Eye Lids and Lacrimal System
Anatomy• Consists of :
– Very thin , loose, fatty less, skin – muscles, artery & veins, lymph, nerve,
glands tied up by tissues which being compact in the posterior area, called Tarsus
– deeper layer : conjunctiva tarsal– Cilia (2-3 lines) found at the margo, that– Glands :
• Zeis : Fat• Moll : Sweat• Meibom :
– 20 - 25 glands– big– narrow straight-line– at tarsus– producing fat
• Tarsus :– build eyelids structure– superior ( height : 10 mm) is bigger
than inferior ( height : 4,5 mm)– width : 29 mm
• Vascularization :– A/V ophthalmic– A/V lacrimalis
• Sensoric Inervation : from N V
• Muscles :– Orbicular oculli muscle :
• circular• function : to open or close
the lids• inervation from N III
– Levator palebra muscle :• attached to upper border
of the tarsus and middle portion of the skin
• inervation from N III– Muller’s muscle :
• smooth muscle• insertion : at the proximal
edge of the tarsus• symphatic nerve ?
• The function of palpebra :– To protect the eye ball from external physic or
chemist injuries/trauma– To keep the eye ball surface wet and slippery
with well distributing tears and glands secretion productions
Eyelid Diseases
• Infection– Hordeolum
• Suppurative acute infection at eyelids gland caused by Staphylococcus
– Hordeolum internum : at meibom gland
– Hordeolum eksternum : at zeis, mole gland
• Therapy :– Systemic & local antibiotics– Incision :
» mostly common on hordeolum externum» Skin incision : margo» Conjuctival incision : margo
• Complication : eyelids abscess
• Kalazion– Chronic lipogranulomal inflammation at the
meibom gland– red-purple painless nodule at the conjunctiva– Therapy : incision
• eyelids abscess– originates from hordeolum or severe eyebrow
infections– Therapy :
• Local and systemic antibiotics
• incision skin line
• Blepharitis– bilateral– chronic infection at the edge of the eye lid– Squamous blepharitis (seborrhea) :
• clinical signs : itching, burning, Squamous seborroic at the lash
• Th/ : cleaning with wet cotton, corticosteroid ointment
– Ulcerate blepharitis :• margo infection caused by
staphylococci at children with bad general condition
• clinical signs : red palpebra, Squamous sebhorroic, ulceration along margo covered by crust,
• lose of lash, margo distortion (if chronic and severe)
• Th/ : improving general condition, clean the crust with wet cotton, antibiotic ointment
• Herpes Zoster Ophtalmica– E/ : herpes zoster viral– clinical signs : very pain and burning (caused
by disturbances of the first branch of nervus V)– Th/ : analgetic, antiviral (acyclovir), antibiotic
(to prevent from secondary infection) and local corticosteroid
• ALERGY– Clinical signs : oedema of palpebra– Type :
• anaphilactic and atopy (urticaria and angioneurotic edema)
• contact allergy (cosmetic)– Th/ :
• eliminate etiological agent• local and systemic steroid ( depend on the E/)
• Tumor– Benign :
• naevus
• verucca
• xanthelasma : – yellowing plaque, irregular esp.. at
medial– Th/ : excision (for cosmetic reason)
• milium :– small and white papil (lenticular)– caused by retention of sebacea gland
• Haemangiom (vascular tumor)– Cavernous haemangiom :
» consists of the big branch of vein at subcutan
» blueing» change at vaso dilatation --> bigger if
crying
– Capilary haemangiom :» consist of widing capillary» red
– Th/ :» cryoangulation (if big and disturbing)» steroid injection
– Malignant• Basal Cell Ca (Rodent Ulcer) ~ 95%
» at geriatric» most common occur on inferior palpebra (esp. at medial
cantus of margo)» clinical signs : ulcerative node, irregular, pigmentation,
metastation rare» Th/ : excision and radio th/
– Squamous Cell Ca (Epithelioma)» at geriatric» esp. at superior palpebra» metastation to preauricular nodes
through lymphatic system» Th/ : wide excision
