Lids, Lacrimal, Orbital

Eye Lid

Chalazion

• Shape: Chalazoin
• Pathology: Inflammatory granuloma of myopyopoin gland
• Site: Mypoypoian glands

Incision of chalazion (extensional biopsy)

if >60 recurrent, do excision to exclude malignancy

Chalazion forceps used in Chalazion surgery (excision)

Infected Chalazion (internal hordeolum)Y

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Stye (External hordeolum)

• Cause: Staphylococcus infection of Zeis glands
• Treatment: Remove affected eyelashes

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Stye

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Xanthelasma

• Cause: Due hyperlipidemia
• Treatment: Cosmetic (Blephroplasty)

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Dermoid Cyst

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Left/Right Orbital Cellulitis

Can be from Paranasal sinusitis

Common cause:

• Sinusitis

Complications:

• Brain Abscess
• Infection spread to brain
• Cavernous Sinus Thrombosis
• vision loss
• Subperiosteal or Orbital Abscess

Investigations: (to exclude orbital causes - tumors, abscess…)

• CT with contrast
• • MRI (may be used if CT is inconclusive, or to better evaluate soft tissues/brain involvement).

Treatment:

• Admission
• Systemic intravenous antibiotic + topical antibiotic

Feature	Preseptal Cellulitis	Orbital Cellulitis
Location	Infection of eyelid/anterior eyelid tissues, anterior to the orbital septum	Infection of orbital fat and ocular muscles, posterior to the septum
Eyelid swelling/erythema	Yes	Yes
Tenderness	Mild–moderate	Moderate–severe
Ocular pain	Often, but no pain with eye movement	Worse on eye movement
Eye movements (motility)	Full range	Restricted
Proptosis	No	Yes
Vision changes	No	May have ↓ visual acuity / RAPD
Systemic signs	May have low-grade fever	Frequently fever, malaise
Skin warmth	May feel warm	Often hot to touch

1. Preseptal Cellulitis:

2. Orbital Cellulitis (Postseptal Cellulitis):

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Lid retraction

Cause: Thyroid eye disease

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Dermatochalasis

Cause: Aging, loss of orbital fatty support - psuedoptosis

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tarsal cyst

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Ptosis

• Simple congenital ptosis:

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• Sign: Ptosis with myosis;

  • Diagnosis: horners syndrome -
  • Affected muscle: Müller’s muscle

• Divergent/Exotropia Ptosis: 3rd nerve palsy

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Marcus Gunn phenomenon

Misdirection between 3rd and 5th nerves

• Marcus Gunn Jaw-Winking Phenomenon

• This is a form of congenital ptosis characterized by synkinesis: an abnormal neurological connection between the Trigeminal Nerve (CN V), specifically branches innervating the pterygoid muscles (jaw movement), and the branch of the Oculomotor Nerve (CN III) innervating the Levator Palpebrae Superioris muscle.

• The ptotic eyelid retracts (lifts up) when the patient moves their jaw (e.g., chewing, sucking, opening mouth, moving jaw side-to-side).

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Muscles (MS) Elevating Upper Eyelid:

• Levator Palpebrae Superioris: Innervated by the Oculomotor Nerve (CN III). This is the primary elevator of the upper eyelid.

• Müller’s muscle (Superior Tarsal Muscle): Innervated by the Sympathetic nervous system. This provides minor (approx. 1-2 mm) eyelid elevation. - Correction: Spelling is Müller’s.

• Frontalis muscle: Innervated by the Facial Nerve (CN VII). This muscle primarily raises the eyebrows. Raising the eyebrows indirectly helps lift the eyelids, especially when compensating for ptosis. It is considered an accessory muscle for eyelid elevation, not a direct elevator like the Levator or Müller’s muscle.

