Orbit/Lids/Adnexa Flashcards
<p>What are the dimensions of the adult orbit?</p>
<p>40mm W x 35mm H x 45mm D</p>
<p>What orbital bones make up the roof of the orbit?</p>
<p>Frontal andSphenoid (lesser wing)</p>
<p>What orbital bones make up the lateral wall?</p>
<p>Zygomatic andSphenoid (greater wing)</p>
<p>What orbital bones make up the floor?</p>
<p>Palatine, Maxillary, Zygomatic</p>
<p>What orbital bones make up the medial wall?</p>
<p>Sphenoid (lesser wing), Maxillary, Ethmoid, Lacrimal</p>
<p>Orbital length of the optic nerve? Intracanalicular length of the optic nerve? Intracranial length?</p>
<p>25-30mm, 9mm,16mm</p>
<p>What structures pass through the superior orbital fissure outside the annulus of Zinn?</p>
<p>Lacrimal (V1)</p>
<p>Frontal (V1)</p>
<p>Trochlear n. (CN IV)</p>
<p>Superior ophthalmic vein</p>
<p>"LFTS"</p>
<p></p>
<p>What structures pass though the superior orbital fissure within the annulus of Zinn?</p>
<p>Sup. division of CNIII</p>
<p>Nasociliary (V1)</p>
<p>Inf. division of CNIII</p>
<p>Abducens (CNVI)</p>
<p>"3N3 is6"</p>
<p>What structures pass through the optic canal?</p>
<p>Optic Nerve (CNII)</p>
<p>Ophthalmic artery</p>
<p>What structures pass through the inferior orbital fissue</p>
<p>Infraorbital neurovascular bundle</p>
<p>Inferior ophthalmic vein</p>
<p>Zygomatic nerve</p>
<p>Ganglionic branches (from pterygopalatine ganglion to maxillary n.)</p>
<p>What is the arcus marginalis?</p>
<p>Fusion of the orbital septum and periosteum at the orbital rim, fuses with dura covering ofoptic nerve</p>
<p>How many fat pads are in the upper eyelid?</p>
<p>2 - nasal fat pad (smaller and paler), and central</p>
<p>How many fat pads are in the lower eyelid? Which fat pads are separated by the inferior oblique?</p>
<p>3 - the IO separates nasal and middle fat pads; the lateral fat pad is smaller and more inferior</p>
<p>What is the innervation of the lacrimal gland?</p>
<p>Secretomotor - superior salivary nucleus of CN7</p>
<p>Sensory - CNV</p>
<p>Sympathetic - fromsuperior cervical ganglion</p>
<p>Whereare the glands of Wolfring found?</p>
<p>At the superior edge of tarsus</p>
<p>Where are the glands of Krause found?</p>
<p>In the fornices</p>
<p>Name the 3 anatomic parts of the orbicularis oculi</p>
<p>Pretarsal</p>
<p>Preseptal</p>
<p>Orbital</p>
<p>Where does the orbital septum fuse in non-Asian eyelids?</p>
<p>To the levator aponeurosis 2-5mm above the superior tarsal border</p>
<p>Where does the orbital septum fuse in Asian eyelids?</p>
<p>To the levator aponeurosis between the eyelid margin and the superior border of the tarsus</p>
<p>How long are the muscular and aponeurotic portions of thethe levator palpebrea?</p>
<p>Muscular = 40mm</p>
<p>Aponeurotic = 14-20mm</p>
<p>Where is Whitnall's tubercle located and what structures are attached to it?</p>
<p>11mm inferior to the FZ suture and 4-5mm posterior to the orbital rim;</p>
<p><strong>4 L's:</strong></p>
<p><strong>L</strong>ockwood suspensoryligament</p>
<p><strong>L</strong>ateral rectus check ligament</p>
<p><strong>L</strong>ateral palpebral ligament</p>
<p><strong>L</strong>evator aponeurosis</p>
<p>(Whitnall's ligament does NOT attach to the Whitnall's tubercle; actually inserts to trochlea medially and the FZ suture temporally)</p>
<p></p>
<p></p>
<p>From where does Muller's muscle originate? Where does it insert? What is it's length? How much does it raise the eyelid?</p>
<p>Origin: undersurface of levator at level of Whitnall's ligament</p>
