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1
Oculoplastic disorders
Meseret
2
Eyelid Disorders
Internal Hordeolum
a staphylococal abscess of Meibomian glands
•Sxspain, redness, swelling
within eye lid• Signs• tender, inflamed mass
within the eye lid.
3
Internal Hordeolum…
• Treatment• _ Hot compress• _ Topical antibiotics• _ If the above treatment fails, Incision and curettage under local anesthesia
4
External Hordeolum /stye/
• An acute staphylococcal infection of a lash follicle and its associated gland of zeis or moll.
• SymptomsPain, redness, lid margin swelling of short
duration
5
External Hordeolum /stye/…
• Signs• Tender inflamed mass
in the lid margin which points
• anteriorly through the skin
6
External Hordeolum /stye/…
• Treatment• Warm compression• Topical antibiotic - Chloramphenicol eye
ointment.• • Epilation of the eyelash associated with the
infected follicle mayenhance drainage of focus.
7
Chalazion
• A chronic lipogranulomatous inflammatory lesion caused by
• blockage of meibomian gland orifices and stagnation of sebaceous Secretion
• Symptom• Painless nodule within the eye lid
8
Chalazion…
• Sign Non tender, firm,
roundish mass within the eye lid.
• Treatment• Hot compression surgical incision and
curettage
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Treatment of chalazion
Injection of local anaesthetic Insertion of clamp Incision and curettage
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Medical treatment of chalazion
• Inject 0.1-0.2ml triamcinolone diacetate aquouse suspension dilauted with lignocaine (5mg/ml)
• Success rate 80%• Can be repeated after 2 weeks.• Systemic tetracycline for recurrent cases
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Preseptal cellulitis
• Inflammation in front of the orbital septum
Causes-stahyloccoci, streptococciH. Influenza…Risk factors Trauma, URTI, insect
BitesRx- Systemic Abtcs
12
Molluscum contagiosum
• - Uncommon skin infection caused by a poxvirus
• - common in children and immunocompromized patienst.
• In immunocompromized patients, it is multiple, large size, bilateral, recurrent and resistant to treatment.
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• Rare tumour which presents soon after birth
• Starts as small, red lesion, most frequently on upper lid
• Blanches with pressure and swells on crying
• Grows quickly during first year
• May be associated with intraorbital extension
• Begins to involute spontaneously during second year
Capillary haemangioma
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Treatment of Capillary hemangioma
• Most of the cases resolve spontanously• For cases that may cause amblyopia-steroid injections, and for selected cases
surgical resection is done/
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Molluscum contagiosum
• Symptom – painless, raised, skin lesion.• Sign• Single or multiple• Pale, waxy Umblicated nodules• If the nodule is located on the lid margin it
may give rise to ipsilateral chronic follicular conjunctivitis and occasionally a superficial keratitis
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Molluscum contagiosum…
• Treatment Shaving and excision• Destruction of the lesion by cauterization,
cryotherapy
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Herpes Zoster Ophthalmicus
Caused by Varicella zoster/herpes virus-3Eye is affected through ophthalmic branch of trigeminal nerve Unilateral Common in immunocompromised patient 95% are seropositive
The rash appears 2-3 days after the pain: the rash is not different in seropositive and seronegatives but recurrent in seropositive patients.
Signs-in chronological order
Maculopapular rash in the fore headDevelopment of vesicles, pustules and crusting ulcerationIn severe cases-periorbital edema due to secondary bacterial cellulitis.
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Treatment Analgesics
Aspirin 600mg Q 4-6hoursParacetamole 1gm Q 4hoursGentian violet - 0.5% clean the wound
Antiviral should be given within 48hours after rash, because the drug need active viral replication.
Acyclovir 800mg 5x/day for 7-10days
Valicaclovir 1gm TID for 7 days
Tamciclovir 25mg TID for 7days
As it is less sensitive to these drugs than H.simplex, giving low dose to save money is wasting money.
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ComplicationIf the tip and side of the nose is involved, the eye is likely involved even if it looks normal. So start treatment is indicated with the following medications.
