Upload
indian-dental-academy
View
212
Download
0
Embed Size (px)
Citation preview
Oculoplastics Review
INDIAN DENTAL ACADEMY
Leader in continuing dental education www.indiandentalacademy.com
www.indiandentalacademy.com
Oculoplastics
• Orbit• Eyelid• Lacrimal
www.indiandentalacademy.com
Orbit
www.indiandentalacademy.com
Orbital Anatomy
• 7 bones• 30 cc (35 mm width x
40 mm height)• 25-30 mm orbital
optic nerve• Rim
– Zygomatic– Maxillary– Frontal
• Floor (3 bones)– Zygomatic, maxillary and
palatine• Medial wall (4 bones)
– Sphenoid, lacrimal, ethmoid, maxillary
• Roof ( 2 bones)– Frontal, sphenoid
• Lateral wall (2 bones)– Zygomatic, sphenoid
(greater wing)
www.indiandentalacademy.com
Orbital Anatomy (cont.)
• Optic foramen– 8-10 mm– Located within lesser
wing of sphenoid– Transmits optic nerve,
ophthalmic a. and sympathetic nerves
• Superior orbital fissure– Bound by greater and
lesser sphenoid wings– Outside annulus
(“luscious French tarts”)
• lacrimal, frontal, IV– Inside annulus (“sit
naked in anticipation)• III-sup, nasociliary III-
inf, VI
www.indiandentalacademy.com
Orbital Anatomy (cont.)
• Inferior orbital fissure– Bound by sphenoid,
maxillary and palatine bones
– Transmits V2 which exits skull through foramen rotundum
• Annulus of Zinn– Fibrous rings formed
by rectus muscles– Does not include IV
www.indiandentalacademy.com
Orbital Pathophysiologic Patterns1
• Inflammation: 57.3%• Neoplasia: 22.3%• Structural Abnormality: 15.8%• Vascular Lesions: 2.8%• Degenerations and Depositions: 1.7%
1 Rootman J. Diseases of the Orbit. J.B. Lippincott. 1988.
www.indiandentalacademy.com
Orbital Inflammation
• Orbital cellulitis• Graves ophthalmopathy• Idiopathic orbital inflammantion
(pseudotumor)• Sarcoidosis• Wegener’s• polyarteritis nodosa
www.indiandentalacademy.com
Orbital Cellulitis
• Medical emergency – because of rapid spread to brain (i.e. cavernous sinus thrombosis, brain abscess) and compressive neuropathy
• 3 causes– Spread from adjacent structures (I.e. sinus most
common)– Direct innoculation – trauma/surgery– Hematogenous spread (rare)
www.indiandentalacademy.com
Orbital Cellulitis (cont.)
• Orbital vs. preseptal cellulitis – Orbital signs: motility changes, proptosis, chemosis,
decreased retropulsion• Evaluation – CT scan• Sinusitis common +/- subperiosteal abscess• Treatment
– IV abx’s with surgical drainage of any abscess– Steroids with vision threatened and no fungal (i.e.
