Oculoplastics review

Oculoplastics Review
INDIAN DENTAL ACADEMY
Leader in continuing dental education
www.indiandentalacademy.com

Oculoplastics
• Orbit
• Eyelid
• Lacrimal

Orbit

Orbital Anatomy
• 7 bones
• 30 cc (35 mm width x
40 mm height)
• 25-30 mm orbital
optic nerve
• Rim
– Zygomatic
– Maxillary
– Frontal
• Floor (3 bones)
– Zygomatic, maxillary and
palatine
• Medial wall (4 bones)
– Sphenoid, lacrimal,
ethmoid, maxillary
• Roof ( 2 bones)
– Frontal, sphenoid
• Lateral wall (2 bones)
– Zygomatic, sphenoid
(greater wing)

Orbital Anatomy (cont.)
• Optic foramen
– 8-10 mm
– Located within lesser
wing of sphenoid
– Transmits optic nerve,
ophthalmic a. and
sympathetic nerves
• Superior orbital fissure
– Bound by greater and
lesser sphenoid wings
– Outside annulus
(“luscious French
tarts”)
• lacrimal, frontal, IV
– Inside annulus (“sit
naked in anticipation)
• III-sup, nasociliary III-
inf, VI

Orbital Anatomy (cont.)
• Inferior orbital fissure
– Bound by sphenoid,
maxillary and palatine
bones
– Transmits V2 which
exits skull through
foramen rotundum
• Annulus of Zinn
– Fibrous rings formed
by rectus muscles
– Does not include IV

Orbital Pathophysiologic
Patterns1
• Inflammation: 57.3%
• Neoplasia: 22.3%
• Structural Abnormality: 15.8%
• Vascular Lesions: 2.8%
• Degenerations and Depositions: 1.7%
1 Rootman J. Diseases of the Orbit. J.B. Lippincott. 1988.

Orbital Inflammation
• Orbital cellulitis
• Graves ophthalmopathy
• Idiopathic orbital inflammantion
(pseudotumor)
• Sarcoidosis
• Wegener’s
• polyarteritis nodosa

Orbital Cellulitis
• Medical emergency – because of rapid spread to
brain (i.e. cavernous sinus thrombosis, brain
abscess) and compressive neuropathy
• 3 causes
– Spread from adjacent structures (I.e. sinus most
common)
– Direct innoculation – trauma/surgery
– Hematogenous spread (rare)

Orbital Cellulitis (cont.)
• Orbital vs. preseptal cellulitis
– Orbital signs: motility changes, proptosis, chemosis,
decreased retropulsion
• Evaluation – CT scan
• Sinusitis common +/- subperiosteal abscess
• Treatment
– IV abx’s with surgical drainage of any abscess
– Steroids with vision threatened and no fungal (i.e.
trauma, immunosuppresion) suspected

Graves Ophthalmopathy
• Eyelid retraction most common finding
• Most common cause of unilateral/bilateral
proptosis
• Women:men 6:1
• 90% hyperthyroid, 6% euthyroid, 4% hypo
• Severity of disease unrelated to T3 and T4
• May be asymmetric
• Optic neuropathy and severe exposure are urgent
• Surgery: decompression, strabismus, retraction
repair www.indiandentalacademy.com

Idiopathic Orbital Inflammation
(“Pseudotumor”)
• May present as focal (I.e. dacryoadenitis, myositis,
sclerotenonitis, perioptic nerve) vs. diffuse soft
tissue
• Acute pain, eom restriction and proptosis
• Bilateral in adults: suspect systemic vasculitis
• Bilateral in 1/3 of children
• Treatment: prednisone 60-80 mg/day with slow
taper (over several months)

Pediatric Orbital Tumors
• Benign
– Dermoid cysts – frontozygomatic suture
– Lipodermoids – Goldenhaar’s sydrome
– Optic nerve glioma – controversial treatment
– Capillary hemangioma – grow 1st
year – usually
involute by age 4 (75%)
• treat with steroids if vision threatening
– Lympangioma
• Worse with URI’s