Atropine 1% eye drops BID to decrease blood supply to iris.If eye is red and painful, It can be Corneal Ulcer- Treatment with
Chloramphinicol eye drops QID If there is no corneal Ulcer- Treatment with Steroid eye drop
Post herpetic Neuralgia Aspirin 600mg Q 4hour Paracetamole 1gm P.O. Q 4hours Carbamazepine 100gm P.O. Per day, increase the full dose 300 to 400gm BID per day
20
Blepharitis
1. Staphylococcal – blepharitis• • Caused by Staph. aureus• • Is ulcerative in type with redness of lid margins with
scales and easily pluckable lashes2. Seborrheic blepharitis• Is associated with seborrhea of the scalp, brows and ears• Is non –ulcerative• The scales are greasy with less marked redness of the lid
margin• A patient may present with a mixed type of Blepharitis
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• Both types of patients could present with:-• Symptoms• • Irritation• Burning• • Itching of the lid margins
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• Signs• • Scales on lid margin• • Eye lid margin
ulceration and redness• Pouting meibomina
orifices
23
Blepharitis….
• Treatment• Lid hygiene• Topical antibiotics (erythromycin or
Chloramphenicol eye drops QID)• Systemic antibiotics-doxcycline50 to 100
mg/day for four wks for infectious cause• Topical steroids (terracortri)l eye suspension
once –twice a day) for seborrheic
24
Herpes Zoster Ophthalmicus
Caused by Varicella zoster/herpes virus-3Eye is affected through ophthalmic branch of trigeminal nerve Unilateral Common in immunocompromised patient 95% are seropositive
The rash appears 2-3 days after the pain: the rash is not different in seropositive and seronegatives but recurrent in seropositive patients.
Signs-in chronological order
Maculopapular rash in the fore headDevelopment of vesicles, pustules and crusting ulcerationIn severe cases-periorbital edema due to secondary bacterial cellulitis.
25
Treatment Analgesics
Aspirin 600mg Q 4-6hoursParacetamole 1gm Q 4hoursGentian violet - 0.5% clean the wound
Antiviral should be given within 48hours after rash, because the drug need active viral replication.
Acyclovir 800mg 5x/day for 7-10days
Valicaclovir 1gm TID for 7 days
Tamciclovir 25mg TID for 7days
As it is less sensitive to these drugs than H.simplex, giving low dose to save money is wasting money.
26
ComplicationIf the tip and side of the nose is involved, the eye is likely involved even if it looks normal. So start treatment is indicated with the following medications.
Atropine 1% eye drops BID to decrease blood supply to iris.If eye is red and painful, It can be Corneal Ulcer- Treatment with
Chloramphinicol eye drops QID If there is no corneal Ulcer- Treatment with Steroid eye drop
Post herpetic Neuralgia Aspirin 600mg Q 4hour Paracetamole 1gm P.O. Q 4hours Carbamazepine 100gm P.O. Per day, increase the full dose 300 to 400gm BID per day
27
Benign eyelid Tumors / lesions Epithelial tumors like:-Squamous papilomasVerruca Vulgaris (wart) Seborrheic Keratosis Inclusion cysts
NeviMelanocytic lesions of the skin arise from three sources. Nevus cells, Dermal melanocytes, Epidermal melanoctes Treatment is needed if it is growing and for cosmetic reasons.
Hemangioma Capillary hemangioma is common in children, may be present at birth. Usually occur at the 1st tweeks or months of life. TreatmentIntralesional corticosteroid injection is the current treatment of choice in patients whose vision is threatened.Capillary hemangioma is usually self limiting and disappears in 5-7 years of age.
Eyelid Tumors
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Malignant eyelid tumors Basal cell carcinoma (BCC)Most common eyelid malignancy, 90-95% of malignant eyelid tumors. More common in fair-skinned, blue-eyed, red hair, middle age to old people Treatment - Excisional biopsy followed by skin grafting & reconstruction
Squamous cell carcinoma (SCC)Less common than BCC but more aggressive (More common in our country)Potentiated by immunodeficiency and human papilloma virus.
