Lids, Lacrimal apparatus and Orbit
Dr. Yasser Al-Fakey
M.D., M.Sc (Ophth.), FRCS
Lash Disorders
Trichiasis:
primary (metaplastic lashes and distichiasis) or secondary
(entropion).
Madarosis: local or systemic.
Poliosis: Local (blepharitis) or systemic (VKH).
Allergic Disorders
Acute
allergic edema: insect bit, angioedema or urticaria.
Unilateral or bilateral painless and pitting edema.
Contact dermatitis: Sensitivity to topical medications.
Xanthelasma
Elderly people or those with hypercholesterolemia.
Cholesterol and lipid subcutaneous plaques.
Treatment: surgical excision or CO2 laser evaporation.
INFECTIONS
Blepharitis.
Hordeolum:
1) Externum (Stye)
2) Internum (Acute chalazion)
Viral infections.
Trachoma.
Blepharitis
Anterior,
posterior or mixed.
Symptoms: burning, grittiness, mild photophobia, crusting and redness of
lid margin.
Signs: lid margin (hyperemia, telangiectasia and tiny abscesses) scales and
lashes (greasy and stuck together).
Complications: Stye, Tear film instability, Hypersensitivity to staph.
toxins, trichiasis, madarosis and poliosis.
Treatment:
1) Lid hygiene
2) Antibiotic ointment
3) Systemic tetracycline
4) Lubricants
5) Weak topical steroid.
External Hordeolum (Stye)
Acute staph. infection of hair follicles and associated glands.
Signs
Mild preseptal cellulitis.
Treatment: Hot compresses, Epilation, Topical antibiotics and
even
systemic if associated with preseptal cellulitis.
Internal Hordeolum (Acute Chalazion)
Acute staph. infection of meibomian gland.
Signs: tender inflamed swelling within the tarsal
plate. It may discharge
anteriorly through the skin or posteriorly through the conjunctiva.
Treatment: Control of infection then curettage if residual mass.
Chalazion (Meibomian cyst)
Chronic
lipogranulomatous inflammation caused by obstruction of the
gland orifice.
Most common lid mass.
Symptoms
Signs
D.D. of recurrent chalazion
Treatment:
1) Surgery
2) Steroid injection
Viral infections
Herpes
simplex:
Primary herpes simplex, usually affects children, crops of small
vesicles with mild edema and may be associated with viral
keratoconjunctivitis.
Treatment with acyclovir
Herpes Zoster Ophthalmicus
Unilateral condition, usually affect elderly people.
Vesicles, pustules and crusting ulceration.
Hutchinson sign
Treatment: systemic and topical acyclovir
Chlamydial Conjunctivitis
Adult
Chlamydial Keratoconjunctivitis:
-Sexually transmitted disease (50% associated with genital
infection) caused by serotypes D to K.
-Subacute onset, unilateral or bilateral mucopurulent discharge.
-Follicular conj. Reaction and corneal involvement is
uncommon.
-Non-tender lymphadenopathy.
-Treatment: Topical tetracycline
Systemic tetracycline, deoxycycline or recently
azithromycin.
Trachoma
Infection caused by Chlamydia trachomatis (serotypes A, B, Ba & C).
Obligate intracellular bacteria.
The common fly is a major vector in the transmission of the disease.
It is the leading cause of preventable blindness allover the world.
Symptoms: During childhood with redness, and mucopurulent discharge.
Signs:
– follicular conjunctivitis.
– Limbal follicles.
– Keratitis.
Lab. Investigations:
1) Direct monoclonal fluorescent antibody microscopy
2) ELISA
3) Polymerase chain reaction (PCR)
4) Giemsa stain (inclusion bodies)
Complications:
– Progressive conjunctival scaring (Arlt line, PTDs and entropion).
– Herbert pits.
– Corneal pannus.
WHO grading:
TF = trachomatous follicles.
TI = trachomatous inflammation.
TS = trachomatous scar.
TT = trachomatous trichiasis.
CO = corneal opacity.
ENTROPION
Types:
1. Involutional
2. Cicatricial
3. Spastic
4. Congenital
Complications
Treatment
ECTROPION
Types:
1. Involutional
2. Cicatricial
3. Paralytic
4. Mechanical
Complications
Treatment
LID TUMORS
Benign: Naevus, Capillary haemangioma, Port-wine
Malignant: BCC, SCC, SGC and Melanoma.
stain …etc
PTOSIS
Drooping of the
Pseudoptosis
Classification:
1.
2.
3.
4.
upper lid.
Neurogenic
Myogenic
Aponeurotic
Mechanical
Clinical Evaluation
History:
Age of onset, Trauma, Previous surgery and Diurnal variations.
Exclusion of Pseudoptosis.
Associated signs.
EOM movements, Bell’s phenomenon, Increased innervations,
Fatigability and Jaw-winking.
Measurements:
PFH, MRD 1, MRD 2, Levator function and lid crease.
Management
Preferable age for
Type of surgery
surgical correction?
1. Levator Resection
2. Frontalis Suspension
3. Mullerectomy
Postop. Complications and patient expectation.
LACRIMAL APPARATUS
Excessive Watering
Lacrimation: reflex over-production of tears.
Epiphora: mechanical obstruction of tear drainage.
Lacrimal pump failure.
Examination of Lacrimal System
The
eyelids.
The dynamics of eyelid closure.
The puncta.
The marginal tear strip.
The lacrimal sac.
Dye Disappearance Test.
Probing and irrigation.
Jones dye test
Radiography
Congenital Nasolacrimal Duct
Obstruction
Symptoms
Signs
DDT
Complications
Management:
Massage
Probing
Probing + Stent
DCR
Infections of The Lacrimal Passages
Acute dacryocystitis:

 Symptoms
 Signs
 Complications
 Treatment:
Systemic antibiotics
Stab incision
DCR
Chronic Dacryocystitis:
 Symptoms: epiphora + mucopurulent discharge
 Signs:
painless swelling
+ve regurgitation test
probing and irrigation
 Treatment: DCR
Dry Eye
Symptoms
Signs: Tear
stain.
Treatment:
meniscus, Tear BUT test, Schirmer test, SPK and Rose Bengal
Preservation of tear
Lubricants
Punctal plugs
Permanent occlusion
Orbital Diseases
Inflammatory:
Orbital cellulites
DD preseptal cellulites (proptosis and limitation of EOM)
Treatment: admition, Iv antibiotics, CT-scan and fever chart.
Graves
Ophthalmopathy
Most common cause of unilateral or bilateral proptosis
Symptoms (active and inactive)
Signs
Treatment
Orbital
Blow-out fracture
Symptoms
Signs
Indications for treatment
Tumors
Metastatic tumor
Lymphoma
Rhabdomyosarcoma