1. 眼科學 Ophthalmology 眼眶及眼整形概論
國防醫學院醫學系眼科學科 助理教授
三軍總醫院眼科部 視力保健科主任
江尚宜 博士

2. Outline
Orbital Cavity
Eyelids
Lacrimal System
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3. Outline
Orbital Cavity
Eyelids
Lacrimal System
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4. Bony socket This consists of 7 bones - Ethmoid - Lacrimal - Sphenoid※
Bony socket
This consists of 7 bones
- Frontal
- Ethmoid
- Lacrimal
- Sphenoid
- Maxillary
- Palatine
- Zygomatic
Volume:30 mL
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5. Various bony openings into the orbital cavity※
Various bony openings into the orbital cavity
CN II, III, IV, V1, VI 通過
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6. Examination Methods
Cardinal symptoms: Unilateral or bilateral enophthalmos or exophthalmos
Visual acuity
Ocular motility
Examination of the fundus
Exophthalmometry
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7. ※
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8. Orbital Involvement in Autoimmune Disorders: Graves Disease
Autoimmune disorder with orbital involvement is frequently associated with thyroid dysfunction.
Histologic examination reveals inflammatory infiltration of the orbital cavity.
Epidemiology. Women are affected eight times as often as men. Sixty percent of patients have hyperthyroidism. Ten percent of patients with thyroid disorders develop Graves disease during the course of their life.
Graves disease is the most frequent cause of both unilateral and bilateral exophthalmos.
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9. ※
Graves Disease
Symptoms: painless disorder between the ages of 20 and 45.
Patients complain of reddened dry eyes with a sensation of
pressure (symptoms of keratoconjunctivitis sicca) and of cosmetic
problems. Ocularmotility is also limited, and patients may
experience double vision.
Diagnostic:
- characteristic eyelid sign
- Thickening of the muscles (primarily the rectus inferior and medial) and subsequent fibrosis lead to limited motility and double vision.
- Elevation is impaired; this can lead to false high values when measuring intraocular pressure with the gaze elevated.
- The tentative clinical diagnosis of Graves disease is supported by thickening of the extraocular muscles identified in ultrasound or CT studies.
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10. ※
Graves Disease
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11. Graves Disease Treatment:
Acute stage: management of the thyroid dysfunction, systemic cortisone (initially 60–100mg of prednisone) and radiation therapy of the orbital cavity.
Surgical decompression of the orbital cavity is indicated in recurrent cases that do not respond to treatment to avoid compressive optic neuropathy.
Exposure keratitis (keratitis due to inability to close the eye) should be treated with artificial tears or tarsorrhaphy (partial or complete suture closure of the upper and lower eyelid to shorten or close the palpebral fissure).
In the postinflammatory stage of the disease, eye muscle surgery can be performed to correct strabismus.
Clinical course and prognosis. Visual acuity will remain good if treatment is initiated promptly. In the postinflammatory phase, exophthalmos often persists despite the fact that the underlying disorder is well controlled
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12. ※
Orbital Inflammation
Definition: Acute inflammation of the contents of the orbital cavity with the cardinal symptoms of limited motility and general malaise.
Orbital cellulitis is the most frequent cause of exophthalmos in children.
Etiology: usually spread from surrounding tissue. Over 60% of cases (as high as 84% in children) can be classified as originating in the sinuses, especially the ethmoidal air cells and the frontal sinus. In infants, tooth germ inflammations may be the cause. Less frequently, this clinical picture occurs in association with facial furuncles, erysipelas, hordeolum, panophthalmitis, orbital injuries, and sepsis.
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13. Orbital Inflammation
The crucial characteristic feature of orbital cellulitis for differential diagnosis is the significantly limited ocular motility (“cemented” globe).
A rhabdomyosarcoma should also be considered in children.
Treatment. This consists of high-dose intravenous antibiotic therapy. Treatment of underlying sinusitis is indicated in applicable cases.
Orbital cellulitis can progress to a life-threatening situation (cavernous sinus thrombosis).
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14. Orbital Pseudotumor
Definition: Lymphocytic orbital tumor of unknown origin.
