2014-2015 Basic and Clinical Science Course (BCSC): Section 7: Orbit Eyelids and Lacrimal System

340 Pages·2014·125.919 MB·English

by  John Bryan Holds

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Visual Acuity Conversion Chart
Snellen fraction
Decimal LogMAR
4-Meter Notation Visual Angle (Minimum Angle
feet Meters Standard (Visus) Minute of Arc of Resolution)
20/10 6/3 4/2 2.00 0.50 -0.30
20/15 6/4.5 4/3 1.33 0.75 -0.12
20/20 6/6 4/4 1.00 1.00 0.00
20/25 6/7.5 4/5 0.80 1.25 0.10
20/30 6/9 4/6 0.67 1.50 0.18
20/40 6/12 4/8 0.50 2.00 0.30
20/50 6/15 4/10 0.40 2.50 0.40
20/60 6/18 4/12 0.33 3.00 0.48
20/80 6/24 4/16 0.25 4.00 0.60
20/100 6/30 4/20 0.20 5.00 0.70
20/120 6/36 4/24 0.17 6.00 0.78
20/150 6/45 4/30 0.13 7.50 0.88
20/200 6/60 4/40 0.10 10.00 1.00
20/400 6/120 4/80 0.05 20.00 1.30
For discussion of this chart, see BCSC Section 3, Clinical Optics.
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Orbit, Eyelids, and
Lacrimal System
Section 7
2014-2015
(Last major revision 2011-2012)
t)� AMERICAN ACADEMY•
\!!) OF OPHTHALMOLOGY
The Eye M.D. Association
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The American Academy of Ophthalmology is accredited by the Accreditation Coun
cil for Continuing Medical Education to provide continuing medical education for
physicians.
The American Academy of Ophthalmology designates this enduring material for a
maximum of 10 AMA PRA Category 1 Credits™. Physicians should claim only the
credit commensurate with the extent of their participation in the activity.
Originally released June 2011; reviewed for currency September 7, 2013; CME expira
tion date: June 1, 2015. AMA PRA Category 1 Credits™ may be claimed only once dur
ing this period.
The BCSC is designed to increase the physician's ophthalmic knowledge through study
and review. Users of this activity are encouraged to read the text and then answer the
study questions provided at the back of the book.
To claim AMA PRA Category 1 Credits™ upon completion of this activity, learners must
demonstrate appropriate knowledge and participation in the activity by taking the post
test for Section 7 and achieving a score of 80% or higher. For further details, please see
the instructions for requesting CME crerut at the back of the book.
The Academy provides this material for educational purposes only. It is not intended
to represent the only or best method or procedure in every case, nor to replace a physi
cian's own judgment or give specific advice for case management. Including all indica
tions, contraindications, side effects, and alternative agents for each drug or treatment
is beyond the scope of this material. All information and recommendations should be
verified, prior to use, with current information included in the manufacturers' package
inserts or other independent sources, and considered in light of the patient's condition
and history. Reference to certain drugs, instruments, and other products in this course
is made for illustrative purposes only and is not intended to constitute an endorsement
of such. Some material may include information on applications that are not considered
community standard, that reflect indications not included in approved FDA labeling, or
that are approved for use only in restricted research settings. The FDA has stated that
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Cover image courtesy of Timothy J. McCulley, MD.
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Copyright © 2014
American Academy of Ophthalmology
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Basic and Clinical Science Course
Louis B. Cantor, MD, Indianapolis, Indiana, Senior Secretary for Clinical
Education
Christopher J. Rapuano, MD, Philadelphia, Pennsylvania, Secretary for
Ophthalmic Knowledge
George A. Cioffi, MD, New York, New York, BCSC Course Chair
Section 7
Faculty
John Bryan Holds, MD, Chair, St Louis, Missouri
Warren J. Chang, MD, Bloomington, Indiana
Vikram D. Durairaj, MD, Denver, Colorado
Jill Annette Foster, MD, Columbus, Ohio
Roberta E. Gausas, MD, Philadelphia, Pennsylvania
Andrew R. Harrison, MD, Minneapolis, Minnesota
Morris E. Hartstein, MD, Consultant, Raanana, Israel
Robert G. Fante, MD, Denver, Colorado
Practicing Ophthalmologists Advisory Committee for Education
Ron W Pelton, MD, PhD, Colorado Springs, Colorado
Practicing Ophthalmologists Advisory Committee for Education
The Academy wishes to acknowledge Robert Bernardino, MD, Committee on Aging, for
his review of this edition.
