Oculoplastics Review
INDIAN DENTAL ACADEMY
Leader in continuing dental education
www.indiandentalacademy.com

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Oculoplastics
• Orbit
• Eyelid
• Lacrimal

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Orbit

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Orbital Anatomy
• 7 bones
• 30 cc (35 mm width x
40 mm height)
• 25-30 mm orbital
optic nerve
• Rim
– Zygomatic
– Maxillar...
Orbital Anatomy (cont.)
• Superior orbital fissure

• Optic foramen
– 8-10 mm
– Located within lesser
wing of sphenoid
– T...
Orbital Anatomy (cont.)
• Inferior orbital fissure
– Bound by sphenoid,
maxillary and palatine
bones
– Transmits V2 which
...
Orbital Pathophysiologic
Patterns1
•
•
•
•
•

Inflammation: 57.3%
Neoplasia: 22.3%
Structural Abnormality: 15.8%
Vascular ...
Orbital Inflammation
• Orbital cellulitis
• Graves ophthalmopathy
• Idiopathic orbital inflammantion
(pseudotumor)
• Sarco...
Orbital Cellulitis
• Medical emergency – because of rapid spread to
brain (i.e. cavernous sinus thrombosis, brain
abscess)...
Orbital Cellulitis (cont.)
• Orbital vs. preseptal cellulitis
– Orbital signs: motility changes, proptosis, chemosis,
decr...
Graves Ophthalmopathy
• Eyelid retraction most common finding
• Most common cause of unilateral/bilateral
proptosis
• Wome...
Idiopathic Orbital Inflammation
(“Pseudotumor”)
• May present as focal (I.e. dacryoadenitis, myositis,
sclerotenonitis, pe...
Pediatric Orbital Tumors
• Benign
–
–
–
–

Dermoid cysts – frontozygomatic suture
Lipodermoids – Goldenhaar’s sydrome
Opti...
Pediatric Orbital Tumors
• Malignant
– Rhabdomyosarcoma
• Average age (7-8)
• Embryonal (most common), alveolar (most mali...
Adult Orbital Tumors
• Benign
– Cavernous hemangioma – removal if
symptomatic
– Meningioma – needs surgery if vision
threa...
Adult Orbital Tumors
• Malignant
– Metastatic
• Breast, lung, prostate, GI and melanoma

– Hemangiopericytoma (malignant
t...
Lacrimal Gland Tumors
• Epithelial (50%)
– Pleomorphic adenoma (benign mixed) –
remove entirely or may recur with malignan...
Orbital Trauma
• LeFort classification
– I – transverse maxillary
– II – nasal, lacrimal and maxillary bones
(includes med...
Orbital Trauma (cont.)
• Indications for surgery of blow-out
fracrure
– Entrapment beyond 7-10 days (urgent
treatment in c...
Eyelid

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Eyelid Anatomy
•
•
•
•
•

Involutional
Paralytic
Cicatricial
Mechanical
Congenital - rare

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Superficial Eyelid Landmarks
• Eyebrow
– Peaks at 9:00 limbus
– 1 cm above orbital rim in youth
– Flatter in males, more f...
Superficial Eyelid Landmarks
• Upper Eyelid Margin
– Peaks slightly nasal to the pupil
– upper limbus in youth
– 1.5 - 2.0...
Superficial Eyelid Landmarks
• Lateral commissure
– 5 mm nasal to lateral rim
– 2 mm above medial in males
– 4 mm above me...
Superficial Eyelid Landmarks
• Upper Eyelid Crease
– 7 - 8 mm above the margin in males
– 9 - 10 mm above the margin in fe...
Eyelid Anatomy
• Divided into anterior
and posterior lamella
– Anterior Lamella
• Skin
• Orbicularis