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Anisocoria – Horner’s Syndrome Acquired

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Anisocoria – Horner’s Syndrome Congenital

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Ptosis, chin elevation - Bilateral severe ptosis

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Bilateral Ptosis of myasthenia gravis

appears more severe at end of day, normal when waking up

Finding: ptosis both eyes

Complications squint, diplopia, eye fatigue

betablockers make em worse

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Partial ptosis

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Total Ptosis

MR affected - 3rd nerve palsy

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Proptosis

Cause:

• Thyroid eye disease common in adults
• Orbital Cellulitis & Benign Cystic Lesions in children

Investigation: (to exclude orbital tumor)

• CT
• MRI

Differential diagnosis

• Trauma (retrobulbar hemorrhage)

• Orbital inflammatory pseudotumor

• Orbital infectious cellulitis

• Orbital tumors (benign or malignant)

• Lacrimal gland tumors

• Carotid-cavernous fistula

• Orbital varix

• Orbital pseudotumor, orbital cellulitis, cavernous sinus thrombosis, intraorbital neoplasm

For Orbital Tumours most common Retinoblastoma never cause proptosis in children. In children, proptosis can be due to rhabdomyosarcoma (malignant), benign orbital cellulitis. In adults, causes include thyroid eye disease and cavernous hemangioma.Z

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Exophthalmos

Proptosis + Lid retraction First sign is lid retraction

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Floor Fractures

Orbital Fractures

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Molluscum contagiosum.Y

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Herpes zoster ophthalmicus

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Anterior Blepharitis (infection of lid margin)

Causative Organism Staphylococcus

Posterior Blepharitis (infection of lid margin)

Name the condition: Posterior or anterior Blepharitis What organism: Staphylcoccus aureus Treatment:

1. Lid Hygiene: (Cornerstone)

   • Warm compresses
   • Lid massage
   • Lid cleaning/scrubs

2. *Topical Medications:

   • Antibiotics (to reduce bacteria)
   • Steroids (short-term, for inflammation)
   • Artificial tears (especially lipid-based)

3. *Oral Medications: (For persistent/severe cases)

   • Tetracyclines (e.g., Doxycycline) or Azithromycin (anti-inflammatory effects)

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Squamous cell carcinomaY

Disease of Lashes

Trichiasis

• Rubbing lashes
• Complication: Corneal irritation, Corneal ulcers
• Treatment: 1- simple removal (however recurrent) 2- cryo or laser therapies 3- surgery in some selective cases

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Poliosis

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Madarosis

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Senile ectropion

• Complications: Dryness

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Paralytic ectropion

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Cicatricial ectropion

Most Common Complication Severe dryness

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Senile entropion

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Cicatricial entropion

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Lacrimal Presentation

Dacryocystitis

located Away from eyelid margin what’s the appropriate treatment? DCR

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Nasolacrimal Duct System

Classification of Nasolacrimal Duct Obstruction

• Congenital NLD obstruction.
• Acquired NLD obstruction.

Examination of Lacrimal System

• The eyelids contour and position.
• The dynamics of eyelid closure.
• The puncta size and position.
• The lacrimal sac swelling and presence of regurgitation on pressing on the sac.
• Irrigation of the NLS.

Congenital Nasolacrimal Duct Obstruction

• Symptoms
• Signs
• Dye Disappearance Test.
• Management:
  • Massage of the lacrimal sac.
  • Topical antibiotics.
  • Probing and syringing ± stenting after the age of 1 year.

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Obstruction in the nasolacrimal system Dacryocystorhinostomy

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Eyelid Trauma

• Types

  • Blunt
  • Sharp/penetrating

• Classification

  • Lid margin
    • Not involved
    • Involved*
  • Canthal involved*
  • Canalicula involved*

Call ophthalmology

Globe Rupture or Laceration

• Stop examination.
• Keep NPO.
• Shield the eye.
• Give tetanus prophylaxis.
• Refer immediately to Ophthalmologist.

Lid Margin Sparing

• Skin and orbicularis only → skin sutures
• Fat protrusion = septum violated
  • Make sure the levator muscle and globe are not involved.