris and Muller’s muscle, supplied by 3rd cranial nerve (parasympathetic) and sympathetic nerves respectively.

EYELIDS (internal anatomy)

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(Anterior lamellae) -Skin

- Orbicularis Oculi

(Posterior lamellae) -Tarsus (meibomian glands)

- Conjunctiva

Superioris (Aponeurosis)

Muller’s muscle

Orbital Septum

Orbital fat

Outward direction of lashes

Presenter
Presentation Notes
Basically, eyelid is divided into anterior [consisting of skin & Orbicularis muscle] and posterior layers [tarsus and conjunctiva]. It is easier to understand eyelid pathologies, by having a clear concept of these two layers.

EYELID POSITION ANOMALIES along horizontal axis

PTOSIS (droopy eyelid)

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Congenital Ptosis FEATURES: - Fair to Poor LPS action - Faint/ Absent lid crease - Lid lag on down gaze

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If chin elevation & frontalis overaction (s/o visual axis obstruction by ptotic lid), It needs urgent intervention, or else amblyopia develops.

Presenter
Presentation Notes
Chin elevation and frontalis overaction are suggestive of visual field being obstructed by droopy eyelid. A young child is at high risk of amblyopia, if visual axis is covered by ptotic lid, thus warranting immediate surgery.

Acquired Ptosis FEATURES: - Good LPS action - High lid crease - No lid lag on down gaze

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Presenter
Presentation Notes
Notice chin elevation and frontalis overaction, suggestive of visual field being obstructed by droopy eyelid.

Acquired Ptosis Causes: Involutional Mechanical Myogenic Traumatic Neurogenic

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Not all acquired cases have classical

features of acquired ptosis

Acquired Ptosis Involutional (Aponeurotic) the most common type of ptosis

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Frontalis overaction (s/o visual axis obstruction by ptotic lid); but surgery depends upon patient’s comfort level. No risk of amblyopia after the age of

8-10 yrs.

Acquired Ptosis

Myogenic:

Chronic Progressive External Ophthalmoplegia [CPEO] Myasthenia gravis [diurnal variation] Ptosis is one component of these syndromes

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Presenter
Presentation Notes
CPEO and Myasthenia gravis affect Levator muscle, thus causing droopiness of eyelids.

Acquired Ptosis Neurogenic: - Third Cranial nerve palsy Note: Total ptosis Exotropia Hypotropia Mydriasis

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Presenter
Presentation Notes
Oculomotor nerve palsy as in brain lesions or trauma or orbital apex syndrome would paralyze Levator muscle, thus causing ptosis. Sympathetic chain lesions would affect Muller’s muscle leading to mild ptosis.

Acquired Ptosis Neurogenic: - Horner’s syndrome Note: - subtle ptosis - miosis

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sympathetic innervation to Pupil (dilators) affected

sympathetic innervation to Muller’s affected

Presenter
Presentation Notes
Oculomotor nerve palsy as in brain lesions or trauma or orbital apex syndrome would paralyze Levator muscle, thus causing ptosis. Sympathetic chain lesions would affect Muller’s muscle leading to mild ptosis.

Acquired Ptosis Mechanical: UL tumors as Hemangioma Lid edema as post-trauma/ surgery Dermatochalasis (aging skin hanging over UL margin)

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Presenter
Presentation Notes
Classic clinical features of acquired ptosis can again vary.

Acquired Ptosis Trauma: Blunt or penetrating Long term contact lens wear Iatrogenic

Causes of mechanical/ traumatic ptosis may overlap

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Presenter
Presentation Notes
Classical features of acquired ptosis may vary.

EYELID POSITION ANOMALIES along horizontal axis

Lid Retraction

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Lid Retraction Causes: Congenital Acquired - Thyroid Eye Disease - Midbrain lesions - Parinaud’s syndrome

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EYELID POSITION ANOMALIES along vertical axis

Ectropion

(eyelid margin is away from the globe)

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ECTROPION Causes: Involutional Cicatricial Paralytic (VII CN palsy) Mechanical

Prolonged ectropion leads to metaplastic changes in exposed conjunctiva

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ECTROPION Causes:

Involutional Cicatricial Paralytic (VII CN palsy) Mechanical

Due to laxity of canthal tendons (structural support of lids at medial & lateral

ends) with age

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ECTROPION Causes: Involutional Cicatricial Paralytic (VII CN palsy) Mechanical

Traumatic scar at cheek pulling the lower lid down

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ECTROPION Causes: Involutional Cicatricial Paralytic (VII CN palsy) Mechanical

Facial nerve supplying Orbicularis Oculi is affected, as in Bell’s palsy, Parotid tumor excision, Acoustic Neuroma

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ECTROPION Causes: Involutional Cicatricial Paralytic (VII CN palsy) Mechanical

Lower eyelid edema causing mechanical ectropion

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EYELID POSITION ANOMALIES along vertical axis

Entropion

(eyelid margin rolled in)

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ENTROPION Causes: Involutional Trauma Cicatricial

Entropion leads to trichiasis (misdirection of lashes), which may cause

punctate epitheliopathy of cornea to frank corneal ulcers.

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Presenter
Presentation Notes
The main pathology in involutional type is over-riding of pre-septal orbicularis on pre-tarsal orbicularis oculi.

