Lecture 2

EYELIDS, LACRYMAL SYSTEM & ORBIT

Lecture is delivered by Ph. D., assistant of professor Tabalyuk Tetyana

DISEASES of

EYELID ANATOMY

The eyelids layers:

skin muscle tarsus conjunctiva

very common chronic inflammation of the eyelid margins Classification: divided into anterior & posterior forms: the former may be staphylococcal or seborrhoeic; a mixed picture is typical, however. Causative factors: staphylococcal: chronic infection of the bases of the lashes common in patients with eczema seborrhoeic: usually associated with seborrhoeix dermatitis involves excess lipid production by eyelid glands, converted to fatty acids by bacteria posterior: dysfunction of the meibomian glands of the posterior lid margins common in patients with acne rosacea

BLEPHARITIS

Clinical features: usually worse in the morning, include grittiness, burning and redness, stickiness and crusting of the lids. SIGNS: staphylococcal: dandruff-like scaling, mainly around the eyelash bases; seborrhoeic: greasy debris around the lashes causing them to adhere to one another; posterior: frothy tear film and pluggung of the meibomian gland orifices
All types usually manifest hyperaemia of the lid margins and conjunctiva, and tear film instability

Complications:

corneal epitheliopathy scarring marginal keratitis reccurent bacterial conjunctivitis chalazia styes loss of lashes (madarosis) misdirection (trichiasis)

Management:
lid margin hygiene using a weak solution or
baby shampoo

tear substitutes (e.g. hypromellose, carbomers)

antibiotic ointment (e.g. fusidic acid, systemic tetracycline
chloramphenocol) rubbed into the lid margins

a lesion consisting of lipogranulomatous inflammation centred on a dysfuctional meibomian gland

Meibomian cyst (chalazion)

Clinical features:
Extremely common, particularly in patients with posterior blepharitis. A chronic, usually solitary, painless, firm swelling in the tarsal plate; Can follow an acute meibomian gland infection. May be assosiated with a secondary conjunctival granuloma

Management: spontaneous

resolution may occur, although usually only if the lesion is small. Surgical incision and curettage is often required

INTERNAL HORDEOLUM (acute chalazion) an acute bacterial meibomian gland infection

Clinical features:
An inflamed swelling within the tarsal plate which may be associated with (mild) preseptal cellulitis

Management:
Topical antibiotic ointment and systemic antibiotic (e.g. flucloxacillin) for preseptal cellulitis. Hot bathing may promote discharge. Incision and curettage Incision and curettage may be required for a large abscess, or for secondary chronic lesion.

EXTERNAL HORDEOLUM (stye) a small abscess of an eyelash follicle

Management:
Removal of the associated lash, and hot bathing. Topical antibiotic ointment. Large lesions may require incision

Clinical features:
An acute painful inflamed swelling on the anterior lid margin, usually pointing through the skin

Cysts of Zeis and Moll

Clinical features:

A cysts of Zeis is a small, whitish, chronic, painless opaque nodule on the lid margin A cysts of Moll is similar but translucent

Management:
simple excision

MOLLUSCUM CONTAGIOSUM

Clinical features: single or multiple, small, pale,

waxy umbilicated nodules, which may cause a secondary chronic ipsilateral follicular conjunctivitis. These virally transmitted lesions are common and more severe, in AIDS patients. Management: expression or cautery.

Benign tumours of the eyelids

Squamous cell papilloma (viral wart) Basal cell papilloma (seborrhoeic
keratosis) Keratoacanthoma Melanocytic naevus Capillary haemangioma (strawberry naevus) Plexiform neurofibroma

Squamous cell papilloma (viral wart)

Clinical features:
The most common benign tumour of the eyelid which may be broadbased (sessile) or pedunculated

Management:
Simple excision, cautery or laser ablation

Basal cell papilloma

(seborrhoeic keratosis)

Clinical features:
This common tumour usually found in the elderly, is a slowlyenlarging brownish papillary lesion with a greasy friable surface

Management:
Simple excision or curettage

Keratoacanthoma

Clinical features:
An uncommon, fastgrowing, firm, pinkish nodule that develops a keratinfilled crater and may be mistaken for a malignancy

Remains static for several months before involution

Melanocytic naevus
Itradermal
Intradermal naevus an elevated lesion with variable
pigmentation. When located on the lid margin may be associated with protruding lashes. No malignant potential. Junctional naevus a flat well circumscribed lesion with a uniform brown colour, so-called because the naevus cells are located at the junction of the dermis and epidermis. Low malignant potential. Compound naevus usually elevated, with a homogeneous tan to brown colour. Consists of both intradermal and junctional components, the latter conferming a low malignant potential.

