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110 Cards in this Set
- Front
- Back
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Orbit Dimension
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Orbit is pear shaped
Widest diameter is 1cm post to rim width x length x depth 40mm x 35mm x 45mm Orbit vol. 30cc medial walls are parallel to each other |
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Name bones that form each orbit wall
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Superior: Frontal, Sphenoid
Medial: Lacrimal, Maxilla, Ethmoid, Sphenoid Inferior: Maxilla, Zygoma, Palatine Lateral: Zygoma, Sphenoid |
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Apertures of orbit
Sup Orbital Fissure Inf Orbital Fissure Optic Canal foramen ovale foramen rotundum foramen lacerum |
Sup Orbital Fissure: CN 3,4,V1,6, sup oph vein, sympathetic fibers to iris dilator
Inf Orbital Fissure: V2, zygomatic nerve, inf oph vein Optic Canal: ON,ophthalmic artery, sympathetic nerves foramen ovale: Mandibular n. foramen rotundum: maxillary n foramen lacerum: Int carotid Artery |
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Dimensions of Optic nerve
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Intraocular 1mm
Intraorbital 25mm Intracanalicular 8-10mm Intracranial 15mm |
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Boundaries of Optic canal, sup orbital fissure, inf orbital fissure
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Optic canal: within lesser wing sphenoid
sup orbital fissure: fissure between the greater and lesser wing Inf orbital fissure: maxilla, zygoma, sphenoid |
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Orbital septum
Which structures posterior to orbital septum? |
fibrous sheath acts as barrier between orbit and eyelid
Originates from periosteum of sup and inf orbital rim. Insert into levator aponeurosis 2-5mm above superior tarsus and lower lid retractors inferiorly and lacrimal crest medially Structures Posterior: preaponeurotic fat pad levator aponeurosis Lower Lid retractors palpebral lobe of lacrimal gland lateral canthal tendon trochlea |
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Medial canthal tendon
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tendinous insertion of the pretarsal and preseptal obicularis, attach to tarsus
Anterior limb: attach to frontal process of maxilla (origin of sup head of pretarsal obicularis Posterior Limb: attach to post lacrimal crest passes behind the lacrimal sac, maintains opposition of lid to globe *the lacrimal sac is anterior to the septum |
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Lockwoods ligament
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analogous to whitnall's ligament but in lower lid. arise from inferior side IR and continues anterior as capsulopalpebral fascia.
medial attached to post lacrimal crest and lateral attach to lateral orbital tubercle, forms the suspensory hammock for globe |
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Whitnall's ligament
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A condensation of the levator muscle sheath. Seem as white line 10mm above the sup tarsus. medially attach to trochlea, lateral attach 10mm above lateral orbital tubercle
functions to change direction of levator to inferior superior, also check ligament to prevent excess lid elevation |
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Lateral orbital tubercle of whitnall
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Located on the zygoma. 1cm inferior to frontozygomatic suture line. Has multiple attachments:
lat canthal tendon lateral horn of levator aponeurosis check ligament of lateral rectus lockwoods ligament whitnalls ligament |
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Obicularis oculi
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main protractor of eyelids. Also the lacrimal pump. innervated by CN 7
3 parts: palpebral (pretarsal and preseptal) --> involuntary orbital --> voluntary lid closure 1. Pretarsal:lies over tarsus, forms muscle riolan, forms MCT. superficial head attach ant lacrimal crest, forms MCT. Deep head, attach post lacrimal crest, surround canaliculi, forms LCT Preseptal: over septum, originates ant limb of MCT, post lac crest, and lac sac fascia. forms the lateral palpebral raphe Orbital: lies beneath the skin, inserts at the MCT, interdigitates with frontalis |
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Muscles of the forehead and eyeborw
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Frontalis: CN7 raises brows
Corrugator: pulls medial brow down, cause vertial glabellar wrinkles procerus: pulls forehead and medial brow inferior, produce the "bunny lines" |
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anatomy of eyelid margin
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From anterior to posterior:
skin lash line gray line meibomain gland orifice mucocutanous junction |
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Eyelid glands
location, gland type, secretion |
Krause: accessory lac gland, in fornix, eccrine, aqueous
Wolfring: accessory lac gland, above tarsus, eccrine, aqueous meibomian: tarsus, holocrine, Oil zies: lash follicle, holocrine, oil moll: lid magin, apocrine, mucous goblet: conjunctiva, holocrine, mucous |
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Muller's muscle
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located posterior to the levator aponeurosis
has sympathetic innervation insert in the upper tarsal bordoer 12-15mm long, raises eyelid 2mm Peripheral arcade is between aponeurosis and muller's |
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Orbital fat pads
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located posterior to the septum, 2 pads in upper lid located preaponeurotic (central and nasal)
3 pads in lower lid, ant to capsulopalprebral fascia. inferior oblique separates the nasal and central fat pad. lateral retinaculum separates the lateral from central. Too much removal in blepharoplasty can cause restrisction, hollowing, orbital hemorrhage |
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Lateral canthotomy
Lateral cantholysis |
Lateral canthotomy: divide the skin and lateral raphe of obicularis
Lateral cantholysis- divide the lateral canthal tendon |
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angular artery anatomy
