Eye Lids and Lacrimal System

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
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
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




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


25 mm
Normal 10 - 15 mm dalam 5
5mm
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 Bowmans 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