trauma, immunosuppresion) suspected
www.indiandentalacademy.com
Graves Ophthalmopathy
• Eyelid retraction most common finding• Most common cause of unilateral/bilateral proptosis• Women:men 6:1• 90% hyperthyroid, 6% euthyroid, 4% hypo• Severity of disease unrelated to T3 and T4• May be asymmetric• Optic neuropathy and severe exposure are urgent• Surgery: decompression, strabismus, retraction repair
www.indiandentalacademy.com
Idiopathic Orbital Inflammation (“Pseudotumor”)
• May present as focal (I.e. dacryoadenitis, myositis, sclerotenonitis, perioptic nerve) vs. diffuse soft tissue
• Acute pain, eom restriction and proptosis• Bilateral in adults: suspect systemic vasculitis• Bilateral in 1/3 of children• Treatment: prednisone 60-80 mg/day with slow
taper (over several months)
www.indiandentalacademy.com
Pediatric Orbital Tumors
• Benign– Dermoid cysts – frontozygomatic suture– Lipodermoids – Goldenhaar’s sydrome– Optic nerve glioma – controversial treatment– Capillary hemangioma – grow 1st year – usually
involute by age 4 (75%)• treat with steroids if vision threatening
– Lympangioma• Worse with URI’s
www.indiandentalacademy.com
Pediatric Orbital Tumors
• Malignant– Rhabdomyosarcoma
• Average age (7-8)• Embryonal (most common), alveolar (most malignant),
pleomorphic, botryoid• Treatment: chemo, XRT
– Metastatic• Neuroblastoma – metastatic (abdomen, mediastinum or neck)• Leukemia – acute lymphoblastic leukemia
www.indiandentalacademy.com
Adult Orbital Tumors
• Benign– Cavernous hemangioma – removal if
symptomatic– Meningioma – needs surgery if vision
threatening or if intracranial extension– Orbital varices– Hemangiopericytoma – may become malignant
www.indiandentalacademy.com
Adult Orbital Tumors
• Malignant– Metastatic
• Breast, lung, prostate, GI and melanoma– Hemangiopericytoma (malignant
transformation from benign form)
www.indiandentalacademy.com
Lacrimal Gland Tumors
• Epithelial (50%)– Pleomorphic adenoma (benign mixed) –
remove entirely or may recur with malignant transformation
– Adenoid cystic carcinoma (swiss cheese) – bad actor
• Lymphoid (50%) – XRT for both– Lymphoma– Benign lymphoid hyperplasia
www.indiandentalacademy.com
Orbital Trauma• LeFort classification
– I – transverse maxillary– II – nasal, lacrimal and maxillary bones
(includes medial floor)– III – craniofacial disjunction (includes all
walls of orbit but roof)
www.indiandentalacademy.com
Orbital Trauma (cont.)• Indications for surgery of blow-out
fracrure– Entrapment beyond 7-10 days (urgent
treatment in children)– Enophthalmos > 2 mm– >50% of floor involved (leads to late
enophthalmos)
www.indiandentalacademy.com
Eyelid
www.indiandentalacademy.com
Eyelid Anatomy
• Involutional• Paralytic• Cicatricial• Mechanical• Congenital - rare
www.indiandentalacademy.com
Superficial Eyelid Landmarks
• Eyebrow– Peaks at 9:00 limbus– 1 cm above orbital rim in youth– Flatter in males, more flared in females
• Palbebral Fissure– Horizontal 28-30 mm– Vertical 9-11 mm
www.indiandentalacademy.com
Superficial Eyelid Landmarks
• Upper Eyelid Margin– Peaks slightly nasal to the pupil– upper limbus in youth– 1.5 - 2.0 mm below in adult
• Lower Eyelid Margin– inferior limbus
• Margin above superior limbus or below inferior limbus termed “retraction” or “scleral show”
www.indiandentalacademy.com
Superficial Eyelid Landmarks
• Lateral commissure– 5 mm nasal to lateral rim– 2 mm above medial in males– 4 mm above medial in females
• Medial commissure
www.indiandentalacademy.com
Superficial Eyelid Landmarks
• Upper Eyelid Crease– 7 - 8 mm above the margin in males– 9 - 10 mm above the margin in females
• Lower Eyelid Crease– poorly defined– 5 mm below the margin
