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The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and offering a wide range of dental certified courses in different formats.

Indian dental academy provides dental crown & Bridge,rotary endodontics,fixed orthodontics,
Dental implants courses.for details pls visit www.indiandentalacademy.com ,or call
0091-9248678078

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Oculoplastics review /certified fixed orthodontic courses by Indian dental academy Oculoplastics review /certified fixed orthodontic courses by Indian dental academy Presentation Transcript

  • 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.) • Superior orbital fissure • Optic foramen – 8-10 mm – Located within lesser wing of sphenoid – Transmits optic nerve, ophthalmic a. and sympathetic nerves – Bound by greater and lesser sphenoid wings – Outside annulus (“luscious French tarts”) • lacrimal, frontal, IV – Inside annulus (“sit naked in anticipation) • III-sup, nasociliary IIIinf, 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 – Vertical 28-30 mm 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 Eyelid Levator 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
  • Ectropion Associated 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
  • Ectropion When lid tightening is enough • Involutional • Paralytic - simple cases www.indiandentalacademy.com
  • Ectropion When 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
  • Entropion When lid tightening is enough • Almost never – Addressing only one of several factors usually associated with recurrence – mild involutional cases may respond www.indiandentalacademy.com
  • Entropion When 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 lesion www.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