Diseases of the Eyelids and Orbita Yrd. Doç. Dr.İlke Bahçeci Şimşek Yeditepe University Department of Ophthalmology 2016-2017 Educational Year

Benign Lesions of the Eyelids Chalazion Caused by blockage of meibomian gland orifices Stagnation of sebaceous secretions causes a chronic inflammation

Benign Lesions of the Eyelids Chalazion Painless, round and firm lesion in the tarsal plate Initial conservative treatment with warm compresses Surgery for large persistent lesions causing astigmatism or cosmetically unacceptable

Benign Lesions of the Eyelids Hordeolum (Stye) Acute Staphylococcal infection of a lash follicle Tender inflamed swelling in the lid margin pointing anteriorly Warm compresses and antibiotic ointments In severe cases there may be preseptal cellulitis necessitating oral antibiotics

Benign Eyelid Lesions Xanthelasma Commonly over medial canthal areas Lipid laden macrophages accumulate in dermal tissues Sometimes associated with disorders of lipid metabolism Surgical excision for cosmetic reasons

Malpositions of the Eyelids Entropion Inversion of the eyelid

Epiblepharon is a condition in which the eyelid pretarsal muscle and skin ride above the eyelid margin to form a horizontal fold of tissue that causes the cilia to assume a vertical position, congenitalEpiblepharon usually resolves spontaneously in the first few years of life as a result of differential growth of the facial bones. Surgery to remove a strip of skin and orbicularis from the lid margin may be necessary occasionally epiblepharon

Malpositions of the Eyelids Entropion 4 main types Involutional (senile) Cicatricial Congenital Spastic Treatment is surgical

Malpositions of the Eyelids Ectropion Outward turning of the eyelid 4 main types Involutional (senile) Cicatricial Congenital Paralytic Treatment is surgical

Malpositions of the Eyelids Ptosis

Malpositions of the Eyelids Ptosis Drooping of the upper eyelid 4 main types according to etiology Myogenic due to congenital or acquired myopathy (e.g. myasthenia) Aponeurotic due to dehiscence of levator aponeurosis (senile, trauma, surgery) Neurogenic due to innervational deficit (e.g. third nerve palsy, Horner`s syndrome, Marcus Gunn Jaw-winking) Mechanical ptosis due to mass or scarring

Malpositions of the Eyelids Ptosis Mechanical due to tumor on the eyelid Treatment is surgical Surgery as soon as possible if congenital ptosis is obscuring the visual axis

Disorders of the Eyelashes Trıchiasis misdırection, distichiasis metaplastic lashes metaplasia of meibomian glands to becaome hair follicles due to stevens johnson and ocular pemphigoid.

Disorders of the Eyelashes Trichiasis Acquired posterior misdirection of previously normal eyelashes Caused by chronic inflammation of the eyelids in trachoma or chronic blepharitis Causes corneal irritation, ulceration Distichiasis A second row of eyelashes growing behind the normal eyelash-line Congenital condition Acquired

Tumors of the Eyelids Signs Suggesting Malignancy Slow painless growth Ulceration, bleeding, crusting İrregular pigmentary changes Distortion of the eyelid margin architecture Telangiectasias Loss of cilia

Tumors of the Eyelids Basal Cell Carcinoma Most common human malignancy 10% involve the eyelids Mostly arises on the lower lid Slow growing, locally invasive, non-metastasizing Treatment with surgical excision followed by reconstruction

Squamous Cell Carcinoma Tumors of the Eyelids Squamous Cell Carcinoma

Squamous Cell Carcinoma Tumors of the Eyelids Squamous Cell Carcinoma 5-10% of eyelid malignancies Mostly on lower lid May arise de novo or from precancerous dermatosis Fair complexion and chronic sun exposure Has potential to metastasize to regional lymph nodes Squamous cell carcinoma, the second most common eyelid malignancy, is more aggressive and dangerous than basal cell carcinoma and may spread to local lymph nodes as well as throughout the body

