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Eye Lid Disorders ,Ophthalmology
This document discusses the anatomy, structure, glands, blood supply, nerve supply, anomalies, diseases, and clinical features of the eyelid. It focuses on congenital and acquired ptosis, including the causes, clinical features, investigations, and treatment options. Specific conditions covered include congenital ptosis, neurogenic ptosis, myogenic ptosis, aponeurotic ptosis, mechanical ptosis, entropion, and ectropion. Surgical correction techniques are described for various types of ptosis and eyelid positioning anomalies.
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Eye Lid Disorders ,Ophthalmology
- 1. EYE LID 06/10/2020 DR MSAQUIB Vice Principal , G.S.Medical College & Hospital MBBS,MS , FSCEH DELHI,FHVDESAI PUNE, EX REGISTRARA JNMCH,AMU CONSULTANT OPHTHALMOLOGIST HOD D/O OPHTHALMOLOGY G.S .MEDICAL COLLEGE Founder sec: MEDICS India , Mail-dms2k5@gmail.com , 9634123800
- 2.
- 3. Structure ▸ Skin ▸ SubcutaneousAreolar Tissue ▸ Layer Of Striated Muscle ▸ Submuscular Areolar Tissue ▸ Fibrous Layer ▸ Layer Of Non Striated Muscles ▸ Conjunctiva 3
- 4. Glands of Eyelid ▸ Meibomian Gland ▸ Gland of Zeis ▸ Gland of Moll ▸ Accessory Lacrimal Gland of Wolfring & Krause 4
- 5. Blood Supply ▸ Arteries ▸Vein ▸ Lymphatics 5
- 6. Nerve Supply ▸ Motor: Facial - Orbicularis ▸ Oculomotor – LPS Muscles ▸ Sympathetic – Muller’s Muscles ▸ Sensory : ▸ Trigeminal ----( UL) Lacrimal , Supraorbital , Supratrochlear ▸ Lower Lid - Infraorbital , Infra trochlear 6
- 7.
- 8. Anomalies & Diseases ▸Congenital Anomalies ▸ Eyelids Oedema ▸ Inflammatory Disorder of Eye lids ▸ Eye lash disorder ▸ Anomalies in Position of Eye Lids – Entropion, Ectropion ▸ Tumours of Eye Lids - 8
- 9.
- 10.
- 11. Congenital Anomalies ▸ Ptosis ▸Coloboma ▸ Epicanthus ▸ Distichiasis ▸ Cryptophthalmos ▸ Microblephron ▸ Epiblephron ▸ Euryblephron 11
- 12. Congenital Ptosis ▸ Adroopy eyelid, also called ptosis occurs when the muscle that elevates the eyelid (the levator palpebrae superioris muscle) is weak from various reasons. ▸ Congenital weakness of LPS due to maldevelopment . 12
- 13.
- 14. Clinical Features: ▸ Droopingof Eye Lid – U/L , B/L ▸ Lid Crease –Diminished or Absent ▸ Lid Lag on Downgaze – Ptotis lid level higher than other in downgaze ▸ LPS- Function –Poor, Fair ,Good 14
- 15. The Droopy EyelidMay Cause: ▸ Astigmatism- If the pressure on the front of the eye causes distortion and refractive error it may need close observation, treatment with glasses or even surgery. ▸ A chin up position- If the ptosis is severe enough it may cause the child to adopt a chin up position in order to be able to see beneath the droopy eyelids and use the eyes together. Contraction of the frontalis muscle (in the forehead) to further elevate the upper eyelid is a very common compensatory mechanism. This is also an indication for surgical correction. ▸ Amblyopia (abnormal visual development)- This results from astigmatism (a misshaping of the cornea) or other refractive errors (refractive amblyopia). (Stimulus deprivation amblyopia). 15
- 16. Associated Features withCongenital Ptosis ▸ Simple Congenital Ptosis ▸ Congenital Ptosis with Superior Rectus Muscle weakness – Double elevator palsy ▸ Blephrophimosis Syndrome ▸ Congenital Synkinetic Ptosis : Ptotic lid retraction with Jaw movement 16
- 17.
