Ophthalmology A Short Textbook - part 2 pot

44
Cavernous hemangioma.
Fig. 2.25 The congenit al vascular
anomaly occurs as a facial lesion most
commonly occur in the eyelids. The le-
sion regresses spontaneously in ap-
proximately 70% of all cases.
Symptoms: Hemangiomas include capillary or superficial, cavernous, and
deep forms.
Diagnostic considerations: Hemangiomas can be compressed, and the skin
will then appear white.
Differential diagnosis: Nevus flammeus: This is characterized by a sharply
demarcated bluish red mark (“port-wine” stain) resulting from vascular
expansion under the epidermis (not a growth or tumor).
Treatment: A watch-and-wait approach is justified in light of the high rate of
spontaneous remission (approximately 70%). Where there is increased risk of
amblyopia due to the size of the lesion, cr yotherapy, intralesional steroid
injections, or radiation therapy can accelerate regression of the hemangioma.
Prognosis: Generally good.
2.7.1.7 Neurofibromatosis (Recklinghausen’s Disease)
Definition
A congenital developmental defect of the neuroectoderm gives rise to neural
tumors and pigment spots (café au lait spots).
Neurofibromatosis is regarded as a phacomatosis (a developmental disorder
involving the simultaneous presence of changes in the skin, central nervous
system, and ectodermal portions of the eye).
2 The Eyelids
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Symptoms and diagnostic considerations: The numerous tumors are soft,

broad-based, or pediculate, and occur either in the skin or in subcutaneous
tissue, usually in the vicinity of the upper eyelid.
They can reach monstrous proportions and present as elephantiasis of the
eyelids (Fig. 2.
26).
Treatment: Smaller fibromas can be easily removed by surgery. Larger
tumors always entail a risk of postoperative blee ding and recurrence. On the
whole, treatment is diff icult.
2.7.2 Malignant Tumors
2.7.2.1 Basal Cell Carcinoma
Definition
Basal cell carcinoma is a frequent, moderately malignant, fibroepithelial tumor
that can cause severe local tissue destruction but very rarely metastasizes.
Neurofibroma.
Fig. 2.26 Larger fibromas can lead to
elephantiasis of the eyelids.
2.7 Tumors
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Epidemiology: Approximately 90% of all malignant eyelid tumors are basal
cell carcinomas. Their incidence increases with age. In approximately 60% of
all cases they are localized on the lower eyelid. Morbidity in sunny countries
is 110 cases per 100000 persons (in central Europe approximately 20 per
100 000 persons). Dark-skinned people are affected significantly less often.
Gender is not a predisposing factor.
Etiology: Causes of basal cell carcinoma may include a genetic disposition.
Increased exposure to the sun’s ultraviolet radiation, carcinogenic substances
(such as arsenic), and chronic skin damage can also lead to an increased inci-
dence. Basal cell carcinomas arise from the basal cell layers of the epidermis

and the sebaceous gland hair follicles, where their growth locally destroys
tissue.
Symptoms: Typical characteristics include a firm, slightly raised margin (a
halo resembling a string of beads) with a central crater and superficial vascular-
ization with an increased tendency to bleed (Fig. 2.
27).
Ulceration with “gnawing” peripheral proliferation is occasionally
referred to as an ulcus rodens; an ulcus terebans refers to deep infiltration with
invasion of cartilage and bone.
Diagnostic considerations: The diagnosis can very often be made on the
basis of clinical evidence. A biopsy is indicated if there is any doubt.
Loss of the eyelashes in the vicinity of the tumor always suggests malig-
nancy.
Treatment: The lesion is treated by surgical excision within a margin of
healthy tissue. This is the safest method. If a radical procedure is not feasible,
Basal cell carcinoma.
Fig. 2.27 A halo
resembling a
string of beads,
superficial vascu-
larization, and a
central crater
with a tendency
to bleed are
characteristic
signs of this mod-
erately malignant
tumor.
2 The Eyelids
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the only remaining options are radiation therapy or cryotherapy with liquid
nitrogen.
Prognosis: The changes of successful treatment by surgical excision are very
good. Frequent follow-up examinations are indicated.
The earlier a basal cell carcinoma is detected, the easier it is to remove.
2.7.2.2 Squamous Cell Carcinoma
This is the second most frequently encountered malignant eyelid tumor. The
carcinoma arises from the epidermis, grows rapidly and destroys tissue. It can
metastasize into the regional lymph nodes. Remote metastases are rarer. The
treatment of choice is complete surgical removal.
2.7.2.3 Adenocarcinoma
The rare adenocarcinoma arises from the meibomian glands or the glands of
Zeis. The
firm, painless swelling is usually located in the upper eyelid and is
mobile with respect to the skin but not with respect to the underlying tissue.
In its early stages it can be mistaken easily for a chalazion (see p. 39). The
lesion can metastasize into local lymph nodes.
An apparent chalazion that cannot be removed by the usual surgical
procedure always suggests a suspected adenocarcinoma.
The treatment of choice is complete surgical removal.
2.7 Tumors
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49
3 Lacrimal System
Peter Wagner and Gerhard K. Lang