The Academy also wishes to acknowledge the American Society of Ophthalmic Plastic
and Reconstructive Surgery for recommending faculty members to the BCSC Section 7
committee.
Financial Disclosures
Academy staff members who contributed to the development of this product state that
within the past 12 months, they have had no financial interest in or other relationship with
any entity discussed in this course that produces, markets, resells, or distributes ophthal
mic health care goods or services consumed by or used in patients, or with any competing
commercial product or service.
The authors state the following financial relationships:
Dr Durairaj: Porex Surgical, lecturer/honoraria recipient; Stryker Corporation, lecturer/
honoraria recipient
Dr Foster: Allergan, lecturer/honoraria recipient, consultant
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Dr Harrison: Merz Pharmaceuticals, consultant •
Dr Holds: QLT Phototherapeutics, consul.ta nt
Dr Pelton: Allergan, lecturer/honoraria recipient
The other authors state that they have no significant financial interest or other relation -
ship with the manufacturer of any commercial product discussed in the chapters that
they contributed to this course or with the manufacturer of any competing commercial
product.
Recent Past Faculty
Roger A. Dailey, MD
Martin H. Devoto, MD
Michael Kazim, MD
Robert C. Kersten, MD
Timothy J. McCulley, MD
In addition, the Academy gratefully acknowledges the contributions of numerous past
faculty and advisory committee members who have played an important role in the devel
opment of previous editions of the Basic and Clinical Science Course.
American Academy of Ophthalmology Staff
Richard A. Zorah, Vice President, Ophthalmic Knowledge
Hal Straus, Director, Publications Department
Christine Arturo, Acquisitions Manager
Stephanie Tanaka, Publications Manager
D. Jean Ray, Production Manager
Ann McGuire, Medical Editor
Crissa M. Williams, Administrative Coordinator
ti[~ AMERICAN ACADEMY$
\_V OF OPHTHALMOLOGY
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655 Beach Street
Box 7424
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Contents
General Introduction xiii
Objectives .1
PART I Orbit. .3
1 Orbital Anatomy .5
Dimensions . . . . . . 5
Topographic Relationships . . 5
Roof of the Orbit . . . . 5
Lateral Wall of the Orbit . . 6
Medial Wall of the Orbit . . 7
Floor of the Orbit . . . 8
Apertures ....... . . 8
Ethmoidal Foramina. . . 8
Superior Orbital Fissure . 9
Inferior Orbital Fissure. .9
Zygomaticofacial and Zygomaticotemporal Canals. .9
Nasolacrimal Canal . .9
Optic Canal .9
Soft Tissues . . . . . . 10
Periorbita . . . . . 10
Intraorbital Optic Nerve . 10
Extraocular Muscles and Orbital Fat . 10
Annulus of Zinn . . . 11
Vasculature of the Orbit 12
Nerves .... . 13
Lacrimal Gland . . . . 17
Periorbital Structures . . . 17
Nose and Paranasal Sinuses. 17
2
Evaluation of Orbital Disorders . 21
History . . . . 21
Pain ...... . 21
Progression. . . . 21
Periorbital Changes 21
Physical Examination . 22
Inspection . 22
Palpation .. 24
Auscultation 25
V
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vi • Contents
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Primary Studies . . . . . . 25
Computed Tomography . . . 25
Magnetic Resonance Imaging . 26
Comparison of CT and MRI 28
Ultrasonography 29
Secondary Studies 30
Venography . . 31
Arteriography . 31
CT and MR Angiography 31
Pathology .... 31
Laboratory Studies . . . . . 32
3 Congenital Orbital Anomalies. 33
Anophthalmia . . . 33
Microphthalmia . . . . . 33
Craniofacial Clefting . . . 34
Congenital Orbital Tumors. 35
Hamartomas and Choristomas 35
Teratoma . ....... . . 37
4 Orbital Inflammatory and Infectious Disorders. 39
