EYELIDS, LACRIMAL APPARATUS

AND ORBIT

YONAS ABRAHAM, M.D.

November, 2013
Anatomy EYELIDS

Eyelids can be divided into seven structural layers

Skin and subcutaneous tissue
Muscle of protraction (Orbicularis oculi muscle)
Orbital septum
Orbital fat
Muscle of retraction (lavatory muscle)
Tarsus-skeleton of the eyelids
Conjunctiva

Eyelashes = About 100 in the upper and 50 in the lower eyelid

Meibomian glands = About 25 in the upper and 20 in the lower

Eyelashes arising from meibomian glands
called districhiasis.

Vascular supply - Eyelids have extensive vascularity, which promotes

 Arterial supply
1) Internal carotid artery by way of the ophthalmic artery and its
branches (supraorbital and lacrimal)
2) External carotid artery by way of arteries of the face (angular and
temporal). Collateral circulation between these two is extensive.

Venous drainage
Into angular vein medially and into temporal vein laterally
Lymphatic Vessels-serving the medial portion of the eyelids drains into
the submandibular lymph nodes. The lateral portion drains into preauricu-
lar (superficial) nodes and into cervical (deeper) lymph nodes.

Nerve supply
Sensory supply in provided by the 1st and 2nd branches of the trigeminal
nerve (CN-V). Branches of the supraorbital nerve (V1) innervate the fore-
head and lateral periocular region. Branches of the maxillary nerve (V2)
innervate the lower eyelid and cheek.

The motor supply is provided from cranial nerve III and VII (Oculmotor
and Facial Nerves) and the sympathetic nerves.
 Diseases of the eyelids
Internal Hordeolum
It is a small abscess collection in the Meibomian glands, caused by staphylococcus

Signs
Tender, inflamed swelling within the tarsal plate

Treatment : Hot compresses, Incision and curettage, Topical antibiotics

External hordeolum /stye/

It is an acute small staphylococcal infection of a lash follicle
Symptoms :Painful, red a lid margin swelling of short duration
Signs: Tender inflamed swelling in the lid margin which points anterior
through the skin In severe cases a mild preseptal cellulitis may be present
Treatment : No treatment in most cases, styes frequently resolve
spontaneously or discharge interiorly.
Hot compression
Topical antibiotic - Chloramphenicol eye ointment.

Systemic antibiotic- Ampicillin 50mg/kg divided in four doses for 7 days

 Chalazion (Meibomian cyst)
It is a chronic lipogranulomatous inflammatory lesion caused by blockage of
meibomian gland orifices and stagnation of sebaceous secretion.
Patient with acne rosacea or seborhoeic dermatitis are at increased risk of cha-
lazion formation which may be multiple or recurrent. If is recurrent, one
should think of sebaceous gland Carcinoma.

Symptoms : Painless nodule within the tarsal plate very slowly

Treatment : Warm compression may reduce its size, Incision and Curettage

Molluscum contagiosum
Uncommon skin infection caused by poxvirus.
In immunocompromized patient, it is multiple, and resistant to treatment

Symptoms : Painless, raised, skin lesions.

Signs : Single or multiple, Pale, waxy and umblicated nodules
If the nodule is located on the lid margin, give rise to chronic follicular
conjunctivitis and occasionally a superficial keratitis
Treatment
Shave excision Expression,
Blepharitis is a general term for Blepharitis
inflammation of the eyelids
Can be associated with conjunctivitis called Blepharoconjunctivitis

Staphylococcal Blepharitis : Caused by staphylococcus aureus

Is ulcerative in type with redness of lid margins
with scales and easily pluckable lashes

Seborrhoeic Blepharitis : Is associated with seborrhea of the scalp,

brows and ears. It is non-ulcerative

Both types of patients presented with:- Irritation, Burning, Itching of

the lid margins, Eye discharge, easily plickable lashes
Treatment
Cleanliness of the scalp (shampoo)
Removal of scales from lid margin by cleaning with (Ether or baby sham-
poo)
Topical antibiotics for infections
Topical steroid --- for Seborrhoeic
Hot compresses and Systemic antibiotics like Doxycycline or Tetracycline
 Abnormality in the function and position of the eyelids