3.1 Basic Knowledge
The lacrimal system (Fig. 3.1) consists of two sections:
❖
Structures that secrete tear fluid.
❖
Structures that facilitate tear drainage.
Anatomy of the lacrimal system.
Orbital part of the
lacrimal gland
Plica semilunaris
Superior punctum lacrimale
Lacrimal sac
Nasolacrimal
duct
Superior lacrimal
canaliculus
Inferior concha
Fundus of the
lacrimal sac
Inferior punctum lacrimale
Fig. 3.1 The lacrimal system consists of tear secretion structures and tear drainage
structures.
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Structure of the tear film.
Oily layer (approx. 0.1 µm)
– cholesteryl esters
– cholesterol
– triglyceride

– phospholipids
Water layer (approx. 8
µ
m)
– 98–99% water
– approx. 1% inorganic salts
– approx. 0.2–0.6% proteins,
globulins, and albumin
– approx. 0.02–0.06%
lysozyme
– Rest: glucose, urea, neutral
mucopolysaccharides
(mucin), and acidic
mucopolysaccharides
Mucin layer (approx. 0.8 µm)
Epithelium with microvilli
and folds
Oily layer,
0.1
µ
m
Meibomian glands
Lacrimal
gland
Water
layer,
8
µ
m
Conjunctival

goblet cells
Mucin layer,
0.8
µ
m
Fig. 3.2 The tear film is composed of three layers:
❖
An oily layer (prevents rapid desiccation).
❖
A watery layer (ensures that the cornea remains clean and smooth for optimal
transparency).
❖
A mucin layer (like the oily outer layer, it stabilizes the tear film).
Position, structure, and nerve supply of the lacrimal gland: The lacrimal
gland
is about the size of a walnut; it lies beneath the superior temporal mar-
gin of the orbital bone in the lacrimal fossa of the frontal bone and is neither
visible nor palpable. A palpable lacrimal gland is usually a sign of a pathologic
change such as dacryoadenitis. The tendon of the levator palpebrae muscle
divides the lacrimal gland into a larger orbital part (two-thirds) and a smaller
palpebral part (one-third). Several tiny
accessory lacrimal glands (glands of
Krause and Wolfring)
located in the superior fornix secrete additional serous
tear fluid.
The lacrimal gland receives its
sensory supply from the lacrimal nerve. Its
parasympathetic secretomotor nerve supply comes from the nervus interme-
dius. The sympathetic fibers arise from the superior cervical sympathetic
ganglion and follow the course of the blood vessels to the gland.