www.indiandentalacademy.com
Eyelid Anatomy
• Divided into anterior and posterior lamella– Anterior Lamella
• Skin• Orbicularis
– Posterior Lamella• Conjunctiva• Tarsus
www.indiandentalacademy.com
Eyelid Anatomy (cont.)• skin and subcutaneous tissue• orbicularis muscle and
submuscular fibroadipose tissue• orbital septum• preaponeurotic fat• retractors• tarsus and conjunctiva
www.indiandentalacademy.com
Skin and Subcutaneous Fascia
• Thinnest of the body (~ 1mm) - thinnest medially
• Little or no subcutaneous fat• Subjected to the most movement; stretching
and relaxing
www.indiandentalacademy.com
Skin and Subcutaneous Fascia
• Upper eyelid crease– 9-10 mm in females, 7-8 mm in males– formed by levator attachments to pretarsal skin– lower in Asians because septum joins levator at
a lower point allowing inferior fat migration• Lower eyelid crease
– marks the lower edge of tarsus– slopes from 5 mm medially to 7 mm laterally
www.indiandentalacademy.com
Eyelid Protractors
• Orbicularis oculi - horseshoe-shaped muscle– Orbital– Preseptal– Pretarsal
www.indiandentalacademy.com
Orbital Orbicularis
• Voluntary• Above - inserts to the anterior supraorbital
margin medial to the supraorbital foramen; shares a common insertion with corrugator supercilli
• Below - inserts to the anterior infraorbital margin medial to infraorbital foramen
www.indiandentalacademy.com
Preseptal Orbicularis
• Involuntary• Laterally: continuous overlying lateral
canthal tendon• Medial insertion
– anteriorly to medial canthal tendon– posteriorly (Jones muscle) to the lacrimal
diaphragm; upper may also insert on posterior lacrimal crest
www.indiandentalacademy.com
Pretarsal Orbicularis
• Firmly attached to tarsus• Lateral - gives rise to lateral canthal tendon• Medial
– Superficial heads form the medial canthal tendon which inserts to the medial orbital margin
– Deep heads (Horner’s muscle) insert into the lacrimal bone at posterior lacrimal crest
– Riolan’s muscle forms grey line
www.indiandentalacademy.com
Medial Orbicularis Attachments
www.indiandentalacademy.com
Orbital Septum
• Orbital septum + tarsus = “middle lamella” of the eyelid
• Originates at the arcus marginalis (periosteum)• Superior - fuses with the levator
aponeurosis 2-5 mm (avg. 3.4 mm) above the superior tarsal border
www.indiandentalacademy.com
Orbital Septum
• Inferior - fuses with inferior border of tarsus, separated from capsulopalpebral fascia by postseptal fat
• Lateral - inserts anterior to lateral canthal tendon
• Medial - inserts on posterior lacrimal crest (i.e, lacrimal sac is outside orbit)
www.indiandentalacademy.com
Orbital Fat Pads
• Upper Eyelid– preaponeurotic– nasal - whiter
shade• Lower Eyelid
– nasal - whiter shade
– central – temporal
www.indiandentalacademy.com
Eyelid Retractors
www.indiandentalacademy.com
Retractors of Upper EyelidLevator palpebrae superioris• Originates at orbital apex• Horizontal (40 mm) and vertical (15-20 mm)
components• Changes from horizontal to vertical at Whitnall’s
ligament• Vertical component has two layers
– levator aponeurosis– superior tarsal muscle (Muller’s)
www.indiandentalacademy.com
Retractors of Upper Eyelid
• Levator Aponeurosis– forms lateral and medial horns - attach to
respective retinaculae– attaches into the pretarsal muscle and skin and
anterior lower 1/3 of anterior tarsal surface
www.indiandentalacademy.com
Retractors of Upper Eyelid
• Superior Tarsal Muscle (Muller’s)– innervated by cervical sympathetic system– inserts at superior tarsal border– medially attaches to the medial horn– Horner’s syndrome is due to Muller’s muscle
paralysis
www.indiandentalacademy.com
Retractors of Upper Eyelid
www.indiandentalacademy.com
Retractors of Lower Eyelid