Tumors of the Eyelids Sebaceous Gland Carcinoma Malignant Melanoma

Sebaceous Gland Carcinoma Tumors of the Eyelids Sebaceous Gland Carcinoma Arises from sebaceous glands Metastasize to regional nodes, lungs, liver or brain 10% mortality rate Malignant Melanoma Rare but potentially lethal

Disorders of the Orbit Thyroid Orbitopathy Seen in ~ 30% of patients with Grave’s disease 90% of orbitopathy cases seen in Grave`s disease, rarely in hypothyroidism or in euthyroid patients Orbital tissue changes caused by autoimmune stimuli can be seen before, simultaneously or after hormonal thyroid disease Severity varies greatly from very mild changes to blindness Initial inflammatory stage with active changes ends in 2-3 years followed by quiescent stage Incidence and severity of orbitopathy is higher in smokers

Disorders of the Orbit Thyroid Orbitopathy

Disorders of the Orbit Thyroid Orbitopathy Mr STIR T1 serial short inversion recovery inflammatory activity

Disorders of the Orbit Thyroid Orbitopathy Clinical Signs Eyelid retraction (also lid-lag and frightened appearance) Proptosis (most common cause of proptosis in adults) Restrictive myopathy (muscle fibrosis causes restricted ocular motility hence diplopia) Soft tissue involvement Lagophtalmos and dry eyes Compressive optic neuropathy (compression of the optic nerve at the orbital apex by enlarged muscles may require emergency treatment with steroids, radiation or surgical decompression)

Disorders of the Orbit Thyroid Orbitopathy Treatment In active inflammatory disease Supportive treatment (artificial tears) and regular follow-up Emergency eyelid surgery if corneal problems threaten vision Steroids, radiotherapy or emergency orbital decompression surgery if compressive optic neuropathy present In inactive disease Strabismus surgery for diplopia Eyelid surgery to repair lid retraction

Infections of the Orbit Preseptal Cellulitis Bacterial infection of the soft tissues anterior to the orbital septum

Infections of the Orbit Preseptal Cellulitis Symptoms & Signs Periorbital swelling and tenderness Normal ocular motility Treatment Oral antibiotics

Infections of the Orbit Orbital Cellulitis Bacterial or fungal infection of the soft tissues behind the orbital septum Etiology Spread of infections to orbita from adjacent structures (sinusitis, dacryocystitis or facial infection) Following injuries penetrating orbital septum or eye surgery

Infections of the Orbit Orbital Cellulitis Symptoms &Signs Proptosis and painful eye movements with diplopia Optic nerve dysfunction Ocular Complications: central retinal artery or vein occlusion , endophthalmitis , optic neuropathy,

Infections of the Orbit Orbital Cellulitis Work-up White cell count CT of the orbit & brain (to rule out complications) Complications Intracranial spread ( meningitis, cavernous sinus thrombosis) Abscess formation ( orbital, subperiosteal, brain)

Infections of the Orbit Orbital Cellulitis Treatment Parenteral broad spectrum antibiotics (polymicrobial infection) in the hospital Surgical drainage of the orbital or subperiosteal abscess may be needed

Inflammations of the Orbit Idioptahic Orbital Inflammatory Disease - IOID Orbital Pseudotumor Idiopathic, non-specific inflammation involving an or all of the soft tissue components of the orbit Myositis Dacryoadenitis Scleritis Optic perineuritis Symptoms & Signs Painful proptosis Lid edema and conjuntival inflammation Limitation of ocular motility May mimic orbital cellulitis

Inflammations of the Orbit Orbital Pseudotumor Treatment Biopsy NSAIDs and Steroids Radiotherapy if unresponsive to steroids Immunosupressives for resistant cases

Inflammations of the Orbit Orbital Myositis Idiopathic orbital inflammation only involves one or more extraocular muscles Tolosa-Hunt syndrome Non-specific granulomatous inflammation of the cavernous sinus Periorbital pain, proptosis and cranial nerve palsies Systemic steroids