– Posterior Lamella
...
Eyelid Anatomy (cont.)
• skin and subcutaneous tissue
• orbicularis muscle and
submuscular fibroadipose tissue
• orbital s...
Skin and Subcutaneous Fascia
• Thinnest of the body (~ 1mm) - thinnest
medially
• Little or no subcutaneous fat
• Subjecte...
Skin and Subcutaneous Fascia
• Upper eyelid crease
– 9-10 mm in females, 7-8 mm in males
– formed by levator attachments t...
Eyelid Protractors
• Orbicularis oculi - horseshoe-shaped muscle
– Orbital
– Preseptal
– Pretarsal

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Orbital Orbicularis
• Voluntary
• Above - inserts to the anterior supraorbital
margin medial to the supraorbital foramen;
...
Preseptal Orbicularis
• Involuntary
• Laterally: continuous overlying lateral
canthal tendon
• Medial insertion
– anterior...
Pretarsal Orbicularis
• Firmly attached to tarsus
• Lateral - gives rise to lateral canthal tendon
• Medial
– Superficial ...
Medial Orbicularis Attachments

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Orbital Septum
• Orbital septum + tarsus = “middle lamella”
of the eyelid
• Originates at the arcus marginalis
(periosteum...
Orbital Septum
• Inferior - fuses with inferior border of
tarsus, separated from capsulopalpebral
fascia by postseptal fat...
Orbital Fat Pads
• Upper Eyelid
– preaponeurotic
– nasal - whiter
shade

• Lower Eyelid
– nasal - whiter
shade
– central
–...
Eyelid Retractors

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Retractors of Upper Eyelid
Levator palpebrae superioris
• Originates at orbital apex
• Horizontal (40 mm) and vertical (15...
Retractors of Upper Eyelid
• Levator Aponeurosis
– forms lateral and medial horns - attach to
respective retinaculae
– att...
Retractors of Upper Eyelid
• Superior Tarsal Muscle (Muller’s)
–
–
–
–

innervated by cervical sympathetic system
inserts ...
Retractors of Upper Eyelid

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Retractors of Lower Eyelid
• capsulopalpebral head given off by inferior
rectus
• splits around inferior oblique and “reun...
Retractors of Lower Eyelid
• inferior tarsal muscle (muller’s) terminates
2.5 mm beneath inferior tarsal border

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Tarsus
• Dense irregular connective tissue - not
collagen
• Meibomian glands
– orifices located posterior to lashes and gr...
Tarsus
• Upper
– 29 mm in length, 10 mm wide
– extends to lateral commissure

• Lower
– 29 mm in length, 4 mm wide
– exten...
Conjunctiva
• Palpebral conjunctiva
– marginal - extends to mucocutaneous border
– tarsal - adherent to tarsus
– orbital -...
Lateral “Whitnall’s” Orbital Tubercle
• Lateral retinaculum
–
–
–
–

lateral horn of levator aponeurosis
lateral canthal t...
Posterior Lacrimal Crest
• Medial ocular retinaculum
–
–
–
–
–

inferior transverse “Lockwood’s” ligament
medial rectus ch...
Vascular Supply

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Lymphatic Drainage

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Sensory Nerve Supply

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Ectropion
•
•
•
•
•

Involutional
Paralytic
Cicatricial
Mechanical
Congenital - rare

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Ectropion
Associated terminology
• Lagophthalmos
exposure of conjunctiva/cornea with attempted
lid closure

• Lid Retracti...
Involutional Ectropion
• Tissue relaxation associated with aging
• Extreme cases termed “tarsal ectropion”
implies detachm...
Paralytic Ectropion
• VII nerve palsy
–
–
–
–

Bell’s palsy (90%)
Herpes Zoster (Ramsey-Hunt syndrome)
Trauma
Tumors (acou...
Cicatricial Ectropion
•
•
•
•
•
•
•