- 18. ACQUIRED PTOSIS ▸ NEUROGENICPTOSIS ▸ MYOGENIC PTOSIS ▸ APONEUROTIC PTOSIS ▸ MECHANICAL PTOSIS 18
- 19. NEUROGENIC PTOSIS ▸ ThirdNerve Palsy ▸ Ophthalmoplegic Migraine ▸ Multiple Sclerosis ▸ Horner’s Syndrome : ▸ Oculosympathetic Paresis ▸ Mild Ptosis (Muller Muscle Paralysis ) ▸ Miosis ( Dilator Pupillae paralysis ) ▸ Reduced Iplsilateral sweating ▸ Enophthalmos 19
- 20.
- 21. Acquired Myogenic Ptosis ▸Acquired disorder of the LPS / Myoneural junction . ▸ Myasthenia Gravis ▸ Dystrophia Myotonica ▸ Ocular Myopathy ▸ Oculopharyngeal Muscular Dystrophy ▸ LPS Trauma ▸ Muscle thyrotoxicosis 21
- 22. Aponeurosis Ptosis ▸ Defectin LPS Aponeurosis. ▸ LPS muscle is normal ▸ Involutional Ptosis ▸ Postoperative Ptosis (Cataract,RD) ▸ Blephrochalasis weakness of aponeurosis ▸ Traumatic Dehiscence or Disintertion ▸ Characteristic features of this type of Ptosis are that patients have a good levator function with a high lid crease, affected eyelid appears lower on down gaze and a thin upper eyelid with redundant skin. 22
- 23. Mechanical Ptosis ▸ LidTumours ▸ Multiple Chalazion ▸ Lid Oedema ▸ Cicatricial Ptosis (Pemphigoid,Trauma ) 23
- 24. History ▸ Age ‘FamilyHistory ▸ Trauma ▸ Surgery ▸ Systemic disorder ▸ A history of dry eyes, intermittent epiphora, or chronic conjunctivitis can indicate a dry eye disorder . 24
- 25. Exclude Pseudoptosis ▸ Microphthalmos ▸Pthisis Bulbi ▸ Enophthalmos ▸ Prosthesis ▸ Brow Ptosis ▸ Dermatochalasis ▸ Hypotropia ▸ Contralateral – Eye lid Retraction ▸ High Myopia ▸ Proptosis 25
- 26. Clinical History ▸ Age ▸Progression ▸ Diurnal variation ▸ Change with Jaw Movement ▸ History of Trauma ▸ History of Previous Ocular Surgery ▸ History of Muscle Fatigue 26
- 27. Clinical Examination▸ Vision ▸Pupil Reaction ▸ Head Posture ▸ Frontalis Overaction /Brow Fold/Level ▸ Lid Crease ▸ MRD – ▸ Palpebral Fissure ( Height & Width) ▸ LPS Function – ▸ Vertical Palpebral Height ▸ Lid Lag on Downgaze ▸ Marcus Gunn Jaw Winking Phenomenon ▸ Bell’s Phenomenon ▸ Extraocular Movement ▸ Corneal Sensation ▸ Tear Film Evaluation ▸ Old Photograph27
- 28. ▸ Measure amountof Ptosis – Mild/Moderate /Severe – 2/3/4 mm ▸ Marginal Reflex distance – MRD- Normal – 4-5 mm ▸ ▸ LPS Function – Normal- 15 mm ▸ Good- 8mm ,fair- 5-7 mm ,Poor -4mm less 28
- 29.
- 30.
- 31. Specific Investigation ▸ Tensilontest – I . V Endrophonium ,cause improvement in Ptosis ( myasthenia) ▸ Phenylephrine Test – Horner’s syndrome Neurological investigation –MRI Photographic Records 31
- 32. Treatment of CongenitalPtosis ▸ Severe Ptosis – Urgent to prevent Amblyopia ▸ Mild –Moderate – Till anatomical structure form ▸ 1.TARS-OCONJUCTIVAL –MULLERECTOMY ▸ 2. LEVATOR RESECTION – ▸ 3.FRONTALIS SLING OPEARTION ▸ 32
- 33.