Tear film: The tear film (Fig. 3.2) that moistens the conjunctiva and cornea is
composed of
three layers:
1. The
outer oily layer (approximately 0.1 µm thick) is a product of the mei-
bomian glands and the sebaceous glands and sweat glands of the margin of
3 Lacrimal System
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51
the eyelid. The primary function of this layer is to stabilize the tear film.
With its hydrophobic properties, it prevents rapid evaporation like a layer
of wax.
2. The
middle watery layer (approximately 8 µm thick) is produced by the
lacrimal gland and the accessory lacrimal glands (glands of Krause and
Wolfring). Its task is to clean the surface of the cornea and ensure mobility
of the palpebral conjunctiva over the cornea and a smooth corneal surface
for high-quality optical images.
3. The
inner mucin layer (approximately 0.8 µm thick) is secreted by the
goblet cells of the conjunctiva and the lacrimal gland. It is hydrophilic with
respect to the microvilli of the corneal epithelium, which also helps to sta-
bilize the tear film. This layer prevents the watery layer from forming beads
on the cornea and ensures that the watery layer moistens the entire surface
of the cornea and conjunctiva.
Lysozyme, beta-lysin, lactoferrin, and gamma globulin (IgA) are
tear-specific
proteins
that give the tear fluid antimicrobial characteristics.

Tear drainage: The shingle-like arrangement of the fibers of the orbicularis
oculi muscle
(supplied by the facial nerve) causes the eye to close progress-
ively from lateral to medial instead of the eyelids simultaneously closing
along their entire length. This windshield wiper motion moves the tear fluid
medially across the eye toward the medial canthus (Figs. 3.
3 a – c).
The
superior and inferior puncta lacrimales collect the tears, which then
drain through the superior and inferior
lacrimal canaliculi into the lacrimal
sac
. From there they pass through the nasolacrimal duct into the inferior
concha
(see Fig. 3.1).
Combined function of the orbicularis oculi muscle and the lower lacrimal
system.
Opening the eye
Levator palpebrae
superioris muscle
(oculomotor nerve)
Closing the eye
Orbicularis oculi
muscle (facial
nerve)
Figs. 3.3 a –c As the eyelids close, they act like a windshield wiper to move the tear
fluid medially across the eye toward the puncta and lacrimal canaliculi.
a b c
3.1 Basic Knowledge
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Measuring tear secretion with Schirmer tear testing.
Fig. 3.4 A strip
of litmus paper is
folded over and
inserted into the
conjunctival sac
of the temporal
third of the lower
eyelid. Normally,
at least 15 mm of
the paper should
turn blue within
five minutes.
3.2 Examination Methods
3.2.1 Evaluation of Tear Formation
Schirmer tear testing: This test (Fig. 3.4) provides information on the quan-
tity of watery component in tear secretion.
❖
Test: A strip of litmus paper is inserted into the conjunctival sac of the tem-
poral third of the lower eyelid.
❖
Normal: After about five minutes, at least 15 mm of the paper should turn
blue due to the alkaline tear fluid.
❖
Abnormal: Values less than 5 mm are abnormal (although they will not
necessarily be associated with clinical symptoms).
The same method is used after application of a topical anesthetic to
evaluate

normal secretion without irritating the conjunctiva
.
Tear break-up time (TBUT): This test evaluates the stability of the tear film.
❖
Test: Fluorescein dye (10 µl of a 0.125% fluorescein solution) is added to the
precorneal tear film. The examiner observes the eye under 10 – 20 power
magnification with slit lamp and cobalt blue filter and notes when the first
signs of drying occur (i) without the patient closing the eye and (ii) with the
patient keeping the eye open as he or she would normally.
❖
Normal: TBUT of at least 10 seconds is normal.
Rose bengal test: Rose bengal dyes dead epithelial cells and mucin. This test
has proven particularly useful in evaluating dry eyes (keratoconjunctivitis
sicca) as it reveals conjunctival and corneal symptoms of desiccation.
3 Lacrimal System
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Impression cytology: A Millipore filter is fastened to a tonometer and
pressed against the superior conjunctiva with 20 –30 mm Hg of pressure for
two seconds. The
density of goblet cells is estimated under a microscope
(normal density is 20 –45 goblet cells per square millimeter of epithelial sur-
face). The number of mucus-producing goblet cells is reduced in various dis-
orders such as keratoconjunctivitis sicca, ocular pemphigoid, and xeroph-
thalmia.
3.2.2 Evaluation of Tear Drainage
Conjunctival fluorescein dye test : Normal tear drainage can be demon-
strated by having the patient blow his or her nose into a facial tissue following
application of a 2% fluorescein sodium solution to the inferior fornix.