Facial nerve palsy

- Usually unilateral
- Patient complain watering of the eye and difficulty of closing the eyelids
- Failure to close the eyelid can lead exposure keratitis

Causes
Intracranial mass-tumors
Disease in the middle brain will affect the nerve in the facial canal
Bell's palsy follows URTI, because of the edemal of the nerve in the facial canal

Treatment
Partial or complete spontaneous recovery in 3-month time
Tear Substitutes for lubrication of the eye
Systemic Steroid-if the patient came with 3-5 days of onset

Surgical-Tarsorrhaphy to prevent exposure keratitis. It can be temporal or

permanent.
 Ectropion
Ectropion is eversion or out ward turning of the eyelid margin exposing some of
the tarsal conjunctiva
Classified as:
Congenital- present at birth
Involution--Aging
Paralytic -- Due to paralysis of the nerve supplying the lid
Cicatricial – Due to scarring
Mechanical- Due to mass effect
Two common types
Cicatrical Ectropion
Caused by scarring and contracture of eyelid skin
Occur after chronic skin infection or burn
Atonic Ectropion
Means lower eyelid is too lose to rest against the eyeball
Caused by senile stretching of the tissue or by facial palsy
Treatment
Local steroid and antibiotic-used to reduce inflammation in the exposed conjunc-
tiva; followed by surgical correction.
 Entropion
Entropion is inversion of the eyelid margin. It may be unilateral or bilateral
Classified as:
Congenital - present at birth
Acute spastic
Involution - Aging
Cicatricial -- Due to scarring
Two common types
Cicatrical entropion
Caused by scarring and contracture of the conjunctiva and tarsal plate following
trachoma
Senile / Atonic / Entropion
Occurs only in lower eyelid in old patients
Tarsal plate in weak, floppy and conjunctival tissue in the eyelids stretch.
Orbicularis oculi muscle contracts to close the eye, lower eyelid rolls in.
Treatment :- Surgical - correction like….

Bilamellar Tarsal Rotation (BTR) or Tarsotomy

Cryotherapy, Electrocautery, Eyelid splitting and Tarsal advance.
 Ptosis (Blepharoptosis)

Ptosis is drooping of the upper eyelid

Types of ptosis: Congenital or Acquired

Myogenic Ptosis
Aponeurotic ptosis
Neurogenic ptosis
Mechanical ptosis
Traumatic ptosis

Treatment: Surgical correction

 Lacrimal apparatus
Anatomy

Secretary Apparatus

Lacrimal gland : It is responsible for production of basic and reflex secretion

Krause and Wolfering responsible for production of basic secretion

Tear film - layers

Inner mucin layer - Produced by Goblet cells with in the conjunctiva

Intermediate aqueous layer- Produced by the main & accessory lacrimal glands
Outer lipid layer- Produced by meibomian glands

Excretory Apparatus
Superior and interior puncta
The canaliculi (each 8-10mm long) form common canaliculus
lacrimal sac (10mm).
Nasolacrimal duct opens to the inferior turbinate of the nose (12mm)
 Evaluation and management of a tearing patient

Congenital tearing

Constant tearing with minimal mucopurulence (surggestive of an upper

system block due to punctual or canalicular dysgenesis)

Constant tearing with frequent mucopurulence and matting of the lashes

(suggestive of a complete obstruction of the nasolacrimal duct)

Intermittent tearing with mucopurulence (suggestive of intermittent obstruction

of NLD)

Management
Topical antibirtics and massage, nasal decongestants in the 1st 6/12 of age
Probing after 6/12 and younger children
Silicone intubation for patients with recurrent epiphora.
Dacryocystorhinostony (DCR)
 Diseases of the lacrimal apparatus

Lacrimal gland
A. Dacryoadenitis - An inflammation of the lacrimal gland, can be caused by
bacterial infection, sarcoidosis, Tb, etc
Treatment : Antibiotics, Anti-inflammatory drugs (NSAID), Steroids
B. Lacrimal Gland tumors - Benign or malignant
Treatment - Surgical
Nasolacrimal passage obstruction: - Can occur at four sites
Punctum : Treatment - Surgical: probing or panctoplasty
Canaliculi : Treatment – Surgical probing with /without intubation
Common Canaliculus : Treatment -Surgical probing with/without intubations
Nasolacrimal duct
dacryocele or dacryocystocele if this accumulation in infected it is called
dacryocystitis
Treatment
Children - Duct will open spontaneously with in the first year, if not probing
under GA.
In adult - Surgical treatment- dacryocystorhinostomy (by- pass surgery)
Topical antibiotic and systemic antibiotic if infected
 ORBITAL CELLULITIS