- 34. Farsanella –Servat Operation ▸Upper Lid eversion ▸ Upper Tarsal Border – ▸ Muller Muscle ▸ Conjuctiva 34
- 35.
- 36. LEVATOR RESECTION ▸ Moderate–Severe grade Ptosis ▸ Contraindicated in severe Ptosis with Poor LPS ▸ Moderate Ptosis ▸ LPS Function -Good –16-17 mm – Minimal Fair -18-22 mm- Moderate Poor – 23-24 mm- Maximum Severe Ptosis – LPS -18-22- LPS Resection – 23-24 mm36
- 37. ▸ Conjuctival -Double Evert Upper Eyelid ▸ Skin Approach Incision along Lid Crease 37
- 38. Frontalis Sling (Brow suspension) ▸ Severe Ptosis with NO levator Function ▸ Material Used – Fascia Lata ,Silicon rod 38
- 39. ▸ Crawford method ▸Fox Pentagon 39
- 40. Treatment of AcquiredPtosis ▸ Treat Underlying cause ▸ Conservative treatment – Neurogenic Ptosis – 6 Month ▸ Surgery – Levator resection 40
- 41. Treatment of AcquiredPtosis ▸ LPS Dehiscence – Levator Advancement ▸ Neurological Ptosis with Bell’s – Conservative – Crutch Glasses 41
- 42. Anomalies in thePosition of Eye lid Margin & Lashes ▸ Entropion – Congenital ▸ Involutional ▸ Cicatrial ▸ Spastic ▸ Mechanical ▸ Ectropion - Congenital ▸ Senile ▸ Paralytic ▸ Cicatrial ▸ Mechanical42
- 43.
- 44. A. Normal LidPosition B. Spastic Entropion C. Cicatricial Entropion D. Senile Ectropion 44
- 45. Congenital Ectropion ▸ Verticalinsufficiency of the anterior Lamella of the Eye lid ▸ Associated with – Blephrophimosis Syndrome Down Syndrome , Ichthyosis , Eublephron . Treatment – Full Thickness Skin graft to lengthen the anterior lamella 45
- 46. Congenital Entropion ▸ CongenitalInversion of Eye lid ▸ Developmental Factor associated – Lower Lid Retractor Dysgenesis,Tarsus kink ,Relative shortening of Posterior lamella 46
- 47. Senile (Involutional )Entropion ▸ Very common ▸ Only lower lid ▸ Factors: Attenuation and disinternation of Eye lid retractors ▸ Tissue atrophy with Horizontal laxity of the Eye lid ▸ Overriding of Pre tarsal fiber of orbicularis by Preseptal Fibres of Orbicularis 47
- 48.
- 49.
- 50. Clinical Features - ▸Foreign Body sensation ▸ Irritaion ▸ Lacrimation ▸ Photophobia ▸ Scarring of Palpebral Conjuctiva ▸ Recurrent corneal abrasion ▸ Superficial corneal Opacity 50
- 51. ▸ Snapback Test: Horizontal laxity detected by poor eye lid tone , ▸ Distraction Test – Ability to pull Eye lid more than 6 mm from the Globe ▸ Grading of Entropion – ▸ Grade 1 –Posterior Lid Border is inrolled ▸ Grade 2- Inturing up to intermarginal strip ▸ Grade 3 –Whole lid margin inturned 51
- 52. Treatment Reattachment of LidRetractors Shortening of Horizontal width of the Tarsal plate Forming cicatrix between pretarsal and preseptal part of Orbicularis 52
- 53. Surgical Correction ofCicatrial Entropion ▸ Mild Entropion -Anterior lamellar Resection ▸ Moderate Entropion with Atrophic Tarsus – Tarsal Wedge Resection ▸ Mild to Moderate Cicatrial Entropion – ▸ Transposition of Tarsoconjuctival Wedge ) – Tarsus Fracture and Eversion of Distal Tarsal ▸ Posterior Lamellar Graft 53
- 54. Surgical Technique forSenile Entropion 1.- Very Old Patient – Temporary Transverse Everting Sutures ▸ 2.Little Horizintal Laxity – Long Term – Wies Procedure –Transverse Lid Split and Everting Sutures ▸ 3.Severe /Recurrence case- Plication of Lower Lid Retractor – Jones Procedure ▸ 4.Severe Horizontal Lid Laxity – Quickert Procedure 54
- 55.