Probing and irrigation: These examination methods are used to locate ste-
noses. After application of a topical anesthetic, a conical probe is used to
dilate the punctum. Then the lower lacrimal system is flushed with a physio-
logic saline solution introduced through a blunt cannula (Figs. 3.
5 a and b). If
the passage is unobstructed, the solution will drain freely into the nose.
Canalicular stenosis will result in reflux through the irrigated punctum.
If the stenosis is deeper, reflux will occur through the opposite punctum
(Fig. 3.6).
A probe can be used to determine the site of the stricture, and possibly to
eliminate obstructions (Fig. 3.
7).
Radiographic contrast studies: Radiographic contrast medium is instilled in
the same manner as the saline solution. These studies demonstrate the
shape,
position, and size of the passage and possible obstructions to drainage.
Digital substraction dacryocystography: These studies demonstrate only
the contrast medium and image the lower lacrimal system without superim-
posed bony structures. They are particularly useful as
preoperative diagnos-
tic studies
(Fig. 3.8).
Lacrimal endoscopy: Fine endoscopes now permit direct visualization of
the mucous membrane of the lower lacrimal system.
Until recently, endo-
scopic examination of the lower lacrimal system was not a routine procedure.
3.2 Examination Methods
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Irrigation of the lower lacrimal system under topical anesthesia.
Figs. 3.5 a and b
First the punc-
tum is dilated by
rotating a conical
probe. Then the
lacrimal passage
is flushed with a
physiologic saline
solution. The ex-
aminer should be
particularly alert
to good drainage
or possible reflux.
a
b
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Localizing an obstruction by irrigating the lower lacrimal system.
No obstruction
Stenosis of the
inferior canaliculus
Stenosis of the inferior
common punctum
Stenosis within the
lacrimal sac
Fig. 3.6 The lower lacrimal system
should be irrigated with care by an ex-

perienced ophthalmologist. Failure to
locate the passage will inflate the eyelid
and provide no diagnostic information.
3.2 Examination Methods
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Opening a stenosis of the lower lacrimal system with a probe.
Figs. 3.7 a –c After application of a topical anesthetic, the probe is carefully intro-
duced into the lower lacrimal system. The puncta are dilated and then the valve of
Hasner is opened (a and b). A dye solution can then be introduced to verify patency
of the lower lacrimal system (c). In infants six months or older, the procedure is best
performed under short-acting general anesthesia.
a
c
b
3 Lacrimal System
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Radiographic image of the lower lacrimal system.
Fig. 3.8 Digital
substraction
dacryocystogra-
phy images the
lower lacrimal
system and can
demonstrate a
possible stenosis
(arrow) without

superimposed
bony structures.
3.3 Di sorders of the Lower Lacrimal System
3.3.1 Dacryocystitis
Inflammation of the lacrimal sac is the most frequent disorder of the lower
lacrimal system. It is usually the result of obstruction of the nasolacrimal duct
and is unilateral in most cases.
3.3.1.1 Acute Dacryocystitis
Epidemiology: The disorder most frequently affects adults between the ages
of 50 and 60.
Etiology: The cause is usually a stenosis within the lacrimal sac. The retention
of tear fluid leads to infection from staphylococci, pneumococci, Pseudo-
monas, or other pathogens.
Symptoms: Clinical symptoms include highly inflamed, painful swelling in
the vicinity of the lacrimal sac (Fig. 3.
9) that may be accompanied by malaise,
fever, and involvement of the regional lymph nodes. The pain may be referred as
far as the forehead and teeth. An abscess in the lacrimal sac may form in
advanced disorders; it can spontaneously rupture the skin and form a drain-
ing fistula.
3.3 Disorders of the Lower Lacrimal System
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Acute dacryocystitis.
Fig. 3.9 Typical
symptoms in-
clude highly in-
flamed, painful
swelling in the vi-