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angular artery lies 6-8mm medial to the medial canthus
Ext carotid --> facial artery --> angular artery |
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Fixing upper lid defect
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< 33% direct closure
33-50% semicircular flap, tenzel 50-100% Free tarsoconjunctival flap with skin flap, cutler-beard, lower eyelid switch flap, medial forehead flap |
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fixing lower lid defect
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<33% direct closure
33-50% semicircular flap, adjacent tarsoconjunctivla flap and full thickness skin graft 50-100% Hughes flap, free tarsoconjunctival graft and skin flap, composite graft with cheek advancement (mustarde) |
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eyelid lacerations that require OR repair
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1. those with ocular trauma
2. involved the lacrimal system 3. invovles the levator aponeurosis 4. medial canthal tendon avulsion 5. those with extensive tissue loss |
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Criteria for repair of Orbital fractures
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immediate repair: CT evidence of entrapped muscle or periocular tissues with oculocardiac reflex. Young patients with "white eyed fractures"
repair in 1-2 weeks: persistent diplopia not improved, + force duction, and Ct evidence of entrapment. Large floor fractures, complex trauma involving rim or zygoma |
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Le fort fractures
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1. low transverse fracture of maxilla above teeth, no orbit involved
2. pyramidal fracture, invovle the nasal, lacrimal, maxillary(involves the medial walls) 3. craniofacial dysjunction, affects the floor, medial, lateral walls and possible optic canal. |
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Type of intraobital foreign bodies. Which are tolerated and which not?
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Poorly tolerated: Organic(vegtable matter,wood), Copper
Fairly well tolerated: less than 85% copper, will cause chronic inflammation well tolerated: stone, glass, plastic, iron, lead, steel, aluminium BB pellets made of 80-90% lead and 10-20% iron, best left behind if not threathing ocular structures |
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Ectropion
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Eversion of eyelid margin
1.Congenital (rare) 2.Involutional-most common, hirozontal lid laxity, disinsertion of LL retractor. Test with a snap back test. Treat: horizontal lid shortning, lateral canthoplasty, repair LL retractors 3. Paralytic-CN 7 palsy, treat with lubrication, taping, googles, lateral tarrsoraphy, gold wt implant, hard palate mucosal graft, horizontal lid tightning 4. cicatricial- from burns, trauma, inflammation, relax the scar, vertical lengthning, horizontal tightning 5. mechanical - eyelid tumor, herniated orbital fat, chronic edema, treat condition |
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Entropion
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Inversion of eyelid margin
Lower lid usually involuational, upper lid cicatricial 1. congenital 2. spastic- assoc with inflammation, trauma, patching. remove irritation ,lid taping, cautery, botox, quicket suture 3. Involutional- horizontal lid laxity, LL retractor dehis, overriding obicularis. Treat with quicket suture, horizontal and vertical tightning, LL retractor advancement, obicularis excision 4. cicatricial- shortning post lamella, caused by OCP, SJS, trachoma, HZV, surgery, trauma, burn. treat lubrication, avoid surgery in active inflammation, tarsal fracture, grafts. |
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congenital ptosis
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75% unilateral. assoc with blepharophimosis (AD)
type: 1. myogenic most common, dysgenesis of levator, there is fat infiltration of levator. Poor levator function, lo lid crease, lid lag 2. aponeurotic-birth trauma, good lid function, high or indistinctlid crease 3. neurogenic- congenital CN3 palsy, marcus gun jaw winking. Surgery depends on the levator function: levator aponeurosis resection (working levator). Frontalis sling (poor levator) |
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Ptosis
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1. Congenital-
2. myogenic- local or systemic muscle disease (myotonic dystrophy, CPEO). Needs sling, treat underlying condition 3. Involutional- most common, disinserted levator, high lid crease, good levator function, think eyelids, no lid lag 4. neurogenic- CN3 palsy, aberrant regentation, horner's, MS. treat horner's with conj muller's resection 5. mechanical- mass effect from eyelid tumor, remove tumor 6. trauma - to levator. |
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signs of lower lid retractor disinsertion
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1. white line seen below the inferior tarsal border caused by leading edge of detached retractors
2. deep inferior fornix 3. Lower lid high than normal 4. little or no inferior movement of lower lid on downgaze. |
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Eyelid retraction
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upper eyelid above sup limbus
lower eyelid exposing sclera most common cause is TAO other causes: orbital pesudotumor, meds(phenylephrine, alphagan, cocaine), contralateral ptosis (herings), lesion in brain (dorsal midbrain, post third ventricle), infant hydrocephalus, marcus gun jaw winking, cirrhosis. treat: lubrication, surgery, levator aponeurosis recession, levator myotomy, spacer. Lower might need skin graft and hard palate graft |
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Preseptal cellulitis
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Infection anterior to orbital septum
risk factor: recent skin trauma most common organism: staph aureus present with lid edema, erythema, pain, no orbital signs treat with systemic oral antibiotics |
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Orbital cellulitis
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Inferior posterior to orbital septum, involves the globe.