- 56.
- 57.
- 58.
- 59. Cicatrial Entropion ▸ Cicatricalcontraction of Palpebral Conjuctiva ▸ Relative shortening of the inner tarsoconjuctival lamina of the lid ▸ Inversion of Lid Margin ▸ Causes : ▸ Trachoma ▸ Trauma ▸ Chemical Burn ▸ Steven Jhonson Syndrome ▸ Cicatrical pemphigoid 59
- 60. Principle- Lengthening of theposterior lid lamina Tarsal Plate Rotation ▸ Mild to Moderate Entropion – with Thick Tarsus- Wedge Resection of Tarsus ▸ Severe Entropion / Entropion without Thick Tarsus – Tarsal Fracture 60
- 61. Mechanical Entropion ▸ Dueto lack of Support ▸ Pthisis Bulbi ▸ Enophthalmos ▸ After Enucleation or Evisceration 61
- 62. Ectropion ▸ Outward turningof the Eye lid margin. Clinical Feature – ▸ Epiphora ▸ Irritation ,Discomfort , ▸ Mild Photophobia 62
- 63. Senile( Involutional )Ectropion ▸ Most common type of Ectropion ▸ Causes- ▸ Horizontal Laxity of Eyelid ▸ Medial Canthal Tendon laxity ▸ Lateral Canthal tendon laxity ▸ Disintertion of lower lid Retractors 63
- 64. Cicatrial Ectropion ▸ Dueto scarring of lid skin ▸ Can involve both lids Causes- ▸ Thermal burn ▸ Chemical burn ▸ Laceration, Ulcer 64
- 65. ▸ The skin,orbicularis muscle, and orbital septum are normally flexible enough that spontaneous movement of the eyelids can occur. ▸ Anterior lamella (skin and muscle) and posterior lamella (tarsus and conjunctiva). Scarring of the anterior lamella can cause a cicatricial ectropion . ▸ Lengthening of the shortened lamella by adding a full- thickness skin graft is the treatment for cicatricial ectropion. ▸ Scarring of the posterior lamella also causes a cicatricial entropion. 65
- 66. Mechanical Ectropion ▸ Proptosis ▸Chemosis ▸ Tumour 66
- 67. Paralytic Ectropion ▸ FacialNerve Palsy ▸ Lower Lid ▸ Causes- ▸ Facial Nerve Palsy ▸ Bell’s Palsy ▸ Head Injury ▸ Infection of middle Ear ▸ Operation of Parotid Gland 67
- 68. Signs ▸ Out rollingof Lid Margin – Grading ▸ Grade I - Puntum is everted ▸ Grade II -Lid Margin is everted ,Palpebral Conjuctiva is visible ▸ Grade III -Fornix is also visible . 68
- 69. If the ectropionis not cicatricial and not paralytic, it must be involutional. Involutional ectropion occurs in older patients with eyelid laxity . The eyelid laxity can be demonstrated by the eyelid distraction test and the eyelid snap test ▸ Involutional Ectropion – Positive snap Test – Horizontal lid laxity ,lid can be easily pulled away from the globe but fails to snape back to the normal position on release . ▸ Medial Canthal Tendon laxity ▸ Lateral canthal tendon Laxity69
- 70.
- 71. 71 The eyelid distractiontest is performed by manually pulling the eyelid away from the eyeball. The lower lid should not move more than 6 mm off the eyeball.
- 72. The Eyelid Distraction Test Theeyelid distraction test is performed by manually pulling the eyelid away from the eyeball. The lower lid should not move more than 6 mm off the eyeball. 72
- 73. Congenital Ectropion ▸ MildEctropion : No Treatment ▸ Moderate –Severe : Horizontal lid Tightening ,Full thickness skin graft , Vertical lengthen anterior lamella. 73
- 74. Paralytic Ectropion ▸ Spontaneousresolved 6 month ▸ Temprarory measures: Topical Lubricant ▸ Taping temporal side of eye lid ▸ Suture tarsorrhaphy ▸ Permanent : ▸ Horizontal lid tightening ▸ Palpebral sling Operation 74
- 75. Cicatrial Ectropion ▸ V-YOPERATION ▸ Z- PLASTY ▸ Excision of scar tissue and full thickness skin grafting - 75
- 76.
