oculoplastics review / orthodontic courses by indian dental academy

Oculoplastics Review

INDIAN DENTAL ACADEMY

Leader in continuing dental education www.indiandentalacademy.com

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


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 EyelidLevator 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)


Retractors of Upper Eyelid

• 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


EctropionAssociated 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


EctropionWhen lid tightening is enough

• Involutional• Paralytic - simple cases


EctropionWhen 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


EntropionWhen lid tightening is enough

• Almost never– Addressing only one of several factors usually

associated with recurrence– mild involutional cases may respond


EntropionWhen 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 lesionwww.indiandentalacademy.com

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


Congenital NLDO Management (cont.)

• Probing considerations– May perform office probing if < 6 months– Probing with silicone intubation and inferior

turbinate infracture if > 6 mos (general anes.)


Congenital NLDO Management (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


The End


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