BCSC 7. Orbit, Eyelids, and Lacrimal System

Question 1

Nasolacrimal duct opens into ->

Answer 1

inferior meatus

Question 2

sphenoid sinus drains ->

Answer 2

sphenoethmoidal recess

Question 3

Frontal sinus, maxillary sinus, anterior and middle ethmoid air cells drain into ->

Answer 3

middle meatus

Question 4

posterior ethmoid air cells drain ->

Answer 4

superior meatus under superior turbinate

Question 5

Largest paranasal sinus

Answer 5

Maxillary

Question 6

Anatomical layer that the temporal (frontal) branch of cranial nerve VII is found

Answer 6

temporoparietal fascial (superficial temporalis fascia)

Question 7

Wider-than-normal separation between medial orbital walls

Answer 7

Hypertelorism (Bone, increased IPD, increased OCD)

Question 8

Wide intercanthal distance

Answer 8

Telecanthus (Normal IPD, normal OCD) ‘T - tissue’

Question 9

Angle between lateral orbital walls greater than 90 degrees, may have shallow orbital depth.

Answer 9

Exorbitisim

Question 10

Proptosis of eye associated with TED

Answer 10

Exophthalmos

Question 11

Failure of what embryonal developmental process results in microphthalmia with orbital cyst

Answer 11

Choroidal fissure closure

Question 12

Failure of what embryonal developmental process results in anophthalmia

Answer 12

Primary optic vesicle fails to grow out from cerebral vesicle at 2-mm stage of embryonic development.

Question 13

Etiology of craniofacial clefts

Answer 13

Developmental arrest (failure of neural crest cell migration) and mechanical disruption of development

Question 14

4 yo M with lytic bony changes on CT and superotemporal orbtial mass. Histology shows fibrous connective tissue and infiltrate of eosinophils and histiocytes. Dx and systemic condition ->

Answer 14

Eosinophilic granuloma - Diabetes insipidus

Question 15

Best way to diagnose pleomorphic adenoma?

Answer 15

Complete excision

Question 16

Le Fort fractures always involve ->

Answer 16

Pterygoid plates - must extend posterior through these plates with possible orbital and nasal involvment

Question 17

Tx for traumatic optic neuropathy

Answer 17

Controversial - observation alone is acceptable. Recent multicenter prospective nonrandomized trial failed to show benefit from corticosteroids or surgical treatment.

Question 18

Best surgical approach for mass in lacrimal gland region

Answer 18

eyelid crease incision - excellent exposure, good cosmesis

Question 19

Best surgical approach for inferior mass

Answer 19

“swinging eyelid” approach

Question 20

Best approach to minimize scarring for mass in medial subperiosteal space

Answer 20

Transcaruncular incision

Question 21

Good access to superior orbital rim and periosteum

Answer 21

eyelid crease incision

Question 22

Typically does not contribute to socket contraction

Answer 22

Wearing conformer or prosthesis 24 hours day

Question 23

Name 3 things that contribute to socket contraction

Answer 23

Radiation, multiple socket operations, extrusion of orbital implant

Question 24

In non-asians, where does the orbital septum of the upper eyelid fuse with the levator aponeurosis

Answer 24

2-5 mm above the superior tarsal border

Question 25

Where does the levator aponeurosis attach to the tarsus

Answer 25

inferior third of the tarsus

Question 26

Fusion of the periosteum of facial bones, periorbita and orbital septum

Answer 26

arcus marginalis

Question 27

Acts as a pulley for the force of the levator muscle and provides suspensory support for the upper eyelid and superior orbital tissues

Answer 27

Whitnall ligament

Question 28

Congenital eyelid condition more common in asian children that may contribute to mechanical entropion of lower eyelid margin

Answer 28

Epiblepharon - lower eyelid pretarsal muscle and skin ride above the lower eyelid margin to form horizontal fold of tissue that causes cilia to assume vertical position. May improve w/o surgical intervention.

Question 29

Horizontal widening of palpebral fissure due to inferior insertion of lateral canthal tendon

Answer 29

Euryblepharon - a/w ectropion of lateral 1/3 of lid

Question 30

Fusion of part or all of eyelid margins

Answer 30

Ankyloblepharon - may be congenital (AD, craniofacial abnormalities) or acquired (Thermal, chemical, OCP, SJS).

Question 31

Congenital bilateral ectropion of the upper eyelids

Answer 31

associated with Down’s syndrome, ichthyosis, and sporadic cases in newborns from black population.

Question 32

Horizontally and vertically shortened palpebral fissures with poor levator function

Answer 32

Blepharophimosis

Question 33

Ptosis, telecanthus, epicanthus inversus, lower lid ectropion, anteverted ears, hypoplasia of nasal bridge, sup orbital rim

Answer 33

Blepharophimosis syndrome (AD, 3q)

Question 34

Lower lid coloboma

Answer 34

Treacher collins, Goldenhar's lateral 1/3, partial

Question 35

Upper lid coloboma

Answer 35

medial 1/3, no systemic, full thickness

Question 36

Medial canthal vertical scin folds

Answer 36

Epicanthus (Tarsalis - upper, asian; inversus - lower blepharomphimosis; Palpebralis - upper and lower equal; Supraciliaris - fold arises from eyebrow and extends to lacrimal sac)

Question 37

Associations of telecanthus

Answer 37

FAS, Waardenburg's blepharophimosis

Question 38

A/w Muir-Torre syndrome and visceral malignancies

Answer 38

Sebaceous hyperplasia

Question 39

Reconstruction of lacrimal system after BCC of lacrimal sac or NLD s/p tumor removal should occur