 Orbital cellulitis is an
acute infection of
the tissues immedi-
ately surrounding
the eye, including
the eyelids, eyebrow,
and cheek
 DEFINITION
 PRESEPTAL CELLULITIS is  ORBITAL CELLULI-
an infection of the soft TIS is an infection of
tissue of the eyelids and the orbital soft tissue
periorbital structures posterior to the orbital
anterior to the orbital septum
septum
Imitators
 ORBITAL SEPTUM
 The orbital septum is a
layer of fascia extend-
ing vertically from the
periosteum of the or-
bital rim to the leava-
tor aponeurosis of the
upper lid and to the
tarsal plate of the
lower lid.
Anatomy
 PATHOGENISIS
 Localized eyelid infection
 Hordolea, chalazia, dacryocystitis
 Trauma

 Dental

 Sinusitis
PATHOPHYSIOLOGY

 results from microbial infection with subsequent

inflammation of the post-septal aspect of the eye-
lids
 most common routes of infection:
 adjacent sinuses or teeth
 direct inoculation through penetrating lid injury
 Common organisms include:
 Staphylococcus aureus
 Streptococcus pyogenes
 Streptococcus pneumoniae
 Haemophilus influenzae in children
 Classification Description

Group 1 Preseptal Erythema & edema of

eyelids, normal vision

Group 2 Orbital cellulits Diffuse edema of orbit,

No abscess

Group 3 Orbital cellulitis with Abscess adjacent to lam-

ina papyracea, proptosis,
subperiostal abscess
change in vision, pain on
eye movement

Group 4 Orbital cellulitis with Proptosis, limited mobil-

ity, loss of vision
abscess in orbital fat

Group 5 Cavernous sinus Bilateral disease

thrombosis
 COMPARISON
Features Orbital Cellulitis Preseptal Cellulitis

Proptosis Yes No

Motility Limited No

Vision Decreased No

Chemosis Yes Infrequent

Source Sinusitis U.R.I.

SIGNS AND SYMPTOMS

 History of upper respiratory tract infection with or

without nasal discharge may be present
 swelling and redness of the eyelid and surrounding soft
tissues
 conjunctival hyperemia
 decreased ocular motility
 pain with eye movements
 decreased visual acuity
 proptosis caused by orbital swelling
 fever, malaise, and headache (should raise suspicion of
associated meningitis)
 afferent pupil defect
Complications of Orbital Celluli-
tis
 Intracranial 4%
Meningitis 2%
Cavernous sinus thrombosis 1%
Brain, Subdural and Epidural abscess 1%
 Orbital abscess 9%
Subperiosteal abscess 7%
Orbital abscess 2%
 Vision loss 1%
ORBITAL CELLULITIS
Proptosis &Chemosis
Motility
M. catarrhalis Strep & Staph

Anaerobes

H Flu
MRSA
 Maxillary Ethmoid Frontal Sphenoid

Acute Acute Acute Acute

Aerobic chronic chronic chronic chronic
S aureus 4% 14% 15% 24% - 15% 56% 14%
S pneumoniae 31 6 35 6 33 - 6 -
H influenza 21 5 27 6 40 15 12 14
M catarrhalis 8 6 8 - 20 15 -
Enterobactiacea 7 6 - 47 - 8 - 28
P aeruginosa 2 3 - 6 - 8 6 14

Anaerobic
Peptostreptoc-
cus 2 56 15 59 3 38 19 57
P acnes - 29 12 18 3 8 12 29
Fusobacterium 2 17 4 47 3 31 6 54
Prevotella 2 47 8 82 62 6 6 86
B fragilis 6 - - - 15 - -
ORBITAL CELLULITIS
TREATMENT IV UNASYN
 REFERENCES
 Ophthalmology a pocketbook book of atlas 2nd Ed. ( G. Lang)

 OPHTHALMOLOGY 1st ed. By Dr. J.H. Fowler

 Harrison’s principles of internal medicine 18th ed.

 Uptodate 19.3