<p>Insertion: superior border of tarsus</p>
<p>Length: 12-15mm</p>
<p>Action: raises eyelid 2mm</p>
<p>What are the lower eyelid retractors?</p>
<p>Capsulopalpebral fascia (analogous to levator aponeurosis), inferior tarsal muscle (analogous to Muller's), Lockwood's suspensory ligament</p>
<p>What are the heights of the superior and inferior tarsal plates?</p>
<p>10mm and 4mm respectively</p>
<p>Which limb of the medial canthal tendon is more important for appearance and function?</p>
<p>Posterior limb (attaches to posterior lacrimal crest), maintains apposition to the globe</p>
<p>What does the grey line demarcate?</p>
<p>Muscle of Riolan aka border of pretarsal orbicularis</p>
<p>What is the arterial supply to the upper eyelid?</p>
<p>ICA --> ophthalmic artery --> superior marginal arcade</p>
<p>What is the arterial supply to the lower eyelid?</p>
<p>External carotid artery --> facial artery --> angular artery --> inferior marginal arcade</p>
<p>What isthe pretarsal venous drainage pathway?</p>
<p>Medially: Angular vein</p>
<p>Temporally: superificial temporal vein</p>
<p>What is the post-tarsal venous drainage?</p>
<p>orbital vein, facial vein, pterygoid plexus</p>
<p>What aspect of the face drain to the submandibular nodes?</p>
<p>Medial 1/3 of upper lid</p>
<p>Medial 2/3 of lower lid</p>
<p>What aspect of the face drains to the preauricular nodes?</p>
<p>Lateral 2/3 of upper lid</p>
<p>Lateral 1/3 of lower lid</p>
<p>What are the lengths of the canalicular system?</p>
<p>Pucta: 2mm</p>
<p>Canaliculus: 8mm</p>
<p>Lacrimal Sac: 10mm</p>
<p>Nasolacrimal duct: ~15mm</p>
<p>Where is the weakest area of the orbit?</p>
<p>Posterior medial floor (blow out fracture)</p>
<p>What is a tripod fracture?</p>
<p>Fracture of the zygomaticomaxillary suture, zygomaticofrontal suture, and the zygomatic arch + the orbital floor</p>
<p>What bone is involved in all LeFort fracture?</p>
<p>Pterygoid plate</p>
<p>What is a LeFort I fracture?</p>
<p>Low transverse fracture of the maxillary bone above teeth, no orbital involvement</p>
<p>"floating palate"</p>
<p>What is a LeFort II fracture?</p>
<p>Pyramidal fracture of nasal, lacrimal and maxillary bones, involves superior medialwall or maxilla (orbital floor)</p>
<p>"Floating maxilla"</p>
<p>What is a LeFort III fracture?</p>
<p>craniofacial dysjunction, through ZF suture, orbit, nose, ethmoids</p>
<p>"Floating face"</p>
<p>What are the stages of globe degeration?</p>
<p>1. atrophia bulbi without shrinkage</p>
<p>2. atrophia bulbi with shrinkage</p>
<p>3. Phthisis bulbi (disorganization)</p>
<p>increased risk of malignancy, get bscan annually</p>
<p>Most common fungal orbital infection?</p>
<p>Phycomycetes</p>
<p>What are the findings of mucormycosis?</p>
<p>non-septae, large branching hyphae;</p>
<p>invasion of blood vessels w/ thrombosis and necrosis</p>
<p></p>
<p>What is the treatment for mucormycosis?</p>
<p>Surgical debridement, IV amphotericin B</p>
<p>Aspergillosis findings & treatment?</p>
<p>Septate, branching hyphae</p>
<p>Disseminated vs Local forms</p>
<p>Treat with surgical debridement, amphotericin B, flucytosine, rifampin</p>
<p>What causes dengue fever and how does it present?</p>
<p>Flavivirus</p>
<p>75% present with eye soreness and pain with movements</p>
<p>What are the most common presentations/locations of orbital pseudotumor?</p>
<p>1. Myositis (involves muscle AND tendon)</p>
<p>2. Dacryoadenitis</p>
<p>3. Scleritis</p>
<p>4. Orbital Apex</p>
<p>5. Diffusely thoughout orbit</p>
