Orbit, Lid and Lacrimal disorders

Dr Mahmood Fauzi AnsariASSIST PROF OPHTHALMOLOGY

AL MAAREFA COLLEGE

Objectives • Review the clinical anatomy and physiology of Eyelids and

Adenexa

• Describe disorders of eyelids (infections, malposition, tumors and congenital conditions)

• Describe disorders of lacrimal system (obstruction ,infection)

• Enumerate causes and management of Epiphora and Dry eye

• Outline Diagnosis and management of orbital infection

• Compare between pre-septal and septal cellulitis

• Develop the Differential diagnoses of Orbital Inflammatory Disease

The orbit Anatomy Function

• protection to the globe• attachments which stabilize

the ocular movement;• transmission of nerves and

blood vessels.

The orbit

The orbit

The orbit

Clinical features of orbital disease

• Eyelid and conjunctival changes• Reduced visual acuity• Pain• Proptosis• Enophthalmos• Diplopia

Proptosis (exopthalmos)• Protrusion of the eye caused by a

space-occupying lesion• Measured with an

exophthalmometer.• 3 mm difference between the two

eyes is significant.• Direction of proptosis• Transient proptosis (orbital varices)• Fast onset proptosis (malignant,

inflammatory)• Slow onset proptosis (benign)• Pain associated with proptosis

( orbital cellulitis)

Thyroid ophthalmopathyPathogenesis

• Disorders of the thyroid gland can be associated with an infiltration of the extraocular muscles with lymphocytes and the deposition of Glycosaminoglycans.

• An immunological process is suspected but not fully determined.

Clinical features

• Proptosis (most common cause in adults)

• Lid retraction (characteristic stare)

• Lid lag• Double vision• Red painful eye

(exposure)• Reduced visual acuity

(optic nerve)

Grading system for thyroid associated ophthalmopathy

Pneumonic NO SPECSN: no signsO: only sign = upper lid retraction; DalrympleS: soft tissue involvement (edema, chemosis, lagophthalmos)P: proptosisE: EOM involvementC: corneal involvement (SPK)S: sight loss (optic nerve compression)

Thyroid Eye Disease

Thyroid ophthalmopathy

Thyroid ophthalmopathy• Treatment of associated ocular emergencies

(optic nerve compression and corneal exposure)

1- systemic steroid2- radiotherapy3- orbital decompression4- heavy lubrication

• Long term treatment Only after stabilization, muscle and lid

surgery

Diplopia (Muscle pathology)

Thyroid ophthalmopathy (Graves’

ophthalmopathy) Idiopathic Orbital Inflammatory Disease( orbital

pseudotumor)

Enophthalmos

• Congenital (small eye)• After trauma ( blow out fracture)

Orbital tumors

• Lacrimal gland tumors• Optic nerve gliomas• Meningiomas• Lymphomas• Rhabdomyosarcoma (most common

orbital malignancy in childhood)• Metastasis from other systemic

cancers (neuroblastomas in children, the breast, Lung, prostate or gastrointestinal tract in the adult).

The orbital septum is the fascia behind that portion of the orbicularis muscle that lies between the orbital rim and the tarsus; it serves as a barrier between the lid and the orbit. The superior

orbital septum blends with the tendon of the levator palpabrae superioris and the superior tarsus; the inferior orbital septum blends with the inferior tarsus.

The orbital septum

Disorders of the Orbit- infections

• Pre-septal Cellulitis (Periorbital cellulitis)

• Post-septal Cellulitis (Orbital cellulitis)

Orbital cellulitis

ORBITAL INFLAMMATORY DISEASE(OID)

• Idiopathic/non specific orbital inflammatory disease - inflammation of the orbital tissues of unknown cause resulting in orbital pain, diplopia and proptosis

• Orbital myositis - inflammation of extraocular muscles, most commonly the superior or lateral rectus, causing orbital pain on movement of affected muscles, diplopia, proptosis

• Dacryoadenitis - inflammation of the lacrimal gland causing painful swollen lacrimal gland and reduced tear production; may be isolated or as part of diffuse idiopathic orbital inflammatory disease

• Wegener's granulomatosis - systemic small-vessel vasculitis characterised by necrotising granulomatous inflammation; c-ANCA positive in most cases; ocular involvement can include conjunctivitis, episcleritis, uveitis, retinal artery occlusion, nasolacrimal duct occlusion and optic nerve vasculitis.

