Eye Lids and Lacrimal System

Dr. Lakshmi Thaufiq, SpM (K)

 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 open or close
the lids
• inervation : N VII
– Levator palebra muscle :
• attached to upper border
of the tarsus and middle
portion of the skin
• inervation : N III
– Muller’s 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
– originates from hordeolum or severe eyebrow
infections
– Therapy :
• Local and systemic antibiotics
• incision skin line
• Blepharitis
– bilateral
– chronic infection margin of the eye lid
– Squamous blepharitis (seborrhea) :
• signs : itching, burning, squamous seborrhoic at the lash
• Th/ : cleaning with wet cotton, corticosteroid ointment
– 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/)
• 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/
– Nodular basal cell Ca
• firm, raised, pearly nodule
• central ulceration
– Morpheaform
• firm, slightly, elevated
• characteristically : ulceration
– 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)
– Th/ :
• fasanela servat
– if some and the function of levator still good
• levator shortening
– skin approach or conjunctival approach
 LACRIMAL SYSTEM
• Secretory apparatus
– Lacrimal gland :
• located in superolateral quadrant of the orbit
• exocrine gland
– Accesoryexocrine glands :
• Krause & Wolfring
• location in the superior fornix and above the
superior border of the tarsus
• Excretion section
– draining the tears into the nasal cavity
• Tear
– slightly alkaline
– containing NaCl, such a lyzozym enzyme that
bacteriostatic
– Normal : tear dampened the eye ball --> apart
are evaporated and most of the tear flows is
actively pump by the action of the orbicularis
muscles/blinking
– measure with Schirmer Test

5mm 25 mm

Normal 10 - 15 mm dalam 5’
 Congenital abnormalities of
the nasolacrimal system
• Nasolacrimal duct obstruction
– complete absence or the puncta
– lacrimal cutaneus fistula
– nasolacrimal obstruction of the distal end (the
valve of Hasner) ---> very often
• Punctum anomaly
– no punctum
– punctum evertion
• loose palpebra -----> facial paralysis
• cicatrix -----> old age
– Th/ : reconstruction
• Dry eye
– caused by decrease of producing tear
– occur at :
• conjunctival cicatrix caused by trachoma/trauma
• Sjorgen syndrome
• Steven Johnson syndrome
• deficiency of Vit A
• lagophthalmos
• Epiphora
– the disturbance of tear excretion
– Occur on :
• lachrymal punctum position disturbance
• paralyze of M. orbicularis --> weaking the
canaliculi suction effect
• obstruction of nasolacrimal duct and sac
 Determining of the lacrimal
system disturbances
• punctum inspection
• palpation at sac area
– on pressure --> discharge reflux
• Dye Disappereance Test (Jones test)
• Anel test (irrigation test)
• probing with Bowman’s probe
• dacryosistography with contrast
• dacryoscintilography, sophisticated, with
radionuclides (technetium-99)
• Management
– The upper system
• dilation ----> probing
• ampullotomy
• cilicon intubation
– Lower system
• dacryocystorrhinostomy (DCR)
 Nasolacrimal Infection
• Acute dacrioadenitis
– signs :
• red painfull swelling with redness of the outer of the
upper eye lid , pseudo ptosis (sometime)
– E/ :
• adult : gonorrhoica
• children : with another disease --> parotitis
• Chronic dacrioadenitis
– slightly edema
– not pain
– often at TB, leukemia, trachoma
– Th/ : depend on the etiological agent
• Chronic dacriosistitis
– more common
– attributed to the nasolacrimal obstruction
– children and adult
– symptom :
• epiphora
• swelling at the site of the sac (distended sac)
• on pressure over the sac --> muco-pus or pus regurgitates
trough the puncta
– Th/ :
• topical and systemic antibiotic
• if obstruction --> dacriosistorinostomi
 Nasolacrimal system tumor
• Lacrimal gland tumor
– benign
• adenoma
• limphangioma
– malignant
• mixed tumor
• sarcoma
– Th/
• operation
• radiation
• Lacrimal sac tumor
– benign
• squamous papiloma
– malignant
• epidermoid Ca
– Th/
• operation (cystectomy)
• radiation