Pediatric Orbital Tumors
• Malignant
– Rhabdomyosarcoma
• Average age (7-8)
• Embryonal (most common), alveolar (most malignant),
pleomorphic, botryoid
• Treatment: chemo, XRT
– Metastatic
• Neuroblastoma – metastatic (abdomen, mediastinum or neck)
• Leukemia – acute lymphoblastic leukemia

Adult Orbital Tumors
• Benign
– Cavernous hemangioma – removal if
symptomatic
– Meningioma – needs surgery if vision
threatening or if intracranial extension
– Orbital varices
– Hemangiopericytoma – may become malignant

Adult Orbital Tumors
• Malignant
– Metastatic
• Breast, lung, prostate, GI and melanoma
– Hemangiopericytoma (malignant
transformation from benign form)

Lacrimal Gland Tumors
• Epithelial (50%)
– Pleomorphic adenoma (benign mixed) –
remove entirely or may recur with malignant
transformation
– Adenoid cystic carcinoma (swiss cheese) – bad
actor
• Lymphoid (50%) – XRT for both
– Lymphoma
– Benign lymphoid hyperplasia

Orbital Trauma
• LeFort classification
– I – transverse maxillary
– II – nasal, lacrimal and maxillary bones
(includes medial floor)
– III – craniofacial disjunction (includes all
walls of orbit but roof)

Orbital Trauma (cont.)
• Indications for surgery of blow-out
fracrure
– Entrapment beyond 7-10 days (urgent
treatment in children)
– Enophthalmos > 2 mm
– >50% of floor involved (leads to late
enophthalmos)

Eyelid

Eyelid Anatomy
• Involutional
• Paralytic
• Cicatricial
• Mechanical
• Congenital - rare

Superficial Eyelid Landmarks
• Eyebrow
– Peaks at 9:00 limbus
– 1 cm above orbital rim in youth
– Flatter in males, more flared in females
• Palbebral Fissure
– Horizontal 28-30 mm
– Vertical 9-11 mm

• Upper Eyelid Margin
– Peaks slightly nasal to the pupil
– upper limbus in youth
– 1.5 - 2.0 mm below in adult
• Lower Eyelid Margin
– inferior limbus
• Margin above superior limbus or below inferior
limbus termed “retraction” or “scleral show”

• Lateral commissure
– 5 mm nasal to lateral rim
– 2 mm above medial in males
– 4 mm above medial in females
• Medial commissure

• Upper Eyelid Crease
– 7 - 8 mm above the margin in males
– 9 - 10 mm above the margin in females
• Lower Eyelid Crease
– poorly defined
– 5 mm below the margin

Eyelid Anatomy
• Divided into anterior
and posterior lamella
– Anterior Lamella
• Skin
• Orbicularis
– Posterior Lamella
• Conjunctiva
• Tarsus

Eyelid Anatomy (cont.)
• skin and subcutaneous tissue
• orbicularis muscle and
submuscular fibroadipose tissue
• orbital septum
• preaponeurotic fat
• retractors
• tarsus and conjunctiva

Skin and Subcutaneous Fascia
• Thinnest of the body (~ 1mm) - thinnest
medially
• Little or no subcutaneous fat
• Subjected to the most movement; stretching
and relaxing

Skin and Subcutaneous Fascia
• Upper eyelid crease
– 9-10 mm in females, 7-8 mm in males
– formed by levator attachments to pretarsal skin
– lower in Asians because septum joins levator at
a lower point allowing inferior fat migration
• Lower eyelid crease
– marks the lower edge of tarsus
– slopes from 5 mm medially to 7 mm laterally

Eyelid Protractors
• Orbicularis oculi - horseshoe-shaped muscle
– Orbital
– Preseptal
– Pretarsal

Orbital Orbicularis
• Voluntary
• Above - inserts to the anterior supraorbital
margin medial to the supraorbital foramen;
shares a common insertion with corrugator
supercilli
• Below - inserts to the anterior infraorbital
margin medial to infraorbital foramen

