Palpebra Dan Jaringan Orbita Fix

7/29/2019 Palpebra Dan Jaringan Orbita Fix

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Kelainan Palpebra dan Jaringan

Orbita

Dr.Irvan



Anatomy• Consists of :

– Skin :• the thinnest• loose• no subcutaneus fat

– Muscle of protraction :• M.orbicularis oculi

– Orbital septum, orbital fat – Muscle of retraction :

• M. levator

– Tarsus – Conjunctiva

– Cilia – Glands :

• Zeis• Moll• Meibom





• Tarsus :

– firm, dense connective tissue--> skeleton of the eye lid

– upper eye lid tarsal plate :10-12 mm

– lower eye lid tarsal plate

:4,5 mm

– width : 29 mm

• Vascularization :

– A/V ophthalmic

– A/V lacrimalis

• Sensoric Inervation : N V





• Muscles : – Orbicularis oculi muscle

• circular

• function : to close the lids

• inervation : N VII

– Levator palebra muscle :• attached to upper border

of the tarsus and middle

portion of the skin• function : to open the lids

• inervation : N III

– Muller’s muscle : • smooth muscle

• insertion : at the proximaledge of the tarsus



• The function of palpebra :

– To protect the eye ball from external physic or

chemist injuries and trauma

– To keep the eye ball surface wet and slippery

with well distributing tears and glands secretion

productions



Eyelid Diseases

• Infection – Hordeolum

• Suppurative acute infection at

eyelids gland caused by

Staphylococcus – Hordeolum internum : at meibom

gland



– Hordeolum eksternum : at zeis, mole

gland

• Therapy :

– Systemic & local antibiotics

– Incision :

» mostly common on hordeolum

externum

» Skin incision : margo

» Conjuctival incision : margo

• Complication : eyelids abscess



• Chalazion

– Chronic lipogranulomatous inflammation of themeibom gland

– red-purple painless nodule at the conjunctiva

– Therapy : incision



• eyelids abscess (abses palpebra)

– originates from hordeolum or severe eyebrow

infections

– Therapy :

• Local and systemic antibiotics

• incision skin line



• Blepharitis

– chronic infection margin of the eye lid

– Squamous blepharitis (seborrhea) :

• signs : itching, burning, squamous seborrhoic at the lash

• Th/ : - Cleaning with wet cotton

- Topical steroid: used infrequently.

- Topical (fusidic acid) +- systemic antibiotic staphylococcal liddisease .



– Ulcerated blepharitis :

• margo infection caused by

staphylococci at children with bad general condition

• clinical signs : red palpebra,

squamous seborrhoic,

ulceration along margo covered

by crust,

• loss of eye lashes, margo

distortion (if chronic and

severe)

• Th/ : improving generalcondition, clean the crust with

wet cotton, antibiotic ointment



• Herpes Zoster Ophtalmica

– E/ : herpes zoster viral

– clinical signs : very pain and burning (caused

by disturbances of the first branch of nervus V)

– Th/ : analgetic, antiviral (acyclovir), antibiotic

(to prevent from secondary infection) and localcorticosteroid



• ALERGY – Clinical signs : eye lids edema

– Type :• anaphylactic and atopy (urticaria and angioneurotic

edema)

• contact allergy (cosmetic)

– Th/ :

• eliminate etiological agent• local and systemic steroid ( depend on the E/)

• Antihistamin



• Tumor – Benign :

• naevus



• verucca



• xanthelasma : – yellowing plaque, irregular esp.. at

medial

– Th/ : excision (for cosmetic reason)



• milium : – small and white papil (lenticular )

– caused by retention of sebacea gland



• Haemangiom (vascular tumor)

– Cavernous haemangiom :» consists of the big branch of vein at

subcutan» blueing

» change at vaso dilatation --> bigger if crying (Valsava test +)





– Capilary haemangiom :» superficial

» consist of widing capillary

» red – Th/ :