• capsulopalpebral head given off by inferior rectus
• splits around inferior oblique and “reunites” as Lockwood’s ligament
• capsulopapebral fascia projects anteriorly from Lockwood’s ligament and attaches to inferior tarsal border
www.indiandentalacademy.com
Retractors of Lower Eyelid
• inferior tarsal muscle (muller’s) terminates 2.5 mm beneath inferior tarsal border
www.indiandentalacademy.com
Tarsus
• Dense irregular connective tissue - not collagen
• Meibomian glands– orifices located posterior to lashes and grey line– 30-40 upper– 20-30 lower
• Cilia bulbs - on top of tarsus
www.indiandentalacademy.com
Tarsus
• Upper– 29 mm in length, 10 mm wide– extends to lateral commissure
• Lower– 29 mm in length, 4 mm wide– extends to puncta
www.indiandentalacademy.com
Conjunctiva
• Palpebral conjunctiva– marginal - extends to mucocutaneous border– tarsal - adherent to tarsus– orbital - portion adherent to tarsal muscles
• Bulbar conjunctiva - starts at fornix and extends on to globe
www.indiandentalacademy.com
Lateral “Whitnall’s” Orbital Tubercle
• Lateral retinaculum– lateral horn of levator aponeurosis– lateral canthal tendon– inferior suspensory “Lockwood’s” ligament– check ligament of lateral rectus
• Whitnall’s ligament inserts 10 mm superior to lateral orbital tubercle (NOT on Whitnall’s tubercle)
www.indiandentalacademy.com
Posterior Lacrimal Crest
• Medial ocular retinaculum– inferior transverse “Lockwood’s” ligament– medial rectus check ligament– deep heads of pretarsal muscle– medial horn of levator aponeurosis– orbital septum
www.indiandentalacademy.com
Vascular Supply
www.indiandentalacademy.com
Lymphatic Drainage
www.indiandentalacademy.com
Sensory Nerve Supply
www.indiandentalacademy.com
Ectropion
• Involutional• Paralytic• Cicatricial• Mechanical• Congenital - rare
www.indiandentalacademy.com
EctropionAssociated terminology
• Lagophthalmos exposure of conjunctiva/cornea with attempted
lid closure• Lid Retraction or Scleral Show
visible conjunctiva between inferior limbus and lower lid margin
www.indiandentalacademy.com
Involutional Ectropion
• Tissue relaxation associated with aging• Extreme cases termed “tarsal ectropion”
implies detachment of retractors in addition to laxity
www.indiandentalacademy.com
Paralytic Ectropion
• VII nerve palsy – Bell’s palsy (90%)– Herpes Zoster (Ramsey-Hunt syndrome) – Trauma– Tumors (acoustic neuroma, SCCA)
www.indiandentalacademy.com
Cicatricial Ectropion
• Actinic changes• Trauma• Burns• Removal of lower lid lesions• Chronic inflammation• Lower lid blepharoplasty• Congenital
www.indiandentalacademy.com
Mechanical Ectropion
• Due to mass effect of lower lid lesion– bulky tumors– herniated orbital fat– chronic lower lid edema
• Addressing primary cause usually effective treatment
www.indiandentalacademy.com
Congenital Ectropion
• Typically involves upper and lower lids• Conservative treatment (i.e. taping of lids,
temporary tarsorrhaphy) usually adequate• Surgical intervention requires full-thickness
skin grafts
www.indiandentalacademy.com
Lateral Tarsal Strip Procedure
• Anderson RL, Gordy DD. Archives of Ophthalmology, 1979
www.indiandentalacademy.com
LTS step 1
www.indiandentalacademy.com
LTS step 2
www.indiandentalacademy.com
LTS step 3
www.indiandentalacademy.com
LTS step 4
www.indiandentalacademy.com
LTS step 5
www.indiandentalacademy.com
LTS step 6
www.indiandentalacademy.com
LTS step 7
www.indiandentalacademy.com
LTS step 8
www.indiandentalacademy.com
Medial Spindle Slide
www.indiandentalacademy.com
EctropionWhen lid tightening is enough
• Involutional• Paralytic - simple cases
www.indiandentalacademy.com
EctropionWhen lid tightening is not enough