<p>What are the laboratory findings for orbital pseudotumor?</p>
<p>1. Eosinophilia</p>
<p>2. Elevated ESR</p>
<p>3. +ANA</p>
<p>4. CSF pleocytosis</p>
<p>Treatment for orbital pseudotumor?</p>
<p>steroids 1mg/kg prednisone, slow taper due to chance of recurrence; if no response, can consider radiation or immunomodulatory therapy (cyclosporine, MTX, cyclophosphamide)</p>
<p>When does orbital pseudotumor warrant work-up for systemic vasculitis or lymphoproliferative disordersz/</p>
<p>Simultaneous bilateral orbital inflammation in adults</p>
<p>(In children, ~1/3 are bilateral and rarely associated with systemic disorders)</p>
<p>What arethe histological findings for orbital pseudotumor?</p>
<p>pleomorphic cellular infiltrate consisting of lymphocytes, plasma cells, and eosinophils with variable degrees of reactive fibrosis</p>
<p>When to biopsy for orbital inflammation?</p>
<p>Isolated inflammation of the lacrimal gland</p>
<p>How does sclerosing orbital pseudotumor differ from NSOI?</p>
<p>Fibrosis of orbit and lacrimal gland</p>
<p>Slow insidious onset, pain less common, eye white and quiet</p>
<p>Less responsive to steroids</p>
<p>A-scan: low reflectivitiy (both lymphoma and orbital pseudotumor)</p>
<p>associated with retroperitoneal fibrosis</p>
<p>What is the most common cause of proptosis?</p>
<p>Thyroid eye disease</p>
<p>What is the most common clinical manifestation of thyroid eye disease?</p>
<p>Lid retraction</p>
<p>What is von Grafe's sign?</p>
<p>Lid lag on downgaze in thyroid eye disease</p>
<p>What would you find on pathology in thyroid eye disease?</p>
<p>patchy infiltrates of lymphocytes, monocytes, mast cells and fibroblasts; enlargement of muscles</p>
<p>What muscles are typically involved in thyroid eye disease?</p>
<p>IMSLO = Inferior > medial > superior > lateral > obliques</p>
<p>(tendons are usually spared)</p>
<p>In what order do you perform surgery for thyroid eye disease?</p>
<p>Orbital decompression --> strabismus --> eyelid surgery</p>
<p>Requirements before strabismus surgery in TED?</p>
<p>stability for 6 months</p>
<p>avoid if anterior inflammation is present</p>
<p>Prefer recession over resection</p>
<p>What are the common findings of sarcoidosis (in the eye)?</p>
<p>Panuveitis (often bilateral)</p>
<p>Thickened Descemet's membrane, band K, nummular keratitis, deep stromal vacuoles</p>
<p>pars planitis</p>
<p>chorioretinitis</p>
<p>orbital apex syndrome</p>
<p>ptosis</p>
<p>conjunctivitis</p>
<p>dacryoadenitis</p>
<p></p>
<p>Pathology for sarcoid</p>
<p>Non-caseating granulomas</p>
<p>Langhans' Giant Cells</p>
<p>Granulomatosis w/Polyagniitis findings</p>
<p>painful proptosis</p>
<p>reduced motility</p>
<p>chemosis</p>
<p>scleritis</p>
<p>keratitis</p>
<p>optic nerve edema</p>
<p>NLDO</p>
<p>GPA pathology</p>
<p>triad of vasculitis, granulomatous inflammation, and tissue necrosis</p>
<p>Differences between direct carotid-cavernous fistula vs dural-sinus fistula?</p>
<p>Direct c-c fistula: high flow, associated with head trauma; dilated corkscrew scleral/episcleral vessels, chemosis, elevated IOP, pulsatile proptosis, orbital bruit, dilated retinal veins; may develop ischemic maculopathy or RAO, enlarged C/D, CN6 palsy, anterior seg ischemia, blood in Schlemm's</p>
<p>Dural-sinus fistula: low-flow communication between meningeal branches of carotid artery and dural walls of cavernous sinus; often asymptomatic, associated with HTN, atherosclerosis, connective tissue diseases, may close spontaenously, need MRI/MRA</p>
