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

Lid and lacrimal disordersLid and lacrimal disorders

Abdulrahman Al-Muammar, MD, FRCSC King Saud University

TrichiasisTrichiasis

DistichiasisDistichiasis

Disorders of LashesDisorders of Lashes

Disorders of LashesDisorders of Lashes

Treatment options for trichiasisTreatment options for trichiasis

EpilationEpilation

ElectrolysisElectrolysis

CryotherapyCryotherapy

Argon laserArgon laser

SurgerySurgery

MadarosisMadarosisLid margin inflammationLid margin inflammationTumorTumorCryotherapy, Cryotherapy, radiotherapy or burnsradiotherapy or burnsAlopeciaAlopeciaSyphilisSyphilisLeprosyLeprosySLESLE

PoliosisPoliosisVKHVKHSympathetic ophthalmiaSympathetic ophthalmia

Disorders of lashesDisorders of lashes

EntropionEntropion

EntropionEntropion

Entropion, or inversion of the lid margin, Entropion, or inversion of the lid margin, may be congenital or acquiredmay be congenital or acquired

The acquired variety can be the result The acquired variety can be the result of:of:

Ageing changes (Ageing changes (involutionalinvolutional) )

Cicatricial changes affecting the posterior Cicatricial changes affecting the posterior lamella of the eyelid (lamella of the eyelid (cicatricialcicatricial))

SpasticSpastic

EntropionEntropion

EntropionEntropion

EntropionEntropion

TreatmentTreatmentLubricationLubrication

Taping the lidTaping the lid

EpilationEpilation

Horizontal lid tighteningHorizontal lid tightening

Tarsal fracture procedureTarsal fracture procedure

EctropionEctropion

EctropionEctropion

Ectropion, or eversion of the lid margin, may Ectropion, or eversion of the lid margin, may be congenital or acquiredbe congenital or acquiredThe acquired forms are the result of The acquired forms are the result of

Ageing changes (Ageing changes (involutional)involutional)Lumps (Lumps (mechanicalmechanical))Scarring of the anterior lamella of the lid Scarring of the anterior lamella of the lid ((cicatricialcicatricial))

• BurnBurn• Infection/ inflammationInfection/ inflammation• Trauma Trauma

Weakness of the orbicularis muscle (Weakness of the orbicularis muscle (paralyticparalytic))

EctropionEctropion

EctropionEctropion

TreatmentTreatmentLubricationLubrication

Horizontal lid shortening or tighteningHorizontal lid shortening or tightening

Punctal inversionPunctal inversion

PtosisPtosis

MARGIN-REFLEXDISTANCE

INTERPALPEBRALDISTANCE

LID CREASE POSTION

PtosisPtosis

PtosisPtosis

PtosisPtosis

PtosisPtosis

PseudoptosisPseudoptosisOrbital volume deficiencyOrbital volume deficiency

ExophthalmosExophthalmos

Excess lid skinExcess lid skin

HypotropiaHypotropia

PtosisPtosis

Acquired or CongenitalAcquired or CongenitalNeurogenicNeurogenic

• 3rd nerve palsy3rd nerve palsy• 3rd nerve misdirection3rd nerve misdirection• Horner syndromeHorner syndrome• Marcus Gunn jaw-winking syndromeMarcus Gunn jaw-winking syndrome

MyogenicMyogenic• Myasthenia gravisMyasthenia gravis• Myotonic dystrophyMyotonic dystrophy• Ocular myopathiesOcular myopathies• Levator dystrophyLevator dystrophy• Aponeurotic (levator dehiscence)Aponeurotic (levator dehiscence)

MechanicalMechanicalTraumaticTraumatic

PtosisPtosis

TreatmentTreatmentPtosis crutchPtosis crutch

Taping of the lidTaping of the lid

SurgicalSurgical• Levator advancementLevator advancement• Muller’s muscle resectionMuller’s muscle resection• Frontalis suspensionFrontalis suspension

BlepharitisBlepharitisAnteriorAnteriorPosteriorPosteriorStaphylococcalStaphylococcalSeborrhoeicSeborrhoeicMeibomianitisMeibomianitis

TreatmentTreatmentLid hygieneLid hygieneTearsTearsAntibioticsAntibioticsWarm compressesWarm compresses

Eyelids inflammationEyelids inflammation

AllergyAllergyAcute allergic Acute allergic blepharoconjuctivitisblepharoconjuctivitis

