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Oculoplastics Review
INDIAN DENTAL ACADEMY
Leader in continuing dental education
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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.)
• Optic foramen
– 8-10 mm
– Located within lesser
wing of sphenoid
– Transmits optic nerve,
ophtha...
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 Les...
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
– Optic n...
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
tr...
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 at su...
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
– extend...
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 tendon...
Posterior Lacrimal Crest
• Medial ocular retinaculum
– inferior transverse “Lockwood’s” ligament
– medial rectus check lig...
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 Retractio...
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 (acous...
Cicatricial Ectropion
• Actinic changes
• Trauma
• Burns
• Removal of lower lid lesions
• Chronic inflammation
• Lower lid...
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
– F...
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 syndrome
•...
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
• Cicat...
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
– nasal ...
Ptosis/Retraction
• Physical Exam
– MRD1 – margin-reflex distance – upper lid
– MRD2 – margin-reflex distance – lower lid
...
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
• Pseudoretract...
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 a...
Oil Secretors
• Meibomian glands
– in the tarsal plates
– 25-40 in upper, 20 in lower
• Zeis
– follicles of eyelashes
• Mo...
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 ligamen...
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
– Pass ...
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 format...
Excretory System
• Upper and lower canaliculi
• Lacrimal sac
• Nasolacrimal duct
• Palpebral parts of the orbicularis ocul...
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
– Canal...
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 insert...
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”
• Indica...
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
• J...
Abnormal Jones II Interpretation
• Reflux out same puncta
– canalicular obstruction
– CDCR w/ pyrex tube
• Reflux out oppo...
Additional Diagnostic Testing
• Scintigraphy
– T99 scan demonstrating physiologic tear flow
• Dacryocystography
– Contrast...
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
• T...
Acquired NLDO - Causes
• Involutional stenosis - most common cause
– women:men 2:1
• Neoplasms
• Dacryoliths
• Naso-orbita...
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...
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Thank you
For more details please visit
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Transcript of "Oculoplastics review"

  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.) • Optic foramen – 8-10 mm – Located within lesser wing of sphenoid – Transmits optic nerve, ophthalmic a. and sympathetic nerves • Superior orbital fissure – Bound by greater and lesser sphenoid wings – Outside annulus (“luscious French tarts”) • lacrimal, frontal, IV – Inside annulus (“sit naked in anticipation) • III-sup, nasociliary III- inf, VI www.indiandentalacademy.com
  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 28-30 mm – Vertical 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. www.indiandentalacademy.com Thank you For more details please visit www.indiandentalacademy.com

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