most common cause of proptosis in children. common cause by ethmoid sinusitis. Organism: children staph aureus, adults poly organisms Can have fever, decrease VA, RAPD, proptosis, EOM restriction, priorbital swelling, chemosis, Optic nerve edema diagnosis: get CT scan with contrast, treat with IV antibiotics, surgical drainage if superiosteal abcess. complications: cavernous sinus thombosis, intracranial extension |
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Orbital mucormycosis
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infection of orbit by fungus phycomycetes. mucormycosis - non-septate large branching hyphae, invades the blood vessels causing thombosis and necrosis. intracranial spread via ophthalmic artery. Is the most common virulent fungal disease
Risk:DM, immunosuppresion, renal disease, leukemia presents with painful orbital apex syndrome, proptosis, ptosis, ophthalmoplegia, decrease VA, corneal anesthesia, retinal occlusion. Treat with immediate surgical debridement, IV amphothericin, control underlying systemic condition |
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Thyroid related orbitopathy
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most common cause of proptosis in adults, most common cause aquired diplopia
often in women, can be euthyroid, hyper, hypo, assc grave's and MG Signs: lid retraction, proptosis, EOM restriction, diplopia, lago, lid lag, dry eyes, conj injection, chemosis, caruncle swelling, corneal exposure, elevated IOP, compressive optic neuropathy Path: enlarged EOM, infiltration of lymphocytes, monocytes, mast cells, fibroblasts. fibroblasts make GAGs --> increase water content in muscles, spare tendons. CT-scan show EOM enlargement sparing tendons. EOM muscle involvement: IR>MR>SR>LR |
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sequence of TAO surgery
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1. orbital decompression
2. strabismus surgery 3. eyelid surgery |
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Orbital meningiomas
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a invasive tumor arising from arachnoid villi, originate from intracranial along sphenoid with extension to orbit via bone, sup orbital fissure, and optic canal. manifestion depends on location.
Sella: VF defect, papilledema, ON atrophy pterion: temporal fossa mass, proptosis Optic nerve: axial proptosis, good vision sphenoid wing - hyperostosis treatment - sphenoid wing: debulking, subtotal resection Optic nerve: if extend to chiasm consider RT, surgical excision |
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histiocytosis X
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disorder fo abnormal proliferation of histiocytes. Children <2 with multifocal disease have poor prognosis
commonly presents as lytic defect in orbit roof causing progressive proptosis. Pathology: granulomatous histiocytic infiltrate, birbeck granules, stain s100, vimectin Types 1. Eosinophilic granuloma- occur in children, benign solitary bone lesion, supero-temporal invovlement. CT shows sharp demarcated lytic bone lesion. treat: incision curettage, steroids, RT 2. Hand-Schuller-Christian- triad of proptosis, lytic skull, diabetis insipidus, mutiple bone lesions. treat systemic steroids, chemo 3. Letterer-siwe- most severe, fatal. rarely involve orbit. treat by systemic steroid, chemo |
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neurolemmoma (schwannoma)
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encapsulated benign proliferation of schwann cells. Not malignant. Painful due ot perineural spread.