Allergic Allergic dermatoblepharitisdermatoblepharitis


ChalazionChalazionFocal inflammation of the Focal inflammation of the eye lids which result from eye lids which result from obstruction of the obstruction of the meibomian glandsmeibomian glands

Chronic Chronic lipogranulomatous lipogranulomatous inflammatory changesinflammatory changes

TreatmentTreatment• Warm compressesWarm compresses

• Local antibioticLocal antibiotic

• ExcisionExcision


HordeolumHordeolumAcute infection involving Acute infection involving the meibomian glands the meibomian glands (internal) or the glands of (internal) or the glands of Moll or Zeis (external)Moll or Zeis (external)

Overtime may evolve into Overtime may evolve into chalazionchalazion

TreatmentTreatment• Warm compressesWarm compresses

• Topical antibioticTopical antibiotic


CystsCystsCyst of MollCyst of Moll

Cyst of ZeissCyst of Zeiss

Sebaceous cystSebaceous cyst

HidrocystomaHidrocystoma

Benign eyelid lesionsBenign eyelid lesions

TumorsTumorsViral wart( papilloma)Viral wart( papilloma)Actinic keratosisActinic keratosisSeborrheic keratosisSeborrheic keratosisKeratocanthomaKeratocanthomaNeviNevi

• JunctionalJunctional• CompoundCompound• DermalDermal

Capillary hemangiomaCapillary hemangiomaXanthelasmaXanthelasmaPyogenic granulomaPyogenic granuloma



Basal cell carcinomaBasal cell carcinoma

Squamous cell carcinomaSquamous cell carcinoma

Meibomian gland carcinomaMeibomian gland carcinoma

MelanomaMelanoma

Kaposi sarcomaKaposi sarcoma

Merkel cell carcinomaMerkel cell carcinoma

Malignant eyelid tumorsMalignant eyelid tumors


Most common Most common malignancy(90%) of the malignancy(90%) of the eyelideyelidUsually located on the lower Usually located on the lower lid and medial canthuslid and medial canthusPearly nodules which Pearly nodules which ulcerate and have ulcerate and have telangiectasiastelangiectasiasTreatmentTreatment

Surgical excisionSurgical excisionCryotherapyCryotherapyRadiation therapyRadiation therapy


Most common Most common malignancy(90%) of the malignancy(90%) of the eyelideyelidUsually located on the lower Usually located on the lower lid and medial canthuslid and medial canthusPearly nodules which Pearly nodules which ulcerate and have ulcerate and have telangiectasiastelangiectasiasTreatmentTreatment

Surgical excisionSurgical excisionCryotherapyCryotherapyRadiation therapyRadiation therapyOrbital exenteration for Orbital exenteration for deep invasive lesionsdeep invasive lesions

Squamous cell carcinomaSquamous cell carcinoma

Less common than Less common than BCCBCC

May arise de-novo May arise de-novo or from pre-existing or from pre-existing actinic keratosisactinic keratosis

May metastasizeMay metastasize

Orbital cellulitisOrbital cellulitis

Preseptal cellulitisPreseptal cellulitisInfection anterior to Infection anterior to orbital septumorbital septum

Orbital cellulitisOrbital cellulitis90% secondary to 90% secondary to sinusitissinusitisTraumaTraumaInsect biteInsect biteEndogenous Endogenous bacteremiabacteremia

Orbital cellulitisOrbital cellulitis

OrganismsOrganismsStaphylococcus aureusStaphylococcus aureusStreptococcusStreptococcusHemophilus influenzaHemophilus influenza

TreatmentTreatmentadmissionadmissionOrbital CTOrbital CTI.V antibiotics (3I.V antibiotics (3rdrd generation cephalosporin and generation cephalosporin and clindamycin)clindamycin)Drainage of orbital abscessDrainage of orbital abscess

Orbital disordersOrbital disorders

ChildrenChildrenOrbital cellulitisOrbital cellulitis

PseudotumorPseudotumor

Dermoid cystDermoid cyst

Capillary hemangiomaCapillary hemangioma

LymphangiomaLymphangioma

RhabdomyosarcomaRhabdomyosarcoma

metastasismetastasis

AdultsAdultsThyroid orbitopathyThyroid orbitopathy

Cavernous hemangiomaCavernous hemangioma

LymphangiomaLymphangioma

PseudotumorPseudotumor

LymphomaLymphoma

MeningiomaMeningioma

Lacrimal gland tumorLacrimal gland tumor

Dermoid cystDermoid cyst

metastasismetastasis

Thyroid orbitopathyThyroid orbitopathyGraves’ diseaseGraves’ disease

Most common cause of exophthalmos in adultMost common cause of exophthalmos in adultOnset: 20-45 yearsOnset: 20-45 yearsClinical picture:Clinical picture:

