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Lecture2 eyelid,orbit,lacrimal

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  • The retractors of the upper eyelid are the levator muscle with its aponeurosis and the sympathetically innervated Muller’s Muscle. In the lower eyelid, the retractors are capsulopalpebral fascia and the inferior trasal muscle.
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    • 1. Eyelids, Orbit and Lacrimal System Hernando L. Cruz Jr., EyeMD Section of Ophthalmic Plastic, Reconstructive, Lacrimal & Orbital Surgery Department of Ophthalmology
    • 2. Eyelids, Orbit and Lacrimal System
      • Eyelids
        • Basic Anatomy and Physiology
        • Eyelid Lesions
        • Disorders of the Eyelashes
        • Entropion
        • Ectropion
        • Ptosis
    • 3. Eyelids, Orbit and Lacrimal System
      • Orbit
        • Applied Anatomy
        • Clinical Evaluation of Orbital Diseases
        • Diagnostic Modalities in Orbital Diseases
        • Graves’ Ophthalmopathy
        • Orbital Infections
        • Orbital Tumors
        • Orbital Fractures
    • 4. Eyelids, Orbit and Lacrimal System
      • Lacrimal System
        • Applied Anatomy and Physiology
        • Epiphora and Lacrimation
        • Clinical Evaluations of Tearing
        • Infections of the Lacrimal Passages
        • Treatment of Lacrimal Obstructions
        • Surgical Techniques
    • 5. Eyelids and Periorbital Structures
    • 6. Anatomy & Physiology
      • Eyelids
        • Globe Protection
          • 1. Screening and Sensing action of the Cilia
          • 2. Secretion of the glands of the Eyelids
          • 3. Movements of the Lids
    • 7. Anatomy & Physiology
      • Cilia “Eyelashes”
        • first line of Defense
        • 2 rows of about 100 - 150 in the upper and 50 - 75 in the lower lid
        • nerve plexuses in each follicle
        • glands in each follicle
    • 8. Anatomy & Physiology
      • Secretion of the Glands of the Eyelids
        • Oily layer of the meibomian glands
        • Forms the superficial element of the precorneal tear film which prevents tear evaporation
    • 9. Eyelid Margin Anatomy
    • 10. Anatomy & Physiology
      • Movements of the Lids
        • 3rd and most important element
        • levator palpebrae superioris, orbicularis oculi and Muller’s muscle
    • 11. Anatomy & Physiology
      • 7 structural layers of the eyelid
        • 1. Skin and Subcutaneous Tissue
        • 2.Muscle of Protraction
        • 3.Orbital Septum
        • 4. Orbital Fat
        • 5. Muscle of retraction
        • 6. Tarsus
        • 7.Conjunctiva
    • 12. Upper Eyelid Anatomy
    • 13. Lower Eyelid Anatomy
    • 14. Anatomy & Physiology
      • I. Skin and Subcutaneous Tissue
        • thinnest of the body
        • no subcutaneous fat
        • Upper lid crease
    • 15. Anatomy & Physiology
      • II. Muscles of protraction
        • orbicularis oculi
        • CN VII
        • Pre-tarsal, Pre-septal, Orbital parts
    • 16. Orbicularis Oculi Muscle
    • 17. Anatomy & Physiology
      • III. Orbital Septum
        • multilayered sheet of fibrous tissue
        • fuses with the aponeurosis to form the lid crease
        • serves as a barrier between the eyelid and the orbit
    • 18. Anatomy & Physiology
      • IV. Orbital Fat
        • lies posterior the orbital septum and anterior the levator aponeurosis
        • with age-related attenuation - “eyebag”
    • 19. Anatomy & Physiology
      • V. Muscles of Retraction
        • Upper Eyelid
          • Levator Muscle and its Aponeurosis
          • Muller’s Muscle
        • Lower Eyelid
          • Capsulopalberal Fascia
          • Inferior Tarsal Muscle
    • 20. Anatomy & Physiology