- 77.
- 78. Involutional Ectropion Age Related MedialConjuctivoplasty : Mild cases of ectropion involving punctal area .Excising a spindle –shaped piece of conjuctiva and subconjuctival tissue Horizontal Lid Shortening – Full thickness pentagonal excision in moderate ectropion . Lateral Tarsal Strip Procedure – Generalised ectropion with horizontal lid laxity Byron Smith’s modified Kuhnt- Szymanowski78
- 79.
- 80. Generalized Ectropion WithAssociated Horizontal Lid Laxity 80
- 81.
- 82.
- 83.
- 84.
- 85.
- 86.
- 87. Lid Oedema ▸ Inflammatory ▸Solid Oedema ▸ Passive Oedema 87
- 88.
- 89.
- 90. Inflammatory Disorder ofEye lids ▸ Blephritis – Anterior , Posterior ( Meibomitis) ▸ External Hordeolum 90
- 91.
- 92.
- 93.
- 94.
- 95.
- 96.
- 97. SECRETORY SYSTEM ▸ Lacrimalgland ▸ Accessory Glands - Gland of Krause - Gland of Wolfring 97
- 98.
- 99. SECRETORY SYSTEM-Development Lacrimalgland- multiple solid ectodermal buds- anterior supero-lateral orbit- 6-8 weeks age of gestation Buds branch and canalize- ducts and alveoli Do not function fully- 6 weeks after birth Newborn infants- do not produce tear- crying Congenital NLDO seen following defective canalization of the Caudal End . 50% of the Newborns will have obstruction of the distal end (Valve of Hasner ) 99
- 100. SECRETORY SYSTEM ▸ Lacrimalgland- Exocrine gland, almond size, situated at lacrimal gland fossa- Superior temporal orbit in frontal bone. ▸ LPS divides gland into orbital & palpebral lobe anteriorly. ▸ Ducts from orbital lobe passes thru palpepral lobe- empty into upper conj fornix temporally. ▸ Biopsy is avoided from Palpebral Lobe 100
- 101. Accessory Glands - Glandof Krause - Gland of Wolfring 101
- 102. ACCESSORY GLANDS ▸ Glandof Krause- Accessory exocrine gland present deep in superior fornix ▸ Gland of Wolfring -situated near superior border of tarsal plate. ▸ Previously- Main lacrimal gland- reflex secretion - Accessory glands- basal secretion Recent evidence- All tearing –Reflex- single unit 102
- 103. TEAR FILM ▸ 1.Lipidlayer- secreted by Meibomian glands Increase surface tension of tear film & decreases its rate of evaporation ▸ 2. Aqueous layer- secreted by main lacrimal glands & gland of Krause & Wolfring. Provides oxygen to cornea & antibacterial function. ▸ 3.Mucinous layer- secreted by goblets cells of conjunctiva-allows even distribution of tear film over ocular surface 103
- 104.
- 105.
- 106. EXCRETORY SYSTEM ▸ Thelacrimal drainage system includes the - Upper & lower puncta - Lacrimal canaliculi - Upper canaliculi - Common canaliculi - Lower canaliculi - Lacrimal Sac - Nasolacrimal duct 106
- 107. Development :5 weeks age of gestation The lacrimal drainage system- ectodermal cord- b/w the lateral nasal process and the maxillary process. Cord canalize- form NLD caudally and lacrimal sac and canaliculi cranially Caudally NLD extends intranasally- exiting-inferior meatus Canalization- complete around birth NLD Obstruction- 50% of infants at time of birth 107
- 108.