Preseptal Orbicularis
• Involuntary
• Laterally: continuous overlying lateral
canthal tendon
• Medial insertion
– anteriorly to medial canthal tendon
– posteriorly (Jones muscle) to the lacrimal
diaphragm; upper may also insert on posterior
lacrimal crest

Pretarsal Orbicularis
• Firmly attached to tarsus
• Lateral - gives rise to lateral canthal tendon
• Medial
– Superficial heads form the medial canthal tendon which
inserts to the medial orbital margin
– Deep heads (Horner’s muscle) insert into the lacrimal
bone at posterior lacrimal crest
– Riolan’s muscle forms grey line

Medial Orbicularis Attachments

Orbital Septum
• Orbital septum + tarsus = “middle lamella”
of the eyelid
• Originates at the arcus marginalis
(periosteum)
• Superior - fuses with the levator
aponeurosis 2-5 mm (avg. 3.4 mm) above
the superior tarsal border

Orbital Septum
• Inferior - fuses with inferior border of
tarsus, separated from capsulopalpebral
fascia by postseptal fat
• Lateral - inserts anterior to lateral canthal
tendon
• Medial - inserts on posterior lacrimal crest
(i.e, lacrimal sac is outside orbit)

Orbital Fat Pads
• Upper Eyelid
– preaponeurotic
– nasal - whiter
shade
• Lower Eyelid
– nasal - whiter
shade
– central
– temporal

Eyelid Retractors

Retractors of Upper Eyelid
Levator palpebrae superioris
• Originates at orbital apex
• Horizontal (40 mm) and vertical (15-20 mm)
components
• Changes from horizontal to vertical at Whitnall’s
ligament
• Vertical component has two layers
– levator aponeurosis
– superior tarsal muscle (Muller’s)

• Levator Aponeurosis
– forms lateral and medial horns - attach to
respective retinaculae
– attaches into the pretarsal muscle and skin and
anterior lower 1/3 of anterior tarsal surface

• Superior Tarsal Muscle (Muller’s)
– innervated by cervical sympathetic system
– inserts at superior tarsal border
– medially attaches to the medial horn
– Horner’s syndrome is due to Muller’s muscle
paralysis

Retractors of Lower Eyelid
• capsulopalpebral head given off by inferior
rectus
• splits around inferior oblique and “reunites”
as Lockwood’s ligament
• capsulopapebral fascia projects anteriorly
from Lockwood’s ligament and attaches to
inferior tarsal border

Retractors of Lower Eyelid
• inferior tarsal muscle (muller’s) terminates
2.5 mm beneath inferior tarsal border

Tarsus
• Dense irregular connective tissue - not
collagen
• Meibomian glands
– orifices located posterior to lashes and grey line
– 30-40 upper
– 20-30 lower
• Cilia bulbs - on top
of tarsus

Tarsus
• Upper
– 29 mm in length, 10 mm wide
– extends to lateral commissure
• Lower
– 29 mm in length, 4 mm wide
– extends to puncta

Conjunctiva
• Palpebral conjunctiva
– marginal - extends to mucocutaneous border
– tarsal - adherent to tarsus
– orbital - portion adherent to tarsal muscles
• Bulbar conjunctiva - starts at fornix and
extends on to globe

Lateral “Whitnall’s” Orbital Tubercle
• Lateral retinaculum
– lateral horn of levator aponeurosis
– lateral canthal tendon
– inferior suspensory “Lockwood’s” ligament
– check ligament of lateral rectus
• Whitnall’s ligament inserts 10 mm superior
to lateral orbital tubercle (NOT on
Whitnall’s tubercle)

Posterior Lacrimal Crest
• Medial ocular retinaculum
– inferior transverse “Lockwood’s” ligament
– medial rectus check ligament
– deep heads of pretarsal muscle
– medial horn of levator aponeurosis
– orbital septum

