Download Basic Clin Sci Course [Sec. 7] Orbit, Eyelids, Lacrimal Syst. - C. Mack, D. Mack (Amer Acad Opthal., 2011) WW PDF

TitleBasic Clin Sci Course [Sec. 7] Orbit, Eyelids, Lacrimal Syst. - C. Mack, D. Mack (Amer Acad Opthal., 2011) WW
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Table of Contents
1. Orbital Anatomy
2. Evaluation of Orbital Disorders
3. Congenital Orbital Anomalies
4. Orbital Inflammatory andInfectious Disorders
5. Orbital Neoplasms andMalformations
6. Orbital Trauma
7. Orbital Surgery
8. The Anophthalmic Socket
9. Facial and Eyelid Anatomy
10. Classification and Management ofEyelid Disorders
11. Periocular Malpositions andInvolutional Changes
12. Development, Anatomy, andPhysiology of the LacrimalSecretory and Drainage Systems
13. Abnormalities of the LacrimalSecretory and Drainage Systems
Related Academy Materials
Study Questions
Answer Sheet for Section 7Study Questions
Document Text Contents
Page 1

Orbit, Eyelids, and

Lacrimal System

Page 2

Orbit, Eyelids, and
Lacrimal System

Section 7



The Eye M.D. Association



Page 159

CHAPTER 10: Classification and M anagement of Eyelid Disorders. 155

palpebral conjunctiva to rub against the pillow or bedding. Initial conservative treatment
using viscous lubricat ion and a patch or eyel id shield at night is helpful. Frequently. surgi-
cal correction by horizontal tightening of the eyelid is indicated. Sleep studies are recom-
mended to ru le out sleep apnea.

Eyelid hnbrication syndrorrle occurs \"hen a lax upper eyelid with normal tarsal plate
overrides the lower eyelid margin during closure. This results in chron ic conjunctivitis.
Management consists of topical lubrication in mUd cases. In more severe cases, horizontal
tightening of the upper eyelid is indicated.

Ezra DG, Beaconsfield M, Si ra M, et al. Long-term outcomes of surgical approaches to the
treatment of floppy eyelid syndrome. Ophthalmology. 20 10; 117(4) :839-846.

Karesh J W, Nirankari VS, Hameroff 5B. Eyelid imbrication: an unrecognized cause of chronic
ocular irritation. Ophthalmology. 1993;100(6}:883- 889.


Trichotil.lomania is an impulse control disorder most common ly seen in preteen or teen-
age girls. It is characterized by the repeated desire to pull out hairs. frequently eyebrows
or eyelashes. Diagnosis may be elusive. as affected patients usually deny the cause. Char-
ac teris ticall y. multiple hairs are broken off and regrowing at d ifferent lengths. Applying
ophthalmic ointment to the affected area sometimes helps diagnosis and treatment by
allOWing hairs to regrow. Habit reversal therapy or oral treatment with selective sero-
tonin reuptake inhibitors may be effective, as employed in the treatment of obsessive-
compulsive behavior.

EVelid Neoplasms

Nu merous be nign and malignant cutaneous neoplasms can develop in the periocular
ski n, arising from the epidermis, dermis, or eyelid adnexal structures. Most lesions,
whether benign or malignant. develop from the epidermis. th e rapidly growing superfi-
ciallayer of the skin. Although many of these lesions may occur elsewhere on the body.
their appearance and behavior in the eyelids may be unique owing to the particular char-
acteristics of eyelid skin and the specialized adnexal elements. The malignant lesions
most frequently affecting the eyelids are basal cell carcinoma. squamous cell carci noma.
sebaceous cell carcinoma, and melanoma. Because clinical judgment is not as exact as
pathologic diagnosis. hi stologic examinat ion of suspected cutaneous malignanCies is gen-
erally recommended.

Clinical Evaluation of Eyelid Tumors

The history and physical examination of eyelid lesions offer important clues regarding the
li keli hood of malignancy. Predisposing factors in the development of skin cancer include

a history of prior skin cancer
excessive su n exposure, especially bl istering sunburn during adolescence
previolls radiation therapy

Page 160

156 • Orbit, Eyelids, and Lacrimal System

history of smoking
Celtic or Scandinavian ancestry. with fair skin, red hah. blue eyes

Signs suggesting eyelid malignancy are

• slow, painless growth of a lesion
ulceration, with intermittent dra inage. bleeding, and crusting

irregular pigmentary changes
destructio n of no rmal eyelid margin architecture (especia lly meihom ian o rifices)
and loss of cilia
heaped-up, pearly, translucent margins with cen tral ulceration

fine telangiectasias
loss of fine cutaneous wrin kles

Palpable induration extending well beyond visibly apparent margins suggests tumor
infiltration into the dermis and subcutaneous tissue.

