Kelainan Palpebra dan Jaringan Orbita

Dr.Irvan

Anatomy
Consists of :
Skin :
the thinnest loose no subcutaneus fat

Muscle of protraction : Orbital septum, orbital fat Muscle of retraction :

M. levator M.orbicularis oculi

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

Mullers muscle :
smooth muscle insertion : at the proximal edge 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 the meibom 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 lid disease .

 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 general condition, 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 local corticosteroid

 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 Recklinghausen disease)

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)

at geriatric esp. at superior palpebra metastation to preauricular nodes through 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)
if some and the function of levator still good
skin approach or conjunctival approach

Th/ :
fasanela servat levator shortening

Kelainan Jaringan Orbita

Clinical Evaluation of Orbital Diseases

6 Ps
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 any thyroid dysfunction Female/male ratio 8:1 4th to 5th decades of life most common cause of adult unilateral and bilateral exophthalmos

Graves Ophthalmopathy
Pathogenesis 1. Hypertrophy of Extraocular Muscles 2. Cellular Infiltration 3. Proliferation of orbital fat, connective tissue

Graves Ophthalmopathy
Main Clinical Manifestation 1. Eyelid retraction 2. Soft Tissue involvement 3. Proptosis 4. Optic Neuropathy 5. Restrictive Myopathy

Graves Ophthalmopathy
Eyelid Retraction

Graves Ophthalmopathy
Soft Tissue Involvement 1. Conjunctival Injection 2. Chemosis 3. Eyelid Fullness

Graves Ophthalmopathy
Proptosis

Graves Ophthalmopathy
Restrictive Myopathy

Graves Ophthalmopathy
CT Scan
EOM Hypertrophy with tendon sparing

 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 than male. 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

Key Points in Graves Ophthalmopathy

Orbital Infections
Preseptal Cellulitis
Infection confined to the eyelids and periorbital tissues anterior to the orbital septum Globe is uninvolved, Pupillary rxn, VA, & EOMs 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 bacterial sinusitis fever, proptosis,chemosis, EOM restrictions, pain on eye movement decrease VA, pupillary abnormalities

Orbital Infections

Orbital Tumors
Vascular
capillary hemangioma cavernous hemangioma lymphangioma

Cystic Lesions
dermoid cyst mucocele

Neural
optic nerve glioma

Lacrimal Gland
Benign Mixed Tumor Malignant Tumor

Rhabdomyosarcoma

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 wellencapsulated 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 with systemic chemotherapy

Pleomorphic Adenoma
Most common epithelial tumor of the lacrimal gland 4th -5th decades of life, mostly men progresssive, painless, downward & inward displacement

Epidermoid / Dermoid Cyst

Dermoid is a benign cystic teratoma well-encapsulated lined by stratified squamous & contain dermal appendages Epidermoid - does not contain dermal appendages

Fractures of the Orbit

Orbital floor Fracture
Most frequently involve wall Usually along the infraorbital canal

Orbital Floor Fracture

Clinical Features
Periocular Changes ecchymosis, edema, subcutaneous emphysema Enophthalmos Infraorbital nerve anesthesia Diplopia

Fractures of the Orbit

Fractures of the Orbit

Fractures of the Orbit

Fractures of the Orbit

Fractures of the Orbit

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 by irritation of the cornea and conjunctiva Epiphora - normal tear production but there is physical obstruction on the drainage system

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 painful swelling at the medial canthal area.

Surgical Techniques
External DCR Endoscopic Laser-Assisted DCR Transcanalicular Endoscopic DCR

Thank you for your kind attention!