– Malignant Melanoma» comes from the metastation of conjuntival melanoma» Th/ : radical operation --> exenterating
– Sebaceous Cell Ca» at gland. Meibom » similar with Kalazion --> repeat growing » multifocal» metastation : rare» Th/ : wide excision
Palpebra Position Anomaly
• Entropion – eyelids margo directing into the eye ball --> the
lash touch the cornea (Trichiasis) --> irritation at cornea --> corneal ulcer
– cicatrical Entropion• caused by cicatrix at tarsal conjunctive and tarsus
• E/ : trauma and trachoma (SBL tarsotomic th/ - Sie Boen Lian)
– Senile Entropion• Th/ : blepharoplasty (reconstruction)
• Ektropion– eyelids margo directing outside --> conjunctive is not well
covering --> thick, red, like chronic conjunctivitis
– Senile Ectropion :• caused by loosing of muscle• at inferior palpebra
– Paralytic Ectropion :• caused by paralyze of M.orbicularis oculi
– Cicatric Ectropion
– Th/ : blepharoplasty/reconstruction
• Simblepharon– the condition of attachment of palpebra and eye
ball (usually with cornea or bulbic conjunctive)– Th/ : leave the condition alone (if small) and
simblepharectomy
• Lagophthalmus– the condition which is eyelids aperture can not
close perfectly– E/ : paralyze of N.VII, cicatrix, proptosis,
tumor– complication : xerosis (drying)
• Ptosis– the condition which is superior palpebra can not open perfectly– unilateral/bilateral– congenital ptosis– acquired ptosis
• senile• myogenic• neurogenic (paralyze of N.III)• traumatic• mechanic (tumor)
– Th/ :• fasanela servat
– if some and the function of levator still good• shorting levator
– from skin and conjunctive
APPARATUS LACRIMALIS
• Built of :– Secretion section -->
tears production• orbital gland
• eyelids gland
• gland. Krause
– Excretion section --> draining the tears into the cavum nasal
• Tear– rather alcalyc– containing NaCl, such a lyzozym enzyme that
bacteriostatic – Normal : tear dampened the eye ball --> the
excesses are evaporates and drainating to lachrymal punctum caused by eye blinking
– measure with Schirmer Test
Clinical features of lachrymal system disturbances
• Dry eye– caused by decrease of producing tear – occur at :
• conjunctival cicatrix caused by trachoma/trauma• Sjorgen syndrome• Steven Johnson syndrome
• deficiency of Vit A• lagophthalmous
• Epiphora– the disturbance of tear excretion– Occur on :
• lachrymal punctum position disturbance
• paralyze of M. orbicularis --> weaking the canaliculi suction effect
• obstruction of nasolacrimal duct and sac
Determining a lachrymal system disturbances
• punctum inspection
• palpation at sac area– push --> the secret come out
• testanel
• probing with probe from Bowman
• dacryosistograph with contrast
• dacryoskintilograph, sophisticated, with radioactive
The congenital disturbances of nasolacrimal system
• Nasolacrimal duct obstruction– often– temporary/permanent characteristic– Th/ :
• antibiotic drop
• massage of lachrymal sac
• irrigation probing
• Punctum anomaly– no punctum– punctum evertion
• loose palpebra -----> facial paralysis
• cicatrix -----> old age
– Th/ : reconstruction
Nasolacrimal system infection• Acute dacrioadenitis
– signs : lachrymal gland red, edema, pain, blepharoptosis (sometime)
– E/ :• adult : gonorrhoica• children : with another disease --> parotitis
• Chronic dacrioadenitis– slow edema– not pain– often at TB, leukemia, trachoma– Th/ : depend on the etiological agent
• Chronic dacriosistitis– caused by the obstruction of nasolacrimal duct– children and adult– signs :
• epiphore• push at sac area --> yellow thick fluid from the punctum
– Th/ : • topical and systemic antibiotic• if obstruction --> dacriosistorinostomi
• Lacrimal sac tumor– benign
• squamous papiloma– malignant
• epidermoid Ca– Th/
• operation (cystectomy)• radiation