Actinic changes
Trauma
Burns
Removal of lower lid lesions
Chronic inflammation
Lower ...
Mechanical Ectropion
• Due to mass effect of lower lid lesion
– bulky tumors
– herniated orbital fat
– chronic lower lid e...
Congenital Ectropion
• Typically involves upper and lower lids
• Conservative treatment (i.e. taping of lids,
temporary ta...
Lateral Tarsal Strip Procedure
• Anderson RL, Gordy DD. Archives of
Ophthalmology, 1979

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LTS step 1

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LTS step 2

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LTS step 3

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LTS step 4

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LTS step 5

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LTS step 6

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LTS step 7

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LTS step 8

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Medial Spindle Slide

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Ectropion
When lid tightening is enough
• Involutional
• Paralytic - simple cases

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Ectropion
When lid tightening is not enough
• Paralytic - severe cases
– Midface lift, fascia lata sling

• Cicatricial
– ...
Entropion
•
•
•
•

Involutional
Transient Spastic
Cicatricial
Congenital

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Involutional Entropion
• Most patients present with eyelid rolled in and
orbicularis spasm
• Accompanied by red, irritated...
Transient Spastic Entropion
• Acute lower lid swelling accompanied by
orbicularis spasm
• Generally resolves with resoluti...
Cicatricial Entropion
•
•
•
•
•

Trauma/Chemical injury
Inflammation
Ocular cicatricial pemphigoid
Stevens-Johnson syndrom...
Congenital Entropion
• Associated with epiblepharon (roll of eyelid
that mechanically rolls lid inward)
• Common in Asian ...
Entropion
When lid tightening is enough
• Almost never
– Addressing only one of several factors usually
associated with re...
Entropion
When lid tightening is not enough
• Involutional
– Jones Procedure

• Transient Spastic
– Quickert suture

• Cic...
Jones Procedure

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Jones Procedure - Illustration

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Quickert Suture

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Posterior Lamella Grafting

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Posterior Lamella Graft

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Posterior Lamella Grafting
(cont.)
• Sources of autogenous graft materials
–
–
–
–

hard palate
buccal mucous membrane
nas...
Ptosis/Retraction
• Physical Exam
–
–
–
–
–
–

MRD1 – margin-reflex distance – upper lid
MRD2 – margin-reflex distance – l...
Ptosis – Etiology
• Myogenic
– Congenital
– CPEO, Myasthenia

• Aponeurotic – aging, most common
• Neurogenic
– Horner’s
–...
Ptosis - Treatment principles
• Moderate to Good levator function
– Levator resection/advancement

• Poor levator function...
Retraction – Etiology
• Graves
– Most common cause

• Post eye muscle surgery
• Superior orbital malignancy
• Pseudoretrac...
Retraction - Treatment
• Levator recession
– Upper lid +/- spacer graft
– Lower lid + spacer graft (hard palate,
Alloderm)...
Lacrimal

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Basic Secretors
• Basic secretors
– decreases with age
– no efferent
innervation

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Mucin Secretors
• Goblet Cells
– throughout the conjunctiva,
denser nasally

• Crypts of Henle
– upper 1/3 of upper tarsus...
Aqueous Secretors
• Glands of Krause
– fornix - subconjunctival
– 40 in upper, 6-8 in lower

• Glands of Wolfring
– upper ...
Oil Secretors
• Meibomian glands
– in the tarsal plates
– 25-40 in upper, 20 in lower

• Zeis
– follicles of eyelashes

• ...
Basic Secretors - Re-cap

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Reflex Secretors
• Lacrimal gland - main (orbital) and
palpebral lacrimal glands
– exocrine glands
– efferent parasympathe...
Main (Orbital) Lacrimal Gland
• 20mm x 12mm x 15mm
• .78 gm
• 4 ligaments firmly hold gland in place
–
–
–
–

Sommering’s ...
Main (Orbital) Lacrimal Gland
• Lacrimal foramen
• 2 to 6 excretory ducts - pierce conjunctiva 5
mm above lateral margin o...
Palpebral Lacrimal Gland
• About 30 loosely knit lobules each with a
secretory duct that empties into a main
excretory duc...
Reflex Secretors
• Fifth cranial nerve is the reflex, afferent pathway
for the main and palpebral lacrimal glands
• Other ...
Reflex Secretors
• Peripheral sensory
• Retinal
• Psychogenic