      • Levator Palpebrae Superioris
        • muscular portion 40 mm
        • aponeurosis 14-20 mm
        • whitnall’s ligament - functions as a suspensory support of the upper eyelid
        • innervated by CN III
    • 21. Whitnalls ligament
    • 22. Anatomy & Physiology
      • Muller’s Muscle
        • originates at the undersurface of the aponeurosis
        • sympathetically innervated
        • provides app. 2 mm of eyelid elevation
    • 23. Anatomy & Physiology
      • Lower lid retractors
        • Capsulopalpebral Fascia - analogous to levator aponeurosis
        • Lockwood’s ligament - analogous to whitnall’s ligament
        • Inferior tarsal Muscle- analogous to Muller’s muscle
    • 24. Lower Eyelid Anatomy
    • 25. Anatomy & Physiology
      • Tarsus
        • firm, dense plate
        • skeleton of the eyelid
      • Conjunctiva
        • non-keratinizing squamous epithelium
        • contains goblet cells & acc. Lacrimal glands
    • 26. Anatomy & Physiology
      • Vascular Supply
      • Arterial Supply
        • ICA - supraorbital and lacrimal artery
        • ECA - angular and temporal artery
      • Venous Drainage
        • Pretarsal - angular vein (medially); superficial temporal vein (laterally)
        • Posttarsal - orbital vein
    • 27. Anatomy & Physiology
      • Nerve Supply
        • Sensory
          • Supraorbital Nerve (V1)- innervates the forehead and lateral periocular area
          • Maxillary Nerve (V2)- innervates lower eyelid and Cheek
        • Motor
          • CN III
          • CN VII
          • Sympathetic Nerves
    • 28. Eyelid Lesions
      • Benign Eyelid Lesions
        • Chalazion
        • Hordeolum
        • Miscellaneous
      • Malignant Lesions
        • BCCa
        • SCCa
    • 29. Cross section of the Eyelid Margin
    • 30. Benign Eyelid Lesions
      • Chalazion - chronic granulomatous inflammation of the meibomian glands.
      • It is a painless round lesion within the tarsal plate
    • 31. Benign Eyelid Lesions
      • External Hordeolum- infection of the glands of Moll and Zeiss. Usually caused by staphylococcus.
      • Tender inflamed swelling in the lid margin
    • 32. Benign Eyelid Lesions
      • Internal Hordeolum- acute staphylococcal infection of the meibomian glands.
      • Tender inflamed swelling within the tarsal plate
    • 33. Benign Eyelid Lesions
      • Treatment
        • Oral Antibiotics
        • Topical Antibiotics
        • Warm compress
        • Surgical: I & C
    • 34. Benign Eyelid Lesions
    • 35. Miscellaneous Eyelid Lesions
      • Molluscum contagiosum - pox virus; painless umbilicated nodule
    • 36. Miscellaneous Eyelid Lesions
      • Strawberry Nevus – flat red lesion within 6 months of birth; involute spontaneously
      • Inc. in size during straining or crying but no pulsation and bruit
    • 37. Miscellaneous Eyelid Lesions
      • Port Wine Stain - nevus flammeus; well demarcated pink patch that darkens with age
      • 45% incidence of glaucoma
      • 5% sturge weber syndrome
    • 38. Miscellaneous Eyelid Lesions
    • 39. Miscellaneous Eyelid Lesions
    • 40. Xanthelasma
    • 41. Malignant Eyelid Lesions
      • Basal cell Carcinoma
        • most common human malignancy
        • 90% of cases occur in head and neck, 10% of these involved the eyelid
        • most common eyelid malignancy(90% of cases)
        • predilection: lower lid, medial canthus, upper lid, lateral canthus
        • SLOW GROWING, LOCALLY INVASIVE BUT NON-METASTASIZING
    • 42. Basal Cell Carcinoma
    • 43. Basal Cell Carcinoma
    • 44. Malignant Eyelid Tumors
      • Squamous Cell Carcinoma
        • hard nodule or a scaly patch which develops crusting erosions and fissures over a few months.