Tumors of the Orbit Classification Vascular Lacrimal gland Lymphoproliferative Cystic Neural Rhabdomyosarcoma Metastatic or invasion from adjacent structures

Tumors of the Orbit Vascular Tumors Capillary Hemangioma Most common orbital and periorbital tumor in children Periocular swelling may increase in size during crying Tumor grows during the first year of life then starts to regress In 75 % of cases complete resolution seen by age 7 Intralesional steroid injection, systemic steroids, systemic betablockers or surgical resection if tumor causes visual impairment

Tumors of the Orbit Capillary Hemangioma

Tumors of the Orbit Vascular Tumors Cavernous Hemangioma Lymphangioma Most common benign orbital tumor in adults Causes slowly progressive proptosis Surgical resection Lymphangioma Orbital varices

Tumors of the Orbit Lacrimal Gland Tumors Pleomorphic adenoma (Benign mixed cell tumor) Most common epithelial tumor Treatment requires surgical excision Incomplete excision may lead to malignant transformation Malignant lacrimal gland tumors Pleomorphic adenocarcinoma Adenoid cystic carcinoma Mucoepidermoid carcinoma Malignant tumors require radical surgical treatment with orbital exenteration followed by radiotherapy

Lymphoproliferative Disorders Tumors of the Orbit Lymphoproliferative Disorders May involve any part of the orbit but sometimes confined to conjunctiva or lacrimal gland Systemic investigation needed to rule out systemic disease Treatment Radiotherapy for local disease Chemotherapy for systemic disease Most lymphomas around the eye arise from mucosa-associated lymphatic tissue (MALT).

Tumors of the Orbit Rhabdomyosarcoma Most common primary malignant orbital tumor in children Presents with rapidly progressive proptosis Examination shows orbital mass CT shows poorly defined mass of homogenous density often with bony destruction Diagnosis requires biopsy Systemic work-up needed to rule out metastasis Treatment by high dose local radiotherapy followed by chemotherapy 90% survival when tumor is confined to the orbit

Tumors of the Orbit Cystic Lesions Dermoid Cyst Mucocele Blood cyst Benign cystic teratoma with a fibrous wall which contains dermal appendages Superficial dermoid cysts present in infancy as an upper temporal or upper nasal round lesion Deep dermoids present later in life Treatment with surgical excision Mucocele Arises in the sinuses and invades the orbita after eroding the orbital walls Blood cyst Rare, may be associated with blunt trauma or vascular lesions of the orbit

Tumors of the Orbit Dermoid Cyst

Tumors of the Orbit Neural Tumors Optic Nerve Glioma Slow growing tumor May be associated with Neurofibromatosis type I Fusiform enlargement of the optic nerve Observation if vision is good Surgical excision if vision is poor and proptosis is prominent Optic Nerve Sheath Meningioma Arises from the meningeal covering of the optic nerve Causes slowly progressive visual loss

Tumors of the Orbit Metastatic In children In Adults Neuroblastoma, Ewing`s sarcoma, Acute Myeloid Leukemia In Adults Breast carcinoma, Lung carcinoma, Prostate carcinoma Treatment is radiotherapy and chemotherapy Tumor invasion from adjacent structures Maxillary sinus ca, Ethmoidal sinus ca, Nasopharyngeal ca

Blow-out Fractures of the Orbit Caused by sudden increase in the orbital pressure Most frequently orbital floor is fractured

Blow-out Fractures of the Orbit

Blow-out Fractures of the Orbit Symptoms & Signs Periocular ecchymosis and edema Enophthalmos Infraorbital nerve anesthesia Diplopia (entrapment of the orbital tissues) Work-up CT Hess test Treatment Conservative treatment with antibiotics initially If diplopia persists surgical repair is done

What is a stye? How do we treat ? What is a hordeolum? How do we treat ? What is a ptosis? How do we treat ? What is preseptal cellulitis and Orbital Cellulitis? What are the differences?

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