» cryocoagulation (if big and disturbing)

» steroid injection





• Neurofibromatosis (von Recklinghausendisease)

» usually occur at temporal



– Malignant• Basal Cell Ca at geriatric

» the most common eye lid malignancy (90-95%) on lower eye lid (near medial cantus)

» clinical signs : ulcerative node, irregular, pigmentation,metastation rare

» Th/ : excision and radio th/



Squamous Cell Ca (Epithelioma)



– Squamous Cell Ca (Epithelioma)

» at geriatric

» esp. at superior palpebra

» metastation to preauricular nodesthrough lymphatic system

» Th/ : wide excision



– Malignant Melanoma» associated with conjuntival melanoma

» Th/ : radical operation --> excenteration





– Sebaceous Cell Ca» at gland. Meibom

» recurrent Chalazion

» multifocal

» metastation : rare

» Th/ : wide excision



Eye Lid Malposition

• Entropion

– turning in of the eye lid margin --> the lashes

touch the cornea (Trichiasis) --> corneal

irritation --> corneal ulcer

– unilateral or bilateral



• Congenital entropion



– Senile Entropion

• Th/ : blepharoplasty (reconstruction)

– Acute spastic• ocular inflamation

• ocular irritation



– Cicatricial entropion

• caused by cicatrix/shortening of the tarsus

• E/ :

– trauma thermal, chemical burns and eye lid injury

– infections : trachoma, herpes zoster

• Th/

– eye lid reconstruction

– trachoma --> Sie Boen Lian technique (SBL)



• Ectropion – turning out of the eye lid margin--> conjunctiva is not well

covering --> thick, red, chronic conjunctivitis



– Congenital ectropion

– Senile ectropion :• caused by tissue relaxation--> loss of eye lid tone-->evertion

of margin• often seen in the lower eye lid

– Paralytic ectropion :• caused by N.VII palsy--> poor blinking & lagophthalmos



– Cicatrical ectropion

• Th/ : blepharoplasty/reconstruction



• Mechanical

– caused by :

» bulky tumor of the eye lid» fluid accumulation



• Simblepharon

– attachment of the eye lid to the eye ball (usually

with cornea) – Th/ : simblepharectomy



• Lagophthalmos

– the eyelids aperture can not close perfectly

– E/ : paralyze of N.VII, cicatrix, proptosis,tumor

– complication : xerosis (dry eye)



• Ptosis – the upper eye lid can not open perfectly

– unilateral/bilateral

– congenital ptosis

– acquired ptosis• senile

• myogenic

• neurogenic (paralyze of N.III)• trauma

• mechanic (tumor)

– Th/ :

• fasanela servat – if some and the function of levator still good

• levator shortening – skin approach or conjunctival approach





Kelainan Jaringan Orbita



Clinical Evaluation of Orbital

Diseases• 6 P’s

– Pain

– Proptosis

– Progression

– Palpation

– Pulsation – Periorbital Changes



Graves’ Ophthalmopathy

• Autoimmune disorder that is related to

excess secretion of thyroid hormone

• 10-25% occurs in the absence of anythyroid dysfunction

• Female/male ratio 8:1

• 4th to 5th decades of life

• most common cause of adult unilateral and

bilateral exophthalmos




Pathogenesis

1. Hypertrophy of

Extraocular Muscles

2. Cellular Infiltration

3. Proliferation of

orbital fat,

connective tissue




Main Clinical Manifestation

1. Eyelid retraction

2. Soft Tissue involvement

3. Proptosis

4. Optic Neuropathy

5. Restrictive Myopathy




• Eyelid Retraction




• Soft Tissue

Involvement

1. Conjunctival

Injection

2. Chemosis

3. Eyelid Fullness




• Proptosis




Restrictive Myopathy




CT Scan – EOM

Hypertrophywith tendon

sparing



Key Points in Graves’

Ophthalmopathy• Eyelid retraction is the most common clinical feature; Graves’

ophthalmopathy is the most common cause of eyelid retraction.

