EYELIDS AND ORBIT

EYELIDS AND ORBIT

Anatomy of Eyelids

• Eyelids are divided by the ‘Grey line’ into:
• Anterior laminae:
• Skin
• Subcutaneous tissue
• Muscles
• Posterior laminae:
• Tarsal plate (fibrous)
• Palpebral conjunctiva
• Glands:
• Modified sebaceous gland
• Meibomian 
• Zeis
• Sweat gland
• Moll 
• Mnemonic:
• Mol sweating
• Sebu → Zei → Mei

• Muscles of Eyelid:

Muscle	Innervation	Function	Injury Effect
LPS	CN 3	Elevation of upper eyelid	Ptosis
Muller's muscle	Sympathetic fibers (Affected in Horners)	Elevation of upper eyelid	Ptosis
Orbicularis oculi	CN 7	Closure of eyelids	Lagophthalmos

Eyelid Pathologies

Chalazion vs. Stye/External Hordeolum:

Eyelash Pathologies

• Trichiasis: Misdirection of cilia.
• Rx: Epilation (to prevent corneal abrasion & opacity)
• Mnemonic: Trichiasis → Thirinj irikkunnath
• NOTE: Don’t confuse Entropion
• V shaped lid margin in entropion

• Distichiasis: Additional posterior row of eyelashes.
• Mnemonic: Di → 2 row

• Madarosis: Absent eyelashes.

• Do not confuse Trichisasis, Distichiasis and entropion

Lid Margin Pathologies

Tylosis: 

• Thickening of lid margin

• Mnemonic: Tylosis → Tile pole thick

Ankyloblepharon: 

• Fusion of upper & lower lid margins.

• Mnemonic: Angles are joined

Symblepharon (a conjunctival disorder)

• Fusion of bulbar & palpebral conjunctiva.

• Mnemonic:
• Simple conjunctiva
• Sym → Spherical Part joined (conjunctiva)

Ectropion: 

• Most common cause (m/c cause): Senility

• Eversion of lid margin.

• Treatments:
• Medial conjunctivoplasty
• Buryon Smith operation
• V-Y procedure is done for cicatricial ectropion
• caused by trauma, burns and chronic inflammation of the skin

• Mnemonic: Senile person → kannu thuungi irangi
• either perform surgery (conjunctivoplasty) or bury (Buryon smith) him

Entropion: 

• Inversion of lid margin.

• Treatments:
• Spastic: Botulinum toxin injection
• Senile: 
• Modified Wheeler operation, Weiss Operation
• Cicatricial: 
• Modified Burrows operation, Wedge resection

Ptosis grades

Congenital Ptosis

• Pathology: LPS malinsertion.

• Clinical Features:
• Lid lag
• Absent upper eyelid crease

• Treatment: 
• Surgery typically done around 5 years of age
• Mild ptosis & good levator function
• Fasanella servat operation
• Also performed for Horners syndrome
• Good lift → send servant
• Moderate ptosis & fair levator function
• Levator resection surgery.
• Fair lift → cut down the lift
• Severe ptosis & poor levator function
• Frontalis sling surgery.
• Poor lift → Put a sling and pick up

Marcus Gunn Jaw winking syndrome (MGJWS)

• Congenital ptosis

• D/t trigemino - oculomotor nerve synkinesis.

• Mandibular division of CN 5 is misdirected into LPS

• Aberrant connection between the LPS and Lateral pterygoid muscle.

• Ptosis disappears on opening mouth

• Treatment
• disinsertion of LPS with sling operation.

Pseudo von Graefe Sign

ㅤ	ㅤ	ㅤ
True von Graefe sign	Graves’ disease	Lid lag on downgaze
Pseudo von Graefe sign	3rd nerve misdirection syndrome	• Aberrant regeneration of CN 3 • Wrongly innervate LPS Example: • Patient looks down → lid retraction

Orbital Pathologies

Proptosis/Exophthalmos:

• Eyeball protrusion >21 mm from lateral orbital rim.

• Mnemonic: girl with bulging eyes (proptosis) → Tell her (hertel) to lead (leudde)

Assessment:

• Hertel’s exophthalmometer (better option)

• Luedde’s exophthalmometer (easier to use, used in children)

Causes of Pseudoproptosis

• Increased eyeball size
• Buphthalmos
• Axial high myopia

• Upper lid retraction

• Contralateral enophthalmos

Causes of Proptosis:

Proptosis in Children

• Bilateral proptosis
• < 5 years: Consider metastatic neuroblastoma
• > 5 years: Consider acute myeloid leukemia (chloroma)

• Unilateral proptosis
• Most common cause: Orbital cellulitis

• Orbital varices:
• Increases on bending forward/Valsalva manoeuvre.
• U/L phleboliths on MRI.

• Orbital lymphangioma: 
• Increases due to URTI (Upper Respiratory Tract Infection).

• Capillary hemangioma: 
• Seen in Child;
• increases on crying.

• Encephalocele: 
• Seen in Infant during crying.

• Carotid cavernous fistula:
• B/L pulsatile proptosis.
• 75% cases traumatic.
• CN VI is the earliest affected nerve.
• IOC (Investigation of Choice): 
• Digital Subtraction Carotid Angiography (DSCA).

Distinguishing Orbital Lesions: 

• (Orbital Cellulitis, Cavernous Sinus Thrombosis, Orbital Apex Syndrome)
• CST
• U/L → B/L
• 1st involve LR (6th CN) → then other nerves + chemosis, proptosis, etc
• No loss of vision
• Mastoid edema ++
• Apex
• U/L
• Involve all nerves together → minimal chemosis, proptosis
• Cellulitis
• U/L
• Chemosis proptosis → then nerves
• Corneal sensation intact

• Cave man →
• Have No Love (No LOV)
• No sensation

• Prisoners → Sensible people, has love

• Apex → Apex or top men → Has Love for family but no sensation (empathy)

Tolosa Hunt Syndrome / Orbital Apex Syndrome

• Hunting Tola at Apex

M/c Associations with Orbit:

• Cystic Orbital Lesions: 
• Ductal cysts of lacrimal gland.

• Cystic Orbital Tumour: 
• Epidermoid and dermoid.

• Orbital Neoplasm (Paediatric Age): Epidermoid and dermoid.

• Orbital Malignant Tumour (Paediatric Age): Rhabdomyosarcoma.

• Orbital and Periorbital Tumour (Children): Capillary hemangioma.

• Benign Orbital Tumour (Adults): Cavernous hemangioma.

• Malignant Orbital Tumour (Adults): B cell NHL (Lymphoma).

• Intrinsic Lacrimal Gland Lesion/Lacrimal Gland Epithelial Neoplasm: Pleomorphic adenoma.

• Orbital Metastasis (Paediatric Age): Neuroblastoma.

• Peripheral Neural Tumour of the Orbit: Plexiform neurofibroma.

• Primary Source of Orbital Metastases:
• Breast (42%)
• Lung (11% - associated with most deaths)
• Neuroblastoma (Paediatric age)

ORBITAL CELLULITIS

Causes

• Most Common Cause:
• Extension from Paranasal Sinusitis
• Most commonly from Ethmoid sinusitis.
• Most common etiological agents: 
• Staphylococcus and Streptococci.
• Most common in children with upper respiratory tract infection.

• Exogenous / Trauma

• Hematogenous spread

Progression & Clinical Presentation