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Reflex Secretors
• VII nerve - parasympathetic/efferent pathway
–
–
–
–
–

Arise in pons
Fibers join sensory route of VII
...
Reflex Secretors
• VII nerve - parasympathetic/efferent pathway

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Reflex Secretors
• Sympathetic - efferent pathway
– Fibers arise in the hypothalamus
– Pass to superior cervical ganglion
...
Distributional System
• Eyelids
–
–
–
–

distribute tears
regulate evaporation
expel superfluous tears
assist in the forma...
Excretory System
•
•
•
•
•

Upper and lower canaliculi
Lacrimal sac
Nasolacrimal duct
Palpebral parts of the orbicularis o...
Canaliculi
• Canaliculi - 10 mm in length, 2 mm vertical
and 8 mm horizontal
• Diameter - punctum 0.3 mm
- ampulla 2 to 3 ...
Canaliculi
• 90% have common
canaliculus - enters
posterior and superior
• Dilation of common
canaliculus is the sinus of
...
Lacrimal Sac and Nasolacrimal
Duct
• Lined double layered
columnar epithelium
• Single structure ~ 35
mm in length
–
–
–
–...
Nasolacrimal Duct
• Meatal NLD - 5 mm:
guarded by Hasner’s valve
• Angled slightly lateral and
posterior
• Opens into the ...
Lacrimal Diaphragm
• Extension of orbital
periosteum
– “sac within a sac”

• Inferior and superior
preseptal muscles inser...
Lacrimal Pump (cont.)

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Lacrimal Disease

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Congenital Epiphora
• Usually begins between 2 and 3 months
• Causes:
– Congenital nasolacrimal duct obstruction
(NLDO)
– ...
Congenital Epiphora Evaluation
• Constant/minimal mucopurulence
– Upper system (i.e., canalicular, punctal)
obstruction

•...
Congenital NLDO
• Caused by membranous block at valve of
Hasner
• Present in 50% of newborns
• Most resolve in 6 weeks
• 9...
Congenital NLDO Evaluation
• Pressure on sac – look for discharge
• Examine lids for open puncta
• Jones testing (DRT, I, ...
Congenital NLDO Management
• Conservative management for 1st year
– Massage
– Topical antibiotics for “flare-ups”

• Indic...
Congenital NLDO Management
(cont.)
• Probing considerations
– May perform office probing if < 6 months
– Probing with sili...
Congenital NLDO Management
(cont.)
• Probing technique
– traction on lid – probe to “hard stop”
– rotate along brow and do...
Congenital Dacryocystocele,
(a.k.a., Mucocele, Amniotocele)
• Plugging of sac with mucous and amniotic
fluid
• Caused by N...
Congenital Dacryocystocele,
(a.k.a., Mucocele, Amniotocele)

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Punctal Agenesis
• Rare
• May have a well developed canalicular
system revealed through a lid cut down
• If entire punctal...
Acquired Epiphora
Etiology:
• Ocular surface irritation with secondary
hypersecretion
• Outflow obstruction (including eye...
Acquired Epiphora - Evaluation
History:
• Topical medications
• Ocular surface discomfort
• Nasal trauma/surgery or sinus ...
Acquired Epiphora - Evaluation
Exam:
• Eyelid/punctal position
– Ectropion with exposure (incl. VII n. palsy)
– Entropion ...
Acquired Epiphora - Diagnostics
• Schirmer tear testing
• Jones testing
– Dye disappearance test (DDT) – abnormal if
dye r...
Jones Testing Interpretation
• Jones I (-) Jones II (+) w/dye
– functional obstruction
– trial of FML, followed by DCR

• ...
Abnormal Jones II Interpretation
• Reflux out same puncta
– canalicular obstruction
– CDCR w/ pyrex tube