Common in superior orbit --> proptosis and dystopia pathology stains S100 types: Antoni A- palisading spindle cells with verocray bodies Antoni B- loose, stellate cells with mucoid stroma CT shoes circumscribed fusiform mass. treat with complete excision |
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Chondrosarcoma
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Malignant mesenchymal tumor,
Destroys bone and has calcification in CT Retinoblastoma patients have high risk of getting osteosarcoma, chondrosarcoma, fibrosarcoma |
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Optic nerve meningioma
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Occurs in female adults
derive from outer arachnoid Get vision loss, optic atrophy, optociliary shunt vessels, proptosis, optic nerve edema, retinal vascular occlusion. pathology show psammoma bodies and spindle cells CT/MRI show railroad tram track sign |
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Optic nerve glioma
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A pilocystic astrocytoma
occurs in children, does not metastasize. Assoc with neurofibroma Have painless proptosis, decrease vision, strabimus, disc swelling, optociliary shunt vessels pathology shows circumscribed astrocytic tumor CT shows fusiform Optic nerve treat: observe, surgery if spread to chiasm. In adults it is very malignant cause death 6-12mo |
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Sphenid wing meningioma
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most common tumor to spread to orbit from intracranial space
present with temporal fullness, proptosis and lid edema. CT shows hyperostosis, calcifications. Treat: observe, surgical excision |
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hemangiopericytoma
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rare tumor of pericytes of blood vessels. common in female. located in superior orbit causes a slow proptosis. can metastasize to lung, bone, liver.
A-scan- low to medium reflectivty. CT shows well circumscribed mass. treat with complete excision |
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Goldenhar's syndrome
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abnormality of 1,2 brachial arches. Have hypoplstic facial bones, pretragal auricular appendages, vertibral abnormalitis, fistula mouth-ear.
Ocular finding: limbal dermoid, lipodermoid, upper lid coloboma assoc. duane's syndrome |
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Craniosynostosis
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premature closure of bony sutures inhibits growth of cranium perpendicular to axis, growth continues parallel to axis. Findings: hypertelorism, proptosis, V pattern strabimus.
Plagiocephaly - premature closure of half of coronal suture, skull normal one side and underdeveloped in another Crouzon's have no hand and foot derformity |
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Orbital lymphoma
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occur adults, in superior orbit.
painless lacrimal gland swelling, salmon patch, EOM limitation. involves the reticuloendothelial system includes retroperitoneal lymph node. pathology shows atypical immature lymphocytes with mitosis, B cell proliferation 60-90% CT show puuty like molding. treat with RT location and chemo systemically. Progonosis: location is important for chance of systemic involvement. eyelid>orbit>conjunctiva |
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systemic lymphoma and waldenstroms macroglobulinemia
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solid infiltrating tumor with putty like molding of tumor
pathology shows: dutcher bodies, intranuclear PAS-positive inclusion of immunoglobulins |
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rhabdomyosarcoma
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most common primary orbital malignancy in children
a malignant spindle cell tumor. pluripotent cell of soft tissue. Common in boys, spreads via orbital bones locally. spreads to lung, cervical lymph node via blood. most common metastasis is to chest Presents with rapid proptosis, tortous retinal vein, choroidal folds, optic nerve edema. 4 types: embryonal- most common, 94% survival rate botryoid- subtype of embryonal pleomorphic-adults, least common, best prognosis alveolar- worst prognosis Ct shows a well circumscribed orbital mass with bony destruction. treat with RT, chemo, surgicla debulking |
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rhabdomyosarcoma prognosis
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Chemo with RT 3yo survival 90%, in localized tumors 100%, invaded adjacent structure 60%
tumors arising orbit, bladder, prostate 77% survival intrathoracic tumor, worst prognosis 24% at 2 years |
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retinoblastoma
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most common intraocular malignacy in children. onset <5yo. 30% BIL 30% multifocal
mapped 13q14, 94% sporatic, 6% AD present with leukocoria, strabismus, decrease vision have yellow white retinal mass, rubeosis, pseudohypopyon, hyphema, angle closure glaucoma, uveitis. endophytic- arise inner retina grows into vitreous exophytic- arise outer retina grows to choroid tumor necrosis can cause calcificaition. metastasis via optic nerve. risk of invasion when exophytic tumor >15mm and secondary glaucoma. most common secondary tumor is osteogenic sarcoma |
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trilateral RB
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BL RB with pinealoblastoma or a parasellar neuroblastoma.