        • clinically, it may be indistinguishable from BCCa but it is important to differentiate the two in view of its metastatic potential of SCC
    • 45. Squamous Cell Carcinoma
    • 46. Malignant Eyelid Lesions
      • Treatment: complete excision is a must!
    • 47. Malignant Eyelid Lesion
      • Treatment:
        • Surgical Excision - complete removal of the entire tumor
          • Fresh frozen section
          • MOH’s technique
          • Eyelid reconstruction
        • Exenteration
        • Radiotherapy
        • Cryotherapy
    • 48. Disorders of Eyelashes
      • Trichiasis
      • Distichiasis
    • 49. Disorders of Eyelashes
      • Trichiasis
        • posterior misdirection of previously normal lashes
        • usually associated with trachoma and severe chronic staph. Blepharitis
    • 50. Disorders of Eyelashes
      • Trichiasis
    • 51. Disorders of Eyelashes
      • Distichiasis
        • - abnormal row of lashes
    • 52. Disorders of Eyelashes
      • Treatment
        • Epilation
        • Electrolysis
        • Cryotherapy
        • Laser thermoablation
    • 53. Entropion
      • Inversion of the Eyelid
      • 4 Types
      • Involutional
      • Cicatricial
      • Congenital
      • Acute Spastic
    • 54. Entropion
      • Involutional entropion
        • most common and affects only the lower lid
      • Pathogenesis
        • 1. Overriding of the orbicularis muscle
        • 2. Horizontal lid laxity
        • 3. Weakness of the lower lid retractors
    • 55. Entropion
    • 56. Involutional Entropion
    • 57. Entropion
      • Treatment
      • 1. Cautery
      • 2. Transverse Lid-everting sutures
      • 3. Weiss procedure
    • 58. Entropion
    • 59. Entropion
    • 60. Entropion
    • 61. Entropion
      • Cicatricial entropion
        • - usually caused by scarring of the palpebral conjunctiva, which pulls the lid margin towards the globe
        • causes: cicatricial pemphigoid, SJ syndromes, trachoma, & chemical burns
    • 62. Cicatricial Entropion
    • 63. Entropion
      • Treatment
        • contact lenses, epilation
        • surgical correction
    • 64. Entropion
      • Congenital entropion
        • due to improper development of the retractor aponeurosis into the inferior border of the tarsal plate
        • inward turning of the entire lower eyelid and lashes
        • absence of lower lid crease
        • DDX: Congenital epiblepharon
    • 65. Entropion
    • 66. Ectropion
      • outward turning of the eyelid
      • usually associated with epiphora and conjunctivitis
      • Types
        • Involutional
        • Cicatricial
        • Congenital
        • Paralytic
    • 67. Ectropion
      • Pathogenesis
        • Involutional (Senile) - excessive eyelid length;
        • weakness of the pretarsal orbicularis; laxity of the medial and canthal ligaments
        • Cicatricial - caused by scarring and contracture of skin and underlying tissues; e.g. trauma, burns, tumors
    • 68. Ectropion
      • Pathogenesis
        • Paralytic Ectropion - facial nerve palsy
    • 69. Ectropion
      • Treatment
      • Involutional Ectropion
        • determined by the position and amount of Horizontal lid Laxity.
    • 70. Ectropion
    • 71. Ectropion
      • Treatment
      • Mild Medial Ectropion
        • Medial Canthoplasty
      • Severe Medial Ectropion
        • Lazy T- procedure
      • Extensive Ectropion
        • Bick procedure
        • Kuhnt-Szymanowski procedure
    • 72. Ptosis
      • Drooping of the eyelids
      • Types ( My NAMe )
        • N eurogenic
        • A poneurotic
          • Involutional
          • Post-operative
        • Me chanical
        • My ogenic
    • 73. Ptosis
      • Neurogenic Ptosis - caused by acquired or congenital innervation defect.