cinity of the lacri-
mal sac.
Acute inflammation that has spread to the surrounding tissue of the
eyelids and cheek entails a risk of sepsis and cavernous sinus thrombo-
sis, which is a life-threatening complication.
Diagnostic considerations: Radiographic contrast studies or digital sub-
straction dacryocystography can visualize the obstruction for preoperative
planning. These studies should be avoided during the acute phase of the dis-
order because of the risk of pathogen dissemination.
Differential diagnosis:
❖
Hordeolum (small, circumscribed, nonmobile inflamed swelling).
❖
Orbital cellulitis (usually associated with reduced motility of the eyeball).
Treatment: Acute cases are treated with local and systemic antibiotics
according to the specific pathogens detected. Disinfectant compresses (such as
a 1:1000 Rivanol solution) can also positively influence the clinical course of
the disorder. Pus from a fluctuating abscess is best drained through a stab inci-
sion following cryoanesthesia with a refrigerant spray.
Treatment after
acute symptoms have subsided often requires surgery
(dacryocystorhinostomy; Figs. 3.
10a– c) to achieve persistent relief. Also
known as a lower system bypass, this operation involves opening the lateral
wall of the nose and bypassing the nasolacrimal duct to create a direct con-
nection between the lacrimal sac and the nasal mucosa.
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Dacryocystorhinostomy.
Orbital rim
a
b
c
Figs. 3.10a – c A skin incision is made,
and the orbital rim is exposed. Then a
window is opened to expose the nasal
mucosa. The nasal mucosa and the lacri-
mal sac are both incised in an H-shape
and door-like flaps are raised. The ante-
rior and posterior mucosal flaps are then
sutured together. This creates a new
drainage route for the tear fluid that by-
passes the nasolacrimal duct.
3.3 Disorders of the Lower Lacrimal System
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3.3.1.2 Chronic Dacryocystitis
Etiology: Obstruction of the nasolacrimal duct is often secondary to chronic
inflammation of the connective tissue or nasal mucosa.
Symptoms and diagnostic considerations: The initial characteristic of
chronic dacryocystitis is increased lacrimation. Signs of inflammation are not
usually present. Applying pressure to the inflamed lacrimal sac causes large
quantities of transparent mucoid pus to regurgitate through the punctum.
Chronic inflammation of the lacrimal sac can lead to a serpiginous cor-
neal ulcer.
Treatment: Surgical intervention is the only effective treatment in the vast
majority of cases. This involves either a dacryocystorhinostomy (creation of a