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retinoblastoma genetics
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chance of having baby with RB
- parent with 1 RB child - 6% - parent with 2 RB child - 40% |
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RB diagnosis
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LDH level aqueous:plasma >1
US- solid, high internal reflectvity, calcium FA- early hyper, late leakage CT/MRI- calcification, pineal tumor, optic nerve involvement metastatic work up: bone scan, bone marrow aspiration, LP |
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Management of RB
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most common vision sparing techique: primary systemic chemo followed by local therapy.
enucleation - for nonsalvable eyes, avoid manipulation, and get long O.N segment External beam radiation: not a primary mode of treatment due to secondary tumors and cranial deformities. Prefer imaging with MRI and US than CT due to radioation |
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secondary tumors of RB
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most common osteogenic sarcoma
malignant melanoma lymphoma leukemia rhabdomyosarcoma medulloblastoma |
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Poor prognosis of RB
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invasion (optic nerve, uvea, sclera), multifocal tumor, delay in diagnosis, type of differentiation.
**BL invovlement does not worsen prognosis. And calcification, necrosis does not influence prognosis |
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Flexner-wintersteiner rosette
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Seen in retinoblastoma
ring of single row of columnar cells around a central lumen. Of photoreceptor origin, retinalal differentiation. |
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Homer Wright rosette
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Found in neuroblastic tumors: neuroblastoma, medulloblastoma, retinoblastoma
no lumen, nuclei surrounded by tangle of neural filaments |
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nevus
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congenital nest of benign nevus cells alonf basal epithelium and or substancia propria
30% amelanotic. moves freely. contain cysts. can enlarge in pregnancy types: Junctional: nevus cells in junction of epithelial and subepithelium Compund: most common, nevus cells in both epithelial and subepithelial location subepithelial - nevus in substacia propria, malignant potential possible |
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Risk factors for skin cancer
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old age
sun exposure white skin previous hx skin cancer fam hx |
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Basal cell carcinoma
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Most common eyelid malignancy, sun exposure a risk. location: Lower >media>upper> lateral
worst prognosis in medial canthus. does not metastasize but has local invasion that can go to CNS and skull. Types: nodular: most common, firm raised pearly, central ulceration morpheaform: more aggressive, firm, flat, indistinct borders, penetrate the dermis, have pagetoid spread. tumor cells in "indian file pattern" pathology: blue basaloid cells arranged in nest cords, and peripheral palisading TX: excisional biopsy: wide excision with frozen section |
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Squamous cell carcinoma
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flat keratinized, ulcerated, red plaque. can form de novo or from actinic keratosis. Can metastasize via heme and lymph. Assoc HIV, HPV
more agressive than BCC common in lower lid. pathology: dyskeratotic cells, keratin pearls, cord like infiltrating strands into dermis. treat with excisional biopsy, wide excision with frozen section |
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Sebaceous cell carcinoma
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Second most common malignancy of lid after BCC
highly malignant, occurs in old. 5yr mortality 30%. arise from caruncle, zies, meibomian gland. upper lid most involved. can metastasize via blood. can masquerade as: recurrent chalazion, chronic blepharitis with madarosis. Pathology: anaplastic cells with foamy lipid laden, vacuolated cytoplasm, skip area, pagetoid invasion. stains oil o red. treat with: wide excision with frozen section, conjunctival mpa biopsy. exenteration if orbital extension. RT used for palliation |
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malignant melanoma
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<1% of eyelid tumors.
types: lentigo maligna melanoma- flat pigmented macule, irregular borders, arise from lentigo maligna, occur in old, sun exposed. 10% metastasis. 90% 5yr suvival sup. spreading melanoma: younger patients, sun exposure, initial horizontal growth then invades deep tissue. 69% 5 yr survival nodular melanoma - most common in eyelid, palpable. aggressive vertical invasion 5yr survival 44%. Look for signs of change: colore, shape, size, induration, ulceration, bleeding treat: wide excision, lymph node dissection if any lymph or vascular involvement |
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Muir torre syndrome
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multiple sebacous tumors, keratoacanthomas, GI tumor
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Keratoacanthoma
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rapid growing lesion (4-8weeks) is a dome lesion of squamous cells, central keratin filled crater with rolled edges. classified as a squamous carcinoma. They can invovolute spontaneously
cause madarosis, and permanent damage to lid margin Pathology shows: cup shape lesion with central keratin core above skin. observe, surgical excision, local steroid injection |
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lymphangioma
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lymphatic filled choristoma. superonasal, can involve the lids, conjuntiva, deep orbit. waxes and wanes. Find: acute pain, proptosis that worsens with URI, may hemorrhage causing chocolate cyst. Pathology: lymph filled vascular channels lined by endothelium, no capsule.
