Di seases of the Eyelids and Orbita Yrd. Doç. Dr.İlke Bahçeci Şimşek

1. Diseases of the Eyelids and OrbitaYrd. Doç. Dr.İlke Bahçeci Şimşek Yeditepe University Department of Ophthalmology 2016-2017 Educational Year

2. Benign Lesions of the Eyelids Chalazion • Caused by blockage of meibomian gland orifices • Stagnation of sebaceous secretions causes a chronic inflammation

3. Benign Lesions of the Eyelids Chalazion • Painless, round and firm lesion in the tarsal plate • Initial conservative treatment with warm compresses • Surgery for large persistent lesions causing astigmatism or cosmetically unacceptable

4. Benign Lesions of the Eyelids Hordeolum (Stye) • Acute Staphylococcal infection of a lash follicle • Tender inflamed swelling in the lid margin pointing anteriorly • Warm compresses and antibiotic ointments • In severe cases there may be preseptal cellulitis necessitating oral antibiotics

5. Benign Eyelid Lesions Xanthelasma • Commonly over medial canthal areas • Lipid laden macrophages accumulate in dermal tissues • Sometimes associated with disorders of lipid metabolism • Surgical excision for cosmetic reasons

6. Malpositions of the Eyelids Entropion • Inversion of the eyelid

7. epiblepharon

8. Malpositions of the Eyelids Entropion • 4 main types • Involutional (senile) • Cicatricial • Congenital • Spastic • Treatment is surgical

9. Malpositions of the Eyelids Ectropion • Outward turning of the eyelid • 4 main types • Involutional (senile) • Cicatricial • Congenital • Paralytic • Treatment is surgical

10. Malpositions of the Eyelids Ptosis

11. Malpositions of the Eyelids Ptosis • Drooping of the upper eyelid • 4 main types according to etiology Myogenic due to congenital or acquired myopathy (e.g. myasthenia) Aponeurotic due to dehiscence of levator aponeurosis (senile, trauma, surgery) Neurogenic due to innervational deficit (e.g. third nerve palsy, Horner`s syndrome, Marcus Gunn Jaw-winking) Mechanical ptosis due to mass or scarring

14. Malpositions of the Eyelids Ptosis Mechanical due totumor on the eyelid • Treatment is surgical • Surgery as soon as possible if congenital ptosis is obscuring the visual axis

15. Disorders of the Eyelashes

16. Disorders of the Eyelashes Trichiasis • Acquired posterior misdirection of previously normal eyelashes • Caused by chronic inflammation of the eyelids in trachoma or chronic blepharitis • Causes corneal irritation, ulceration Distichiasis • A second row of eyelashes growing behind the normal eyelash-line • Congenital condition • Acquired

17. Tumors of the Eyelids Signs Suggesting Malignancy • Slow painless growth • Ulceration, bleeding, crusting • İrregular pigmentary changes • Distortion of the eyelid margin architecture • Telangiectasias • Loss of cilia

18. Tumors of the Eyelids Basal Cell Carcinoma • Most common human malignancy • 10% involve the eyelids • Mostly arises on the lower lid • Slow growing, locally invasive, non-metastasizing • Treatment with surgical excision followed by reconstruction

19. Tumors of the Eyelids Squamous Cell Carcinoma

20. Tumors of the Eyelids Squamous Cell Carcinoma • 5-10% of eyelid malignancies • Mostly on lower lid • May arise de novo or from precancerous dermatosis • Fair complexion and chronic sun exposure • Has potential to metastasize to regional lymph nodes

21. Tumors of the Eyelids Sebaceous Gland Carcinoma Malignant Melanoma

22. Tumors of the Eyelids Sebaceous Gland Carcinoma • Arises from sebaceous glands • Metastasize to regional nodes, lungs, liver or brain • 10% mortality rate Malignant Melanoma • Rare but potentially lethal

23. Disorders of the Orbit Thyroid Orbitopathy • Seen in ~30% of patients with Grave’s disease • 90% of orbitopathy cases seen in Grave`s disease, rarely in hypothyroidism or in euthyroid patients • Orbital tissue changes caused by autoimmune stimuli can be seen before, simultaneously or after hormonal thyroid disease • Severity varies greatly from very mild changes to blindness • Initial inflammatory stage with active changes ends in 2-3 years followed by quiescent stage • Incidence and severity of orbitopathy is higher in smokers

24. Disorders of the Orbit Thyroid Orbitopathy

25. Disorders of the Orbit Thyroid Orbitopathy

26. Disorders of the Orbit Thyroid Orbitopathy Clinical Signs • Eyelid retraction (also lid-lag and frightened appearance) • Proptosis (most common cause of proptosis in adults) • Restrictive myopathy (muscle fibrosis causes restricted ocular motility hence diplopia) • Soft tissue involvement • Lagophtalmos and dry eyes • Compressive optic neuropathy (compression of the optic nerve at the orbital apex by enlarged muscles may require emergency treatment with steroids, radiation or surgical decompression)

27. Disorders of the Orbit Thyroid Orbitopathy Treatment In active inflammatory disease • Supportive treatment (artificial tears) and regular follow-up • Emergency eyelid surgery if corneal problems threaten vision • Steroids, radiotherapy or emergency orbital decompression surgery if compressive optic neuropathy present In inactive disease • Strabismus surgery for diplopia • Eyelid surgery to repair lid retraction

28. Infections of the Orbit Preseptal Cellulitis • Bacterial infection of the soft tissues anterior to the orbital septum

29. Infections of the Orbit Preseptal Cellulitis Symptoms & Signs • Periorbital swelling and tenderness • Normal ocular motility Treatment • Oral antibiotics