direct connection between the lacrimal sac and the nasal mucosa; see Figs.
3.
10a– c) or removal of the lacrimal sac.
3.3.1.3 Neonatal Dacryocystitis
Etiology: Approximately 6% of newborns have a stenosis of the mouth of the
nasolacrimal duct due to a persistent mucosal fold (lacrimal fold or valve of
Hasner). The resulting retention of tear fluid provides ideal growth conditions
for bacteria, particularly staphylococci, streptococci, and pneumococci.
Symptoms and diagnostic considerations: Shortly after birth (usually
within two to four weeks), pus is secreted from the puncta. The disease con-
tinues subcutaneously and pus collects in the palpebral fissure. The conjunc-
tiva is not usually involved.
Differential diagnosis:
❖
Gonococcal conjunctivitis and inclusion conjunctivitis (see Fig. 4.3).
❖
Silver catarrh (harmless conjunctivitis with slimy mucosal secretion fol-
lowing Credé’s method of prophylaxis with silver nitrate).
Treatment: During the first few weeks, the infant should be monitored for
spontaneous opening of the stenosis. During this period, antibiotic and anti-
inflammatory eyedrops and nose drops (such as erythromycin and xylo-
metazoline 0.5% for infants) are administered.
If symptoms persist, irrigation or probing under short-acting general anes-
thesia may be indicated (see Figs. 3.
7 a – c).
Often massaging the region several times daily while carefully applying
pressure to the lacrimal sac will be sufficient to open the valve of Hasner
and eliminate the obstruction.
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3.3.2 Canaliculitis
Definition
This usually involves inflammation of the canaliculus.
Epidemiology and etiology: Genuine canaliculitis is rare. Usually a stricture
will be present and the actual inflammation proceeds from the conjunctiva.
Actinomycetes (fungoid bacteria) often cause persistent purulent granular
concrements that are difficult to express.
Symptoms and diagnostic considerations: The canaliculus region is swol-
len, reddened, and often tender to palpation. Pus or granular concrements
can be expressed.
Treatment: The disorder is treated with antibiotic eyedrops and ointments
according to the specific pathogens detected in cytologic smears. Successful
treatment occasionally requires surgical incision of the canaliculus.
3.3.3 Tumors of the Lacrimal Sac
Epidemiology: Tumors of the lacrimal sac are rare but are primarily malig-
nant when they do occur. They include papillomas, carcinomas, and sar-
comas.
Symptoms and diagnostic considerations: Usually the tumors cause uni-
lateral painless swelling followed by dacryostenosis.
Diagnostic considerations: The irregular and occasionally bizarre form of
the structure in radiographic contrast studies is typical. Ultrasound, CT, MRI,
and biopsy all contribute to confirming the diagnosis.
Differential diagnosis: Chronic dacryocystitis (see above), mucocele of the
ethmoid cells.
Treatment: The entire tumor should be removed.
3.3 Disorders of the Lower Lacrimal System
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3. 4 Lacr imal System Dysfunction
3.4.1 Keratoconjunctivitis Sicca
Definition
Noninfectious keratopathy characterized by reduced moistening of the con-
junctiva and cornea (dry eyes).
Epidemiology: Keratoconjunctivitis sicca as a result of dry eyes is one of the
most common eye problems between the ages of 40 and 50. As a result of hor-
monal changes in menopause, women are far more frequently affected (86%)
than men. There are also indications that keratoconjunctivitis sicca is more
prevalent in regions with higher levels of environmental pollution.
Etiology: Keratoconjunctivitis sicca results from dry eyes, which may be due
to one of two causes:
❖
Reduced tear production associated with certain systemic disorders (such
as Sjögren’s syndrome and rheumatoid arthritis) or as a result of atrophy or
destruction of the lacrimal gland.
❖
Altered composition of the tear film. The composition of the tear film can
alter due to vitamin A deficiency, medications (such as oral contraceptives
and retinoids), or certain environmental influences (such as nicotine,
smog, or air conditioning). The tear film breaks up too quickly and causes
corneal drying.
Dry eyes can represent a
disorder in and of itself.
Symptoms: Patients complain of burning, reddened eyes, and excessive lacri-
mation (reflex lacrimation) from only slight environmental causes such as
wind, cold, low humidity, or reading for an extended period of time. A foreign
body sensation is also present. These symptoms may be accompanied by
intense pain. Eyesight is usually minimally compromised if at all.

Diagnostic considerations: Often there is a discrepancy between the mini-
mal clinical findings that the ophthalmologist can establish and the intense
symptoms reported by the patient. Results from
Schirmer tear testing usually
show reductions of the watery component of tears, and the
tear break-up
time
(which provides information about the mucin content of the tear film
which is important for its stability) is reduced. Values of at least 10 seconds
are normal; the tear break-up time in keratoconjunctivitis sicca is less than 5
seconds.
Slit lamp examination will reveal dilated conjunctival vessels and minimal
pericorneal injection. A tear film meniscus cannot be demonstrated on the
lower eyelid margin, and the lower eyelid will push the conjunctiva along in
folds in front of it.
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In severe cases the eye will be reddened, and the tear film will contain thick
mucus and small filaments that proceed from a superficial epithelial lesion
(filamentary keratitis; see Fig. 5.
11). The corneal lesion can be demonstrated
with
fluorescein dye. In less severe cases the eye will only be reddened,
although application of fluorescein dye will reveal corneal lesions (superficial
punctate keratitis; see p. 138). The
rose bengal test (see p. 52) and impression
cytology
(see p. 53) are additional diagnostic tests that are useful in evaluat-