<p>Dilated superior orbital vein on CT along with dilated corkscrew episcleral/scleral vessels, chemosis, orbital bruit, recent history of head trauma; diagnosis?</p>
<p>Carotid-cavernous fistula</p>
<p>Hamartoma vs Choristoma</p>
<p>Hamartoma = growth arising from tissue normal found in that site (nevus, neurofibroma, neurilemmoma, schwannoma, glioma, hemangioma, hemangiopericytoma, lymphangioma, trichoepithelioma)</p>
<p>Choristoma = growth arising from tissue not normally found in that site (dermoid, dermatolipoma, ectopic lacrimal gland)</p>
<p>Most common benign orbital tumor in adults?</p>
<p>Cavernous hemangioma</p>
<p>Pathology: blood-filled cavernous spaces, lined by epithelial cells</p>
<p>Findings: slowly progressive proptosis, may induce hyperopia, retinal striae, IOP elevation, strabismus, ON compression</p>
<p>Imaging findings for cavernous hemangioma?</p>
<p>US: high internal reflectivity</p>
<p>CT: well-demarcated, encapsulated intraconal mass</p>
<p>MRI: hypointense to fat on T1; hyperintense to fat on T2, equivalent to vitreous</p>
<p>Treatment of hemangiopericytoma?</p>
<p>Complete excision (concern for metastasis)</p>
<p>Most common benign orbital tumor in children?</p>
<p>Capillary hemangioma</p>
<p>Pathology: numerous blood-filled channels lined by epithelium; unencapsulated</p>
<p>Location: superonasal orbit, medial upper eyelid</p>
<p>Often regresses spontaneously by age 5-8 in 80% of cases</p>
<p>Most common location for Neurilemmoma (Schwannoma)</p>
<p>Superior orbit, causing progressive proptosis and globe dystopia</p>
<p>Schwannoma pathology stain and types?</p>
<p>S-100 stain</p>
<p>Antoni A: spindle cells arranged in cords/whorls/palisades, Verocay bodies</p>
<p>Antoni B: loose, myxoid; stellate cells w/ mucoid stoma</p>
<p>Optic nerve sheath meningioma spenser's triad?</p>
<p>optociliary shunt vessels, optic atrophy, optic nerve meningioma</p>
<p>Pathology: sheets of cells or whorls,Psammoma bodies in center</p>
<p>Treatment: observation, excision to prevent ON or chiasm involvement</p>
<p>bilateral lacrimal gland enlargement, limitation of EOMs, visual disturbance, diagnosis?</p>
<p>Benign reactive lymphoid proliferation</p>
<p>Pathology: mature lymphocytes with reactive germinal centers; T-cells, 60-80% w/ scattered polyclonal B-cells, high degree of endothelial cell production</p>
<p>Atypical lymphoid hyperplasia findings</p>
<p>low-grade lymphoma, no mitotic activity</p>
<p>Path: follicles and polymorphous response</p>
<p>40% develop systemic disease within 5 years</p>
<p>Orbital Lymphoma findings</p>
<p>EOM limitation, painless lacrimal gland swelling, salmon patch, visual changes, 17% bilateral</p>
<p>Orbital Lymphoma Pathology</p>
<p>atypical immature lymphocytes with mitoses; diffuse or follicular; monoclonal b-cells 60-90% w/ scattered reactive T-cells</p>
<p>Risk of systemic involvement of orbital lymphoma by location?</p>
<p>eyelid (67% have systemic) > orbita (35%) > conjunctiva (20%)</p>
<p>Ossifying fibroma</p>
<p>Occurs 2nd and 3rd decades, more common in women</p>
<p>well-circumscribed, slow growin, monostotic lesion</p>
<p>Pathology: vascular stroma containing lamellar bone with rim of osteoid and osteoblasts</p>
<p>Where do osteomas originate from?</p>
<p>frontal and ethmoid sinuses</p>
<p>Pathology: lamellar bone with variable amounts of fibrous stroma</p>
<p>What is the most common mesenchymal orbital lesion in adults?</p>
<p>Fibrous histiocytoma</p>
<p>distinguishable form hemangiopericytoma only on biopsy</p>