• Paralytic - severe cases– Midface lift, fascia lata sling
• Cicatricial– Full thickness skin graft
• Congenital
www.indiandentalacademy.com
Entropion
• Involutional• Transient Spastic• Cicatricial• Congenital
www.indiandentalacademy.com
Involutional Entropion• Most patients present with eyelid rolled in and
orbicularis spasm• Accompanied by red, irritated eye• Initially transient - may stimulate by repeated
forceful closure and upgaze• Three factors implicated
– horizontal laxity– disinsertion of capsulopalpebral fascia– overriding orbicularis oculi
www.indiandentalacademy.com
Transient Spastic Entropion
• Acute lower lid swelling accompanied by orbicularis spasm
• Generally resolves with resolution of swelling
• Suture technique quick and effective and may provide permanent relief
www.indiandentalacademy.com
Cicatricial Entropion
• Trauma/Chemical injury• Inflammation • Ocular cicatricial pemphigoid • Stevens-Johnson syndrome • Trachoma
www.indiandentalacademy.com
Congenital Entropion
• Associated with epiblepharon (roll of eyelid that mechanically rolls lid inward)
• Common in Asian population• Irritation from lashes requires treatment
www.indiandentalacademy.com
EntropionWhen lid tightening is enough
• Almost never– Addressing only one of several factors usually
associated with recurrence– mild involutional cases may respond
www.indiandentalacademy.com
EntropionWhen lid tightening is not enough
• Involutional– Jones Procedure
• Transient Spastic– Quickert suture
• Cicatricial– Posterior lamellar grafting
• Congenital – Jones-like Procedure without tightening– Reduction of epiblepharon skin if present
www.indiandentalacademy.com
Jones Procedure
www.indiandentalacademy.com
Jones Procedure - Illustration
www.indiandentalacademy.com
Quickert Suture
www.indiandentalacademy.com
Posterior Lamella Grafting
www.indiandentalacademy.com
Posterior Lamella Graft
www.indiandentalacademy.com
Posterior Lamella Grafting (cont.)
• Sources of autogenous graft materials– hard palate– buccal mucous membrane– nasal chrondomucosa– ear cartilage
• Processed donor material– Alloderm® - acellular dermal matrix from
donor tissue
www.indiandentalacademy.com
Ptosis/Retraction
• Physical Exam– MRD1 – margin-reflex distance – upper lid
– MRD2 – margin-reflex distance – lower lid– Levator function– Lid fissure height– Lid crease– Scleral show/retraction noted, if present
www.indiandentalacademy.com
Ptosis – Etiology
• Myogenic– Congenital– CPEO, Myasthenia
• Aponeurotic – aging, most common• Neurogenic
– Horner’s– IIIrd nerve palsy
• Mechanical – dermatochalasis, lid lesionwww.indiandentalacademy.com
Ptosis - Treatment principles
• Moderate to Good levator function– Levator resection/advancement
• Poor levator function– Frontalis suspension
• Autologous fascia lata ideal• Silicon can be used prior to age 3 (leg not big
enough)
www.indiandentalacademy.com
Retraction – Etiology
• Graves– Most common cause
• Post eye muscle surgery• Superior orbital malignancy• Pseudoretraction – due to contralateral
ptosis (i.e., Hering’s law)
www.indiandentalacademy.com
Retraction - Treatment
• Levator recession – Upper lid +/- spacer graft– Lower lid + spacer graft (hard palate,
Alloderm)• Mullerectomy (excision through crease or
trans-conjunctival incision) – usually combined with levator recession
www.indiandentalacademy.com
Lacrimal
www.indiandentalacademy.com
Basic Secretors
• Basic secretors– decreases with age– no efferent
innervation
www.indiandentalacademy.com
Mucin Secretors• Goblet Cells
– throughout the conjunctiva, denser nasally
• Crypts of Henle– upper 1/3 of upper tarsus– lower 1/3 of lower tarsus
• Glands of Manz– circumcorneal ring of the
limbal conj.