ing persistent cases.
Treatment: Depending on the severity of findings, artificial tear solutions in
varying viscosities are prescribed. These range from eyedrops to high-viscos-
ity long-acting gels that may be applied every hour or every half hour,
depending on the severity of the disorder. In persistent cases, the puncta can
be temporarily closed with silicone
punctal plugs (Fig. 3.11) to at least retain
the few tears that are still produced.
Surgical obliteration of the puncta may
be indicated in severe cases.
Patients should also be informed about the possibility of installing an
air
humidifier
in the home and redirecting blowers in automobiles to avoid
further drying of the eyes. Dry eyes in women may also be due to hormonal
changes, and a
gynecologist should be consulted regarding the patient’s hor-
monal status.
Prognosis: The prognosis is good for those treatments discusse d here.
However, the disorder cannot be completely healed.
Treatment of dry eyes.
Fig. 3.11 Treat-
ment can be aug-
mented by tem-
porarily closing
the puncta with
silicone punctal
plugs.
3.4 Lacrimal System Dysfunction
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3.4.2 Illacrimation
Illacrimation or epiphora may be due to hypersecretion from the lacrimal
gland. However, it is more often caused by obstructed drainage through the
lower lacrimal system.
Causes of hypersecretion:
❖
Emotional distress (crying).
❖
Increased irritation of the eyes (by smoke, dust, foreign bodies, injury, or
intraocular inflammation) leads to excessive lacrimation in the context of
the defensive triad of blepharospasm, photosensitivity, and epiphora.
Causes of obstructed drainage:
❖
Stricture or stenosis in the lower lacrimal system.
❖
Eyelid deformity (eversion of the punctum lacrimale, ectropion, or
entropion).
3.5 Disorders of the Lacrimal Gland
3.5.1 Acute Dacryoadenitis
Definition
Acute inflammation of the lacrimal gland is a rare disorder characterized by
intense inflammation and extreme tenderness to palpation.
Etiology: The disorder is often attributable to pneumococci and staphylo-
cocci, and less frequently to streptococci. There may be a relationship
between the disorder and infectious diseases such as mumps, measles, scar-
let fever, diphtheria, and influenza.
Symptoms and diagnostic considerations: Acute dacryoadenitis usually
occurs unilaterally. The inflamed swollen gland is especially tender to palpa-

tion.
The upper eyelid exhibits a characteristic S-curve (Fig. 3.12).
Differential diagnosis:
❖
Internal hordeolum (smaller and circumscribed).
❖
Eyelid abscess (fluctuation).
❖
Orbital cellulitis (usually associated with reduced motility of the eyeball).
Treatment: This will depend on the underlying disorder. Moist heat, disinfect-
ant compresses (Rivanol), and local antibiotics are helpful.
Clinical course and prognosis: Acute inflammation of the lacrimal gland is
characterized by a rapid clinical course and spontaneous healing within eight
3 Lacrimal System
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65
to ten days. The prognosis is good, and complications are not usually to be
expected.
3.5.2 Chronic Dacryoadenitis
Etiology: The chronic form of inflammation of the lacrimal gland may be the
result of an incompletely healed acute dacryoadenitis. Diseases such as tuber-
culosis, sarcoidosis, leukemia, or lymphogranulomatosis can be causes of
chronic dacryoadenitis.
Bilateral chronic inflammation of the lacrimal and salivary glands is
referred to as Mikulicz’s syn dr om e.
Symptoms and diagnostic considerations: Usually there is no pain. The
symptoms are less pronounced than in the acute form. However, the S-curve
deformity of the palpebral fissure resulting from swelling of the lacrimal
gland is readily apparent (see Fig. 3.

