Lids and Orbits A Patient s Perspective. Dr. Paul Cauchi Consultant Ophthalmologist Southern General and Gartnavel General Hospitals, Glasgow

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1 Lids and Orbits A Patient s Perspective Dr. Paul Cauchi Consultant Ophthalmologist Southern General and Gartnavel General Hospitals, Glasgow

2 Overview Pathophsiology. Symptoms. Signs. Management.

3 Pathophysiology Autoimmune-mediated inflammation of the extraocular muscles, orbital fat, and periorbital connective tissue.

4 Pathophysiology Lymphocytic infiltration of orbital tissue causes a release of cytokines like IL-1. Fibroblasts are believed to be the target cells and are extremely sensitive to stimulation by cytokines and immunoglobulins released in the course of an immune response.

5 Pathophysiology Cytokines stimulate quiescent fibroblasts to secrete hyalurnic acid (GAG). This causes a massive increase in tissue osmotic load resulting in muscle oedema, proptosis with subsequent fibrosis and eventually tissue atrophy.

6 Symptoms Can sometimes be non-specific. Sometimes hard for a person to describe symptoms. 2 main groups: Eye surface Orbit (eye socket)

7 Eye Surface Gritty Dry Scratchy Itchy Something in the eye Watery

8 Orbit/Eye socket Pressure feeling Ache Pain behind the eye

9 Signs/Appearance - Patient A disease that steals your identity Starey eyes Bulgy eyes My eyes stick out I can see the whites of my eyes more than before Puffy eyes Red eyes

10 Signs/Appearance - Doctor Lid retraction upper and lower Lid lag Soft tissue swelling Proptosis/Exophthalmos

11 Management ACTIVE OR INACTIVE?

12 ACTIVE Orbital pain (none, at rest, movement) Chemosis Eyelid oedema Conjunctival injection Eyelid injection

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16 INACTIVE None of previous signs. Residual disease Stable for a period of time with no progression

17 Activity

18 Management - Active If sight threatening and medical treatment has not worked urgent decompression If severe corneal exposure decompression or lid procedures

19 ACTIVE MEDICAL TREATMENTS OPTIC NERVE COMPRESSION EXPOSURE TOPICAL DECOMPRESSION LID PROCEDURES DECOMPRESSION

20 Management - Inactive Topical tear drops Topical steroids Upper eyelid lowering Lower eyelid raising Orbital decompression

21 Stable Disease No change for 6 months. Individualised treatment. Patient Education/Expectations. Risks/Benefits. Mechanical. Cosmetic.

22 STABLE DECOMPRESSION BONY SOFT TISSUE MUSCLE SURGERY EYELID SURGERY

23 Fat or Orbital Decompression? Fat resection (Olivari) CT/MRI to determine fat/muscle ratio. Proptosis. Soft tissue signs. Lid retraction. Orbital apex crowding. Signs of congestion.

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25 Bony decompression For severe proptosis For relief of congestion For orbital apex crowding For corneal exposure

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27 Acrobat Document

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34 Bony Decompression

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36 Complications Loss of vision Diplopia CSF leak Significant haemorrhage Infection Bruising/swelling

37 Soft tissue decompression For reduction in soft tissue signs For more modest reduction in proptosis For simultaneous lid lowering For relief of pressure feeling

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41 Soft Tissue Decompression

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46 Complications Loss of vision Lacrimal gland prolapse Diplopia Haemorrhage Bruising/swelling

47 Upper eyelid lowering Helps with ocular surface symptoms. Cosmesis. Skin crease incision. Recession of Muller s and levator muscles avoiding medial end to preserve contour.

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50 Lower eyelid elevation Lower eyelid retraction often forgotten. Elevation can help exposure Cosmesis Hard palate graft Can use vicryl/goretex

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53 Complications All upper eyelid surgery can lead to orbital haemorrhage and visual loss Under and over corrections

54 EUGOGO Consensus Statement European Journal of Endocrinology(2008)158,

55 Thank You