ENTROPION Causes: Involutional Trauma Cicatricial Ocular Cicatricial Pemphigoid Stevens Johnson syndrome Trachoma (developing countries) Chemical injury Contraction and thus, shortening of posterior lamella of the eyelid: which

pulls and rolls in the eyelid margin along with eyelashes.

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Presenter
Presentation Notes
The main pathology in involutional type is over-riding of pre-septal orbicularis on pre-tarsal orbicularis oculi.

ORBIT

Gener

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General overview of Orbital bones

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Frontal, Sphenoid

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Zygomatic, Sphenoid

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Zygomatic, Maxilla, Palatine

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Maxilla, Lacrimal, Ethmoid, Sphenoid

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•Optic Nerve •Ophthalmic A •Sympathetic N plexus

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Annulus of Zinn

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Orbital septum is a white 360° tough barrier between orbit and lid tissues, stretching from distal

tarsus border to orbital rim

Important to differentiate, if inflammation/ infection is limited in front of OS extends behind the orbital septum

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Skull Sinuses & Orbit

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Frontal Sinus

Ethmoid Sinus

Maxillary Sinus

Skull Sinuses & Orbit

Function of sinuses: Decrease weight of skull. Increase resonance of voice. Humidify and heat the inhaled air

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Orbit examination • Visual acuity • Pupils – miosis, mydriasis, RAPD • Visual field • Extra-ocular movements • Exophthalmometer – axial/non-axial, look from above/below • Palpate orbit for masses • Lids – retraction, masses, scleral show • Optic nerve

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Common Orbital disorders

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Pre-septal cellulitis Etiology: Trauma, Insect bite, Stye Features: - Inflamed, oedematous lids - Nil/ mild pain on eye movements - Visual acuity good - Intact Optic Nerve function

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Orbital Cellulitis Aetiology: Sinusitis (commoner in children) Trauma/ Tumor in adjoining sinuses Features: - Proptosis - Inflamed pre-septal tissues - Painful/ limited eye movements - Drop in Visual acuity - Compromised Optic Nerve function

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Thyroid Eye Disease

Lid changes as lid lag, lid retraction, lagophthalmos

Ocular surface Inflammation esp. over horizontal recti muscles

Proptosis Myopathy [strabismus]

Optic Neuropathy

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Thyroid Eye Disease

CT scan features in Thyroid eye disease • Thick extra-ocular (recti) muscles • Maximum diameter of globe beyond lateral orbital rim • Tenting of optic nerve on right side ( )

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Thyroid Eye Disease

Keep a close watch on: Corneal exposure – treat with lubricants/ taping eyelids shut Optic nerve functions due to its possible compression by

enlarged extra-ocular muscles – might need urgent surgical intervention

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Orbital Fracture

Classical Signs: Hypotropia Enophthalmos Restricted motility, esp. vertical gaze Infra-orbital anesthesia

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Orbital Fracture

Orbital Floor fracture and prolapse of Inf. Rectus & soft tissues in maxillary sinus

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Common Eyelid Lesions

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Benign Eyelid Lesions

Chalazion - Chronic, granulomatous inflammation of meibomian glands - Involving posterior eyelid lamellae

Stye - Tender, acute inflammation of sebaceous glands of Zeiss or sweat glands of Moll at the base of eyelashes in anterior eyelid lamellae

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Benign Eyelid Lesions

Stye Treatment: - Warm compresses, antibiotic ointment - Expression of pus ± lash removal

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Benign Eyelid Lesions

Chalazion

Treatment: -Warm compresses/ antibiotic ointment, if recent onset -Incision & Curettage in resistant cases

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Benign Eyelid Lesions

Xanthelasmas - Yellowish, sessile plaques - S/o hypercholesterolaemia

Treatment: - Removal for cosmesis

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Malignant Eyelid Lesions

Basal cell cancer - Commonest lid malignancy (90%) - Risk factors: Fair skin & UV exposure

Features: - Nodular/ulcerative with rolled edges - Loss of lashes - Telengiectatic blood vessels on surface Treatment: Excision with wide margins ± Cryotherapy

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Malignant Eyelid Lesions

Squamous cell cancer - Fast growing skin cancer

Features: - Nodular - Hyperkeratotic surface

Treatment: Excision Biopsy with wide margins ± radiotherapy depending upon the depth of involvement

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Lacrimal Drainage System

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Lacrimal gland produce tears (aqueous part)

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Lacrimal gland produce tears (aqueous part)

Lacrimal drainage system

Common Lacrimal Disorders

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Congenital Naso-lacrimal Duct Obstruction

Symptoms start soon after birth - Watering ± discharge

- Fluorescein dye disappearance delayed

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Congenital Naso-lacrimal Duct Obstruction

Treatment Options in order of preference: a) Conservative [Lacrimal Massage ± Antibiotics] b) Probing & Syringing c) Intubation/ Balloon Dacryoplasty d) Dacryocystorhinostomy

Nearly 95% resolve conservatively by the end of one year of age

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Acquired Naso-lacrimal Duct Obstruction

• Commoner in females > 40 years of age • Delayed Fluorescein dye disappearance test • Syringing: Complete/ partial regurgitation of fluid Treatment: - Dacryocystorhinostomy [external/ endoscopic] ± silicon intubation

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The End

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