The differential diagnosis of OID includes infection, inflammation, and tumor.

(a) Orbital cellulitis in patient

who presented with acute onset orbital

inflammation post-foreign body.

(b) Idiopathic OID in patient who presented with acute

onset of orbital inflammation. (c) Thyroid orbitopathy in

patient who presented with a several months history of

increasing proptosis. (d) Tumour in region of the

lacrimal gland, note S-shaped ptosis.

The eyelids are composed of several layers of tissue which protect the anterior

eyeball. From superficial to deep, they are the skin layer, a layer of striated muscle (orbicularis oculi), areolar tissue, fibrous tissue (tarsal plates), and a layer of mucous membrane

(palpebral conjunctiva).

The main supporting structure of the eyelids is a dense fibrous tissue layer, called the

tarsal plate. The palpebral conjunctiva is the mucous membrane which adheres firmly to

the tarsal plates and lines the posterior eyelids. 

The sensory nerve supply to the eyelids is derived from the first and second divisions of

the trigeminal nerve (V). The blood supply to the lids is derived from the lacrimal and ophthalmic arteries by their

lateral and medial palpebral branches.

Anatomy and Physiology of the Eyelids and Adnexa

Layers of eyelid

Muscles of eyelids

The lid margins are divided into the anterior and posterior margins at the

mucocutaneous junction.Glands of Zeis and glands of Moll are both found on the anterior margin. Glands of Zeis are small, modified

sebaceous glands that open into the hair follicles at the base of the

eyelashes; whereas glands of Moll are modified sweat glands that open in a row near the base of the eyelashes. The posterior lid margin is in close

contact with the globe, and along this margin are the small orifices of

modified sebaceous glands, called meibomian glands.

Summary of Eyelid Pathology

Disorders of the Eyelids• EYELID INFECTIONS• Blepharitis: Inflammation of lid margins

Anterior blepharitis

Posterior Blepharitis• Involving the meibomian gland orifices (meibomitis)• Associated with acne rosacea• Symptoms: similiar to anterior blepharitis• Signs: thickening and telangiectasia of lid margins,

decreased tear break-up time, rosacea

 • Management• Lid massage after heat• Topical antibiotics/steroids• Tear film supplements• Systemic tetracyclines in persistent or severe cases

LID LUMPS

Anterior Lamella • External hordeolum (stye) - acute abscess within

lash follicle and its associated glands of Moll or Zeis

• Signs: tender, warm, swollen, red eyelid lump• Management - warm compression, topical

antibiotic; add oral antibiotic in preseptal cellulitis

• Cyst of Moll - translucent cyst arises from blockage of gland of Moll (apocrine sweat gland)

• Cyst of Zeis - poorly translucent cyst arises from blockage of gland of Zeis (modified sebaceous gland)

• Xanthelasma - deposition of lipids within perivascular xanthoid cells which may be idiopathic or associated with hyperlipidaemia, hypothyroidism or primary biliary cirrhosis.

Posterior Lamella • Internal hordeolum - acute abscess within a

meibomian gland resulting in tender lump with inflammation

• Usually caused by Staphylococcus aureus• Management - warm compression, oral

antibiotics in preseptal cellulitis

• Chalazion - chronic lipogranulomatous inflammation of blocked meibomian glands.

• Often evolving from an internal hordeolum• Common in patients with chronic marginal

blepharitis, rosacea, seborrhoeic dermatitis. • Management - small chalazion tends to resolve

itself; persistent and symptomatic chalazion can be surgically removed by incision and curettage.