- 109. EXCRETORY SYSTEM Lacrimalpuncta- 0.3 mm in diameter located medially on upper & lower lid margin, 6 mm & 6.5 mm from inner canthus respectively- directed posteriorly towards tear lake vertical canaliculus(ampulla)- 2 mm-turns 90 deg horizontal canaliculus- 8 mm opens into sac by common canaliculus(90%) Common canaliculus- Mucosal fold- Valve of Rosenmuller- 1 way valve prevents tear reflux from lacrimal sac back into the canaliculi 109
- 110. EXCRETORY SYSTEM Lacrimalsac- lies b/w ant & post head MCT in lacrimal fossa bordered by anterior & posterior lacrimal crest Size of sac 12-15x5 mm when distended, Fundus - part of sac above common canaliculus Body of sac Medial wall- lacrimal fossa- lacrimal bone posteriorly & frontal process of maxilla anteriorly Medial to lacrimal fossa- Middle meatus of nose 110
- 111. EXCRETORY -Nasolacrimal duct ▸-12- 18 mm in length - Travels thru bony nasolacrimal canal- directed Inferiorly, Laterally And Posteriorly -opens thru an ostium into inferior nasal meatus ,lateral & below inferior turbinate - ostium- covered by partial mucosal fold ( Valve of Hasner) 111
- 112. DACRYOCYSTITIS ▸ Infection ofLacrimal sac- b,coz of stasis of fluid(tears & mucus secretions) due to NLD blockage 112
- 113. CLASSIFICATION ▸ Congenital ▸ Acquired -Acute - Chronic 113
- 114. EPIDEMIOLOGY ▸ Age: mostcommon in patients older than 40 years- with a peak at 60-70 years. ▸ Sex: MC in females- NLD more angulated & narrow ▸ Race: Rare in blacks-the nasolacrimal ostium into the nose is large. Also the NLD is shorter and straighter in blacks 114
- 115. EPIDEMIOLOGY ▸ Facial features:Individuals with brachycephalic heads- the NLD is longer, narrower. ▸ patients with a flat nose and narrow face- narrow osseous nasolacrimal canal. ▸ MC on left side than on the right side - the nasolacrimal duct and lacrimal fossa formed a greater angle on the right side than on the left side. 115
- 116. ETIOLOGY ▸ PrimaryAcquired NasolacrimalDuct Obstruction(PANDO): Idiopathic ▸ Involutional stenosis-older persons- due to compression of NLD lumen b.coz of fibrous obstruction by chronic inflammation 116
- 117. ETIOLOGY ▸ Secondary: 1. Dacryolith 2.Sinusdisease- Ethmoid sinusitis 3.Trauma- Naso orbital #- involve NLD - Surgical- Endoscopic sinus surgery - Rhinoplasty 4. Granulomatous diseases: -Sarcoidosis - Wegner granulomatosis 117
- 118. PATHOGENESIS ▸ There aretwo main factors resulting in vicious cycle- 1. Stasis of sac contents due to NLD blockage 2. Infection may- ascend from nose - descend from conjunctiva Both aerobic and anaerobic bacteria- Mainly gram positive & gram negative. 118
- 119. ACUTE DACRYOCYSTITIS ▸ Acutedacryocystitis is characterized by the sudden onset of - severe pain - redness & - oedema in the medial canthal region - Epiphora 119
- 120. ACUTE DACRYOCYSTITIS ▸ SIGNS 1.A Tender & Hyperemic Palpable Mass Is Noted Inferior To The Medial Canthal Tendon- Non Reducible 2. Purulent Discharge Is Noted From The Puncta. 3.Lacimal Abscess- Rupture- Lacrimal Fistula Through The Skin. 4.Conjunctival Injection And Preseptal Cellulitis 120
- 121.