        • Horner’s syndrome
        • Marcus Gunn jaw winking syndrome
        • Misdirection of CN III
    • 74. Neurogenic Ptosis
    • 75. Isolated CN III Paralysis
    • 76. Ptosis
      • Aponeurotic Ptosis - defect in the levator aponeurosis. It could be due to disinsertion or stretching.
        • Involutional Ptosis - degenerative changes in the levator aponeurosis
        • Post-operative Ptosis - occurs in 5% of patients following intraocular surgery (SR bridle)
    • 77. Involutional Ptosis
    • 78. Involutional Ptosis
    • 79. Ptosis
      • Mechanical Ptosis
        • physical obstruction impeding eyelid elevation in the presence of an otherwise normal levator muscle and CN III
        • E.g. Tumors, deramtochalasis, edema
    • 80. Ptosis
      • Myogenic ptosis
        • congenital or acquired myopathy of the Levator muscle
        • 2 Types
        • Simple congenital Ptosis
        • Blepharophimosis Syndrome
    • 81. Ptosis
      • Simple Congenital Ptosis
        • may be unilateral or bilateral
        • during downgaze, the ptotic eyelid is higher than the normal eyelid
        • weakness of the superior rectus (some cases)
        • head tilt with chin elevation
        • high EOR and astigmatism
    • 82. Ptosis
    • 83. Ptosis
      • Blepharophimosis syndrome
        • Telecanthus
        • Epicanthus
        • Other features: ectropion, poorly developed nasal bridge, hypoplasia of the superior orbital rims
        • Amblyopia 50% of cases
    • 84. Ptosis
      • Blepharophimosis Syndrome
    • 85. Ptosis
      • Clinical Evaluation:
      • Excellent history taking
      • Is it a true ptosis or pseudoptosis ?
    • 86. Ptosis
      • Causes of Pseudoptosis
      • 1. Decrease vertical fissure height
      • 2. Contralateral lid retraction
      • 3. Ipsilateral hypotropia
      • 4. Dermatochalasis
    • 87. Ptosis
      • Parameters
      • 1. Marginal Reflex distance
        • NV 4-5mm; Mild +3 Mod. +2 Severe 0 to -1
      • 2. Vertical Fissure height
        • NV male 7-10mm female 8-12mm
      • 3. Levator Function
        • good 12mm; fair 6-11mm poor 5mm or less
    • 88. Anatomy and Physiology
      • Orbit
        • bony cavities : globes, EOM, nerves, fat and blood vessels
        • pyramidal or conical in shape
        • consists of an apex, a base and 4 sides: roof floor,medial wall and lateral wall
        • 7 bones: frontal, zygomatic, maxillary, sphenoid, ethmoid, lacrimal, & palatine
    • 89. Anatomy and Physiology
      • The Bony Orbit:
    • 90. Anatomy and Physiology
      • Roof of the Orbit
        • frontal bone and lesser wing of the sphenoid
        • located adjacent to anterior cranial fossa and frontal sinus
      • Lateral wall of the Orbit
        • zygomatic bone and greater wing of the sphenoid
    • 91. Anatomy and Physiology
      • Orbital Roof
    • 92. Anatomy and Physiology
      • Medial Wall
        • ethmoid, lacrimal, maxillary and sphenoid bones
        • forms the lateral wall of the sphenoid sinus
      • Floor of the Orbit
        • maxillary, palatine,& zygomatic bones
    • 93. Anatomy and Physiology
      • Medial Wall
    • 94. Anatomy and Physiology
      • Orbital Apertures
      • 1. Optic Canal
        • Optic Nerve, Ophthalmic Artery, Sympathetic Nerves
      • 2. Superior Orbital Fissure
        • CN III,IV,VI, V1, Sympathetic Nerves
      • 3. Inferior Orbital Fissure
        • CN V2,
    • 95. Anatomy and Physiology
    • 96. Clinical Evaluation of Orbital Diseases
      • 6 P’s
        • Pain
        • Proptosis
        • Progression
        • Palpation
        • Pulsation