Capillary haemangioma
(strawberry naevus)

Clinical features: an irregular red lesion in an infant which

may cause a mechanical ptosis and amblyopia. Management: local steroids if necessary, but frequently undergoes gradual spontaneous involution.

Plexiform neurofibroma

Typically occurs in neurofibromatosis-1, characteristically giving rise to an S-shaped lid margin and ptosis

Premalignant and malignant tumours of the eyelids

Actinic (solar) keratosis Basal cell carcinoma Squamous cell carcinoma Sebaceous gland carcinoma
Management:

Surgical excision with a wide clearance margin is

the treatment of choice for most lid malignancies Radiotherapy in selected cases

Actinic (solar) keratosis

Clinical features: although rare, this is most common

premalignant lid condition and is strongly associated with excessive sun exposure in light-skinned individuals. It is usually presents as a persistent scaly plaque, which must be biopsied.

Basal cell carcinoma

Clinical features: most common eyelid malignancy, is locally

invasive but does not metastasize. About 50 % involve the lower lid, 30 % the medial canthal area. Nodule ulcerative - a rodent ulcer, with rolled hyperkeratotic edges and central granulation, gradually enlarging over 1-2 years. A purely nodular appearance is common. Sclerosing - a flat indurated plaque with poorly demarcated margins, often with loss of overlying lashes that may simulate chronic blepharitis

Squamosus cell carcinoma

Clinical features: is much less common than basal cell

carcinoma. It grows more quiclkly and may metastasize. It may arise de novo or from premalignant condition such as actinic keratosis. Nodular starts as a hyperkeratotic nodule or plaque which later develops crusting fissures Ulcerative resembles a rodent ulcer

Sebaceous gland carcinoma

Clinical features: this is rare but very aggressive tumour,

which may originate in a meibomian or Zeus gland as a film nodule either on the lid margin or within the tarsal plate, when it may be mistaken for an chalazion.

an inward-turning of the eyelid

Entropion

Classification: Involutional most common form, results from age-related changes in lower lid Cicatrical most frequently secondary to scarring : of the upper conjunctiva, as on chronic trachoma Spastic lower lid, caused by spasm of the orbicularis muscle due to ocular irritation or essential Congenital very rare, only involves the lower lid. Caused the hypertrophy of skin and orbicularis Management : surgical correction

an outward-turning of the eyelid

Ectropion

Classification: Involutional most common form, age-related tissue laxity Cicatrical scarring resulting from burns or surgery (e.g. tumour resection) : Mechanical excess lid weight (e.g. large tumour) Paralytic facial nerve palsy, associated with incomplete blinking and lid closure Congenital may be part of blepharophimosis syndrome Management : surgical correction

Lacrymal system anatomy:

Larcymal productive part & Lacrymal excretory part

Investigation of lacrymal system

Functional ability of lacrymal excretory system 1%

Shirmer test

Fluorecsein is dropped into conjunctival cavity Positive canalicular test disapearing of S. Fluorecsein Reveals hyposecretion of from conjunctival cavity till 5 lacrymal gland wetting minutes, usually 1-2 minutes of filter paper less then 15 Positive nose test appering of mm S. Fluorecsein in 5 minutes

DACRYOADENITIS inflammation of lacrymal gland

Clinical features: hyperemia, oedema and pain in upper-

external part of orbit Eyeball can be dislocated down and nasally Prearicular lymph nodes are increased and painfull Increased body temperature Key sign S-like form of rima ophthalmica Management: systemically antibiotics, sulfanilamids, salicilates In abscess incision and

DACRYOCYSTITIS inflammation of lacrymal sac

Ethiology: in infants atresia of lower part of nasolacrymal duct;
in adults stenosis of nasolacrymal duct Clinical features: exess tearing, pus discharge usually from one eye Key sign pus discharge from lower lacrymal point in palpation of area of lacrymal sac Management: in infants massage of lacrymal sac Syringing of lacrymal excretory ways Dreanage of lacrymal excretory ways Chonic in adults surgical - dacryocystorhinostomy

Orbital cellulitis
Signs:

eyelids oedema chemosis proptosis limiting of eye movements decreasing of visual acuity general intoxication (headacke,

increased temperature, brain signs). Optic neuritis, papilloedema, central vein occlusion may occur with outcome in optic atrophy.

Management:

incision of orbit with drainage antibiotics systemically osmotherapy

Fissura orbitalis superior syndrome

Tumour, haematoma, foreign body in the area of fissura orbitalis superior usually causes:
Proptosis Ptosis Ophthalmoplegy Mydriasis Paralysis of accomodation Decreasing of corneal sensitivity and skin sensitivity in the area of innervation of I branch n.trigeminus

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