• Reflux out opp...
Additional Diagnostic Testing
• Scintigraphy
– T99 scan demonstrating physiologic tear flow

• Dacryocystography
– Contras...
Acquired Canalicular Obstruction
• Causes
– Trauma
– Toxic medications (5-FU, phospholine iodide,
Tamoxifen)
– Autoimmune ...
Canalicular
Infection/Inflammation
• Most common cause: Actinomyces israelli
– erythematous, dilated, “pouting” puncta

• ...
Acquired NLDO - Causes
• Involutional stenosis - most common cause
– women:men 2:1

•
•
•
•

Neoplasms
Dacryoliths
Naso-or...
Acquired NLDO - Treatment
• NLD probing w/ Si intubation occasionally
effective (if tubes pass easily)
• Dacryocystorhinos...
Acute Dacryocystitis
• Chronic tear stasis
leading to secondary
infection
• Treatment
– Oral/topical antibiotics
(Augmenti...
Lacrimal Sac Tumors
• Usually present as a mass above the medial
canthal tendon
• Lymphadenopathy
• Blood reflux from punc...
Lacrimal Sac Tumors - Treatment
• Dacryocystectomy (combined with lateral
rhinotomy, if malignant)
• Exenteration (incl. b...
Lacrimal Sac Tumors - Treatment

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Dacryocystorhinostomy (DCR)
Perioperative considerations
– Stop all anticoagulants prior to surgery (i.e.,
coumadin, aspir...
Dacryocystorhinostomy (DCR)
Basic surgical steps:
• Incision into lacrimal sac
• Removal of bone between sac and nose
• In...
The End

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Oculoplastics review /certified fixed orthodontic courses by Indian dental academy

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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

