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Oculoplastic disorders

Meseret

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Eyelid Disorders

Internal Hordeolum

a staphylococal abscess of Meibomian glands

•Sxspain, redness, swelling

within eye lid• Signs• tender, inflamed mass

within the eye lid.

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Internal Hordeolum…

• Treatment• _ Hot compress• _ Topical antibiotics• _ If the above treatment fails, Incision and curettage under local anesthesia

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External Hordeolum /stye/

• An acute staphylococcal infection of a lash follicle and its associated gland of zeis or moll.

• SymptomsPain, redness, lid margin swelling of short

duration

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External Hordeolum /stye/…

• Signs• Tender inflamed mass

in the lid margin which points

• anteriorly through the skin

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External Hordeolum /stye/…

• Treatment• Warm compression• Topical antibiotic - Chloramphenicol eye

ointment.• • Epilation of the eyelash associated with the

infected follicle mayenhance drainage of focus.

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Chalazion

• A chronic lipogranulomatous inflammatory lesion caused by

• blockage of meibomian gland orifices and stagnation of sebaceous Secretion

• Symptom• Painless nodule within the eye lid

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Chalazion…

• Sign Non tender, firm,

roundish mass within the eye lid.

• Treatment• Hot compression surgical incision and

curettage

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Treatment of chalazion

Injection of local anaesthetic Insertion of clamp Incision and curettage

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Medical treatment of chalazion

• Inject 0.1-0.2ml triamcinolone diacetate aquouse suspension dilauted with lignocaine (5mg/ml)

• Success rate 80%• Can be repeated after 2 weeks.• Systemic tetracycline for recurrent cases

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Preseptal cellulitis

• Inflammation in front of the orbital septum

Causes-stahyloccoci, streptococciH. Influenza…Risk factors Trauma, URTI, insect

BitesRx- Systemic Abtcs

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Molluscum contagiosum

• - Uncommon skin infection caused by a poxvirus

• - common in children and immunocompromized patienst.

• In immunocompromized patients, it is multiple, large size, bilateral, recurrent and resistant to treatment.

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• Rare tumour which presents soon after birth

• Starts as small, red lesion, most frequently on upper lid

• Blanches with pressure and swells on crying

• Grows quickly during first year

• May be associated with intraorbital extension

• Begins to involute spontaneously during second year

Capillary haemangioma

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Treatment of Capillary hemangioma

• Most of the cases resolve spontanously• For cases that may cause amblyopia-steroid injections, and for selected cases

surgical resection is done/

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Molluscum contagiosum

• Symptom – painless, raised, skin lesion.• Sign• Single or multiple• Pale, waxy Umblicated nodules• If the nodule is located on the lid margin it

may give rise to ipsilateral chronic follicular conjunctivitis and occasionally a superficial keratitis

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Molluscum contagiosum…

• Treatment Shaving and excision• Destruction of the lesion by cauterization,

cryotherapy

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Herpes Zoster Ophthalmicus

Caused by Varicella zoster/herpes virus-3Eye is affected through ophthalmic branch of trigeminal nerve Unilateral Common in immunocompromised patient 95% are seropositive

The rash appears 2-3 days after the pain: the rash is not different in seropositive and seronegatives but recurrent in seropositive patients.

Signs-in chronological order

Maculopapular rash in the fore headDevelopment of vesicles, pustules and crusting ulcerationIn severe cases-periorbital edema due to secondary bacterial cellulitis.

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Treatment Analgesics

Aspirin 600mg Q 4-6hoursParacetamole 1gm Q 4hoursGentian violet - 0.5% clean the wound

Antiviral should be given within 48hours after rash, because the drug need active viral replication.

Acyclovir 800mg 5x/day for 7-10days

Valicaclovir 1gm TID for 7 days

Tamciclovir 25mg TID for 7days

As it is less sensitive to these drugs than H.simplex, giving low dose to save money is wasting money.

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ComplicationIf the tip and side of the nose is involved, the eye is likely involved even if it looks normal. So start treatment is indicated with the following medications.

