Lid and lacrimal disorders Abdulrahman Al-Muammar, MD, FRCSC King Saud University

Disorders of Lashes Trichiasis Distichiasis

Disorders of Lashes

Treatment options for trichiasis Epilation Electrolysis Cryotherapy Argon laser Surgery

Disorders of lashes Madarosis Poliosis Lid margin inflammation Tumor Cryotherapy, radiotherapy or burns Alopecia Syphilis Leprosy SLE Poliosis VKH Sympathetic ophthalmia

Entropion

Entropion Entropion, or inversion of the lid margin, may be congenital or acquired The acquired variety can be the result of: Ageing changes (involutional) Cicatricial changes affecting the posterior lamella of the eyelid (cicatricial) Spastic

Entropion

Entropion

Entropion Treatment Lubrication Taping the lid Epilation Horizontal lid tightening Tarsal fracture procedure

Ectropion

Ectropion Ectropion, or eversion of the lid margin, may be congenital or acquired The acquired forms are the result of Ageing changes (involutional) Lumps (mechanical) Scarring of the anterior lamella of the lid (cicatricial) Burn Infection/ inflammation Trauma Weakness of the orbicularis muscle (paralytic)

Ectropion

Ectropion Treatment Lubrication Horizontal lid shortening or tightening Punctal inversion

Ptosis MARGIN-REFLEX DISTANCE INTERPALPEBRAL DISTANCE LID CREASE POSTION

Ptosis

Ptosis

Ptosis

Ptosis Pseudoptosis Orbital volume deficiency Exophthalmos Excess lid skin Hypotropia

Ptosis Acquired or Congenital Neurogenic Myogenic Mechanical Traumatic 3rd nerve palsy 3rd nerve misdirection Horner syndrome Marcus Gunn jaw-winking syndrome Myogenic Myasthenia gravis Myotonic dystrophy Ocular myopathies Levator dystrophy Aponeurotic (levator dehiscence) Mechanical Traumatic

Ptosis Treatment Ptosis crutch Taping of the lid Surgical Levator advancement Muller’s muscle resection Frontalis suspension

Eyelids inflammation Blepharitis Treatment Anterior Posterior Staphylococcal Seborrhoeic Meibomianitis Treatment Lid hygiene Tears Antibiotics Warm compresses

Eyelids inflammation Allergy Acute allergic blepharoconjuctivitis Allergic dermatoblepharitis

Eyelids inflammation Chalazion Focal inflammation of the eye lids which result from obstruction of the meibomian glands Chronic lipogranulomatous inflammatory changes Treatment Warm compresses Local antibiotic Excision

Eyelids inflammation Hordeolum Acute infection involving the meibomian glands (internal) or the glands of Moll or Zeis (external) Overtime may evolve into chalazion Treatment Warm compresses Topical antibiotic

Benign eyelid lesions Cysts Cyst of Moll Cyst of Zeiss Sebaceous cyst Hidrocystoma

Benign eyelid lesions Tumors Viral wart( papilloma) Actinic keratosis Seborrheic keratosis Keratocanthoma Nevi Junctional Compound Dermal Capillary hemangioma Xanthelasma Pyogenic granuloma

Benign eyelid lesions

Malignant eyelid tumors Basal cell carcinoma Squamous cell carcinoma Meibomian gland carcinoma Melanoma Kaposi sarcoma Merkel cell carcinoma

Basal cell carcinoma Most common malignancy(90%) of the eyelid Usually located on the lower lid and medial canthus Pearly nodules which ulcerate and have telangiectasias Treatment Surgical excision Cryotherapy Radiation therapy

Basal cell carcinoma Most common malignancy(90%) of the eyelid Usually located on the lower lid and medial canthus Pearly nodules which ulcerate and have telangiectasias Treatment Surgical excision Cryotherapy Radiation therapy Orbital exenteration for deep invasive lesions

Squamous cell carcinoma Less common than BCC May arise de-novo or from pre-existing actinic keratosis May metastasize

Orbital cellulitis Preseptal cellulitis Orbital cellulitis Infection anterior to orbital septum Orbital cellulitis 90% secondary to sinusitis Trauma Insect bite Endogenous bacteremia

Orbital cellulitis Organisms Treatment Staphylococcus aureus Streptococcus Hemophilus influenza Treatment admission Orbital CT I.V antibiotics (3rd generation cephalosporin and clindamycin) Drainage of orbital abscess

Orbital disorders Children Adults Orbital cellulitis Pseudotumor Dermoid cyst Capillary hemangioma Lymphangioma Rhabdomyosarcoma metastasis Adults Thyroid orbitopathy Cavernous hemangioma Lymphangioma Pseudotumor Lymphoma Meningioma Lacrimal gland tumor Dermoid cyst metastasis

Thyroid orbitopathy Graves’ disease Most common cause of exophthalmos in adult Onset: 20-45 years Clinical picture: Unilateral or bilateral exophthalmos Eyelid retraction Lid lag Diplopia Periorbital edema Chemosis Optic neuropathy 90% HYPER, 1% HYPO, 6%EUTHYROID

Thyroid orbitopathy

Thyroid orbitopathy Complication: Treatment Diplopia Redness Corneal exposure Optic neuropathy Treatment Lubrication Tape eyelids at night Steroid Radiation Surgery Decompression Muscle surgery Optic nerve fenestration

Anatomy and physiology of the lacrimal system Secretory apparatus Lacrimal gland Lacrimal ducts empty into superior cul-de-sac Afferent pathway: V nerve Efferent pathway: VII nerve (reflex tear) Accessory lacrimal glands of Krause and Wolfring (basic tear) Tear film Inner layer: mucin Middle layer: aqueous Outer layer: meibomian

Anatomy and physiology of the lacrimal system Lacrimal excretory apparatus Puncta Canaliculi Lacrimal sac Nasolacrimal duct Inferior meatus VALVE OF HASNER

Anatomy and physiology of the lacrimal system Lacrimal evaluation Dye disappearance test Primary and secondary dye test Lacrimal irrigation Tear break up time Schirmer test

Lacrimal disorders Congenital nasolacrimal duct obstruction Membranous block at the valve of hasner 2-4% of full term new baby Usually resolve spontaneously within 4 to 6 weeks Treatment Topical antibiotics Massage Probing: 6 to 12 months

Lacrimal disorders Dacryocystocele Combination of nasolacrimal duct obstruction and amniotic fluid or mucus trapped in the sac Treatment Antibiotics Massage probing

Lacrimal disorders Punctal stenosis Canaliculitis Dilation Snip procedure Canaliculitis Irrigation with antibiotics Oral antibiotics Canalicular obstruction Dacryoliths Dacryocystitis Dacryocystorhinostomy

Lacrimal disorders Lacrimal sac tumors Lacrimal gland tumors Squamous cell papilloma Transitional cell papilloma Squamous cell carcinoma Transitional cell carcinoma Adenocarcinoma Lacrimal gland tumors 70% of lacrimal gland masses are non-epithelial masses: Idiopathic inflammation Sarcoidosis, TB Lymphoid tumors 30% are epithelial Cyst Adenoid cystic carcinoma Pleomorphic adenoma(benign and malignant mixed tumor)

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