Unilateral or bilateral exophthalmosUnilateral or bilateral exophthalmosEyelid retractionEyelid retractionLid lagLid lagDiplopiaDiplopiaPeriorbital edemaPeriorbital edemaChemosisChemosisOptic neuropathyOptic neuropathy90% HYPER, 1% HYPO, 6%EUTHYROID90% HYPER, 1% HYPO, 6%EUTHYROID

Thyroid orbitopathyThyroid orbitopathy

Thyroid orbitopathyThyroid orbitopathy

Complication:Complication:DiplopiaDiplopiaRednessRednessCorneal exposureCorneal exposureOptic neuropathyOptic neuropathy

TreatmentTreatmentLubricationLubricationTape eyelids at nightTape eyelids at nightSteroidSteroidRadiationRadiationSurgerySurgery

• DecompressionDecompression• Muscle surgeryMuscle surgery• Optic nerve fenestrationOptic nerve fenestration

Anatomy and physiology of the Anatomy and physiology of the lacrimal systemlacrimal system

Secretory apparatusSecretory apparatusLacrimal glandLacrimal glandLacrimal ducts empty into Lacrimal ducts empty into superior cul-de-sacsuperior cul-de-sacAfferent pathway: V nerveAfferent pathway: V nerveEfferent pathway: VII nerve Efferent pathway: VII nerve (reflex tear)(reflex tear)Accessory lacrimal glands Accessory lacrimal glands of Krause and Wolfring of Krause and Wolfring (basic tear)(basic tear)Tear filmTear film

• Inner layer: mucinInner layer: mucin• Middle layer: aqueousMiddle layer: aqueous• Outer layer: meibomianOuter layer: meibomian


Lacrimal excretory Lacrimal excretory apparatusapparatus

PunctaPuncta

CanaliculiCanaliculi

Lacrimal sacLacrimal sac

Nasolacrimal ductNasolacrimal duct

Inferior meatusInferior meatus

VALVE OF HASNERVALVE OF HASNER


Lacrimal evaluationLacrimal evaluationDye disappearance testDye disappearance test

Primary and secondary dye testPrimary and secondary dye test

Lacrimal irrigationLacrimal irrigation

Tear break up timeTear break up time

Schirmer testSchirmer test

Lacrimal disordersLacrimal disorders

Congenital nasolacrimal Congenital nasolacrimal duct obstructionduct obstruction

Membranous block at the Membranous block at the valve of hasnervalve of hasner2-4% of full term new 2-4% of full term new babybabyUsually resolve Usually resolve spontaneously within 4 to spontaneously within 4 to 6 weeks6 weeksTreatmentTreatment

• Topical antibioticsTopical antibiotics• MassageMassage• Probing: 6 to 12 monthsProbing: 6 to 12 months


DacryocystoceleDacryocystoceleCombination of Combination of nasolacrimal duct nasolacrimal duct obstruction and obstruction and amniotic fluid or amniotic fluid or mucus trapped in the mucus trapped in the sacsacTreatmentTreatment

• AntibioticsAntibiotics• MassageMassage• probingprobing


Punctal stenosisPunctal stenosisDilationDilationSnip procedureSnip procedure

CanaliculitisCanaliculitisIrrigation with antibioticsIrrigation with antibioticsOral antibioticsOral antibiotics

Canalicular obstructionCanalicular obstructionDacryolithsDacryolithsDacryocystitisDacryocystitis

Dacryocystorhinostomy


Lacrimal sac tumorsLacrimal sac tumorsSquamous cell papillomaSquamous cell papillomaTransitional cell Transitional cell papillomapapillomaSquamous cell Squamous cell carcinomacarcinomaTransitional cell Transitional cell carcinomacarcinomaAdenocarcinomaAdenocarcinoma

Lacrimal gland tumorsLacrimal gland tumors70% of lacrimal gland 70% of lacrimal gland masses are non-masses are non-epithelial masses:epithelial masses:

• Idiopathic inflammationIdiopathic inflammation• Sarcoidosis, TBSarcoidosis, TB• Lymphoid tumorsLymphoid tumors

30% are epithelial30% are epithelial• CystCyst• Adenoid cystic Adenoid cystic

carcinomacarcinoma• Pleomorphic Pleomorphic

adenoma(benign and adenoma(benign and malignant mixed tumor)malignant mixed tumor)

Thank you

Documents

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