12).
Differential diagnosis:
❖
Periostitis of the upper orbital rim (rare).
❖
Lipodermoid (no signs of inflammation).
Treatment: This will depend on the underlying disorder. Systemic corti-
costeroids may be effective in treating unspecific forms.
Prognosis: The prognosis for chronic dacryoadenitis is good when the under-
lying disorder can be identified.
Acute dacryoadenitis.
Fig. 3.12
Characteristic
S-curve of the
upper eyelid.
3.5 Disorders of the Lacrimal Gland
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3.5.3 Tumors of the Lacrimal Gland
Epidemiology: Tumors of the lacrimal gland account for 5 – 7% of orbital neo-
plasms. Lacrimal gland tumors are much rarer in children (approximately 2 %
of orbital tumors). The relation of benign to malignant tumors of the lacrimal
gland specified in the literature is 10: 1. The
most frequent benign epithelial
lacrimal gland tumor
is the pleomorphic adenoma. Malignant tumors
include the adenoid cystic carcinoma and pleomorphic adenocarcinoma.
Etiology: The WHO classification of 1980 divides lacrimal gland tumors into
the following categories:

I. Epithelial tumors.
II. Tumors of the hematopoietic or lymphatic tissue.
III. Secondary tumors.
IV. Inflamed tumors.
V. Other and unclassified tumors.
Symptoms: Tumors usually grow very slowly. After a while, they displace the
eyeball inferiorly and medially, which can cause double vision.
Diagnostic considerations: Testing motility provides information about the
infiltration of the tumor into the extraocular muscles or mechanical changes
in the eyeball resulting from tumor growth. The echogenicity of the tumor in
ultrasound studies is an indication of its consistency. CT and MRI studies
show the exact location and extent of the tumor. A biopsy will confirm
whether it is malignant and what type of tumor it is.
Treatment: To the extent that this is possible, the entire tumor should be
removed; orbital exenteration (removal of the entire contents of the orbit)
may be required. Systemic administration of corticosteroids is indicated for
unspecific tumors.
Prognosis: This depends on the degree of malignancy of the tumor. Adenoid
cystic carcinomas have the most unfavorable prognosis.
3 Lacrimal System
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4 Conjunctiv a
Gerhard K. Lang and Gabriele E. Lang
4.1 Basic Knowledge
Structure of the conjunctiva (Fig. 4.1): The conjunctiva is a thin vascular
mucous membrane that normally of shiny appearance. It forms the conjunc-
tival sac together with the surface of the cornea. The
bulbar conjunctiva is

loosely attached to the sclera and is more closely attached to the limbus of the
cornea. There the conjunctival epithelium fuses with the corneal epithelium.
The
palpebral conjunctiva lines the inner surface of the eyelid and is firmly
attached to the tarsus. The loose palpebral conjunctiva forms a fold in the
conjunctival fornix, where it joins the bulbar conjunctiva. A half-moon-
shaped fold of mucous membrane, the plica semilunaris, is located in the
medial corner of the palpebral fissure. This borders on the lacrimal caruncle,
which contains hairs and sebaceous glands.
Function of the conjunctival sac: The conjunctival sac has three main tasks:
1. Motility of the eyeball. The loose connection between the bulbar conjunc-
tiva and the sclera and the “spare” conjunctival tissue in the fornices allow
the eyeball to move freely in every direction of gaze.
2. Articulating layer. The surface of the conjunctiva is smooth and moist to
allow the mucous membranes to glide easily and painlessly across each
other. The tear film acts as a lubricant.
3. Protective function. The conjunctiva must be able to protect against
pathogens. Follicle-like aggregations of lymphocytes and plasma cells (the
lymph nodes of the eye) are located beneath the palpebral conjunctiva and
in the fornices. Antibacterial substances, immunoglobulins, interferon,
and prostaglandins help protect the eye.
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Anatomy of the conjunctiva.
Glands of Krause
Glands of Wolfring
Accessory lacrimal
glands:
Meibomian

gland
Bulbar
conjunctiva
Conjunctival
fornix
Palpebral
conjunctiva
Surface of the
cornea (functions
as a part of the
conjunctival sac)
Fig. 4.1 The conjunctiva consists of the bulbar conjunctiva, the conjunctival for-
nices, and the palpebral conjunctiva. The surface of the cornea functions as the floor
of the conjunctival sac.
4.2 Examination Methods
Inspection: The bulbar conjunctiva can be evaluated by direct inspection
under a focused light. Normally it is shiny and transparent. The
other parts of
the conjunctiva
will not normally be visible. They can be inspected by evert-
ing the upper or lower eyelid (see eyelid eversion below).
4 Conjunctiva
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