• Graves’ Ophthalmopathy is the most common cause of unilateral and

bilateral proptosis.

• Graves’ Ophthalmopathy is 6 more times more common in female thanmale.

• This condition is associated with hyperthyroidism in 90% of cases, but 6%

are Euthyroid.

• Severity of Ophthalmopathy may not parallel serum levels of T3 or T4.

• Ophthalmopathy may be asymmetric.

• Urgent care may be required for optic Neuropathy or severe proptosis

• If surgery is needed the usual order of surgery is DECOMPRESSION

followed by SQUINT SURGERY followed by EYELID SURGERY



Orbital Infections

• Preseptal Cellulitis

– Infection confined to the eyelids and periorbital

tissues anterior to the orbital septum – Globe is uninvolved,

– Pupillary rxn, VA, & EOM’s are NORMAL

– no chemosis, no pain



Orbital Infections



Orbital Infections

• Orbital Cellulitis

– active infection posterior to the septum

– 90% occurs as a 2ndary extension of bacterialsinusitis

– fever, proptosis,chemosis, EOM restrictions,

pain on eye movement

– decrease VA, pupillary abnormalities



Orbital Infections



Orbital Tumors

• Vascular

– capillary hemangioma

–

cavernous hemangioma – lymphangioma

• Lacrimal Gland

– Benign Mixed Tumor

– Malignant Tumor

• Rhabdomyosarcoma

• Cystic Lesions

– dermoid cyst

–

mucocele• Neural

– optic nerve glioma

• Metastatic

• Tumor invasion from

adjacent structures



Capillary Hemangioma

– Most common

tumor of the orbit in

childhood

– increase in tumor size during crying

and straining

– absent bruit and

pulsation – involute

spontaneously



Cavernous Hemangioma

• Most common benign

orbital lesion in adults

• middle-aged women

commonly affected

• enhanced well-

encapsulated mass on

CT scan

• Tx: Surgical Excision



Rhabdomyosarcoma

• Most common primary

orbital malignancy of

childhood

• age-onset is 7-8 y/o

• rapid onset of proptosis

• Tx: Exenteration,

Radiation Therapy

combined withsystemic chemotherapy



Pleomorphic Adenoma

• Most common

epithelial tumor of the

lacrimal gland

• 4th -5th decades of

life, mostly men

• progresssive, painless,

downward & inwarddisplacement



Epidermoid / Dermoid Cyst

• Dermoid is a benign

cystic teratoma

•well-encapsulated lined by stratified squamous

& contain dermal

appendages

• Epidermoid - does notcontain dermal

appendages



Fractures of the Orbit

• Orbital floor

Fracture

– Most frequentlyinvolve wall

– Usually along the

infraorbital canal



Orbital Floor Fracture

• Clinical Features

– Periocular Changes – ecchymosis, edema,

subcutaneous emphysema – Enophthalmos

– Infraorbital nerve anesthesia

– Diplopia


















Lacrimal System

• Puncta

• Ampullae

• canaliculi

• lacrimal sac

• nasolacrimal duct



Tear Flow Physiology



Evaluation of Tearing

Lacrimation vs Epiphora

• Lacrimation - reflex over production of

tears from stimulation of CN V byirritation of the cornea and conjunctiva

• Epiphora - normal tear production but there

is physical obstruction on the drainagesystem



Infections of Lacrimal Passages

• Canaliculits -

unilateral epiphora

with mucopurulent

discharge. “Pouting of

the punctum” on slit

lamp exam.



Infections of Lacrimal Passages

• Dacryocystitis infection

of the lacrimal sac.

Presents as a painfulswelling at the medial

canthal area.



Surgical Techniques

• External DCR

• Endoscopic Laser-Assisted DCR

• Transcanalicular Endoscopic DCR



Thank you for your kind attention!

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Palpebra Dan Jaringan Orbita Fix