Atropine 1% eye drops BID to decrease blood supply to iris.If eye is red and painful, It can be Corneal Ulcer- Treatment with

Chloramphinicol eye drops QID If there is no corneal Ulcer- Treatment with Steroid eye drop

Post herpetic Neuralgia Aspirin 600mg Q 4hour Paracetamole 1gm P.O. Q 4hours Carbamazepine 100gm P.O. Per day, increase the full dose 300 to 400gm BID per day

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Blepharitis

1. Staphylococcal – blepharitis• • Caused by Staph. aureus• • Is ulcerative in type with redness of lid margins with

scales and easily pluckable lashes2. Seborrheic blepharitis• Is associated with seborrhea of the scalp, brows and ears• Is non –ulcerative• The scales are greasy with less marked redness of the lid

margin• A patient may present with a mixed type of Blepharitis

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• Both types of patients could present with:-• Symptoms• • Irritation• Burning• • Itching of the lid margins

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• Signs• • Scales on lid margin• • Eye lid margin

ulceration and redness• Pouting meibomina

orifices

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Blepharitis….

• Treatment• Lid hygiene• Topical antibiotics (erythromycin or

Chloramphenicol eye drops QID)• Systemic antibiotics-doxcycline50 to 100

mg/day for four wks for infectious cause• Topical steroids (terracortri)l eye suspension

once –twice a day) for seborrheic

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Herpes Zoster Ophthalmicus

Caused by Varicella zoster/herpes virus-3Eye is affected through ophthalmic branch of trigeminal nerve Unilateral Common in immunocompromised patient 95% are seropositive

The rash appears 2-3 days after the pain: the rash is not different in seropositive and seronegatives but recurrent in seropositive patients.

Signs-in chronological order

Maculopapular rash in the fore headDevelopment of vesicles, pustules and crusting ulcerationIn severe cases-periorbital edema due to secondary bacterial cellulitis.

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Treatment Analgesics

Aspirin 600mg Q 4-6hoursParacetamole 1gm Q 4hoursGentian violet - 0.5% clean the wound

Antiviral should be given within 48hours after rash, because the drug need active viral replication.

Acyclovir 800mg 5x/day for 7-10days

Valicaclovir 1gm TID for 7 days

Tamciclovir 25mg TID for 7days

As it is less sensitive to these drugs than H.simplex, giving low dose to save money is wasting money.

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ComplicationIf the tip and side of the nose is involved, the eye is likely involved even if it looks normal. So start treatment is indicated with the following medications.

Atropine 1% eye drops BID to decrease blood supply to iris.If eye is red and painful, It can be Corneal Ulcer- Treatment with

Chloramphinicol eye drops QID If there is no corneal Ulcer- Treatment with Steroid eye drop

Post herpetic Neuralgia Aspirin 600mg Q 4hour Paracetamole 1gm P.O. Q 4hours Carbamazepine 100gm P.O. Per day, increase the full dose 300 to 400gm BID per day

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Benign eyelid Tumors / lesions Epithelial tumors like:-Squamous papilomasVerruca Vulgaris (wart) Seborrheic Keratosis Inclusion cysts

NeviMelanocytic lesions of the skin arise from three sources. Nevus cells, Dermal melanocytes, Epidermal melanoctes Treatment is needed if it is growing and for cosmetic reasons.

Hemangioma Capillary hemangioma is common in children, may be present at birth. Usually occur at the 1st tweeks or months of life. TreatmentIntralesional corticosteroid injection is the current treatment of choice in patients whose vision is threatened.Capillary hemangioma is usually self limiting and disappears in 5-7 years of age.

Eyelid Tumors

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Malignant eyelid tumors Basal cell carcinoma (BCC)Most common eyelid malignancy, 90-95% of malignant eyelid tumors. More common in fair-skinned, blue-eyed, red hair, middle age to old people Treatment - Excisional biopsy followed by skin grafting & reconstruction

Squamous cell carcinoma (SCC)Less common than BCC but more aggressive (More common in our country)Potentiated by immunodeficiency and human papilloma virus.