CT shows layered blood, lobular cystic mass Treat: observe, can regres spontaneously. surgicla excision difficult |
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cavernous hemangioma
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most common benign orbital tumor in adults
vascular tumor, well encapsulated compsed of blood filled cavernous spaces, lined by endothelial cells cause proptosis, retinal striae, hyperopia, increase IOP, ON compression, strabismus A scan show high internal reflectivity CT- well circumscribed mass treat with surgical excisionj |
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Orbital varix
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most common vascular abnormality, a dilation of preexisting venous channels
proptosis worst on valsalva. con hemorrahge after trauma. EOM restricted, disc edema, optic atrophy. CT shows phlebolith 30% treat with surgery (difficult) Surgical indication: cosmetic, severe proptosis, ON compression, pain |
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carotid sinus fistula
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assoc with head trauma (basal skull fractures), high flow lesion
cause dilated scleral/episcleral vessels. increase IOP, pulsitile proptosis, orbital bruit, tortuous retinal veins, retinal artery occlusion, increase c/d, CN6 palsy. CT/MRI can show dilated superior oph vein dilation. treat with embolization, surgical ligation |
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Dural sinus fistula
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A low flow lesion, connection between meningeal branch of carotid artery and dural walls of cavernous sinus. Asymptomatic, assoc HTN, atherosclerosis, connective tissue dz, can close spontaneously
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pilomatrixoma
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A solitary firm lesion
most common cystic lesion in childhood arise in upper lid, brow assoc: myotonic dystrophy, gardner's syndrome |
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tricholemmoma
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small crusty lesion with rough ulcerated surface, occurs in face
arise from glycogen rich cells in outer hair sheath resembles BCC, SCC, sebaceous cell cowden's disease: AD, multi facial tricholemmoma, a marker of breast or thyroid cancer |
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trichoepithelioma
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skin colored nodule, papule. common in female. occur in forehead, eyelids, nasolabial folds, upper lip.
pathology-basaloid cells surrounding keratin center. Brook's tumor - AD, multiple trichoephtheliomas. can excise, dermabrasion, cryoablation, electrodessication |
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trichofolliculoma
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keratin filled cystic hair follicle surrounding by immature hair follicle, appears as small umbilicated nodule with central white hairs
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sinus mucocele
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slow expanding lesion, trapped mucus in aerated space due to obstruction of sinus ostium. can get infected. occurs from inflammation, trauma, narroe ostea, osteoma, polyp, septal deviation, mucous retention cyst. Assoc with cystic fibrosis. rule out encephalocele and meningocele.
Frontal-ethmoid: most common, out and down globe displacement sphenoid and post ethmoid - cause visual symptoms, retrobulbar pain, CN palsies maxillary sinus: upward globe, erosion of orbit floor cause enophthalmos. Pathology: lined by pseudostratified columnar epithelium CT shows: homgenous opacified cyst, erosion of bone Treat: surgical excision, IV antibiotics, reestablish drain or obliterate the sinus |
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fibrous histiocytoma
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a firm orbital mass of fibroblasts ans histiocytes.
usually benign (10% malignant) fibrous hystiocytoma and hemngiopericytoma distinguished by biopsy (both are spindle cell tumor) pathology shows classic storiform pattern CT- well circumscribed mass in upper nasal quadrant. treat with surgical excision, can recur |
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ddx enophthalmos
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trauma (orbital fractures)
sclerosing orbital pseudotumor metastatic breast cancer |
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ablepharon
ankyloblepharon blepharophimosis distichiasis epiblepharon epicanthus euryblepharon microblepharon telecanthus |
ablepharon- no lid
ankyloblepharon- fusion lids blepharophimosis- horizontal and vertical lid shortnening, no lid crease, poor levator distichiasis- extra row lashes emerge at meibomian glands epiblepharon-skin and obicularis override pushing lashes up epicanthus-medial canthus skin fold euryblepharon - horizontal widening of palpebral fissure, inferior insertion of LCT microblepharon- vertical shortening of lids telecanthus - widening of the intercanthal distance. |
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2.5% phenylephrine test
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Used to activate the sympathetic fibers muller's muscle.