www.indiandentalacademy.com
Aqueous Secretors
• Glands of Krause– fornix - subconjunctival– 40 in upper, 6-8 in lower
• Glands of Wolfring– upper and lower border of tarsus– 2-5 in upper, 2 in lower
www.indiandentalacademy.com
Oil Secretors
• Meibomian glands– in the tarsal plates– 25-40 in upper, 20 in lower
• Zeis– follicles of eyelashes
• Moll– root of eyelashes
www.indiandentalacademy.com
Basic Secretors - Re-cap
www.indiandentalacademy.com
Reflex Secretors
• Lacrimal gland - main (orbital) and palpebral lacrimal glands– exocrine glands – efferent parasympathetic innervation – hypersecretion
www.indiandentalacademy.com
Main (Orbital) Lacrimal Gland
• 20mm x 12mm x 15mm• .78 gm• 4 ligaments firmly hold gland in place
– Sommering’s ligament - periosteum from roof– Posterior - inferior ligament of Schwalbe– Superior transverse “Whitnall’s” ligament– Lateral horn of levator aponeurosis
www.indiandentalacademy.com
Main (Orbital) Lacrimal Gland
• Lacrimal foramen• 2 to 6 excretory ducts - pierce conjunctiva 5
mm above lateral margin of the tarsus
www.indiandentalacademy.com
Palpebral Lacrimal Gland
• About 30 loosely knit lobules each with a secretory duct that empties into a main excretory duct
• Upper lobules present at lacrimal foramen• Can be prolapsed into view• May have 1 to 2 main excretory ducts
www.indiandentalacademy.com
Reflex Secretors
• Fifth cranial nerve is the reflex, afferent pathway for the main and palpebral lacrimal glands
• Other areas that may initiate a response - retina - thalamus - frontal cortex - hypothalamus - basal ganglia - cervical sympathetic ganglia
www.indiandentalacademy.com
Reflex Secretors
• Peripheral sensory• Retinal• Psychogenic
www.indiandentalacademy.com
Reflex Secretors
• VII nerve - parasympathetic/efferent pathway– Arise in pons– Fibers join sensory route of VII– Pass through facial nucleus– Synapse in sphenopalatine ganglion– Post-ganglionic fibers incorporated in zygomatic
nerve (V2)
– Fibers join lacrimal nerve (V1)
www.indiandentalacademy.com
Reflex Secretors
• VII nerve - parasympathetic/efferent pathway
www.indiandentalacademy.com
Reflex Secretors
• Sympathetic - efferent pathway– Fibers arise in the hypothalamus– Pass to superior cervical ganglion– Post-ganglionic fibers : 3 routes
• Sphenopalatine ganglion and zygomatic nerve• Accompany the lacrimal artery• Within the lacrimal nerve
www.indiandentalacademy.com
Distributional System
• Eyelids – distribute tears– regulate evaporation– expel superfluous tears – assist in the formation of the precorneal tear
film
www.indiandentalacademy.com
Excretory System
• Upper and lower canaliculi• Lacrimal sac• Nasolacrimal duct• Palpebral parts of the orbicularis oculi• Approx. 35 mm in length
www.indiandentalacademy.com
Canaliculi
• Canaliculi - 10 mm in length, 2 mm vertical and 8 mm horizontal
• Diameter - punctum 0.3 mm - ampulla 2 to 3 mm - canaliculi 0.5 mm • Lined by stratified squamous epithelium,
surrounded by dense connective tissue
www.indiandentalacademy.com
Canaliculi
• 90% have common canaliculus - enters posterior and superior
• Dilation of common canaliculus is the sinus of Maier
• Valve of Rosenmuller at distal end of common canaliculus
www.indiandentalacademy.com
Lacrimal Sac and Nasolacrimal Duct
• Lined double layered columnar epithelium
• Single structure ~ 35 mm in length– Canaliculi 8-10 mm– Fundus - 4 mm– Body - 8 mm– Duct - 12 mm
www.indiandentalacademy.com
Nasolacrimal Duct
• Meatal NLD - 5 mm: guarded by Hasner’s valve
• Angled slightly lateral and posterior
• Opens into the inferior meatus
• Distance from the entrance of nose to duct is 35 mm (less in infants)
www.indiandentalacademy.com
Lacrimal Diaphragm
• Extension of orbital periosteum– “sac within a sac”
• Inferior and superior preseptal muscles insert into it
• Thinnest at lower end of anterior lacrimal crest
www.indiandentalacademy.com
Lacrimal Pump (cont.)
