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Lids, Lacrimal apparatus and Orbit Dr. Yasser Al-Fakey M.D., M.Sc (Ophth.), FRCS Lash Disorders Trichiasis: primary (metaplastic lashes and distichiasis) or secondary (entropion). Madarosis: local or systemic. Poliosis: Local (blepharitis) or systemic (VKH). Allergic Disorders Acute allergic edema: insect bit, angioedema or urticaria. Unilateral or bilateral painless and pitting edema. Contact dermatitis: Sensitivity to topical medications. Xanthelasma Elderly people or those with hypercholesterolemia. Cholesterol and lipid subcutaneous plaques. Treatment: surgical excision or CO2 laser evaporation. INFECTIONS Blepharitis. Hordeolum: 1) Externum (Stye) 2) Internum (Acute chalazion) Viral infections. Trachoma. Blepharitis Anterior, posterior or mixed. Symptoms: burning, grittiness, mild photophobia, crusting and redness of lid margin. Signs: lid margin (hyperemia, telangiectasia and tiny abscesses) scales and lashes (greasy and stuck together). Complications: Stye, Tear film instability, Hypersensitivity to staph. toxins, trichiasis, madarosis and poliosis. Treatment: 1) Lid hygiene 2) Antibiotic ointment 3) Systemic tetracycline 4) Lubricants 5) Weak topical steroid. External Hordeolum (Stye) Acute staph. infection of hair follicles and associated glands. Signs Mild preseptal cellulitis. Treatment: Hot compresses, Epilation, Topical antibiotics and even systemic if associated with preseptal cellulitis. Internal Hordeolum (Acute Chalazion) Acute staph. infection of meibomian gland. Signs: tender inflamed swelling within the tarsal plate. It may discharge anteriorly through the skin or posteriorly through the conjunctiva. Treatment: Control of infection then curettage if residual mass. Chalazion (Meibomian cyst) Chronic lipogranulomatous inflammation caused by obstruction of the gland orifice. Most common lid mass. Symptoms Signs D.D. of recurrent chalazion Treatment: 1) Surgery 2) Steroid injection Viral infections Herpes simplex: Primary herpes simplex, usually affects children, crops of small vesicles with mild edema and may be associated with viral keratoconjunctivitis. Treatment with acyclovir Herpes Zoster Ophthalmicus Unilateral condition, usually affect elderly people. Vesicles, pustules and crusting ulceration. Hutchinson sign Treatment: systemic and topical acyclovir Chlamydial Conjunctivitis Adult Chlamydial Keratoconjunctivitis: -Sexually transmitted disease (50% associated with genital infection) caused by serotypes D to K. -Subacute onset, unilateral or bilateral mucopurulent discharge. -Follicular conj. Reaction and corneal involvement is uncommon. -Non-tender lymphadenopathy. -Treatment: Topical tetracycline Systemic tetracycline, deoxycycline or recently azithromycin. Trachoma Infection caused by Chlamydia trachomatis (serotypes A, B, Ba & C). Obligate intracellular bacteria. The common fly is a major vector in the transmission of the disease. It is the leading cause of preventable blindness allover the world. Symptoms: During childhood with redness, and mucopurulent discharge. Signs: – follicular conjunctivitis. – Limbal follicles. – Keratitis. Lab. Investigations: 1) Direct monoclonal fluorescent antibody microscopy 2) ELISA 3) Polymerase chain reaction (PCR) 4) Giemsa stain (inclusion bodies) Complications: – Progressive conjunctival scaring (Arlt line, PTDs and entropion). – Herbert pits. – Corneal pannus. WHO grading: TF = trachomatous follicles. TI = trachomatous inflammation. TS = trachomatous scar. TT = trachomatous trichiasis. CO = corneal opacity. ENTROPION Types: 1. Involutional 2. Cicatricial 3. Spastic 4. Congenital Complications Treatment ECTROPION Types: 1. Involutional 2. Cicatricial 3. Paralytic 4. Mechanical Complications Treatment LID TUMORS Benign: Naevus, Capillary haemangioma, Port-wine Malignant: BCC, SCC, SGC and Melanoma. stain …etc PTOSIS Drooping of the Pseudoptosis Classification: 1. 2. 3. 4. upper lid. Neurogenic Myogenic Aponeurotic Mechanical Clinical Evaluation History: Age of onset, Trauma, Previous surgery and Diurnal variations. Exclusion of Pseudoptosis. Associated signs. EOM movements, Bell’s phenomenon, Increased innervations, Fatigability and Jaw-winking. Measurements: PFH, MRD 1, MRD 2, Levator function and lid crease. Management Preferable age for Type of surgery surgical correction? 1. Levator Resection 2. Frontalis Suspension 3. Mullerectomy Postop. Complications and patient expectation. LACRIMAL APPARATUS Excessive Watering Lacrimation: reflex over-production of tears. Epiphora: mechanical obstruction of tear drainage. Lacrimal pump failure. Examination of Lacrimal System The eyelids. The dynamics of eyelid closure. The puncta. The marginal tear strip. The lacrimal sac. Dye Disappearance Test. Probing and irrigation. Jones dye test Radiography Congenital Nasolacrimal Duct Obstruction Symptoms Signs DDT Complications Management: Massage Probing Probing + Stent DCR Infections of The Lacrimal Passages Acute dacryocystitis: Symptoms Signs Complications Treatment: Systemic antibiotics Stab incision DCR Chronic Dacryocystitis: Symptoms: epiphora + mucopurulent discharge Signs: painless swelling +ve regurgitation test probing and irrigation Treatment: DCR Dry Eye Symptoms Signs: Tear stain. Treatment: meniscus, Tear BUT test, Schirmer test, SPK and Rose Bengal Preservation of tear Lubricants Punctal plugs Permanent occlusion Orbital Diseases Inflammatory: Orbital cellulites DD preseptal cellulites (proptosis and limitation of EOM) Treatment: admition, Iv antibiotics, CT-scan and fever chart. Graves Ophthalmopathy Most common cause of unilateral or bilateral proptosis Symptoms (active and inactive) Signs Treatment Orbital Blow-out fracture Symptoms Signs Indications for treatment Tumors Metastatic tumor Lymphoma Rhabdomyosarcoma