<p>storiform (cartwheel/spiral), nebullar pattern (fibroblasts)</p>
<p>image: histocytes on left, fibrous on right</p>
<p>Most common epitheloid tumor of the lacrimal gland?</p>
<p></p>
<p>Pleomorphic adenoma (Benign mixed tumor)</p>
<p>Firm mass, painless proptosis</p>
<p>CT: well-circumscribed, may be nodular, may indent bone</p>
<p>Path: ductal structures, osteoid and cartilaginous metaplasia</p>
<p>What is the preferred treatment for pleomorphic adenoma?</p>
<p>Complete surgical resection, incomplete excision may lead to recurrence and malignant transformation into pleomorphina adenocarcinoma</p>
<p>Rapidly progressive, painful lacrimal gland tumor in elderly with long history of lacrimal mass?</p>
<p>Pleomorphic adenocarcinoma (malignant mixed tumor)</p>
<p>Treat with radical orbitectomy w/ bone removal</p>
<p>Most common malignant lacrimal gland tumor?</p>
<p>Adenoid cystic carcinoma</p>
<p>4th decade of life</p>
<p>rapid progression, painful proptosis due to perineural spread</p>
<p>Highly malignant</p>
<p>Swiss chess appearance on path</p>
<p>CT may show bony erosion, poorly circumscribed</p>
<p>Treat with resection including bone, radiation</p>
<p>Poor prognosis</p>
<p>Which sinus tumor is associated with cystic fibrosis? Most common location?</p>
<p>Sinus mucocele (must rule out encephalocele/meningocele)</p>
<p>Frontoethmoidal sinus (most common): above medical canthal tendon, displaces globe down and out</p>
<p>Sphenoid and posterior ethmoid sinus: retrobulbar pain, 50% have nasal symptoms, cranial nerve palsies</p>
<p>Maxillary sinus: globe displaced upward, erosion of orbital floor may cause enophthalmos</p>
<p>What type of cancer is most common in sinus carcinomas?</p>
<p>Squamous cell carcinomas, most commonly frommaxillary sinus</p>
<p>How do mets to orbit differ in pediatrics vs adults?</p>
<p>peds tumors metastasize more commonly to orbit than to uvea</p>
<p>Most common source of orbital mets in women?</p>
<p>Breast cancer</p>
<p>Most common source of orbital mets in men?</p>
<p>Lung cancer</p>
<p>Orbital mets causing enophthalmos and ophthalmoplegia?</p>
<p>Breast cancer</p>
<p>Orbital mets mimicking pseudotumor?</p>
<p>Prostate cancer</p>
<p>Closure for small eyelid lacerations?</p>
<p>Closure for 25-50% eyelid defect?</p>
<p>Closure for >50% eyelid defect?</p>
<p>Small: direct closure</p>
<p>Moderate: Tenzel rotational flap</p>
<p>Large: Cutler-Beard (upper);Hughes (lower)</p>
<p>External hordeolum origin?</p>
<p>Glands of Zeiss</p>
<p>Internal hordeolum origin?</p>
<p>Meibomian gland</p>
<p>Organism associated with angular blepharitis?</p>
<p>Moraxella</p>
<p>Type of hypersensitivity in acne rosacea?</p>
<p>Type IV</p>
<p>Findings and treatment of contact dermatitis?</p>
<p>Erythematous, scaling lesions, may have vesicles or weeping lesions</p>
<p>Treat with elimination of inciting agent, mild topical steroid or tacrolimus 0.1%</p>
<p>Organism responsible for this lesion?</p>
<p>Poxvirus MCV (molluscom contagiosum virus)</p>
<p>Treat with excision, cryo, curettage</p>
<p>Organism, findings, treatment of Leprosy?</p>
<p>Mycobacteria leprae</p>
<p>loss of lashes, trichiasis, ectropion, exposure keratitis</p>
<p>dapsone, rifampin</p>
<p>Blepharospasm vs hemifacial spasm</p>
<p>BEB: bilateral, not present during sleep, unclear etiology but potentially basal ganglia</p>
<p>HFS: usually unilateral due to CN7 compression, or CPA tumor</p>
<p>recurrent attacks of transient, painless eyelid edema resulting in atrophy, wrinkling, and redundancy of eyelid skin; usually women, familial</p>