Treatment -Wide surgical excision-Exenteration
Sebaceous Adenocarcinoma- Sebaceous gland carcinoma (SGC)Highly malignant and potentially lethal tumor. Clinically, they may simulate chalazia, blepharitis, BCC or SCC
Treatment : Wide surgical excision
Kaposi sarcoma Treatment : There is no definitive surgical management.
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ABNORMALITY IN THE FUNCTION AND POSITION OF THE EYELIDS
• EctropionIt is eversion of the eyelid margins away from
the globeCausesParalytic –facial nerve palsyMechanical- Mass or edema on the lower lidCicatricial- secondary to inflammation or burnInvolutional- age related changes
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Ectropion
Cicatricial ectropionInvolutional ectropion
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Entropion Inversion of the eyelid margins• Causes
ParalyticInvolutionalcicatricial
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Management Treatemnt of ectropion
Prevent exposure keratopathy Treat the cause (if possible) Surgical correction
Treatment of Entropion
Protect corneal damage from trichiasis Treat the cause when possible Do Surgical correction
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Ptosis• It is drooping of the upper eyelid• Causes could be
1. Congenital unilateral or bilateral Can cause amblyopia
2. Acquired Ptosis• Neurogenic 3rd nerve palsy (partial or complete) sympathetic palsy (Hornor’s syndrome)
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Ptosis (contd)
3.MechanicalExample – tumors, edema…pulling the lid down4. Involutional• Age related changes to the levator muscle5. Myogenic• Mygoenic dystrophy to Levator6. Apponeurotic-Damage to the levator apponeurosis
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Management of Ptosis
• Prevent amblyopia in children• Address the cause when possible• Surgical correction –when cosmetically and
functionally significant
Proceduers of ptosis surgery1. Frontalis sling2. Levator advancement
36
THYROID EYE DISEASE
• An autoimmune inflammatory disorder of the orbit whose underlying cause is not fully understood.
• 90% assocaited with graves disease• 6% asso with euthyroid state• 3% associated with Hashimotos thyroidits• 1% associated with hypothyroid state
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1. Soft tissue involvement• Periorbital and lid swelling• Conjunctival hyperaemia• Chemosis• Superior limbic keratoconjunctivitis
2. Eyelid retraction3. Proptosis4. Optic neuropathy5. Restrictive myopathy
Clinnical Features
38
Soft tissue involvementPeriorbital and lid swelling
Chemosis
Conjunctival hyperaemia
Superior limbic keratoconjunctivitis
39
Signs of eyelid retraction Occurs in about 50%
• Bilateral lid retraction • No associated proptosis
• Bilateral lid retraction • Bilateral proptosis
• Lid lag in downgaze • Unilateral lid retraction • Unilateral proptosis
40
Proptosis
Treatment options • Systemic steroids • Radiotherapy • Surgical decompression
• Occurs in about 50% • Uninfluenced by treatment of hyperthyroidism
Axial and permanent in about 70% May be associated with choroidal folds
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Optic neuropathy• Occurs in about 5% • Early defective colour vision • Usually normal disc appearance
Caused by optic nerve compression at orbital apex by enlarged recti
Often occurs in absence of significant proptosis
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• Occurs in about 40% • Due to fibrotic contracture
Restrictive myopathy
Elevation defect - most common Abduction defect - less common
Depression defect - uncommon Adduction defect - rare
43
Treatment of Thyroid Eye disease
• Lubrication of the corena• Tape the lid if blinking function is not good• Steroids• Surgical decompression of the orbital walls
44
ORBITAnatomy
The orbits are bony cavities contain the globes, extra ocular muscles, nerves, fat, and blood vessels Each bony orbit is pearl (cone) shaped.
Dimensions Volume - 30 cc
Entrance height - 35 mm Entrance width - 40 mm
The orbital walls are composed of seven bones
Ethmoid
Frontal Four walls of the orbitLacrimal Maxillary Roof of OrbitPalatine Lateral wall of orbitSphenoid Medial wall of the orbitZygomatic Floor of Orbit
45
The six Ps
Pain - May be a symptom of inflammatory and infections lesions, orbital hemorrhage, malignant lacrimal gland tumors, and nasopharyngeal carcinoma.