Vascular Supply

Lymphatic Drainage

Sensory Nerve Supply

Ectropion
• Involutional
• Paralytic
• Cicatricial
• Mechanical
• Congenital - rare

Ectropion
Associated terminology
• Lagophthalmos
exposure of conjunctiva/cornea with attempted
lid closure
• Lid Retraction or Scleral Show
visible conjunctiva between inferior limbus and
lower lid margin

Involutional Ectropion
• Tissue relaxation associated with aging
• Extreme cases termed “tarsal ectropion”
implies detachment of retractors in addition
to laxity

Paralytic Ectropion
• VII nerve palsy
– Bell’s palsy (90%)
– Herpes Zoster (Ramsey-Hunt syndrome)
– Trauma
– Tumors (acoustic neuroma, SCCA)

Cicatricial Ectropion
• Actinic changes
• Trauma
• Burns
• Removal of lower lid lesions
• Chronic inflammation
• Lower lid blepharoplasty
• Congenital

Mechanical Ectropion
• Due to mass effect of lower lid lesion
– bulky tumors
– herniated orbital fat
– chronic lower lid edema
• Addressing primary cause usually effective
treatment

Congenital Ectropion
• Typically involves upper and lower lids
• Conservative treatment (i.e. taping of lids,
temporary tarsorrhaphy) usually adequate
• Surgical intervention requires full-thickness
skin grafts

Lateral Tarsal Strip Procedure
• Anderson RL, Gordy DD. Archives of
Ophthalmology, 1979

LTS step 1

LTS step 2

LTS step 3

LTS step 4

LTS step 5

LTS step 6

LTS step 7

LTS step 8

Medial Spindle Slide

Ectropion
When lid tightening is enough
• Involutional
• Paralytic - simple cases

Ectropion
When lid tightening is not enough
• Paralytic - severe cases
– Midface lift, fascia lata sling
• Cicatricial
– Full thickness skin graft
• Congenital

Entropion
• Involutional
• Transient Spastic
• Cicatricial
• Congenital

Involutional Entropion
• Most patients present with eyelid rolled in and
orbicularis spasm
• Accompanied by red, irritated eye
• Initially transient - may stimulate by repeated
forceful closure and upgaze
• Three factors implicated
– horizontal laxity
– disinsertion of capsulopalpebral fascia
– overriding orbicularis oculi

Transient Spastic Entropion
• Acute lower lid swelling accompanied by
orbicularis spasm
• Generally resolves with resolution of
swelling
• Suture technique quick and effective and
may provide permanent relief

Cicatricial Entropion
• Trauma/Chemical injury
• Inflammation
• Ocular cicatricial pemphigoid
• Stevens-Johnson syndrome
• Trachoma

Congenital Entropion
• Associated with epiblepharon (roll of eyelid
that mechanically rolls lid inward)
• Common in Asian population
• Irritation from lashes requires treatment

Entropion
When lid tightening is enough
• Almost never
– Addressing only one of several factors usually
associated with recurrence
– mild involutional cases may respond

Entropion
When lid tightening is not enough
• Involutional
– Jones Procedure
• Transient Spastic
– Quickert suture
• Cicatricial
– Posterior lamellar grafting
• Congenital
– Jones-like Procedure without tightening
– Reduction of epiblepharon skin if present

Jones Procedure

Jones Procedure - Illustration

Quickert Suture

Posterior Lamella Grafting

Posterior Lamella Graft

Posterior Lamella Grafting
(cont.)
• Sources of autogenous graft materials
– hard palate
– buccal mucous membrane
– nasal chrondomucosa
– ear cartilage
• Processed donor material
– Alloderm® - acellular dermal matrix from
donor tissue

Ptosis/Retraction
• Physical Exam
– MRD1 – margin-reflex distance – upper lid
– MRD2 – margin-reflex distance – lower lid
– Levator function
– Lid fissure height
– Lid crease
– Scleral show/retraction noted, if present