<p>blepharochalasis</p>
<p>Testing for ptosis:</p>
<p>Normal palpebral fissure height?</p>
<p>Normal MRD-1?</p>
<p>Normal levator function?</p>
<p>Muller muscle contribution?</p>
<p></p>
<p>PF normally 10-11mm</p>
<p>MRD-1 ~4mm</p>
<p>LF: normal >12mm, fair 6-11mm, poor if <5mm</p>
<p>Muller's muscle raises lid about 2mm</p>
<p>Most common cause of eyelid retraction</p>
<p>Thyroid eye disease</p>
<p>Types of ectropion</p>
<p>Involutional</p>
<p>Paralytic</p>
<p>Cicatricial</p>
<p>Mechanical</p>
<p>Types of entropion</p>
<p>Spastic</p>
<p>Involutional</p>
<p>Cicatricial</p>
<p>Congenital (very rare, epiblepharon or tarsal kink)</p>
<p>Floppy eyelid sydrome findings</p>
<p>Chronic papillary conjunctivitis</p>
<p>associated wtih obesity, keratoconus, sleep apnea</p>
<p>Differential Dx for madarosis</p>
<p>eyelid neoplasm, chronic blepharitis, trauma, burns, trichotillomania, alopecia, seborrheic dermatitis, chemotherapy, malnutrition, leprosy, lupus</p>
<p>Conditions associated with poliosis/vitiligo</p>
<p>VKH</p>
<p>Sympathetic ophthalmia</p>
<p>Wardenburg syndrome</p>
<p>Tuberous sclerosis</p>
<p>Radiation</p>
<p>Dermatitis</p>
<p>Virus associated with this eyelid lesion?</p>
<p>HPV - Squamous papilloma</p>
<p>Most common benign eyelid lesion</p>
<p>Papillomatous proliferation of suprabasalar (prickle cells)</p>
<p></p>
<p>Seborrheic keratosis</p>
<p>Single-lumen, round/oval lesion lined by keratinized, stratified squamous epithelium and filled with cheesy keratin debris</p>
<p>Epidermal inclusion cyst (epidermoid cyst)</p>
<p>lined by keratinized, stratified, squamous epithelium and dermal appendages such as hair shafts and sebaceous glands</p>
<p>Dermoid cyst</p>
<p>Fluid-filled lesipons near lateral canthus</p>
<p>Hydrocystoma, most often eccrine (can be apocrine if arising from glands of Moll)</p>
<p>Muir-Torre Syndrome</p>
<p>multiple sebaceous neoplasms, keratoacanothomas, and visceral tumors (esp GI)</p>
<p>waxy, yellow nodules on lower lid, usually in young women, benign proliferation of eccrine ductal structures</p>
<p>Syringoma</p>
<p>Benign adnexal tumor of hair follicle origin; firm flesh-colored/yellowish dome-shaped papule</p>
<p>Trichoepithelioma</p>
<p>Mean age 45ys, more common in women</p>
<p>Will increase in size and number</p>
<p>Histopathology: basaloid cells surrounding a keratin center</p>
<p>Treatment: excision, dermabrasion, cryo, laser</p>
<p>Hamartoma of hair follicle tissue; solitary, small, dome-shaped, flesh-colored papule or nodule w/ a diagnostic central keratin killed pore, may have wisps of hair</p>
<p>Trichfolliculoma</p>
<p>No malignent potential, simple excision</p>
<p>Cowden's disease</p>
<p>Multiple trichilemmomas, marker for breast (40%) or thyroid cancer</p>
<p>crusty lesion with rough surface, may mimick BCC/SCC/sebaceous CA</p>
<p>Calcifying epithelioma of Malherbe</p>
<p>Pilomatrixoma</p>
<p>solitary, firm deep nodule with overlying normal pink or bluish skin</p>
<p>Common in children</p>
<p>associated with Myotonic Dystrophy and Gardner's sydrome</p>
<p>Percentage of actinic keratosis that evovle into SCC?</p>
<p>12% (25% will resolve spontaneously)</p>
<p>Elastoic degeneration, overlying hyperkeratosis, focal parakeratosis, clefts in dyskeratotic areas</p>
<p>Actinic Keratosis</p>
<p>Benignpigmented lesion from neural crest cells?</p>
<p>Nevus</p>
<p>Type of nevus with greatest malignant potential?</p>
<p>Junctional nevus</p>