EYELID MALPOSITION

• Ectropion - Abnormal eversion of eyelid (usually the lower) away from the globe

• Entropion - Abnormal inversion of eyelid (usually lower) towards the globe

• Ptosis - Abnormally low position of the upper lid

• Horner's Syndrome (ptosis+meiosis+anhydrosis+enopthalmos)

Ectropion • Abnormal eversion of eyelid (usually the

lower) away from the globe Congenital - rare

• Paralytic - due to orbicularis weakness secondary to seventh cranial nerve palsy

• Involutional - due to age-related tissue laxity

• Cicatricial - due to shortened anterior lamella resulting from scarring

• Mechanical• Management• Lubricants and artificial tears• Taping lower and upper eyelids together

overnight• Corrective surgery

Entropion

• Congenital - rare

• Acute spastic - caused by sustained eyelid orbicularis contraction secondary to ocular irritation

• Involutional - due to inferior refractor dysfunction/tissue laxity

• Cicatricial - due to shortened posterior lamella resulting from scarring

• Management• Taping eyelid to the cheek • Botulinum injection• Corrective surgery

Ptosis• Involutional/aponeurotic ptosis –• most common form of ptosis; arises from disinsertion, dehiscence or

attenuation of levator palpebrae superioris• Neurogenic ptosis - third nerve palsy (dilated pupil, inability to elevate

and adduct the globe), Horner's syndrome (constricted pupil; partial ptosis due to weakness of Muller's muscle)

• Myasthenic ptosis - Myasthenia gravis (fatiguable ptosis)• Myopathic ptosis - chronic progressive external ophthalmoplegia,

myotonic dystrophy• Mechanical ptosis - masses, infiltration, oedema of upper lid• Dermatochalasis (a form of pseudoptosis) - excess skin of upper lids

• Management • Conservative• Surgery - depending on the amount and type of ptosis, degree of

levator function. There are three main approaches including • anterior (transcutaneous/external)• posterior (transconjunctival/internal)• brow/frontalis suspension surgery

Viral InfectionsVaricella zoster – • Widespread vesicular rash, primarily affecting the head neck and

trunk. • Reactivation of virus gives rise to shingles

Herpes zoster ophthalmicus(shingles)• Occurring in the first division of the trigeminal nerve • Characteristic unilateral maculopapular rash, • Associated with marked pain and systemic malaise (1 week prior to

the development of the rash)• Common in older patient .• Hutchinson's sign: cutaneous involvement of the tip of the nose

suggests an increased likelihood of ocular complications).

• Treatment• Systemic Antivirals (eg famciclovir )• Management of lid involves cool compresses and topical lubrication

± topical antibiotics for secondary infections

Herpes simplex• primary infection is usually not clinically apparent unless occurring

in the neonate or when associated with immunodeficiency. • Secondary infection frequently manifests as a dendritic corneal ulcer

Malignant tumours

Basal cell carcinoma (rodent ulcer)• >90% of all neoplastic eye lesions• Frequently occurs on the lower

lid• Indurated Plaque ± Lid distortion

and Lash Abnormalities. • Treatment is with wide local

excision.

Is Basal Cell Carcinoma Serious? …Yes, Basal Cell Carcinoma can kill if left untreated.

Sebaceous Gland Carcinoma

• accounts for 5% of all malignant eyelid tumors. can originate from Meibomian glands, Zeis glands or the sebaceous glands of the caruncle.

• more common in the upper eyelid

Squamous cell carcinoma

• accounts for ~2-5% of lid malignancies

• The tumour tends to occur on the lower lid at the margin,

• commonly in fair-skinned elderly people with a history of sun exposure.

• Plaque-like (rough, scaly erythematous patch), nodular or ulcerating with a sharply defined base and everting borders.

• It can be aggressive: refer early if you suspect this.

Congenital disorders of the lid

• Epicanthic folds

• Coloboma-uncommon condition of a partial or full thickness defect of the lid

-associated with systemic conditions such as Treacher Collins' syndrome.

-Treatment is surgical.

• Cryptophthalmos –• failure of lid development

vertical folds of skin extending from the upper eyelids to the side of the noseThese are NORMAL features in Orientals.

The lacrimal system

The lacrimal drainage system

Disorders of the Lacrimal System

• CONGENITAL OBSTRUCTION OF THE NASOLACRIMAL SYSTEM

•Nasolacrimal duct obstruction •Dacryocystocele

• INFECTIONS OF THE LACRIMAL SYSTEM

•Canaliculitis: •Acute Dacryocystitis:

NLD obstruction

Congenital NLD obstruction

• 5% of all full-term newborns.

• 90% open spontaneously in the first year of life.

• Tx: massage and antibiotics drops if infected.

• Sometimes need probing and tubing

Adult NLD obstruction

Dacryocystitis

Nasolacrimal duct obstruction, right eye. Note the build-up of tears and mucous along the lower lid margin.