Lesions near the puncta should be evaluated for puncta! or canalicu lar involvement.
Probing and irrigation may be required to exclude lacrimal system involvement o r to pre-

pare for surgical resection .
Large lesions should be palpated for evidence offixation to deeper tissues or bone. In

addition, regional lymph nodes should be palpated for evidence of metastases in cases of
suspected squamous cell carcinoma, sebaceous carcinoma, melanoma, or Merkel cell car-

cinoma. Lymphatic tumor spread may produce rubbery swelling along the line of the jaw
or in front of the ear. Restriction of ocular motility and proptosis suggest orbital extension
of an eyelid malignancy. The fun ction of cranial nerves VII and V is assessed so that any
deficiencies possibly indicating perineural tumor spread can be detected. Perineural inva-
sion is a feature of squamous ce ll carcinoma. Systemic evidence of liver, pulmonary, bone,
or neurological involvement sho uld be sought in cases of sebaceous adenocarcinoma or

melanoma of the eyelid.
I! is important to obtain photographs prior to treat ment of the lesion. If photographs

cannot be obtained, drawings and measurements are recorded for future comparison.

The following discussions of eyelid neoplas ms are intended to proVide a brief over-
view of the most prevalent lesions. For more extensive coverage and add itional clinical
and pathologic photographs, see BeSe Section 4, Ophthalmic Pathology alld Intraocular

Cook BE Jr, Bartley GB. Ep idem iologic characteri stics and cl inical course of patients with ma-
lignant eyel id tumors in an incidence cohort in Olmsted County, Minnesota. Ophthalmol-
ogy. 1999; 106(4)]46- 750 .

de la Garza AG. Kersten RC, Carter KD. Evaluation and treatment of benign eyelid les ions.
Focal Points: Clinical Modules for Ophthalmologists. San Francisco: American Academy of
Ophthalmology; 20 I 0, module 5.

Page 317

322 • Index

Ulcerative basa l cell carcinoma. 1691 See also Basal cell

Uhrasonography/ullraSQund, in orbital evaluation,

Ultraviolet light (ultraviolet radiation)
actinic keratosis and. 166, 167/
basal cell cucinOlll3 and, 168
lentigines and, 165
melanoma and, 175

UnifocaJ eosi nophilic granu loma of bone, 84
Upgaze, diso rders/limitation of

in blowout fractures, 100- 10\
surgery and, 102

monocular deficiency (double elevator palsy) and. 205
Upper eyelid. See Eyelids, upper

Valve of Hasner, 245f. 246
nasolacrimal duct obstruction and, 243, 246, 250 .

Valve of Rosenmiiller, 245
Varices, orbital, 66-6i
Vascular malformations, orbital, 63-69
Vascular system

of eyelids, 143
of orb ii , 12- 13, 13f. 14f. IS!

Vascular tUlllors. of orbit, 63-69
Vasculitis. See IIlso specific Iype lind Arteritis

connective tissue disorders associated with, 58
giant cell (temporal) arteritis, 55-56
orbital manifestations of, 391, 55-58, 571

Venography, in orbital evaluation, 31
Venous malformations (varices), orbital, 66-67
Verrucae (warts), vulgaris, of eyelid, 158, 1581
Vertical diplopia, in blowout fractures, 100-101

surgery and, 102
Vert ical eyelid splitting, for orbitotomy, I08f, 109
Vertical interpalpebral fi ssure height, in ptosis, 202, 2021
Vertical reclUS muscles, surgery of, eyelid position

changes after, 214
Vistl:;ll :;lcuity. See (llso Visuallosslimp:;lirment

periocular trauma and, 104- 106
in ptosis, 203

Visual field testi ng, in ptosis, 204

after blepharoplasty, 226
in blowout fractures. 10 1
in meningioma. 74
after orbital surger)', 116
in ptosis, 201, 203-204
in th)' roid eye disease, 51
traumatic, with clear media, 104-106

von Graefe sign, 24
von Recklinghausen disease. See Neurofibromatosis,

von Rccklinghausen (type I)

Warts (verrucae), of eyelid, 158. 1581
Wegener granulomatosis. 32, 56-58, 571
White-eyed blowout fracture, 100
Whitnaliligament (superior transverse ligilment ), USf,

138, 139f, 244
Wbitnalltubercle, 6, 6f, 7/
Wolfring, glands of, 135f, 141 ,244
Worm's-eye view pOSition, 23, 241

Xanthelasma, of eyelid. 160, 1601
Xanthogranuloma, of orbit, 85
Xeomin (incobotulinumtoxinA). See Botulinum toxin,

type A
Xeroderma pigmentosum, 168
Xylocaine. See Lidocai ne

for blepharophimosis syndrome, 145
for epicanthus, 148

Z- plasties
for blepharophimosis syndrome, 145
for epicanthus, 148
for eyelid repair, 180
for symblepharon, 199

Zeis, glands of, 142f, 160
hordeolum caused by infeClion of, 154
sebaceous adenocarcinoma arising in, 173

Zin n, annulus of. II, 121
ZMC fractures. Sec Zygomaticomaxilla ry complex

(ZMC) fractu res
Zygomatic bone, 6f, 71

fractures of. 95-97. 971
Zygomatic nerve, 133, 134/

in renex tear arc, 244
Zygomati cofacial canal, 9
Zygoma ti cofacial foramen, 6/
Zygomalicomaxillary complex (ZMC) fractures (tri pod

fractures), 95- 97, 971
Zygomaticotemporal canal, 6f, 9
Zygomaticotemporal nerve, in reflex tCar arc, 244
Zygomaticus muscles, 13\ , 1331
Zygomycetes (zygomycosis/mucormycosisl

phycomycosis). orbit involved in , 45- 46
exenteration in management of, 45.126

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Item No. 02800071

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