- 122. COMPLICATIONS ▸ Orbital Cellulitis-bact overgrowth which rupture thru lacrimal sac wall into surrounding orbital soft tissue. ▸ Cavenous sinus thrombosis ▸ Blindness ▸ Osteomyelitis of lacrimal bone 122
- 123. MANAGMENT ▸ Syringing/Probing- CONTRAINDICATED- extremely painful-cellulitis ▸ Oral Broad Spectrum Antibiotics- Amoxicillin ( 250-500 mg) Cloxacillin (250-500 mg) TDS ▸ Anti inflammatory/ Analgesics drugs ▸ Hot compress ▸ Parentral antibiotics- severe cases- orbital cellulitis 123
- 124. MANAGMENT ▸ Aspiration oflacrimal sac- If lacrimal abcess is localised & approaching the skin. ▸ Incision & drainage- in severe cases not responding to conservative mgt ▸ abscess involving lacrimal sac & adjacent soft tissue- vertical incision is given- wound is packed- open- healing by secondary intention- lacrimal fistula formation 124
- 125. MANAGMENT ▸ DACRYOCYSTORHINOSTOMY(D CR) - Definitivetreatment after resolution of acute inflammation 125
- 126. CHRONIC DACRYOCYSTITIS ▸ ChronicSuppurative Inflammation Of Lacrimal Sac Usually Resulting From Obstruction Of NL 126
- 127. SYMPTOMS 1. Epiphora withor without mucopurulent discharge 2. Swelling over sac area- present or absent 3. Matting of eyelashes 4. Recurrent conjunctivitis 127
- 128. Sign Swelling inlacrimal sac area (below MCT) which is reducible- regurgitation test +ve Fullness in medial canthal area with no obvious swelling Enlarging mucocele- due to chronic low grade infection of sac-Increased glandular secretions into the sac. Pooling of tears at medial canthus. Chronic discharging fistula of sac 128
- 129.
- 130. SEQULAE ▸ Atonic sac ▸Lacrimal abscess ▸ Lacrimal fistula Following I.O. injury ▸ Hypopyon corneal ulcer ▸ Panophthalmitis 130
- 131. DIFFERENTIAL DIAGNOSIS ▸ DermoidCyst ▸ Cavernous haemangioma ▸ Neurofibromas ▸ Lacrimal sac tumours Above lesions are not reducible NLD may be blocked on syringing but DCG is diagnostic. 131
- 132. MANAGMENT ▸ EVALUATION ▸ TREATMENT Dacryocystorhinostomy (DCR)- External DCR Endonasal DCR Laser DCR- Transcanalicular or Endonasal External DCR with silicone intubation Conjunctivo DCR 132
- 133. EXTERNAL DCR ▸ Standardgold treatment, success rate >90% ▸ Indications: Chronic dacryocystitis with NLD blockage Mucocele of lacrimal sac Congenital dacryocystitis-failed conservative managment 133
- 134. EXTERNAL DCR ▸ Itis a lacrimal drainage surgery in which a fistula is created b/w the lacrimal sac & middle meatus of the nasal cavity in order to bypass a obstruction in NLD 134
- 135.
- 136. EXTERNAL DCR ▸ Contraindications: 1.Ageless than 3 years 2.Acute dacryocystitis 3.Tumour of sac 4.Atrophic Rhinitis ▸ Disadvantage- Scar mark 136
- 137. ENDONASAL DCR Done withthe help of a nasal endoscope. Indication : Blockage at NLD Advantage : 1.No Cutaneous Scar 2. Short Operative Time 3. Minimum disruption of adjacent structures. Disadvantage : Low success rate (80%- 85%) 137
- 138.