        • Periorbital Changes
    • 97. Clinical Evaluation of Orbital Diseases
      • Proptosis
        • Axial Displacement - retrobulbar lesions like cavernous hemangioma, glioma, meningioma, AV mal, lesions with in the muscle cone
    • 98. Clinical Evaluation of Orbital Diseases
        • Non Axial Displacement - outside the muscle cone
        • Superior Displacement - maxillary tumor invading the floor of the orbit
        • Inferomedial displacement - dermoid cyst and lacrimal gland tumor
        • Bilateral proptosis Grave’s disease and lymphoma, pseudotumor
    • 99. Clinical Evaluation of Orbital Diseases
      • Progression
        • Days to weeks - inflammatory diseases. Infectious diseases, metastatic tumors
        • Months to years - dermoids, benign mixed tumors, lymphomas
    • 100. Clinical Evaluation of Orbital Diseases
      • Palpation
        • superonasal - Mucoceles, neurofibromas dermoids
        • superotemporal - lacrimal gland tumor pseudo tumor
      • Pulsations
        • with bruit - CCS Fistula
        • without bruit - meningoencephalocoeles
    • 101. Diagnostic Modalities in Orbital Diseases
      • Primary Studies
        • CT scan
        • MRI
        • Ultrasonography
        • Histopathology
      • Secondary Studies
        • Venography
        • Arteriography
    • 102. Clinical Evaluation of Orbital Diseases
    • 103. Clinical Evaluation of Orbital Diseases
      • CT Scan
      • Good for most orbital conditions, esp fractures
      • Good view of bone & Ca
      • Degraded image of orbital apex due to bony artifact
      • Less soft tissue detail
      • Good for metallic foreign body
      • Less expensive
      • Shorter Scanning time
      • MRI
      • Better for orbitocranial lesions
      • No view of bone & Ca
      • Good view of Orbital Apex
      • More soft tissue detail
      • Contraindicated for Metallic Foreign Body
      • More expensive
      • Longer Scanning time
    • 104. Graves’ Ophthalmopathy
      • Autoimmune disorder that is related to excess secretion of thyroid hormone
      • 10-25% occurs in the absence of any thyroid dysfunction
      • Female/male ratio 8:1
      • 4th to 5th decades of life
      • most common cause of adult unilateral and bilateral exophthalmos
    • 105. Graves’ Ophthalmopathy
      • Pathogenesis
      • 1. Hypertrophy of Extraocular Muscles
      • 2. Cellular Infiltration
      • 3. Proliferation of orbital fat, connective tissue
    • 106. Graves’ Ophthalmopathy
      • Main Clinical Manifestation
      • 1. Eyelid retraction
      • 2. Soft Tissue involvement
      • 3. Proptosis
      • 4. Optic Neuropathy
      • 5. Restrictive Myopathy
    • 107. Graves’ Ophthalmopathy
      • Eyelid Retraction
    • 108. Graves’ Ophthalmopathy
      • Soft Tissue Involvement
      • 1. Conjunctival Injection
      • 2. Chemosis
      • 3. Eyelid Fullness
    • 109. Graves’ Ophthalmopathy
      • Proptosis
    • 110. Graves’ Ophthalmopathy
      • Restrictive Myopathy
      • IR>MR>SR>LR
    • 111. Graves’ Ophthalmopathy
      • CT Scan
        • EOM Hypertrophy with tendon sparing
    • 112. Key Points in Graves’ Ophthalmopathy
      • Eyelid retraction is the most common clinical feature; Graves’ ophthalmopathy is the most common cause of eyelid retraction.
      • Graves’ Ophthalmopathy is the most common cause of unilateral and bilateral proptosis.
      • Graves’ Ophthalmopathy is 6 more times more common in female than male.
      • This condition is associated with hyperthyroidism in 90% of cases, but 6% are Euthyroid.
      • Severity of Ophthalmopathy may not parallel serum levels of T3 or T4.