Ptosis – Etiology
• Myogenic
– Congenital
– CPEO, Myasthenia
• Aponeurotic – aging, most common
• Neurogenic
– Horner’s
– IIIrd nerve palsy
• Mechanical – dermatochalasis, lid lesion

Ptosis - Treatment principles
• Moderate to Good levator function
– Levator resection/advancement
• Poor levator function
– Frontalis suspension
• Autologous fascia lata ideal
• Silicon can be used prior to age 3 (leg not big
enough)

Retraction – Etiology
• Graves
– Most common cause
• Post eye muscle surgery
• Superior orbital malignancy
• Pseudoretraction – due to contralateral
ptosis (i.e., Hering’s law)

Retraction - Treatment
• Levator recession
– Upper lid +/- spacer graft
– Lower lid + spacer graft (hard palate,
Alloderm)
• Mullerectomy (excision through crease or
trans-conjunctival incision) – usually
combined with levator recession

Lacrimal

Basic Secretors
• Basic secretors
– decreases with age
– no efferent
innervation

Mucin Secretors
• Goblet Cells
– throughout the conjunctiva,
denser nasally
• Crypts of Henle
– upper 1/3 of upper tarsus
– lower 1/3 of lower tarsus
• Glands of Manz
– circumcorneal ring of the
limbal conj.

Aqueous Secretors
• Glands of Krause
– fornix - subconjunctival
– 40 in upper, 6-8 in lower
• Glands of Wolfring
– upper and lower border of tarsus
– 2-5 in upper, 2 in lower

Oil Secretors
• Meibomian glands
– in the tarsal plates
– 25-40 in upper, 20 in lower
• Zeis
– follicles of eyelashes
• Moll
– root of eyelashes

Basic Secretors - Re-cap

Reflex Secretors
• Lacrimal gland - main (orbital) and
palpebral lacrimal glands
– exocrine glands
– efferent parasympathetic innervation
– hypersecretion

Main (Orbital) Lacrimal Gland
• 20mm x 12mm x 15mm
• .78 gm
• 4 ligaments firmly hold gland in place
– Sommering’s ligament - periosteum from roof
– Posterior - inferior ligament of Schwalbe
– Superior transverse “Whitnall’s” ligament
– Lateral horn of levator aponeurosis

Main (Orbital) Lacrimal Gland
• Lacrimal foramen
• 2 to 6 excretory ducts - pierce conjunctiva 5
mm above lateral margin of the tarsus

Palpebral Lacrimal Gland
• About 30 loosely knit lobules each with a
secretory duct that empties into a main
excretory duct
• Upper lobules present at lacrimal foramen
• Can be prolapsed into view
• May have 1 to 2 main excretory ducts

Reflex Secretors
• Fifth cranial nerve is the reflex, afferent pathway
for the main and palpebral lacrimal glands
• Other areas that may initiate a response
- retina - thalamus
- frontal cortex - hypothalamus
- basal ganglia
- cervical sympathetic ganglia

Reflex Secretors
• Peripheral sensory
• Retinal
• Psychogenic

Reflex Secretors
• VII nerve - parasympathetic/efferent pathway
– Arise in pons
– Fibers join sensory route of VII
– Pass through facial nucleus
– Synapse in sphenopalatine ganglion
– Post-ganglionic fibers incorporated in zygomatic
nerve (V2)
– Fibers join lacrimal nerve (V1)

Reflex Secretors
• VII nerve - parasympathetic/efferent pathway

Reflex Secretors
• Sympathetic - efferent pathway
– Fibers arise in the hypothalamus
– Pass to superior cervical ganglion
– Post-ganglionic fibers : 3 routes
• Sphenopalatine ganglion and zygomatic nerve
• Accompany the lacrimal artery
• Within the lacrimal nerve

Distributional System
• Eyelids
– distribute tears
– regulate evaporation
– expel superfluous tears
– assist in the formation of the precorneal tear
film

Excretory System
• Upper and lower canaliculi
• Lacrimal sac
• Nasolacrimal duct
• Palpebral parts of the orbicularis oculi
• Approx. 35 mm in length