- 139. LASER DCR ▸ Donethrough endonasal or canalicular approach. ▸ Endonasal laser DCR : - KTP ( Potassium-Titanyl-Phosphate ) Laser - Ho:Yag ( Holium YAG ) Laser ▸ Transcanalicular laser DCR: - 980 nm Diode Laser 139
- 140. EXTERNAL DCR WITHSILICONE INTUBATION ▸ It is the procedure of DCR in which there is insertion of a silicone stent. The function of stent is to maintain patency of fistula created. Indications: 1. Failed DCR 2. Traumatic Dacryocystitis 3. Common canalicular blockage 4. Canalicular Blockage(<8mm) 140
- 141. EXTERNAL DCR WITH SILICONEINTUBATION 141
- 142. DACRYOCYSTECTOMY ▸ Excision oflacrimal sac done Indication - Fibrosed contracted sac, - Sac tumors - Atrophic rhinitis Disadvantage: Persistent epiphora 142
- 143. TEAR DRAINAGE Evaporation -10%-Young - 20%-Old Most of the tears are actively pumped by orbicularis Tears flows- upper & lower marginal strips Enter –Upper & Lower canaliculi by capillarity & suction - 70% -Lower canaliculi - 30%- Upper canaliculi 143
- 144. PHYSIOLOGY OF TEARDRAINAGE 144
- 145. PHYSIOLOGY OF TEARDRAINAGE Mechanism( Rosengren-Doane) of tear drainage - Blinking- contraction of Orbicularis oculi- ampulla is compressed- horizontal canaliculi is shortened- puncta move medially - Simultaneously lacrimal sac expands- negative pressure- sucking tears from canaliculi - Eye opens-muscle relaxes-sac collapses-positive pressure-forces the tears down the NLD into nose - Puncta move laterally- canaliculi lenghtens-fill with tears145
- 146. CONGENITAL NLD OBSTRUCTION(NLDO) ▸Caused by membranous block of valve of Hasner ▸ Present in 50% of new borns ▸ Opens spontaneously in 4-6 weeks ▸ Becomes clinically evident in 2-6% at 4- 6 weeks of age. 1/3rd is B/L ▸ 90% of these symptomatic cases resolve in 1st year of life 146
- 147. Evaluation Congenital TearingEvaluation-Straight forward H/o tearing and/or mucopurulent discharge shortly after birth Constant tearing with minimal mucopurulence- upper system block-punctal or canalicular stenosis/ dysgenesis Constant tearing with frequent mucopurulence- complete obstruction of NLD Intermittent tearing with mucopurulence- intermittent obstruction of NLD- impaction of swollen inferior turbinate associated with URTI147
- 148. Evaluation Eyelid marginexamination- puncta open/absent Hypersecretion causes- rule out - infectious conjunctivitis - trichiasis - congenital glaucoma Inspection of medial canthus - cong dacryocystocele/mucocele - inflammation of sac - Cong encephalocele 148
- 149. SYMPTOMS 1. Epiphora- usuallyfew weeks of birth, commonly unilateral, may be bilateral. (normally tears are secreted after 4-6 weeks after birth). 2. Mucopurulent discharge. Infective discharge at birth always due to conjunctivitis. 149
- 150. SIGNS 1. Epiphora 2. Discharge-mucopurulent 3. Regurgitation test positive- Gentle pressure over the lacrimal sac causes reflex of mucopurulent material from puncta- complete obstruction at the level of NLD 4. Rarely Acute dacryocystitis 150
- 151.
- 152. CONSERVATIVE MANAGMENT Crigler massageover lacrimal sac area-Bilateral/ unilateral massage. 10 strokes four times a day. Place index finger at common canaliculus & massage firmly downwards Mechanism: Massage increases hydrostatic pressure in the sac & helps to open membranous occlusion Broad spectrum antibiotic drops- instilled after massage if discharge is present 90% cure rate 152
- 153.
- 154. SURGICAL MANAGMENT Probing& Irrigation Done at 1 yr of age under GA Punctal dilatation is required Bowman’s probe is introduced first vertically then horizontially towards medial canthus then rotate superiorly- inferiorly, laterally & posteriorly. Visualize with nasal endoscope Syringing with saline mixed with fluorescein followed by suction Repeat probing- 6 weeks if no improvement154
- 155. Irrigation Of NasolacrimalSystem 155
- 156. Nasolacrimal Silicone Intubation Indications -Failed probing - Older children with scarring or stenosis - punctal stenosis or canalicular stenosis Silicone stent having two lacrimal probes at both ends passed through both canaliculi, common canliculus, L. sac, NLD, pulled out through NLD openings in inferior meatus where both ends are tied with simple square knots Removal of silicon tube after 3-6 months 156
- 157. Congenital Dacryocystocele/Mucocele Alsok/a Amniontocele Collection of amniotic fluid or mucus in the lacrimal sac- imperforate Hasner valve. Presentation: Perinatal with a bluish cystic swelling- at or below the medial canthal area - accompanied epiphora Sign: A tense lacrimal sac- mucus- secondarily infected157
- 158. Differential Diagnosis Encephalocele-pulsatile swelling above the medial canthal tendon Treatment - Conservative initially - If fails- probing should not be delayed 158
- 159.