  1. 1. Oculoplastics Review INDIAN DENTAL ACADEMY Leader in continuing dental education www.indiandentalacademy.com www.indiandentalacademy.com
  2. 2. Oculoplastics • Orbit • Eyelid • Lacrimal www.indiandentalacademy.com
  3. 3. Orbit www.indiandentalacademy.com
  4. 4. 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
  5. 5. 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
  6. 6. 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
  7. 7. 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
  8. 8. Orbital Inflammation • Orbital cellulitis • Graves ophthalmopathy • Idiopathic orbital inflammantion (pseudotumor) • Sarcoidosis • Wegener’s • polyarteritis nodosa www.indiandentalacademy.com
  9. 9. 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
  10. 10. 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
  11. 11. 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
  12. 12. 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
  13. 13. 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
  14. 14. 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
  15. 15. 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
  16. 16. Adult Orbital Tumors • Malignant – Metastatic • Breast, lung, prostate, GI and melanoma – Hemangiopericytoma (malignant transformation from benign form) www.indiandentalacademy.com
  17. 17. 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
  18. 18. 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
  19. 19. 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
  20. 20. Eyelid www.indiandentalacademy.com
  21. 21. Eyelid Anatomy • • • • • Involutional Paralytic Cicatricial Mechanical Congenital - rare www.indiandentalacademy.com
  22. 22. 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
  23. 23. 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
  24. 24. 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
  25. 25. 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
  26. 26. Eyelid Anatomy • Divided into anterior and posterior lamella – Anterior Lamella • Skin • Orbicularis – Posterior Lamella • Conjunctiva • Tarsus www.indiandentalacademy.com
  27. 27. Eyelid Anatomy (cont.) • skin and subcutaneous tissue • orbicularis muscle and submuscular fibroadipose tissue • orbital septum • preaponeurotic fat • retractors • tarsus and conjunctiva www.indiandentalacademy.com
  28. 28. 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
  29. 29. 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
  30. 30. Eyelid Protractors • Orbicularis oculi - horseshoe-shaped muscle – Orbital – Preseptal – Pretarsal www.indiandentalacademy.com
  31. 31. 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
  32. 32. 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
  33. 33. 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
  34. 34. Medial Orbicularis Attachments www.indiandentalacademy.com
  35. 35. 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
  36. 36. 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
  37. 37. Orbital Fat Pads • Upper Eyelid – preaponeurotic – nasal - whiter shade • Lower Eyelid – nasal - whiter shade – central – temporal www.indiandentalacademy.com
  38. 38. Eyelid Retractors www.indiandentalacademy.com
  39. 39. 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
  40. 40. 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
  41. 41. 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
  42. 42. Retractors of Upper Eyelid www.indiandentalacademy.com
  43. 43. 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
  44. 44. Retractors of Lower Eyelid • inferior tarsal muscle (muller’s) terminates 2.5 mm beneath inferior tarsal border www.indiandentalacademy.com
  45. 45. 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
  46. 46. 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
  47. 47. 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
  48. 48. 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
  49. 49. 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
  50. 50. Vascular Supply www.indiandentalacademy.com
  51. 51. Lymphatic Drainage www.indiandentalacademy.com
  52. 52. Sensory Nerve Supply www.indiandentalacademy.com
  53. 53. Ectropion • • • • • Involutional Paralytic Cicatricial Mechanical Congenital - rare www.indiandentalacademy.com
  54. 54. 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
  55. 55. Involutional Ectropion • Tissue relaxation associated with aging • Extreme cases termed “tarsal ectropion” implies detachment of retractors in addition to laxity www.indiandentalacademy.com
  56. 56. Paralytic Ectropion • VII nerve palsy – – – – Bell’s palsy (90%) Herpes Zoster (Ramsey-Hunt syndrome) Trauma Tumors (acoustic neuroma, SCCA) www.indiandentalacademy.com
  57. 57. Cicatricial Ectropion • • • • • • • Actinic changes Trauma Burns Removal of lower lid lesions Chronic inflammation Lower lid blepharoplasty Congenital www.indiandentalacademy.com
  58. 58. 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
  59. 59. 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
  60. 60. Lateral Tarsal Strip Procedure • Anderson RL, Gordy DD. Archives of Ophthalmology, 1979 www.indiandentalacademy.com
  61. 61. LTS step 1 www.indiandentalacademy.com
  62. 62. LTS step 2 www.indiandentalacademy.com
  63. 63. LTS step 3 www.indiandentalacademy.com
  64. 64. LTS step 4 www.indiandentalacademy.com
  65. 65. LTS step 5 www.indiandentalacademy.com
  66. 66. LTS step 6 www.indiandentalacademy.com
  67. 67. LTS step 7 www.indiandentalacademy.com
  68. 68. LTS step 8 www.indiandentalacademy.com
  69. 69. Medial Spindle Slide www.indiandentalacademy.com
  70. 70. Ectropion When lid tightening is enough • Involutional • Paralytic - simple cases www.indiandentalacademy.com
  71. 71. Ectropion When lid tightening is not enough • Paralytic - severe cases – Midface lift, fascia lata sling • Cicatricial – Full thickness skin graft • Congenital www.indiandentalacademy.com
  72. 72. Entropion • • • • Involutional Transient Spastic Cicatricial Congenital www.indiandentalacademy.com