<p>Pigmented skin lesion</p>
<p>Compound nevus</p>
<p>Both intradermal and junctional components, malignant potential from junctional component</p>
<p>Most common type of nevus?</p>
<p>Intradermal nevus</p>
<p>most bening, can be amelanotic, can be papillomatous, flat or dome-shaped</p>
<p>Congenital nevus secondary to fusion of lids during embyonic development? involves upper and lower lids?</p>
<p>Kissing nevus</p>
<p>Nevus with no malignant potential?</p>
<p>Spindle cell nevus</p>
<p>compound nevus of childhood</p>
<p>Melanotic Freckle of Hutchinson</p>
<p>aka Lentigo Maligna</p>
<p>cutaneous version of PAM</p>
<p>melanoma arises in 30%</p>
<p>may have conj but no episcleral pigment</p>
<p>Freckles, scaling in young patient due to defect in DNA repair?</p>
<p>Xeroderma pigmentosa</p>
<p>AR inheritence</p>
<p>UV light endonuclease defect</p>
<p>3% incidence of malignant melanoma</p>
<p>Pathology: Basaloid blue cells arranged in nests and cords, peripheral palisading commonly seen</p>
<p>Basal Cell Carcinoma</p>
<p>most common malignancy of the eyelid (40x more common than SCC)</p>
<p></p>
<p>Site of BCC with poorest prognosis?</p>
<p>Medial canthus, often extends deeper into lacrimal system</p>
<p>Location in order of frequency:</p>
<p>lower lid > medial canthus > upper lid > lateral canthus</p>
<p></p>
<p>Most common form of BCC?</p>
<p>Nodular</p>
<p>More aggressive form of BCC?</p>
<p>Morpheaform</p>
<p>Firm, flat lesion with indistinct borders</p>
<p>Penetrates into dermis, pagetoid spread</p>
<p>Pathology: thin cords of basal cells</p>
<p></p>
<p>Dome-shaped squamous lesion, rapid onset, usually elderly patients, may involutespontaneously</p>
<p>Keratoacanthoma</p>
<p>central keratin-filled crater and elevated rolled edges, resembles BCC</p>
<p>Pathology: cup-shaped lesion with keratin core</p>
<p>Treatment: observation, excision, local steroid injection</p>
<p>2nd or 3rd most common malignancy of the eyelid, may mimick chronic blepharitis</p>
<p>Sebaceous gland carcinoma</p>
<p>Highly malignant, lethal (5 yr mortality = 30%)</p>
<p>Argument over whether more common than SCC</p>
<p></p>
<p>origin of sebaceous gland carcinoma</p>
<p>Meibomian gland</p>
<p>Can arise from Zeis glands or caruncle</p>
<p>Orange-yellow nodule</p>
<p>Pathology: large foamy, lipid-laden tumor cells, vacuolated cytoplasm</p>
<p>Treatment for sebaceous gland carcinoma</p>
<p>wide excision, send for frozen section, conj map biopsy</p>
<p>exenteration for pagetoid spread or orbital involvement</p>
<p>palliative radiation</p>
<p>Most common form of melanoma?</p>
<p>Superficial spreading</p>
<p>Spreading macule w/ irreg outline, variable pigmentation, invasive phase marked by papules and nodules</p>
<p>Path: pagetoid nests in all levels of epidermis</p>
<p>69% 5-year survival</p>
<p>Most common type of melanoma of the eyelid?</p>
<p>Nodular melanoma</p>
<p>5th decade, more common in men, palpable lesion</p>
<p>more aggressive, with vertical invasion</p>
<p>44% 5-year survival</p>
<p>Treatment and prognosis of malignant melanoma?</p>
<p>wide surgical excision, lymph node dissection if indicated</p>
<p>prognosis depends on depth of vertical invasion</p>
<p><0.75mm indicates favorable prognosis</p>
<p>Most common site for Merkel Cell tumor?</p>
<p>upper eyelid</p>
<p>rare, vascular red-blue vascular tumor</p>
<p>mets and death in 30% of patients</p>
<p>Treatment: wide excision with immunohistochemical stains, lymph node dissection, radiation</p>
<p>Systemic involvement of Xanthalesma?</p>