Canaliculi
• Canaliculi - 10 mm in length, 2 mm
vertical and 8 mm horizontal
• Diameter - punctum 0.3 mm
- ampulla 2 to 3 mm
- canaliculi 0.5 mm
• Lined by stratified squamous epithelium,
surrounded by dense connective tissue

Canaliculi
• 90% have common
canaliculus - enters
posterior and superior
• Dilation of common
canaliculus is the sinus of
Maier
• Valve of Rosenmuller at
distal end of common
canaliculus

Lacrimal Sac and Nasolacrimal
Duct
• Lined double layered
columnar epithelium
• Single structure ~ 35
mm in length
– Canaliculi 8-10 mm
– Fundus - 4 mm
– Body - 8 mm
– Duct - 12 mm

Nasolacrimal Duct
• Meatal NLD - 5 mm:
guarded by Hasner’s valve
• Angled slightly lateral and
posterior
• Opens into the inferior
meatus
• Distance from the entrance
of nose to duct is 35 mm
(less in infants)

Lacrimal Diaphragm
• Extension of orbital
periosteum
– “sac within a sac”
• Inferior and superior
preseptal muscles insert
into it
• Thinnest at lower end of
anterior lacrimal crest

Lacrimal Pump (cont.)

Lacrimal Disease

Congenital Epiphora
• Usually begins between 2 and 3 months
• Causes:
– Congenital nasolacrimal duct obstruction
(NLDO)
– Punctal agenesis
– Reflex tearing (e.g., conjunctivitis,
epiblepharon with secondary trichiasis,
distichiasis, congenital glaucoma)

Congenital Epiphora Evaluation
• Constant/minimal mucopurulence
– Upper system (i.e., canalicular, punctal)
obstruction
• Constant/frequent mucopurulence
– Lower system (i.e. NLDO) obstruction
• Intermittent/frequent mucopurulence
– URI infection causing intermittent obstruction
at inferior turbinate

Congenital NLDO
• Caused by membranous block at valve of
Hasner
• Present in 50% of newborns
• Most resolve in 6 weeks
• 90% resolve in 1 year
• Majority with symptoms @ 6 mos will clear
by 12 months w/o surgery

Congenital NLDO Evaluation
• Pressure on sac – look for discharge
• Examine lids for open puncta
• Jones testing (DRT, I, not II) – look for dye
in throat

Congenital NLDO Management
• Conservative management for 1st
year
– Massage
– Topical antibiotics for “flare-ups”
• Indications for probing
– Acute dacyrocystitis
– Chronic skin irritation
– Parent frustration with chronic infection

(cont.)
• Probing considerations
– May perform office probing if < 6 months
– Probing with silicone intubation and inferior
turbinate infracture if > 6 mos (general anes.)

(cont.)
• Probing technique
– traction on lid – probe to “hard stop”
– rotate along brow and down duct – don’t force!
– pop through Hasner’s valve

Congenital Dacryocystocele,
(a.k.a., Mucocele, Amniotocele)
• Plugging of sac with mucous and amniotic
fluid
• Caused by NLDO – may extend into nose
• Usually sterile, may become secondarily
infected
• Probing indicated if infection develops

Congenital Dacryocystocele,
(a.k.a., Mucocele, Amniotocele)

Punctal Agenesis
• Rare
• May have a well developed canalicular
system revealed through a lid cut down
• If entire punctal-canalicular system absent,
CDCR (w/Jones tube) necessary

Acquired Epiphora
Etiology:
• Ocular surface irritation with secondary
hypersecretion
• Outflow obstruction (including eyelid or
punctal malposition)
• Primary idiopathic hypersecretion (rare)

Acquired Epiphora - Evaluation
History:
• Topical medications
• Ocular surface discomfort
• Nasal trauma/surgery or sinus disease
• Blood reflux