      • Ophthalmopathy may be asymmetric.
      • Urgent care may be required for optic Neuropathy or severe proptosis
      • If surgery is needed the usual order of surgery is DECOMPRESSION followed by SQUINT SURGERY followed by EYELID SURGERY
    • 113. Orbital Infections
      • Preseptal Cellulitis
        • Infection confined to the eyelids and periorbital tissues anterior to the orbital septum
        • Globe is uninvolved,
        • Pupillary rxn, VA, & EOM’s are NORMAL
        • no chemosis, no pain
    • 114. Orbital Infections
    • 115. Orbital Infections
      • Orbital Cellulitis
        • active infection posterior to the septum
        • 90% occurs as a 2ndary extension of bacterial sinusitis
        • fever, proptosis,chemosis, EOM restrictions, pain on eye movement
        • decrease VA, pupillary abnormalities
    • 116. Orbital Infections
    • 117. Orbital Tumors
      • Vascular
        • capillary hemangioma
        • cavernous hemangioma
        • lymphangioma
      • Lacrimal Gland
        • Benign Mixed Tumor
        • Malignant Tumor
      • Rhabdomyosarcoma
      • Cystic Lesions
        • dermoid cyst
        • mucocele
      • Neural
        • optic nerve glioma
      • Metastatic
      • Tumor invasion from adjacent structures
    • 118. Capillary Hemangioma
        • Most common tumor of the orbit in childhood
        • increase in tumor size during crying and straining
        • absent bruit and pulsation
        • involute spontaneously
    • 119. Cavernous Hemangioma
      • Most common benign orbital lesion in adults
      • middle-aged women commonly affected
      • enhanced well-encapsulated mass on CT scan
      • Tx: Surgical Excision
    • 120. Rhabdomyosarcoma
      • Most common primary orbital malignancy of childhood
      • age-onset is 7-8 y/o
      • rapid onset of proptosis
      • Tx: Exenteration, Radiation Therapy combined with systemic chemotherapy
    • 121. Pleomorphic Adenoma
      • Most common epithelial tumor of the lacrimal gland
      • 4th -5th decades of life, mostly men
      • progresssive, painless, downward & inward displacement
    • 122. Epidermoid / Dermoid Cyst
      • Dermoid is a benign cystic teratoma
      • well-encapsulated lined by stratified squamous & contain dermal appendages
      • Epidermoid - does not contain dermal appendages
    • 123. Fractures of the Orbit
      • Orbital floor Fracture
        • Most frequently involve wall
        • Usually along the infraorbital canal
    • 124. Orbital Floor Fracture
      • Clinical Features
        • Periocular Changes – ecchymosis, edema, subcutaneous emphysema
        • Enophthalmos
        • Infraorbital nerve anesthesia
        • Diplopia
    • 125. Fractures of the Orbit
    • 126. Fractures of the Orbit
    • 127. Fractures of the Orbit
    • 128. Fractures of the Orbit
    • 129. Fractures of the Orbit
    • 130. Lacrimal System
      • Puncta
      • Ampullae
      • canaliculi
      • lacrimal sac
      • nasolacrimal duct
    • 131. Tear Flow Physiology
    • 132. Evaluation of Tearing
      • Lacrimation vs Epiphora
      • Lacrimation - reflex over production of tears from stimulation of CN V by irritation of the cornea and conjunctiva
      • Epiphora - normal tear production but there is physical obstruction on the drainage system
    • 133. Infections of Lacrimal Passages
      • Canaliculits - unilateral epiphora with mucopurulent discharge. “Pouting of the punctum” on slit lamp exam.
    • 134. Infections of Lacrimal Passages
      • Dacryocystitis infection of the lacrimal sac. Presents as a painful swelling at the medial canthal area.
    • 135. Surgical Techniques
      • External DCR
      • Endoscopic Laser-Assisted DCR
      • Transcanalicular Endoscopic DCR
    • 136.
      • Thank you for your kind attention!

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