Treatment -Wide surgical excision-Exenteration

Sebaceous Adenocarcinoma- Sebaceous gland carcinoma (SGC)Highly malignant and potentially lethal tumor. Clinically, they may simulate chalazia, blepharitis, BCC or SCC

Treatment : Wide surgical excision

Kaposi sarcoma Treatment : There is no definitive surgical management.

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ABNORMALITY IN THE FUNCTION AND POSITION OF THE EYELIDS

• EctropionIt is eversion of the eyelid margins away from

the globeCausesParalytic –facial nerve palsyMechanical- Mass or edema on the lower lidCicatricial- secondary to inflammation or burnInvolutional- age related changes

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Ectropion

Cicatricial ectropionInvolutional ectropion

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Entropion Inversion of the eyelid margins• Causes

ParalyticInvolutionalcicatricial

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Management Treatemnt of ectropion

Prevent exposure keratopathy Treat the cause (if possible) Surgical correction

Treatment of Entropion

Protect corneal damage from trichiasis Treat the cause when possible Do Surgical correction

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Ptosis• It is drooping of the upper eyelid• Causes could be

1. Congenital unilateral or bilateral Can cause amblyopia

2. Acquired Ptosis• Neurogenic 3rd nerve palsy (partial or complete) sympathetic palsy (Hornor’s syndrome)

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Ptosis (contd)

3.MechanicalExample – tumors, edema…pulling the lid down4. Involutional• Age related changes to the levator muscle5. Myogenic• Mygoenic dystrophy to Levator6. Apponeurotic-Damage to the levator apponeurosis

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Management of Ptosis

• Prevent amblyopia in children• Address the cause when possible• Surgical correction –when cosmetically and

functionally significant

Proceduers of ptosis surgery1. Frontalis sling2. Levator advancement

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THYROID EYE DISEASE

• An autoimmune inflammatory disorder of the orbit whose underlying cause is not fully understood.

• 90% assocaited with graves disease• 6% asso with euthyroid state• 3% associated with Hashimotos thyroidits• 1% associated with hypothyroid state

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1. Soft tissue involvement• Periorbital and lid swelling• Conjunctival hyperaemia• Chemosis• Superior limbic keratoconjunctivitis

2. Eyelid retraction3. Proptosis4. Optic neuropathy5. Restrictive myopathy

Clinnical Features

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Soft tissue involvementPeriorbital and lid swelling

Chemosis

Conjunctival hyperaemia

Superior limbic keratoconjunctivitis

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Signs of eyelid retraction Occurs in about 50%

• Bilateral lid retraction • No associated proptosis

• Bilateral lid retraction • Bilateral proptosis

• Lid lag in downgaze • Unilateral lid retraction • Unilateral proptosis

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Proptosis

Treatment options • Systemic steroids • Radiotherapy • Surgical decompression

• Occurs in about 50% • Uninfluenced by treatment of hyperthyroidism

Axial and permanent in about 70% May be associated with choroidal folds

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Optic neuropathy• Occurs in about 5% • Early defective colour vision • Usually normal disc appearance

Caused by optic nerve compression at orbital apex by enlarged recti

Often occurs in absence of significant proptosis

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• Occurs in about 40% • Due to fibrotic contracture

Restrictive myopathy

Elevation defect - most common Abduction defect - less common

Depression defect - uncommon Adduction defect - rare

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Treatment of Thyroid Eye disease

• Lubrication of the corena• Tape the lid if blinking function is not good• Steroids• Surgical decompression of the orbital walls

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ORBITAnatomy

The orbits are bony cavities contain the globes, extra ocular muscles, nerves, fat, and blood vessels Each bony orbit is pearl (cone) shaped.

Dimensions Volume - 30 cc

Entrance height - 35 mm Entrance width - 40 mm

The orbital walls are composed of seven bones

Ethmoid

Frontal Four walls of the orbitLacrimal Maxillary Roof of OrbitPalatine Lateral wall of orbitSphenoid Medial wall of the orbitZygomatic Floor of Orbit

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The six Ps

Pain - May be a symptom of inflammatory and infections lesions, orbital hemorrhage, malignant lacrimal gland tumors, and nasopharyngeal carcinoma.