Acquired Epiphora - Evaluation
Exam:
• Eyelid/punctal position
– Ectropion with exposure (incl. VII n. palsy)
– Entropion with secondary trichiasis
• Tear instability (tear BUT<10 sec)
– Dry eyes/blepharitis
• Pressure on sac for mucous discharge
• Nasal exam – intranasal tumor, turbinate
impaction, polyps or allergic rhinitis

Acquired Epiphora - Diagnostics
• Schirmer tear testing
• Jones testing
– Dye disappearance test (DDT) – abnormal if
dye remains after 5 minutes
– Jones I – normal (pos) if dye spontaneously
reaches nose – Jones II not necessary
– Jones II – normal (pos) if saline irrigates freely
into nose with dye and without reflux

Jones Testing Interpretation
• Jones I (-) Jones II (+) w/dye
– functional obstruction
– trial of FML, followed by DCR
• Jones I (-) Jones II (+) w/o dye
– lid malposition vs. punctal stenosis
– treat lid disease (one snip punctoplasty, ectropion
repair)
• Jones I and II (-)
– complete obstruction – determine site

Abnormal Jones II Interpretation
• Reflux out same puncta
– canalicular obstruction
– CDCR w/ pyrex tube
• Reflux out opposite puncta without sac distension
– common canalicular obstruction
– CDCR w/ pyrex tube
• Reflux out opposite puncta with sac distension
– nasolacrimal duct obstruction
– DCR

Additional Diagnostic Testing
• Scintigraphy
– T99 scan demonstrating physiologic tear flow
• Dacryocystography
– Contrast study demonstrating anatomy

Acquired Canalicular Obstruction
• Causes
– Trauma
– Toxic medications (5-FU, phospholine iodide,
Tamoxifen)
– Autoimmune disorders (OCP, Stevens-Johnson
• Treatment
– Probing w/Si if constricted
– CDCR if obstructed

Canalicular
Infection/Inflammation
• Most common cause: Actinomyces israelli
– erythematous, dilated, “pouting” puncta
• Treatment
– Warm compresses
– Abx’s
– Curettage/canaliculotomy

Acquired NLDO - Causes
• Involutional stenosis - most common cause
– women:men 2:1
• Neoplasms
• Dacryoliths
• Naso-orbital trauma, chronic sinusitis
• Granulomatous disease
– sarcoidosis
– Wegener’s

Acquired NLDO - Treatment
• NLD probing w/ Si intubation occasionally
effective (if tubes pass easily)
• Dacryocystorhinostomy (DCR) usually
required

Acute Dacryocystitis
• Chronic tear stasis
leading to secondary
infection
• Treatment
– Oral/topical antibiotics
(Augmentin, Polytrim)
– IV Abx’s in severe cases
– I&D of any abscess
– DCR when acute
inflammation controlled

Lacrimal Sac Tumors
• Usually present as a mass above the medial
canthal tendon
• Lymphadenopathy
• Blood reflux from puncta frequently present
• Histology
– 45% benign (squamous cell papillomas)
– 55% malignant (squamous and transitional cell
carcinomas)

Lacrimal Sac Tumors - Treatment
• Dacryocystectomy (combined with lateral
rhinotomy, if malignant)
• Exenteration (incl. bone removal, if bone
involved)
• 50% recurrence rate for malignant tumors
with 50% of those being fatal
• Radiation for lymphomas and as adjunctive
treatment for carcinomas

Lacrimal Sac Tumors - Treatment

Dacryocystorhinostomy (DCR)
Perioperative considerations
– Stop all anticoagulants prior to surgery (i.e.,
coumadin, aspirin, NSAID’s)
– MAC with local anesthesia, when possible
• general anesthesia causes increased bleeding due to
systemic vasodilation
• minimal discomfort if local administered properly
• quicker recovery

Dacryocystorhinostomy (DCR)
Basic surgical steps:
• Incision into lacrimal sac
• Removal of bone between sac and nose
• Incision into nasal mucosa
• Anastamosis of lacrimal sac and nasal
mucosa
• Silicon intubation

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Oculoplastics review

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