Congenital dacryocystocele of the lacrimal sac in a newborn baby. A dacryocystocele is

located just inferior to the medial canthus and presents as a purplish or greyish-blue swelling.

The lacrimal apparatus consists of the lacrimal gland, accessory lacrimal gland, lacrimal puncta, lacrimal canaliculi, lacrimal sac and nasolacrimal duct.

These structures are involved in the production and drainage of tears. The blood supply of the lacrimal gland is derived from the lacrimal artery. The lymphatic drainage drain into the

pre-auricular lymph nodes. The nerve supply of the lacrimal gland is by the lacrimal nerve (sensory), a branch of the trigeminal first division, the great petrosal nerve (parasympathetic secretory), which comes from the superior salivary nucleus and is a branch of the facial nerve; and sympathetic nerves accompanying the lacrimal artery and the lacrimal nerve.

The lacrimal puncta, canaliculi, and sac, and the nasolacrimal duct form the drainage system, ultimately

draining into the nose. The nose is lined by a highly vascular mucosal epithelium;

consequently, topically applied medications that pass

through this nasolacrimal system have direct access to

the systemic circulation. Valve-like folds of the

epithelial lining of the duct, called the valve of

Hasner tend to resist the retrograde flow of tears and

air. When the structure is imperforate, it is the most

common cause of congenital nasolacrimal duct obstruction,

resulting in epiphora and chronic dacryocystitis

Any abnormality of one of the three layers produces an unstable tear film and the symptoms of dry eyes.

A tear Layer frequently affected is the Aqueous Layer, Resulting in Aqueous Tear Deficiency (ATD) or lacrimal hyposecretion.

• Common causes of watery eyes include: • Blepharitis(eyelid inflammation)• Blocked tear duct• Common cold • Ectropion (outwardly turned eyelid)• Entropion (inwardly turned eyelid)• Foreign object in the eye • Hay fever • Infection of the tear duct• Ingrown eyelash (trichiasis)• Irritation of the cornea (front of the eye)• conjunctivitis • Trachoma • some times, dry eye can be a contributing factor

Medications that can cause watery eyes include: • Epinephrine , Chemotherapy drugs, Cholinergic agonists, Eyedrops, especially

echothiophate iodide (Phospholine Iodide) and pilocarpine

• Managing the ‘Tearing’ patient• Dilation, • punctoplasty, • silicone intubation

Epiphora- watery eyes A tearing eye may be a nuisance but usually is not a serious

problem. Successful management of the

tearing patient requires the clinician to determine the

underlying cause of the epiphora.

Dry eye• Dry eye syndrome can occur if your eyes do not produce enough tears

or your tears evaporate too quickly• Symptoms of dry eye:• Pain ,Light sensitivity, A gritty sensation, A feeling of a foreign body or

sand in the eye,Itching,Redness• Blurring of vision (Without tear film, good vision not possible.)• What Causes Dry Eyes?• The natural aging process, especially menopause• Side effects of certain drugs such as antihistamines and birth control pills• Diseases that affect the ability to make tears, such as Sjogren's syndrome,

rheumatoid arthritis, and collagen vascular diseases• Structural problems with the eyelids that don't allow them to close

properly• Managing the dry eye• Artificial tear drops and ointments.• Temporary punctal occlusion• Lipiflow. use heat and pressure on the eyelids to unclog blocked glands.• Restasis. (Cyclosporine Ophthalmic Emulsion) 0.05% increases eyes’ natural ability to

produce tears, in Chronic Dry Eye. RESTASIS® did not increase tear production in patients using anti-inflammatory eye drops or tear duct plugs

Useful Resources • Diagnosis and Management of Eyelids and

Lacrimal Abnormalities. http://www.optometry.co.uk/uploads/articles/a9a9411f4103e999dd58c633a30329bd_Wearne1991105.pdf

• External Eye Overview - Lashes, eyelids and lacrimal system. http://www.patient.co.uk/doctor/External-Eye-Lashes-Eyelids-and-Lacrimal-System.htm

• Eyelids, Orbit and Lacrimal System. http://www.slideshare.net/sectionbmd/lecture2-eyelidorbitlacrimal

• http://quizlet.com/37218591/flashcards