Answer 39

after 5 years to minimize tumor spread

Question 40

Repair for defect >50% of lower eyelid

Answer 40

Hughes flap (eyesharing) combined with skin grafting of anterior lamella

Question 41

Repair for defect >50% of upper eyelid

Answer 41

Cutler-Beard

Question 42

Characteristic finding in blepharophimosis-ptosis-epicanthus inversus syndrome (BPES)

Answer 42

Telecanthus, epicanthus inversus, severe ptosis, limited levator function (+/- hypertelorism, ectropion, hypoplasia of superior orbital rims)

Question 43

Typical feature of cicatricial ectropion of lower eyelid

Answer 43

Anterior lamellar deficiency

Question 44

Finding often a/w cicatricial entropion of lower eyelid

Answer 44

posterior lamellar shortening

Question 45

Lower eyelid retractor disinserition, lower eyelid laxity, overriding preseptal orbicularis muscle

Answer 45

involutional entropion

Question 46

Finding seen in involutional ptosis

Answer 46

higher than normal eyelid crease, normally functioning levator >15 mm, ipsilateral compensatory eyebrow elevation

Question 47

Deep superior sulcus

Answer 47

Aponeurotic disinsertion resulting in superior migration of orbital septum and underlying preaponeurotic fat

Question 48

Absent or poorly formed eyelid

Answer 48

congenital ptosis

Question 49

inability to close the eyelids completely

Answer 49

Lagophthalmos

Question 50

Levator function <6mm

Answer 50

Frontalis sling

Question 51

Sign of hemifacial spasm

Answer 51

Unilateral sx that persist at night

Question 52

Bilateral involvement of eyelid protractors, abate at night

Answer 52

BEB - benign essential blepharospasm

Question 53

BEB benign essential blepharospasm may progress to

Answer 53

Meige syndrome

Question 54

Rare neurological movement disorder characterized by involuntary and often forceful contractions of the muscles of the jaw and tongue (oromandibular dystonia) and involuntary muscle spasms and contractions of the muscles around the eyes (blepharospasm)

Answer 54

Meige syndrome, | BEB benign essential blepharospasm may progress to this

Question 55

Vessel that lies anterior to the lacrimal sac

Answer 55

Angular artery and vein

Question 56

Extension of orbicularis in the deep head of the medial canthal tendon

Answer 56

Horner muscle

Question 57

Why does lacrimal sac distend inferiorly in dacryocystitis

Answer 57

Superior portion of sac is fibrinous

Question 58

Valve of rosenmuller

Answer 58

mucosal fold located at junction of common canaliculus and lacrimal sac. 1-way valve to prevent reflux of tears into common canaliculus during lacrimal pump cycle.

Question 59

Valve of hasner

Answer 59

Distal end of NLD, inferior meatus

Question 60

Most cases of symptomatic congenital NLDO resolve by

Answer 60

12 months

Question 61

B/L congenital NLDO occurs in

Answer 61

1/3 of cases

Question 62

When is surgical indication necessary for congenital NLDO

Answer 62

dacryocystitis

Question 63

Helps distinguish between true epiphora resulting from NLDO and other conditions causing excessive tearing

Answer 63

Dye disappearance test (first test to perform)

Question 64

Procedure with highest likelihood of creating an intact lacrimal drainage system.

Answer 64

CDCR - conjunctivodacryocystorhinostomy (DCR will not address problem at canaliculus)

Question 65

Most crucial step in successful external DCR

Answer 65

osteotomy through the lacrimal sac fossa and into nose

Question 66

First line treatment for adult with acute erythrematous, tender medial canthal mass inferior to the medial canthal tendon

Answer 66

Dx - acute dacryocystitis 1. give oral abx 2. I&D if no improvement with abx or relief of acute pain is necessary. 3. External DCR after acute infection resolves.

Question 67

Vascular congestion over the insertions of the rectus muscle (particularly the LR)

Answer 67

TED

Question 68

Corkscrew conjunctival vessels

Answer 68

AV fistula

Question 69

S-shaped eyelid

Answer 69

Plexiform neurofibroma or lacrimal gland mass

Question 70

Eczematous lesions of eyelids

Answer 70

Mycosis fungoides (T-cell lymphoma)

Question 71

Ecchymosis of eyelid skin

Answer 71

Metastatic neuroblastoma, leukemia, or amyloidosis

Question 72

Prominent temple

Answer 72

Shenoid wing meningioma or metastatic neuroblastoma

Question 73

Edematous swelling of lower eyelid

Answer 73

Meningioma, inflammatory tumor, metastasis

Question 74

Frozen globe

Answer 74

Mets or zygomycosis

Question 75

Black crusted lesions in nasopharynx

Answer 75

Phacomycosis

Question 76

Facial asymmetry

Answer 76

Fibrous dysplasia or neurofibromatosis

Question 77

Eyelid retraction and lid lag

Answer 77

TED

Question 78

Protruding contents of meninges

Answer 78

Meningocele

Question 79

Protruding contents of brain

Answer 79

encephalocele

Question 80

protruding contents of brain and meninges

Answer 80

meningoencephalocele

Question 81

Mechanism of TED

Answer 81

Circulating immunoglobulin (IgG) recognizes and activates insulin like growth factor I receptor expressed on surface of fibroblasts (origin NCC), stimulating to secrete GAGs, cytokines, chemoattractants.