Proptosis- Reflect the location of the mass the globe is usually displaced away from the mass

Axial displacement - caverious hemangima, glioma, meningiona, etc.

Superior displacement- maxillary sinus tumors

Down & medial placement- lacrimal gland tumor, demoid

Down & lateral displacement- frontoethmoidal mucoceles, abscesses, osteomas, and sinus carcinomas.

Bilateral protosis- Thyriod ophthalmopathy, lymphomas, vasculitis, idiopathic orbital inflammatory disease (pseudotumor),metastatic tumors, leukemias, carotid cavernous fistuals, etc. Enophathalmos- Can occur due to sclerosing tumors such as metastatic

breast carcinoma and orbital floor fracture.

Evaluation of orbital disorders

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Progression –Disorder occurring over days and weeks PseudotumorCellulitisHemorrhageThrombophobitisRhabdomyosarcomaThyroid ophthalomopathy

Disorders occurring over months to years. Dermoids Neurogenic tumorsLymphomas Benign mixed tumors of LG Cavernous hemangiomas Metastatic tumors

Palpation - Consistency of the mass, location tenderness, hotness

Pulsation – Arteriovenous fistulas, neurofibromatosis, meningoencephalocele

Periobital changes- These changes may indicate the underlying disorders. E.g- Corkscrew conjunctival vessels-Arteriovenous fistula

-Anterior uveitis-pseudotumor or sarcoid -Eyelid retraction & eyelid lag-Thyroid ophthalmopathy.

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Physical examination of orbital disorders

Inspection - Globe displacement measured by exophthalmometry. Palpation - Presence of mass, retropulsion displacement

Palpate regional lymph nodesPalpate for pulsation - vascular tumors

Auscultation - Bruits may be detected with stethoscope or subjectively by the patient

Primary studies of orbital disorders

Plain - film radiographyUltrasonographyComputed tomography (CT)Magnetic Resonance Imaging (MRI)

Secondary studies

Venography Pathology - FNAB, Tissue BiopsyArteriography Laboratory studies - T3, T4, TSH for thyroid ophthalmopathy

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Disorders Occurring Predominantly in Children Orbital cellulitis - most common cause of proptosis in children Rhabdomyosarcoma - most common primary orbital malignancy in children Dermoid and epidermoid cysts

Capillary hemangionia and lymplangioma

Orbital nerve glioma

Leukemia (granulocytic chloroma)

Orbital inflammatory syndromc (Orbital pseudotumor )

Neurofibroma

Retinoblastoma

Metastatic neuroblastoma (most common metastatic ca. to the orbit in children)

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Disorders occurring predominantly in Adults

Thyroid ophthalmopathy - most common cause of unilateral and bilateral proptosis in Adults

Cavemous hemangioma - most common benign primary orbital tumor in Adults

Orbital inflammatory syndrome (orbital pseudotumor)

Lymphocytic lesions

Meningioma

Lacrimal gland tumors

Dermoid and epidermoid cysts

Treatment of Orbital disorders : Mainly Surgical

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Preseptal cellulitis

– Inflammation and infection confined to the eyelids and periorbital structures anterior to the orbital septum

– Motility of the globe is full, normal VA and no conjunctival chemosis

Diagnosis- blood culture, pus culture

Treatment - oral Antibiotics (third generation cephalosporin, Ampicillin,...)

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Orbital Cellulitis

Active infection of the orbital soft tissue posterior to the orbital septum. 90% of cases orbital cellulitis occurs as a secondary extension of acute or chronic bacterial sinusitis. Clinical findings

FeverproptosisChemosisrestriction of ocular motilityPain on movement of the globe. Decreased vision and pupillary abnormalities suggest involvement of the orbital apex and demand immediate investigation and aggressive management.

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Complications Orbital apex syndrome (cavernous sinus thrombosis)BlindnessCranial nerve palsiesBrain abscessDeath

Management Evaluation of paranasal sinuses (CT)Plain - filmENT consultation

Treatment - Admission Parenteral broad spectrum Antibiotics Nasal decongestantsSurgical sinus drainage