<p>Erdheim-Chester disease (lipoid granulomatosis)</p>
<p>lipogranulomas of the liver, heart, kindey, lung, bones</p>
<p>Mycosis fungiodes</p>
<p>Cutaneous T-cell lymphoma</p>
<p>Pathology: Lutzner cells and Pautrier abscesses</p>
<p>What is the dye disappearance test?</p>
<p>Instillation of fluorescein</p>
<p>Wait 5 minutes</p>
<p>Check for clearance of dye from tear meniscus</p>
<p>Jones I test?</p>
<p>Perform Dye Disappearance Test first</p>
<p>Recover dye from nose with cotton tipped applicator</p>
<p>(abnormal test results occurs in 1/3 of individuals)</p>
<p>Jones II test?</p>
<p>After Jones I test, flush residual fluorescine from conjunctival sac</p>
<p>Then irrigate nasolacrimal system with saline</p>
<p>In the Jones II test, what does recovery of dyein the nose after irrigation indicate?</p>
<p>Functional obstruction of the nasolacrimal duct</p>
<p>In the Jones II test, what does recovery of clear saline in the nose represent?</p>
<p>canalicular obstruction or non-functional lacrimal pump</p>
<p>What is a dacryoscintogram?</p>
<p>Instillation of technetium 99 - physiologic test</p>
<p>What is a dacryocystogram?</p>
<p>Injection of Lipiodol (Ethiodol) - outlines drainage system</p>
<p>Correction of canalicular obstruction?</p>
<p>Punctal obstruction - dilation, punctoplasty</p>
<p>Partial Canalicular obstruction - crawford stents, vier rods</p>
<p>Canalicular obstruction <8mm from punctum - Jones tube</p>
<p>Canalicular obstruction >8mm from punctum - DCR</p>
<p>Etiologies for NLDO?</p>
<p>involutional, trauma, chronic sinus disease, nasal polyps, dacryocystitis, granulomatous disease</p>
<p>Treat wtih silicone intubation, DCR</p>
<p>Lacrimal sac obstruction etiology and treatment?</p>
<p>trauma, acute or chronic dacryostitis</p>
<p>Treat with DCR</p>
<p>Typical microrganism in canaliculitis?</p>
<p>Typical findings?</p>
<p>Treatment?</p>
<p>Micro: Actinomyces israelii (most common), also candida albicans, aspergillus, nocardia, HSV, VZV</p>
<p>Findings: pouting punctum, discharge, may have bloody tears, sulfur granules</p>
<p>Treatment: warm compress, probing and irrigation with penicillin, canalicular curettage, incision and debridement</p>
<p>Dacryocystitis organisms?</p>
<p>Staph, strep, pseudomonas, H.flu (children, rare after vaccination), Klebsiella, actinomyces, candida</p>
<p>Dacryocystitis findings and treatment?</p>
<p>Acute: edema, erythema, distention below medial canthal tendon</p>
<p>Chronic: distended lacrimal sac, minimal inflammation</p>
<p>Treatment: warm compress, topical/systemic abx, I&D, avoid probing and irrigation during acute infection, DCR after acute inflammation subsides</p>
<p>Etiology of dacryoadenitis?</p>
<p>Acute: infection (Staph, gonorrhea, mumps, EBV, VZV)</p>
<p>Chronic: inflammation or infection (NSOI, sarcoid, Mikulicz, lympoid, syphilis, TB)</p>
<p>Diagnosis and treatment of dacryoadenitis?</p>
<p>Treatment: CT scan, consider culture, labs, biopsy</p>
<p>Treatment: systemic abx if indicated, treatment of underlying condition, excision, I&D</p>
<p>Findings in lacrimal sac tumors?</p>
<p>Painless mass<em>above</em>the medial canthal tendon, tearing, may have bloody tears (hemolacria), bleeding with probing</p>
<p>dacryocystogram outlines tumor</p>
<p>Most common primary lacrimal sac tumor?</p>
<p>Squamous papilloma</p>
<p>Most common primary malignant lacrimal sac tumor?</p>
<p>Squamous cell carcinoma</p>
<p>Second most common malignant lacrimal sac tumor?</p>
<p>Lymphoma</p>