helps simulate a conjunctival mullerectomy and hering's in contralateral lid |
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xanthalesma
erdhein chester |
yellow plaques, commoin in medial upper lids. 2/3 patients have normal lipids
can occur in hypercholesterolemia, JXG, histriocytosis X. pathology shows lipid contaning macrophages surrounded by inflammaiton. treat with observation, excision Assoc Erdheim Chester disease. a multi systemic disease with lipogranuloma formation in liver, heart, kidney, lungs,bones. have proptosis, xanthelesma. patho show histiocytes and touton giant cells. |
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coloboma of eyelid
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more common upper lid.
upper lid: medial third. not assoc with systemic abnormality, full thickness lower lid: usually lateral third, assoc with syndrome. partial thickness. Treat with lubrication and surgical repair |
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Blepharochalasis
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familial variant of angioneurotic edema, idiopathic inflammation of eyelids, young women 10-18yo
recurrent attacks of transient, painless, eyelid edema. causes atrophy, wrinkling, and eyelid skin redundancy can develop ptosis, fat atrophy, and herniation of lacrimal gland. |
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hypertelorism vs telecanthus
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hypertelorism - widening of medial orbital wall
telecanthus - widening of the space between medialo canthal tendon |
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blepharophimosis syndrome
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AD, horizontal and vertical shortening of the palpebral fissure. poor elevators, no lid crease.
find: ptosis, telecanthus, epicanthus inversus, LL ectropion, hypoplasia of nasal bridge, anteverted ears, hypertelorism. can surgically correct, transnasal wiring |
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botox
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inh acetylcholine release by binding receptors of motor nerve terminals. Some patients develop antibodies to the botox causing decrease efficacy.
effect starts in 2-3 days last about 3 months Used in blepharospasm, hemifacial spasm, paralytic strabimus, spasmotic dysphonia, torticollis |
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Benign mixed tumor (pleomorphic adenoma)
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most common epithelial tumor of lacrimal gland. pseudoencapsulated
common in men with slow onset firm painless mass at lacrimal fossa. can have proptosis medially and downward. Slow growth indent the bone and can also stimulate bone production. CT- well cicumscribed. treat by complete enbloc excision, without biopsy. There is risk of malignant transformation and recurrence. Pathology: benign epithelial cells proliferating double layer forming lumen |
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pleaomorhic adenocarcinoma
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lacrimal fossa mass, a rapid progressive painful proptosis. occurs in the old. pathology like pleomorphic adenoma with malignant change. treat with radical orbitectomy and bone removal
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adenoid cystic carcinoma
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most common malignant tumor of lacrimal gland, supe malignant. cause rapid, painful, proptosis, and paresthesia. perineural invastion and bone destruction. Pathology shows swiss chess pattern. CT: poor defined mass with bone destruction and calcification. treat by exenteration, remove involved bone, radiation, chemo. poor survival
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Mechanism of lacrimal pump
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eyes close, obicularis contracts, + pressure in tear sac, forces tears out through valve of hasner
eyes open, - pressure in tear sac draws tears in. |
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nasolacrimal canal bones
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maxillary, lacrimal, inf turbinate
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canaliculitis
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infection of canaliculus
commonly actinomyces israelii (gram + rod) occur in middle age cause tearing, redness, pain, discharge find: red, dilated, pouting punctum, express discharge, have sulfur granules, gritty sensation on probing. treat: warm compress, probe and irrigation with penicillin, canalicular curettage, I and D |
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lacrimal gland anatomy
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lacrimal gland in lacrimal fossa. within frontal bone. 2 lobes a orbital and palpebral seprated by levator aponeurosis. duct from both lobes pass the palpebral lobe in the superior fornix. blood supply by lacrimal artery.
Accessory glands: krauss (fornix) wolfring (above tarsus) |
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acute dacryocystitis
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infection of lacrimal sac, common caused by strep pneumo, cause erythema, swelling below MCT. mucocele, chornic conjunctivitis, cellulitis.
treat with: warm compresses, topical and systemic antibiotics. I and D if abcess, Do not probe and irrigate when active infection. DCR once infection subsides. |
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dacryoadenitis
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acute or chronic inflammation of the lacrimal gland. acute infection caused by Staph A. Chronic inflammation: orbital pseudotumor, sarcoid, lymphoid, syphilis, TB.
present: swelling, pain, red, tearing, discharge, swelling lacrimal gland, fever, preauricular lymphadenopathy, globe dystopia, restricted EOM, diagnose with CT scan, biopsy, culture, serology. Treat: antibiotic, I and D, excision |
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DCR
indications |
create a passage between the lacrimal sac and nasal cavity. osteotomy made by removing lacrimal sac fossa and superior nasal wall of Nasolacrimal duct. bony window 15mmx15mm.