Symptoms and findings. Painful, moderately severe inflammatory reaction with eyelid swelling, chemosis, and unilateral or bilateral exophthalmos.
Involvement of the ocular muscles results in limited motility with diplopia.
Diagnostic considerations. The CT and MR images will show diffuse soft-tissue swelling.
A biopsy is required to confirm the diagnosis.
Occasionally the CT image will simulate an infiltrative tumor.
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15. Orbital Pseudotumor
Differential diagnosis. Various disorders should be excluded. These include Graves disease and orbital cellulitis, which is usually bacterial.
Special forms of orbital pseudotumor include myositis and Tolosa–Hunt syndrome (painful total ophthalmoplegia produced by an idiopathic granuloma at the apex of the orbit).
Treatment. High-dose systemic cortisone (initially 100mg of prednisone) usually leads to remission.
Orbital radiation therapy or surgical intervention may be indicated in patients with no response to treatment.
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16. Pulsating Exophthalmos※
Pulsating Exophthalmos
Etiology. An abnormal communication between the cavernous sinus and the internal carotid artery (a direct shunt) or its branches (indirect shunt) results in distention of the orbital venous network. 80% are attributable to trauma; less frequently the disorder is due to syphilis or arteriosclerosis.
Diagnostic considerations. The increased venous pressure leads to dilation of the episcleral and conjunctival vessels, retinal signs of venous stasis with bleeding, exudation, and papilledema. Intraocular pressure is also increased. The increased pressure in the cavernous sinus can also result in oculomotor and abducent nerve palsy.
Doppler ultrasound studies can confirm a clinical suspicion. Only angiography can determine the exact
location of the shunt.
Treatment. Selective embolization
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17. Orbital Tumors-Hemangioma
The most common benign orbital tumors in both children and adults.
Usually occur in a nasal superior location.
Capillary hemangiomas are more common in children (they swell when the child screams), and cavernous hemangiomas are more common in adults.
Treatment is only indicated where the tumor threatens to occlude the visual axis with resulting amblyopia or where there is a risk of compressive optic neuropathy.
Capillary hemangiomas in children can be treated with cortisone or low-dose radiation therapy.
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18. Orbital Tumors- Dermoid and Epidermoid Cyst
These lesions are the most common orbital tumors in children.
Etiologically, they are choristomas—i.e., dermal or epidermal structures that have been displaced into deeper layers. However, they usually are located anterior to the orbital septum (and therefore are not in the actual orbit itself).
Lesions located posterior to the orbital septum usually become clinically significant only in adults.
Treatment consists of complete removal.
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19. ※
Orbital Tumors
Meningioma : proceed from the optic nerve (meningioma of the optic nerve sheath) or from within the cranium (sphenoid meningioma).
Histiocytosis X: proliferation of Langerhans cells of undetermined, all three of the following types can cause exophthalmos where there is orbital involvement:
- Letterer–Siwe disease (malignant).
- Hand–Schuller–Christian disease (benign).
- Eosinophilic granuloma (rare and benign).
Lymphoma: treated by radiation therapy or chemotherapy. Usually these tumors are only slightly malignant. The highly malignant Burkitt lymphoma, which has a high affinity for the orbital cavity.
Rhabdomyosarcoma: the commonest primary malignant tumor in children.
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20. Blunt Ocular Trauma (Ocular Contusion)
Epidemiology and etiology: resulting from blunt trauma such as a fist, ball, champagne cork, stone, falling on the eye, or a cow’s horn are very common. Significant deformation of the globe can result where the diameter of the blunt object is less than that of the bony structures of the orbit.
Clinical picture and diagnostic considerations: Deformation exerts significant traction on intraocular structures and can cause them to tear. Often there will be blood in the anterior chamber, which will initially prevent the examiner from evaluating the more posterior intraocular structures.
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21. ※
Blow-Out Fracture
This fracture usually occurs where the bone is thinnest, along
the paper-thin floor of the orbit over the maxillary sinus.
