Eyelids & Lacrimal System PDF - Qassim University 2024

Eyelids &Lacrimal system Abdulmajeed Alharbi, MD, OPRS (McGill University) Assistant Professor Ophthalmic Plastic and Reconstructive Surgery Department of Ophthalmology, Qassim University Eyelids  Objectives 1. Anatomy: 2. Eyelid malposition 3. Common lid Pathology Anatomy ...

Eyelids &Lacrimal system Abdulmajeed Alharbi, MD, OPRS (McGill University) Assistant Professor Ophthalmic Plastic and Reconstructive Surgery Department of Ophthalmology, Qassim University Eyelids  Objectives 1. Anatomy: 2. Eyelid malposition 3. Common lid Pathology Anatomy  Lamellae of Upper Eyelid Skin Anterior Orbicularis Tarsus Posterior Palpebral conjunctiva  Anatomy – Skin of the eyelids ◦ Skin ◦ The skin of the eyelid is among the body's thinnest. This allows for quick blinking movements which afford protection to the eyes. It is subject to unusual amounts of stress and relaxation with each blink. ◦ Superior Palpebral Crease ◦ it is located approximately 10 mm above the lid margin in Caucasian women and 8 to 9 mm above the lid margin in Caucasian men. ◦ It denotes the dividing point between loosely adherent preseptal skin and the more adherent pretarsal skin. ◦  The lower lid displays three lines:- 1) The inferior palpebral crease it courses from about 5 mm below the lower lid margin medially to about 7 mm laterally. 1) The nasojugal crease is located below the medial aspect of the inferior palpebral crease and extends infralaterally at 45 degree. 1) The malar crease originates lateral to and below the lateral canthus. It courses inferomedially until it meets th nasojugal crease 15 mm below the center of the lower eye lid margin.  Protractors – Orbicularis oculi Extend in a round circular fashion around the orbit 1.Orbital Forced eyelid closure Overlie the orbital septum 2.Preseptal Involuntary eyelid movement (blinking/sleep) lies anterior to the tarsus 3.Pretarsal Involuntary eyelid movement (blinking/sleep) Nerve supply: Facial nerve ORBITAL SEPTUM ◦ The Orbital Septum of the Upper Eyelid ◦ The orbital septum well-defined structure arising from the arcus marginalis. The arcus marginalis is a condensation at the orbital rim of the periosteum of the forehead and cheekbones with the periorbita of the orbit. ◦ The Orbital Septum of the Lower Eyelid ◦ In the lower eyelid, the orbital septum arises from the inferior orbital rim as a condensation of the periosteum and the periorbita.  Anatomy - Orbital septum ◦ Dens fibrous sheath that acts as a barrier between the orbit & eyelid → stop spread of infection ◦ Originates: from periosteum of the superior & inferior orbital rims ◦ Inserts into levator aponeurosis superiorly & into lower eyelid retractors inferiorly ◦ Within the lids it is thickened to form tarsal plates—embedded in it are tarsal glands. THE EYELID RETRACTORS ◦ Upper lid: levator palpebrae superioris muscle and the sympathetically innervated muscle of Müller. ◦ Lowerlid: capsulopalpebral fascia and the sympathetically innervated inferior tarsal muscle.  Levator Palpebrae Superioris ◦ Originate from lesser wing of sphenoid bone above annulus of Zinn ◦ Its is two portions: 1. Muscular 40 mm 2. Aponeurosis 14-20 mm (with medial & lateral horns) ◦ It broadens & decreases in thickness (becomes thinner) & becomes the levator aponeurosis. ◦ Insertion: an aponeurosis on the ant surface of superior tarsal plate, forming eyelid crease ◦ From its inferior surface arises the superior tarsal muscle (Muller`s muscle): Sympathetic nerve supply ◦ Nerve supply: Oculomotor  Anatomy - Tarsus ◦ Dens CT plate in each eyelid ◦ Contains meibomian glands ◦ 29 mm long ◦ 1 mm thick ◦ Rigid attachment to periosteum medially & laterally Common EYE Lid Pathologies Eyelashes disorders ◦ Trichiasis is a misdirection of otherwise ◦ Distichiasis is defined as aberrant cilia normally positioned eyelashes in the anterior emerging through the meibomian orifices, in lamellae of the eyelid while the lid margin is in addition to a normal row of lashes anteriorly. a normal position.  