30. Infections of the Orbit Orbital Cellulitis • Bacterial or fungal infection of the soft tissues behind the orbital septum Etiology • Spread of infections to orbita from adjacent structures (sinusitis, dacryocystitis or facial infection) • Following injuries penetrating orbital septum or eye surgery

31. Infections of the Orbit Orbital Cellulitis Symptoms &Signs Proptosis and painful eye movements with diplopia Optic nerve dysfunction Ocular Complications: central retinal artery or vein occlusion , endophthalmitis , optic neuropathy,

32. Infections of the Orbit Orbital Cellulitis Work-up • White cell count • CT of the orbit & brain (to rule out complications) Complications • Intracranial spread ( meningitis, cavernous sinus thrombosis) • Abscess formation ( orbital, subperiosteal, brain)

33. Infections of the Orbit Orbital Cellulitis Treatment • Parenteral broad spectrum antibiotics (polymicrobial infection) in the hospital • Surgical drainage of the orbital or subperiosteal abscess may be needed

34. Inflammations of the Orbit Idioptahic Orbital Inflammatory Disease - IOID Orbital Pseudotumor • Idiopathic, non-specific inflammation involving an or all of the soft tissue components of the orbit • Myositis • Dacryoadenitis • Scleritis • Optic perineuritis Symptoms & Signs • Painful proptosis • Lid edema and conjuntival inflammation • Limitation of ocular motility • May mimic orbital cellulitis

35. Inflammations of the Orbit Orbital Pseudotumor Treatment • Biopsy • NSAIDs and Steroids • Radiotherapy if unresponsive to steroids • Immunosupressives for resistant cases

36. Inflammations of the Orbit Orbital Myositis • Idiopathic orbital inflammation only involves one or more extraocular muscles Tolosa-Hunt syndrome • Non-specific granulomatous inflammation of the cavernous sinus • Periorbital pain, proptosis and cranial nerve palsies • Systemic steroids

37. Tumors of the Orbit Classification • Vascular • Lacrimal gland • Lymphoproliferative • Cystic • Neural • Rhabdomyosarcoma • Metastatic or invasion from adjacent structures

38. Tumors of the Orbit Vascular Tumors • Capillary Hemangioma • Most common orbital and periorbital tumor in children • Periocular swelling may increase in size during crying • Tumor grows during the first year of life then starts to regress • In 75 % of cases complete resolution seen by age 7 • Intralesional steroid injection, systemic steroids, systemic betablockers or surgical resection if tumor causes visual impairment

39. Tumors of the Orbit Capillary Hemangioma

40. Tumors of the Orbit Vascular Tumors • Cavernous Hemangioma • Most common benign orbital tumor in adults • Causes slowly progressive proptosis • Surgical resection • Lymphangioma • Orbital varices

41. Tumors of the Orbit Lacrimal Gland Tumors Pleomorphic adenoma (Benign mixed cell tumor) • Most common epithelial tumor • Treatment requires surgical excision • Incomplete excision may lead to malignant transformation Malignant lacrimal gland tumors • Pleomorphic adenocarcinoma • Adenoid cystic carcinoma • Mucoepidermoid carcinoma Malignant tumors require radical surgical treatment with orbital exenteration followed by radiotherapy

42. Tumors of the Orbit Lymphoproliferative Disorders • May involve any part of the orbit but sometimes confined to conjunctiva or lacrimal gland • Systemic investigation needed to rule out systemic disease Treatment • Radiotherapy for local disease • Chemotherapy for systemic disease

43. Tumors of the Orbit Rhabdomyosarcoma • Most common primary malignant orbital tumor in children • Presents with rapidly progressive proptosis • Examination shows orbital mass • CT shows poorly defined mass of homogenous density often with bony destruction • Diagnosis requires biopsy • Systemic work-up needed to rule out metastasis • Treatment by high dose local radiotherapy followed bychemotherapy • 90% survival when tumor is confined to the orbit

44. Tumors of the Orbit Cystic Lesions Dermoid Cyst • Benign cystic teratoma with a fibrous wall which contains dermal appendages • Superficial dermoid cysts present in infancy as an upper temporal or upper nasal round lesion • Deep dermoids present later in life • Treatment with surgical excision Mucocele • Arises in the sinuses and invades the orbita after eroding the orbital walls Blood cyst • Rare, may be associated with blunt trauma or vascular lesions of the orbit

45. Tumors of the Orbit Dermoid Cyst

46. Tumors of the Orbit Neural Tumors Optic Nerve Glioma • Slow growing tumor • May be associated with Neurofibromatosis type I • Fusiform enlargement of the optic nerve • Observation if vision is good • Surgical excision if vision is poor and proptosis is prominent Optic Nerve Sheath Meningioma • Arises from the meningeal covering of the optic nerve • Causes slowly progressive visual loss

47. Tumors of the Orbit Metastatic In children • Neuroblastoma, Ewing`s sarcoma, Acute Myeloid Leukemia In Adults • Breast carcinoma, Lung carcinoma, Prostate carcinoma Treatment is radiotherapy and chemotherapy Tumor invasion from adjacent structures • Maxillary sinus ca, Ethmoidal sinus ca, Nasopharyngeal ca

48. Blow-out Fractures of the Orbit • Caused by sudden increase in the orbital pressure • Most frequently orbital floor is fractured

49. Blow-out Fractures of the Orbit

50. Blow-out Fractures of the Orbit Symptoms & Signs • Periocular ecchymosis and edema • Enophthalmos • Infraorbital nerve anesthesia • Diplopia (entrapment of the orbital tissues) Work-up • CT • Hess test Treatment • Conservative treatment with antibiotics initially • If diplopia persists surgical repair is done