The ring-shaped bony orbital rim usually remains intact. The fracture can result in protrusion and impingement of orbital fat and the inferior rectus and its sheaths in the fracture gap. Where the medial ethmoid wall fractures instead of the orbital floor, emphysema(眼瞼皮下氣腫) in the eyelids will result.
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22. Outline
Orbital Cavity
Eyelids
Lacrimal System
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23. Structure of the eyelids※
Structure of the eyelids
Superficial layer (supplied by NV1, V2):
– skin, modified sweat glands (ciliary glands or glands of Moll) and sebaceous glands (glands of Zeis),
– orbicularis oculi muscle (supplied by the CNVII),
– levator palpebrae muscle, which actively opens the eye (supplied by the CNIII).
Deep layer:
– tarsal plate, tarsal muscle (supplied by the sympathetic nervous system),
– palpebral conjunctiva is firmly attached to the tarsal plate.
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24. Eyelid position & Width of the palpebral fissure
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25. Ptosis
Definition: Paralysis of the levator palpebrae muscle with resulting drooping of one or both upper eyelids
The following forms are differentiated according to their origin:
Congenital ptosis.
Acquired ptosis:
– Paralytic ptosis.
– Sympathetic ptosis.
– Myotonic ptosis.
– Traumatic ptosis.
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26. Congenital ptosis
Usually hereditary and is primarily autosomal-dominant as opposed to recessive.
The cause is frequently aplasia in the core of the oculomotor nerve (neurogenic) that supplies the levator palpebrae muscle; less frequently it is attributable to an underdeveloped levator palpebrae muscle (myogenic).
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27. Acquired ptosis Neurogenic causes:
– Oculomotor palsy (paralytic ptosis).
– Lesions in the sympathetic nerve (sympathetic ptosis) in Horner’s
palsy (ptosis, miosis, and enophthalmos).
Myotonic ptosis: myasthenia gravis and myotonic dystrophy.
Traumatic ptosis can occur after injuries.
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28. Methods of surgical retraction of the upper eyelid※
Methods of surgical retraction of the upper eyelid
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29. ※
Entropion
Definition: Entropion is characterized by inward rotation of the eyelid margin. The margin of the eyelid and eyelashes or even the outer skin of the eyelid are in contact with the globe instead of only the conjunctiva.
The following forms are differentiated according to their origin:
- Congenital entropion: Usually the lower eyelid is affected.
- Spastic entropion: affects only the lower eyelid
- Cicatricial entropion: frequently the result of postinfectious or post-traumatic tarsal contracture (such as trachoma; burns and chemical injuries).
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30. Ectropion
Definition: Ectropion refers to the condition in which the margin of the eyelid is turned away from the eyeball. This condition almost exclusively affects the lower eyelid.
The following forms are differentiated according to their origin:
- Congenital ectropion.
- Senile ectropion.
- Paralytic ectropion.
- Cicatricial ectropion.
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31. ※
Blepharospasm
Definition: involuntary spasmodic contraction of the orbicularis oculi muscle supplied by the facial nerve.
Etiology: Causes of the disorder include extrapyramidal disease such as encephalitis or multiple sclerosis. Trigeminal neuralgia or psychogenic causes may also be present.
Treatment: depends on the cause of the disorder.
- Mild cases: muscle relaxants.
- Severe cases: transection of the fibers of the facial nerve supplying the orbicularis oculi muscle.
The disorder may also be successfully treated with repeated local injections of botulinum toxin.
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32. Disorders of the Skin and Margin of the Eyelid
Edema
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33. Disorders of the Skin and Margin of the Eyelid
Seborrheic Blepharitis
Herpes Simplex of the Eyelids
Herpes Zoster Ophthalmicus
Eyelid Abscess
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34. Disorders of the Eyelid Glands-Hordeolum※
Disorders of the Eyelid Glands-Hordeolum
Epidemiology and etiology. Staphylococcus aureus is a common cause of hordeolum. External hordeolum involves infection of the glands of Zeis or Moll. Internal hordeolum arises from infection of the meibomian glands.
Hordeolum is often associated with diabetes, gastrointestinal disorders, or acne.
Differential diagnosis. Chalazion (tender to palpation) and inflammation of the lacrimal glands (rarer and more painful).