  73. 73. 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
  74. 74. 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
  75. 75. Cicatricial Entropion • • • • • Trauma/Chemical injury Inflammation Ocular cicatricial pemphigoid Stevens-Johnson syndrome Trachoma www.indiandentalacademy.com
  76. 76. 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
  77. 77. 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
  78. 78. 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
  79. 79. Jones Procedure www.indiandentalacademy.com
  80. 80. Jones Procedure - Illustration www.indiandentalacademy.com
  81. 81. Quickert Suture www.indiandentalacademy.com
  82. 82. Posterior Lamella Grafting www.indiandentalacademy.com
  83. 83. Posterior Lamella Graft www.indiandentalacademy.com
  84. 84. 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
  85. 85. 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
  86. 86. Ptosis – Etiology • Myogenic – Congenital – CPEO, Myasthenia • Aponeurotic – aging, most common • Neurogenic – Horner’s – IIIrd nerve palsy • Mechanical – dermatochalasis, lid lesion www.indiandentalacademy.com
  87. 87. 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
  88. 88. 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
  89. 89. 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
  90. 90. Lacrimal www.indiandentalacademy.com
  91. 91. Basic Secretors • Basic secretors – decreases with age – no efferent innervation www.indiandentalacademy.com
  92. 92. 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
  93. 93. 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
  94. 94. 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
  95. 95. Basic Secretors - Re-cap www.indiandentalacademy.com
  96. 96. Reflex Secretors • Lacrimal gland - main (orbital) and palpebral lacrimal glands – exocrine glands – efferent parasympathetic innervation – hypersecretion www.indiandentalacademy.com
  97. 97. 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
  98. 98. Main (Orbital) Lacrimal Gland • Lacrimal foramen • 2 to 6 excretory ducts - pierce conjunctiva 5 mm above lateral margin of the tarsus www.indiandentalacademy.com
  99. 99. 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
  100. 100. 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
  101. 101. Reflex Secretors • Peripheral sensory • Retinal • Psychogenic www.indiandentalacademy.com
  102. 102. 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
  103. 103. Reflex Secretors • VII nerve - parasympathetic/efferent pathway www.indiandentalacademy.com
  104. 104. 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
  105. 105. Distributional System • Eyelids – – – – distribute tears regulate evaporation expel superfluous tears assist in the formation of the precorneal tear film www.indiandentalacademy.com
  106. 106. Excretory System • • • • • Upper and lower canaliculi Lacrimal sac Nasolacrimal duct Palpebral parts of the orbicularis oculi Approx. 35 mm in length www.indiandentalacademy.com
  107. 107. 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
  108. 108. 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
  109. 109. 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
  110. 110. 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
  111. 111. 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
  112. 112. Lacrimal Pump (cont.) www.indiandentalacademy.com
  113. 113. Lacrimal Disease www.indiandentalacademy.com
  114. 114. 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
  115. 115. 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
  116. 116. 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
  117. 117. 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
  118. 118. 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
  119. 119. 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
  120. 120. 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
  121. 121. 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
  122. 122. Congenital Dacryocystocele, (a.k.a., Mucocele, Amniotocele) www.indiandentalacademy.com
  123. 123. 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
  124. 124. Acquired Epiphora Etiology: • Ocular surface irritation with secondary hypersecretion • Outflow obstruction (including eyelid or punctal malposition) • Primary idiopathic hypersecretion (rare) www.indiandentalacademy.com
  125. 125. Acquired Epiphora - Evaluation History: • Topical medications • Ocular surface discomfort • Nasal trauma/surgery or sinus disease • Blood reflux www.indiandentalacademy.com
  126. 126. 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
  127. 127. 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
  128. 128. 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
  129. 129. 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
  130. 130. Additional Diagnostic Testing • Scintigraphy – T99 scan demonstrating physiologic tear flow • Dacryocystography – Contrast study demonstrating anatomy www.indiandentalacademy.com
  131. 131. 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
  132. 132. Canalicular Infection/Inflammation • Most common cause: Actinomyces israelli – erythematous, dilated, “pouting” puncta • Treatment – Warm compresses – Abx’s – Curettage/canaliculotomy www.indiandentalacademy.com
  133. 133. 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
  134. 134. Acquired NLDO - Treatment • NLD probing w/ Si intubation occasionally effective (if tubes pass easily) • Dacryocystorhinostomy (DCR) usually required www.indiandentalacademy.com
  135. 135. 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
  136. 136. 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
  137. 137. 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
  138. 138. Lacrimal Sac Tumors - Treatment www.indiandentalacademy.com
  139. 139. 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
  140. 140. 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
  141. 141. The End www.indiandentalacademy.com

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