Infectious Inflammation . 40
Cellulitis . . . . . . 40
Necrotizing Fasciitis . 44
Orbital Tuberculosis . 45
Zygomycosis . . . 45
Aspergillosis . . . . 46
Parasitic Diseases . . 47
Noninfectious Inflammation . 47
Thyroid Eye Disease . 47
Vasculitis . . . . . . . 55
Sarcoidosis . . . . . . . 58
Nonspecific Orbital Inflammation. 59
5 Orbital Neoplasms and Malformations. 63
Vascular Tumors, Malformations, and Fistulas 63
Capillary Hemangiomas . 63
Cavernous Hemangioma . 64
Hemangiopericytoma . . 65
Lymphatic Malformation . 65
Venous Malformation .. 66
Arteriovenous Malformations. 67
Arteriovenous Fistula 67
Orbital Hemorrhage . 69
Neural Tumors ..... 69
Optic Nerve Glioma . 69
Neurofibroma ... 72
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Contents • vii
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Neurofibromatosis 1. 73
Meningioma . . . 73
Schwannoma . . . . • 76
Mesenchymal Tumors . . 76
Rhabdomyosarcoma. 76
Miscellaneous Mesenchymal Tumors 78
Lymphoproliferative Disorders . . . . . 79
Lymphoid Hyperplasia and Lymphoma 79
Plasma Cell Tumors . 84
Histiocytic Disorders 84
Xanthogranuloma . . 85
Lacrimal Gland Tumors . 85
Epithelial Tumors of the Lacrimal Gland . 86
Nonepithelial Tumors of the Lacrimal Gland 88
Secondary Orbital Tumors . . 88
Globe and Eyelid Origin . 88
Sinus Origin . . . . . . 88
Metastatic Tumors . . . . . 90
Metastatic Tumors in Children 90
Metastatic Tumors in Adults . 91
Management of Orbital Metastases 93
6 Orbital Trauma . . . . 95
Midfacial (Le Fort) Fractures . 95
Orbital Fractures . . . . . 95
Zygomatic Fractures . . 95
Orbital Apex Fractures. 97
Orbital Roof Fractures . 98
Medial Orbital Fractures . 98
Orbital Floor Fractures. . 100
Intraorbital Foreign Bodies. . 104
Orbital Hemorrhage . . . . 104
Traumatic Visual Loss With Clear Media. 104
Management . . 106
7 Orbital Surgery 107
Surgical Spaces . . . . 107
Orbitotomy . . . . . 108
Superior Approach . 108
Inferior Approach . . 109
Medial Approach . . 110
Lateral Approach . . 112
Orbital Decompression . 113
Postoperative Care for Orbital Surgery. . 115
Special Surgical Techniques in the Orbit . . 115
Complications of Orbital Surgery . . . . . 116
viii • Contents"
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8 The Anophthalmic Socket 117
Enucleation . . . . . . . . . . 117
Guidelines for Enucleatidn . . . 118
Enucleation in Childhood . . . 119
Intraoperative Complications of Enucleation . 119
Evisceration . . . . . . . . . . . 119
Advantages of Evisceration . . . 120
Disadvantages of Evisceration. . 120
Techniques of Evisceration . . 120
Orbital Implants . . . . . . . . . 121
Prostheses . . . . . . . . . . 122
Anophthalmic Socket Complications and Treatment. . 122
Deep Superior Sulcus . . . . . . . 122
Contracture of Fornices . . . . . . 123
Exposure and Extrusion of Implant . 123
Contracted Sockets . . . . 124
Anophthalmic Ectropion. . 124
Anophthalmic Ptosis . . 125
Lash Margin Entropion . 125
Cosmetic Optics . . . . 125
Exenteration . . . . . . . . 126
Considerations for Exenteration. . 126
Types of Exenteration . . . . . . 127
PART II Periocular Soft Tissues. 129
9 Facial and Eyelid Anatomy. 131
Face ............. . . 131
Eyelids ........... . . 134
Skin and Subcutaneous Tissue . 136
Protractors . . . . 136
Orbital Septum . . 137
Orbital Fat . . 138
Retractors . . 138
Tarsus ... . 140
Conjunctiva . 141
Additional Anatomical Considerations . . 141
10 Classification and Management of Eyelid Disorders 145
Congenital Anomalies . . . . . . . . . . 145
Blepharophimosis Syndrome . . . . . 145
Congenital Ptosis of the Upper Eyelid . 146
Congenital Ectropion . 146
Euryblepharon . . . 146
Ankyloblepharon . . 147
Epicanthus . . . . . 147
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