Treatment. Antibiotic ointments and application of dry heat
(red heat lamp) will rapidly heal the lesion.
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35. Disorders of the Eyelid Glands- Chalazion※
Disorders of the Eyelid Glands- Chalazion
Definition: Firm nodular bulb within the tarsus.
Epidemiology and etiology. Chalazia occur relatively frequently and are caused by a chronic granulomatous inflammation due to buildup of secretion from the meibomian gland.
Symptoms. The firm painless nodule develops very slowly. Aside from the cosmetic flaw, it is usually asymptomatic.
Differential diagnosis. Hordeolum (tender to palpation) and adenocarcinoma.
Treatment. Surgical incision.
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36. Eyelids Benign Tumors Ductal Cysts:※
Eyelids Benign Tumors
Ductal Cysts:
The round cysts of the glands of Moll are usually located in the angle of the eye. Their contents are clear and watery and can be transilluminated. Gravity can result in ectropion.Therapy consists of marsupialization. The prognosis is good.
Xanthelasma
Local fat metabolism disorder that produces lipoprotein deposits. These are usually bilateral in the medial canthus. Postmenopausal women are most frequently affected. A higher incidence in patients with diabetes, increased levels of plasma lipoprotein, or bile duct disorders.
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37. Eyelids Malignant Tumors※
Eyelids Malignant Tumors
Basal Cell Carcinoma
frequent, moderately malignant, fibroepithelial tumor that can cause severe local tissue destruction but very rarely metastasizes.
Approximately 90% of malignant eyelid tumors are basal cell
carcinomas. Their incidence increases with age. In approximately 60% of cases they are localized on the lower eyelid. Dark-skinned people are affected significantly less often.
Increased exposure to the sun’s ultraviolet radiation, carcinogenic substances (such as arsenic), and chronic skin damage can also lead to an increased incidence.
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38. Eyelids Malignant Tumors
Basal Cell Carcinoma
Loss of the eyelashes in the vicinity of the tumor always suggests malignancy.
Treatment. The lesion is treated by surgical excision within a margin of healthy tissue.
The earlier a basal cell carcinoma is detected, the easier it is to remove.
Prognosis. The chances of successful treatment by surgical excision are very good. Frequent follow-up examinations are indicated.
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39. Eyelids Malignant Tumors
Squamous Cell Carcinoma
This is the second most frequently encountered malignant eyelid tumor.
The carcinoma arises from the epidermis, grows rapidly and destroys tissue. It can metastasize into the regional lymph nodes. Distant metastases are rarer.
The treatment of choice is complete surgical removal.
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40. Eyelids Malignant Tumors
Adenocarcinoma
Arises from the meibomian glands or the glands of Zeis.
The firm, painless swelling is usually located in the upper eyelid and is mobile with respect to the skin but not with respect to the underlying tissue.
In its early stages it can be mistaken easily for a chalazion.
The lesion can metastasize into local lymph nodes.
An apparent chalazion that cannot be removed by the usual surgical procedure always suggests a suspected adenocarcinoma.
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41. Outline
Orbital Cavity
Eyelids
Lacrimal System
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42. Anatomy of the lacrimal system※
Anatomy of the lacrimal system
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43. ※ 外 內
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44. Evaluation of Tear Drainage
Conjunctival fluorescein dye test.
Probing and irrigation
A probe can be used to determine the site
of the stricture, and possibly to eliminate
obstructions
Radiographic contrast studies
Digital subtraction dacryocystography
Lacrimal duct endoscopy
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46. Disorders of the Lower Lacrimal System
Dacryocystitis
Inflammation of the lacrimal sac is the most frequent disorder of the lower lacrimal system. It is usually the result of obstruction of the nasolacrimal duct and is unilateral in most cases.
- Acute Dacryocystitis
- Chronic Dacryocystitis
- Neonatal Dacryocystitis
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47. ※
Acute Dacryocystitis
Epidemiology: most frequently affects adults between 50 and 60.
Etiology: The cause is usually a stenosis within the lacrimal sac. The retention of tear fluid leads to infection from staphylococci, pneumococci, Pseudomonas, or other pathogens.
