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

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

3. 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

4. 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

5. 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

6. Malpositions of the Eyelids
Entropion
Inversion of the eyelid

7. 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

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

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

10. Malpositions of the Eyelids
Ptosis

11. 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

14. 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

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

16. 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

17. 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

18. 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

19. Squamous Cell Carcinoma
Tumors of the Eyelids
Squamous Cell Carcinoma

20. 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

21. Tumors of the Eyelids
Sebaceous Gland Carcinoma Malignant Melanoma

22. 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

23. 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

24. Disorders of the Orbit
Thyroid Orbitopathy

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

26. 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)

27. 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

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

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

30. 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

31. 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,

32. 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)

33. 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

34. 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

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

36. 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

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

38. 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

39. Tumors of the Orbit
Capillary Hemangioma

40. 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

41. 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

42. 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).

43. 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

44. 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

45. Tumors of the Orbit
Dermoid Cyst

46. 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

47. 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

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

49. Blow-out Fractures of the Orbit

50. 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

51. 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?

52. The End