osteotomy site is 10mm from cribiform plate. indicated in focal distal canalicular block and NLDO. two most common caue of DCR failure: 1. obstrucion of common canaliculus. 2. obstruction at ostium site |
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lacrimal tests
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DDT: place dye at fornix wait 5min eval clearance of dye and tear meniscus
Jones 1: DDT and try to retrive dye at inf meatus with cotton swab Jones 2: Jones 1, then irrigate saline into lacrimal system. helps determine location, but can still be functional block. dacryoscintogram- psysiological test using technetium 99 dacryocystogram- injects lipoidol to outlinje drainage system. |
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tumors of lacrimal sac
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painless mass located above the MCT, may have bloody tears, bleedind with probing, and dacryocystitis.
SCC - most common primary lacrical sac tumor lymphoma - second most common squamous papilloma - most common benign lac sac tumor |
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canalicular obstruction
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can occur from trauma, medication (antivirals, strong miotics, epinephrine), infections (HSV, EBV, trachoma), dacryolith, inflammatory (SJS, OCP), allergy, radiation, tumor, canaliculitis
Repair if trauma. partial obstruction - crawford tubes obstruction within 8mm punctum use jone's tube. obstruction > 8mm punctum can DCR |
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NLDO
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more common in women, most common due to involutional stenosis. casued by inflammatory, trauma, chronic sinus disaese, nasal polyps, dacryocystitis, granulomatous disease.
treat with silicone intubation, DCR. most common aquired NLDO is at the level of nasolacrimal duct. |
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ddx of intraocular calcification
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RB
phthsical eye choroidal osteroma choroidal hemangioma osseous choristoma |
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Orbital pseudotumor
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idiopathic inflammation of orbit
cause acute pain, lid erythema, lacrimal gland enlargement, restricted eye, proptosis, diplopia, decrease vision if optic nerve involved. adults: unilateral, if bilateral: suspect sarcoid, wegeners, polyarteritis nodosa, lymphoma. In Children bilateral more common Get blood test as needed (ESR, cbc, ANA, BUN/Cr, fasting BG, ACE, C-ANCA, P-ANCA, gallium scan, CXR CT orbit :shows enlarge EOM involving the tendons, thick sclera.B-scan can show acoustically hollow edematous post tenons. treat with oral predinisone, if not responsive biopsy. |
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Childhood lesions
well circumscribed on CT or MRI |
dermoid cyst rhabomyosarcoma
optic nerve glioma plexiform neurofibroma capillary hemangioma |
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Childhood leisons
diffusely infiltrating on CT or MRI |
lymphangioma, leukemia, orbital pseudotumor, capillary hemangioma, neuroblastoma, teratoma
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Adult orbital lesions in CT or MRI well cricumscribed
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cavernous hemangioma
neurolemoma (schwannoma) fibrous histiocytoma solitary neurofibroma hemangiopericytoma mucocele optic nerve meningioma |
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Adult orbital lesions in CT or MRI diffusely infiltrating
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pseudotumor, lymphoid tumors, lymphangioma, metastasis
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orbital lesions with high reflectivty on US
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neurofibroma
cavernous hemangioma thyroid eye fresh blood |
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orbital lesions with low reflectivity on US
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metastatic cancer
orbital pseudotumor lymphoma dermoid varix mucocele cyst |
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orbital aspergillosis
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several forms.
1. acute aspergillosis- fulminant sinus infection with secondary orbital invasion. has orbital pain, decrease vision, proptosis biopsy shows septate branching hyphae. Must aggressively excise all infected tissue and start ampho B, flucytosin, rifampin or combo. 2. Chronic aspergillosis - indolent infection causing slow destruction of sinus and adjacent structures 3. Chronic localized noninvasive aspergillosis- occurs in immunocompetent affect sinus, form fungus ball, lack inflammation and bone erosion. 4. allergic aspergillosis sinusitis- occurs in immunocompetent with nasal polyposis and chronic sinusitis, have thick mucus, bone erosions. Must debride endoscopically and use steroids. |
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kaposi sarcoma
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rare tumor present as chronic reddish mass, frequent in AIDS patients. can have conj lesion. composed of spindle cells and endothelial origin. Can be treated with cryo, excision, radiation, or intralesional chemo. They can regress with adequate HIV treatment
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