Symptoms. Clinical symptoms include highly inflamed, painful swelling in the vicinity of the lacrimal sac.
Treatment. Acute cases are treated with local and systemic antibiotics according to the specific pathogens detected.
Treatment after acute symptoms have subsided often requires surgery (dacryocystorhinostomy) to achieve persistent relief.
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48. Chronic Dacryocystitis※
Chronic Dacryocystitis
Etiology. Obstruction of the nasolacrimal duct is often secondary to chronic inflammation of the connective tissue or nasal mucosa.
Symptoms and diagnostic considerations. The initial characteristic is increased lacrimation. Signs of inflammation are not usually present. Applying pressure to the inflamed lacrimal sac causes large quantities of transparent mucoid pus to regurgitate through the punctum.
Treatment. Surgical intervention is the only effective treatment in the vast majority of cases. This involves either a dacryocystorhinostomy (DCR 淚囊鼻腔吻合術) (creation of a direct connection between the lacrimal sac and the nasal mucosa) or removal of the lacrimal sac.
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49. Neonatal Dacryocystitis※
Neonatal Dacryocystitis
Etiology. Approximately 6% of newborns have a stenosis of the mouth of the nasolacrimal duct due to a persistent mucosal fold (lacrimal fold or valve of Hasner). The resulting retention of tear fluid provides ideal growth conditions for bacteria, particularly staphylococci, streptococci, and pneumococci.
Symptoms and diagnostic considerations. Shortly after birth (usually within 2–4weeks), pus is secreted from the puncta.
Treatment: During the first few weeks, the infant should be monitored for spontaneous opening of the stenosis. During this period, antibiotic and antiinflammatory eyedrops and nose drops (such as erythromycin and xylometazoline 0.5% for infants) are administered.
If symptoms persist, irrigation or probing under short-acting general anesthesia may be indicated
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51. Tumors of the Lacrimal Sac
Epidemiology. Tumors of the lacrimal sac are rare but are primarily malignant . They include papillomas, carcinomas, and sarcomas.
Symptoms and diagnostic considerations. Usually the tumors cause unilateral painless swelling followed by dacryostenosis.
Diagnostic considerations. The irregular and occasionally bizarre form of the structure in radiographic contrast studies is typical. Ultrasound, CT, MRI, and
biopsy all contribute to confirming the diagnosis.
Differential diagnosis. Chronic dacryocystitis, mucocele of the ethmoid cells.
Treatment. The entire tumor should be removed.
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52. Disorders of the Lacrimal Gland
Acute Dacryoadenitis
Definition: Acute inflammation of the
lacrimal gland is a rare disorder
characterized by intense inflammation
and extreme tenderness to palpation.
Etiology: Pneumococci and staphylococci, and less frequently to streptococci. There may be a relationship between the disorder and infectious diseases such as mumps, measles, scarlet fever, diphtheria, and influenza.
Symptoms: Usually occurs unilaterally. The inflamed swollen gland is especially tender to palpation. The upper eyelid exhibits a characteristic S-curve.
Treatment. Depend on the underlying disorder. Moist heat, disinfectant compress, and local antibiotics are helpful.
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53. Disorders of the Lacrimal Gland
Chronic Dacryoadenitis
Etiology: result of an incompletely healed acute dacryoadenitis. Diseases such as tuberculosis, sarcoidosis, leukemia, or lymphogranulomatosis.
Symptoms: Usually there is no pain. Less pronounced than in the acute form. However, the S-curve deformity of the palpebral fissure resulting from swelling of the lacrimal gland is readily apparent.
Treatment. This will depend on the underlying disorder. Systemic corticosteroids may be effective in treating unspecific forms.
Prognosis: good when the underlying disorder can be identified.
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54. Tumors of the Lacrimal Gland
Epidemiology. Tumors of the lacrimal gland account for 5–7% of orbital neoplasms. Lacrimal gland tumors are much rarer in children.
The most frequent benign epithelial lacrimal gland tumor is the pleomorphic adenoma. Malignant tumors include the adenoid cystic carcinoma and pleomorphic adenocarcinoma.
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