www.indiandentalacademy.com
Lacrimal Disease
www.indiandentalacademy.com
Congenital Epiphora
• Usually begins between 2 and 3 months• Causes:
– Congenital nasolacrimal duct obstruction (NLDO)
– Punctal agenesis– Reflex tearing (e.g., conjunctivitis,
epiblepharon with secondary trichiasis, distichiasis, congenital glaucoma)
www.indiandentalacademy.com
Congenital Epiphora Evaluation
• Constant/minimal mucopurulence– Upper system (i.e., canalicular, punctal)
obstruction• Constant/frequent mucopurulence
– Lower system (i.e. NLDO) obstruction• Intermittent/frequent mucopurulence
– URI infection causing intermittent obstruction at inferior turbinate
www.indiandentalacademy.com
Congenital NLDO
• Caused by membranous block at valve of Hasner
• Present in 50% of newborns• Most resolve in 6 weeks• 90% resolve in 1 year• Majority with symptoms @ 6 mos will clear
by 12 months w/o surgery
www.indiandentalacademy.com
Congenital NLDO Evaluation
• Pressure on sac – look for discharge• Examine lids for open puncta• Jones testing (DRT, I, not II) – look for dye
in throat
www.indiandentalacademy.com
Congenital NLDO Management
• Conservative management for 1st year– Massage– Topical antibiotics for “flare-ups”
• Indications for probing– Acute dacyrocystitis– Chronic skin irritation– Parent frustration with chronic infection
www.indiandentalacademy.com
Congenital NLDO Management (cont.)
• Probing considerations– May perform office probing if < 6 months– Probing with silicone intubation and inferior
turbinate infracture if > 6 mos (general anes.)
www.indiandentalacademy.com
Congenital NLDO Management (cont.)
• Probing technique– traction on lid – probe to “hard stop”– rotate along brow and down duct – don’t force!– pop through Hasner’s valve
www.indiandentalacademy.com
Congenital Dacryocystocele, (a.k.a., Mucocele, Amniotocele)
• Plugging of sac with mucous and amniotic fluid
• Caused by NLDO – may extend into nose• Usually sterile, may become secondarily
infected• Probing indicated if infection develops
www.indiandentalacademy.com
Congenital Dacryocystocele, (a.k.a., Mucocele, Amniotocele)
www.indiandentalacademy.com
Punctal Agenesis
• Rare• May have a well developed canalicular
system revealed through a lid cut down• If entire punctal-canalicular system absent,
CDCR (w/Jones tube) necessary
www.indiandentalacademy.com
Acquired Epiphora
Etiology:• Ocular surface irritation with secondary
hypersecretion• Outflow obstruction (including eyelid or
punctal malposition)• Primary idiopathic hypersecretion (rare)
www.indiandentalacademy.com
Acquired Epiphora - Evaluation
History:• Topical medications• Ocular surface discomfort• Nasal trauma/surgery or sinus disease• Blood reflux
www.indiandentalacademy.com
Acquired Epiphora - Evaluation
Exam:• Eyelid/punctal position
– Ectropion with exposure (incl. VII n. palsy)– Entropion with secondary trichiasis
• Tear instability (tear BUT<10 sec)– Dry eyes/blepharitis
• Pressure on sac for mucous discharge• Nasal exam – intranasal tumor, turbinate
impaction, polyps or allergic rhinitis
www.indiandentalacademy.com
Acquired Epiphora - Diagnostics
• Schirmer tear testing• Jones testing
– Dye disappearance test (DDT) – abnormal if dye remains after 5 minutes
– Jones I – normal (pos) if dye spontaneously reaches nose – Jones II not necessary