Proptosis- Reflect the location of the mass the globe is usually displaced away from the mass
Axial displacement - caverious hemangima, glioma, meningiona, etc.
Superior displacement- maxillary sinus tumors
Down & medial placement- lacrimal gland tumor, demoid
Down & lateral displacement- frontoethmoidal mucoceles, abscesses, osteomas, and sinus carcinomas.
Bilateral protosis- Thyriod ophthalmopathy, lymphomas, vasculitis, idiopathic orbital inflammatory disease (pseudotumor),metastatic tumors, leukemias, carotid cavernous fistuals, etc. Enophathalmos- Can occur due to sclerosing tumors such as metastatic
breast carcinoma and orbital floor fracture.
Evaluation of orbital disorders
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Progression –Disorder occurring over days and weeks PseudotumorCellulitisHemorrhageThrombophobitisRhabdomyosarcomaThyroid ophthalomopathy
Disorders occurring over months to years. Dermoids Neurogenic tumorsLymphomas Benign mixed tumors of LG Cavernous hemangiomas Metastatic tumors
Palpation - Consistency of the mass, location tenderness, hotness
Pulsation – Arteriovenous fistulas, neurofibromatosis, meningoencephalocele
Periobital changes- These changes may indicate the underlying disorders. E.g- Corkscrew conjunctival vessels-Arteriovenous fistula
-Anterior uveitis-pseudotumor or sarcoid -Eyelid retraction & eyelid lag-Thyroid ophthalmopathy.
47
Physical examination of orbital disorders
Inspection - Globe displacement measured by exophthalmometry. Palpation - Presence of mass, retropulsion displacement
Palpate regional lymph nodesPalpate for pulsation - vascular tumors
Auscultation - Bruits may be detected with stethoscope or subjectively by the patient
Primary studies of orbital disorders
Plain - film radiographyUltrasonographyComputed tomography (CT)Magnetic Resonance Imaging (MRI)
Secondary studies
Venography Pathology - FNAB, Tissue BiopsyArteriography Laboratory studies - T3, T4, TSH for thyroid ophthalmopathy
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50
Disorders Occurring Predominantly in Children Orbital cellulitis - most common cause of proptosis in children Rhabdomyosarcoma - most common primary orbital malignancy in children Dermoid and epidermoid cysts
Capillary hemangionia and lymplangioma
Orbital nerve glioma
Leukemia (granulocytic chloroma)
Orbital inflammatory syndromc (Orbital pseudotumor )
Neurofibroma
Retinoblastoma
Metastatic neuroblastoma (most common metastatic ca. to the orbit in children)
51
Disorders occurring predominantly in Adults
Thyroid ophthalmopathy - most common cause of unilateral and bilateral proptosis in Adults
Cavemous hemangioma - most common benign primary orbital tumor in Adults
Orbital inflammatory syndrome (orbital pseudotumor)
Lymphocytic lesions
Meningioma
Lacrimal gland tumors
Dermoid and epidermoid cysts
Treatment of Orbital disorders : Mainly Surgical
52
Preseptal cellulitis
– Inflammation and infection confined to the eyelids and periorbital structures anterior to the orbital septum
– Motility of the globe is full, normal VA and no conjunctival chemosis
Diagnosis- blood culture, pus culture
Treatment - oral Antibiotics (third generation cephalosporin, Ampicillin,...)
53
Orbital Cellulitis
Active infection of the orbital soft tissue posterior to the orbital septum. 90% of cases orbital cellulitis occurs as a secondary extension of acute or chronic bacterial sinusitis. Clinical findings
FeverproptosisChemosisrestriction of ocular motilityPain on movement of the globe. Decreased vision and pupillary abnormalities suggest involvement of the orbital apex and demand immediate investigation and aggressive management.
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Complications Orbital apex syndrome (cavernous sinus thrombosis)BlindnessCranial nerve palsiesBrain abscessDeath
Management Evaluation of paranasal sinuses (CT)Plain - filmENT consultation
Treatment - Admission Parenteral broad spectrum Antibiotics Nasal decongestantsSurgical sinus drainage