Hordeolum (Acute chalazion) Internal ◦ Acute staphylococcal infection of meibomian gland ◦ Tender nodule within the tarsal plate which may be associated with preseptal or orbital cellulitis ◦ Rx: ◦ Hot compresses ◦ Topical Abx ◦ incision and curettage (I&C) when subside  Hordeolum (Acute chalazion) External (stye) ◦ Severe acute staphylococcal abscess of a lash follicle and its associated gland of zeis or Moll ◦ Tender nodule in the lid margin pointing through the skin which may be associated with cellulitis ◦ Rx: ◦ Hot compresses ◦ Topical Abx ◦ Epilation of the eyelash  Chalazion (chronic) ◦ Lipogranulomatous inflammatory reaction caused by leaking of retained meibomian gland secretions ◦ Predisposing factors: ◦ Chronic posterior blepharitis ◦ Acne rosacea ◦ Seborrhoeic dermatitis ◦ Rx: ◦ Observation of small lesion ◦ Incision & curettage  Ectropion ◦ Eversion of eyelid margin ◦ May cause keratinization & hypertrophy of conjunctiva ◦ Four different causes: ◦ 1. Involutional (age-related) ◦ Most common cause of ectropion ◦ Often in lower lid ◦ Rx: ectropion repair  Ectropion ◦ 2. Paralytic ◦ After CN 7 palsy ◦ Rx: lubrication – taping of eyelid – ectropion repair ◦ 3. Cicatricial (scaring/contraction) ◦ Burn/trauma/tumor/infection ◦ Rx: revision of cicatrix – ectropion repair ◦ 4. Mechanical ◦ Tumor/fat/Edema ◦ Rx: remove the cause  Entropion ◦ Inversion of eyelid margin ◦ Lower eyelid entropion usually → involutional ◦ Upper eyelid entopion usually → cicatricial ◦ Causes: 1. Congenital 2. Spastic Involutional 3. Cicatricial  Blepharoptosis (Ptosis) ◦ Drooping of upper eyelid ◦ Onset: ◦ Congenital (60%) – myogenic (maldevelopment of levator muscle) ◦ Acquired (40%) – Aponeurotic (involutional) ◦ Causes: 1. Myogenic: Myasthenia graves – myotonic dystrophy 2. Aponeurotic (involutional – post op - VKC) 3. Neurogenic (3rd CN palsy – Horner syndrome) 4. Mechanical (tumor - edema) 5. Traumatic  Blepharoptosis (Ptosis) ◦ Presentation: ◦ Unilateral or bilateral ◦ Absent of upper lid crease ◦ Poor levator function ◦ In down gaze ptotic lid is higher ◦ Chin up position ◦ Risk of amblyopia ◦ Treatment: 1. At preschool years 2. Levator resection  ◦ MRD: marginal reflex distance (n: 4mm) ◦ Chin-up position ◦ In down gaze ptotic lid is higher Blepharophimosis Syndrome : Diagnosis: Blepharophimosis (horizontal shortening of palpebral fissure) Ptosis (droopy lid) Epicanthus inversus (prominent skin fold extend from lower to the upper lid) Telecanthus (widened intercanthal distance ) Complication: Amblyopia Treatment: Frontalis suspension  Lagophthalmos ◦ Definition: incomplete closure of the palpebral fissure Causes: 1. Eyelid (7th CN palsy) 2. Globe (Thyroid) 3. systemic causes ◦ Complications: 1 conjunctival 2. corneal ◦ Treatment: 1. Cause 2. Protection of the cornea (Tapping/lubricants) 3. Temporary or permanent tarsorrhaphy Floppy eyelid syndrome ◦ loose or “floppy” eyelid that easily contorts or everts without spontaneously returning to its normal shape. ◦ Symptoms: tearing, irritation, photosensitivity, and foreign body sensation ◦ Signs: swelling, discharge, and papillary conjunctivitis. ◦ FES is a common yet underdiagnosed eyelid syndrome. ◦ There is a strong association between FES and obstructive sleep apnea (OSA). ◦ Management: ◦ Treat OSA first then consider surgical repair. Nasolacrimal system  Lacrimal System ◦ Secretory System ◦ Excretory system  Lacrimal System ◦ Secretory System: 1. Main lacrimal gland (aqueous-exocrine): ◦ Orbital part ◦ Palpebral part 2. Accessory lacrimal glands (aqueous- exocrine): ◦ Kraus glands ◦ Wolfering glands 3. Goblet cells of conjunctiva (mucin) 4. Meibomian glands (oily)  Lacrimal Gland ◦ Paired almond-shaped exocrine gland ◦ It is two parts: ◦ Small palpebral portion ◦ Larger orbital portion ◦ Secrete aqueous layer of the tear film ◦ Situated in the upper lateral region of each orbit in the lacrimal fossa of frontal bone. ◦ Inflammation of the gland is called: dacryoadenitis.  Nasolacrimal System (excretory) ◦ Drains the tear from the eye to the nasal cavity: 1. Puncti 2. Canaliculi 3. Lacrimal sac 4. Nasolacrimal duct  Congenital NLD Obstruction Caused by delayed canalization of valve of Hasner at the lower end of the duct  Congenital NLD Obstruction Presentation: Epiphora Matting of eyelashes soon after birth (4-8 weeks of age) On pressure reflux of purulent material from punctum (positive regurgitation test)  Dye disappearance test  Congenital NLD Obstruction Rx: Massage of the lacrimal sac (95% spontaneous canalization) Probing if > one year old  Acute Dacryocystitis Acute staphylococcal infection of the lacrimal sac Usually secondary to chronic NLD obstruction Presentation: Tender canthal swelling Mild preseptal cellulitis May develop into abscess Rx: Systemic antibiotics and warm compresses NLDO ◦ Endo DCR (Dacryocystorhinostomy) or ext. DCR after acute infection or in cases of chronic epiphora.  Dacryolithiasis ◦ Frequently caused by chronic canaliculitis ◦ Oraganism Actinomyces (Streptothrix sp.) ◦ Rx: Expression of stones and irrigation with antibiotic if necessary. Summary ◦ Thanks.