– Jones II – normal (pos) if saline irrigates freely into nose with dye and without reflux
www.indiandentalacademy.com
Jones Testing Interpretation
• Jones I (-) Jones II (+) w/dye– functional obstruction– trial of FML, followed by DCR
• Jones I (-) Jones II (+) w/o dye– lid malposition vs. punctal stenosis– treat lid disease (one snip punctoplasty, ectropion
repair)• Jones I and II (-)
– complete obstruction – determine site
www.indiandentalacademy.com
Abnormal Jones II Interpretation
• Reflux out same puncta– canalicular obstruction– CDCR w/ pyrex tube
• Reflux out opposite puncta without sac distension – common canalicular obstruction– CDCR w/ pyrex tube
• Reflux out opposite puncta with sac distension– nasolacrimal duct obstruction– DCR
www.indiandentalacademy.com
Additional Diagnostic Testing
• Scintigraphy– T99 scan demonstrating physiologic tear flow
• Dacryocystography– Contrast study demonstrating anatomy
www.indiandentalacademy.com
Acquired Canalicular Obstruction
• Causes– Trauma– Toxic medications (5-FU, phospholine iodide,
Tamoxifen)– Autoimmune disorders (OCP, Stevens-Johnson
• Treatment– Probing w/Si if constricted– CDCR if obstructed
www.indiandentalacademy.com
Canalicular Infection/Inflammation
• Most common cause: Actinomyces israelli– erythematous, dilated, “pouting” puncta
• Treatment– Warm compresses– Abx’s– Curettage/canaliculotomy
www.indiandentalacademy.com
Acquired NLDO - Causes
• Involutional stenosis - most common cause– women:men 2:1
• Neoplasms• Dacryoliths• Naso-orbital trauma, chronic sinusitis• Granulomatous disease
– sarcoidosis– Wegener’s
www.indiandentalacademy.com
Acquired NLDO - Treatment
• NLD probing w/ Si intubation occasionally effective (if tubes pass easily)
• Dacryocystorhinostomy (DCR) usually required
www.indiandentalacademy.com
Acute Dacryocystitis
• Chronic tear stasis leading to secondary infection
• Treatment– Oral/topical antibiotics
(Augmentin, Polytrim)– IV Abx’s in severe cases– I&D of any abscess– DCR when acute
inflammation controlled
www.indiandentalacademy.com
Lacrimal Sac Tumors
• Usually present as a mass above the medial canthal tendon
• Lymphadenopathy• Blood reflux from puncta frequently present• Histology
– 45% benign (squamous cell papillomas)– 55% malignant (squamous and transitional cell
carcinomas)
www.indiandentalacademy.com
Lacrimal Sac Tumors - Treatment
• Dacryocystectomy (combined with lateral rhinotomy, if malignant)
• Exenteration (incl. bone removal, if bone involved)
• 50% recurrence rate for malignant tumors with 50% of those being fatal
• Radiation for lymphomas and as adjunctive treatment for carcinomas
www.indiandentalacademy.com
Lacrimal Sac Tumors - Treatment
www.indiandentalacademy.com
Dacryocystorhinostomy (DCR)
Perioperative considerations– Stop all anticoagulants prior to surgery (i.e.,
coumadin, aspirin, NSAID’s)– MAC with local anesthesia, when possible
• general anesthesia causes increased bleeding due to systemic vasodilation
• minimal discomfort if local administered properly• quicker recovery
www.indiandentalacademy.com
Dacryocystorhinostomy (DCR)
Basic surgical steps:• Incision into lacrimal sac• Removal of bone between sac and nose• Incision into nasal mucosa• Anastamosis of lacrimal sac and nasal
mucosa• Silicon intubation
www.indiandentalacademy.com
The End
www.indiandentalacademy.com