Lacrimal System

Overview, Signs and Symptoms of an Obstruction

The lacrimal gland produces tears which enter into the "duct" that drain the tears from the eye into the nose. The most common symptoms are If one has a plugged up "tear duct," not only will tears spill over the eyelids and run down the face, but the stagnant tears within the system can become infected.
      (1) excess tearing (tears may run down the face) and
      (2) mucous discharge

This may lead to recurrent red eyes and infections.
The excessive tearing can also produce secondary skin changes on the lower eyelids.



Congenital Nasolacrimal Duct Obstruction

The nasolacrimal duct is a duct that connects the lacrimal glands in the eye to the nasal cavity. In this article, we shall briefly review the epidemiology, clinical presentation and the common causes of this condition.


Epidemiology

Clinical research has shown that nasolacrimal duct obstruction occurs in 2 to 4 out of 100 newborn babies. However, this number dramatically increases in children who have Down syndrome with statistics suggesting about 22% to 36% developing this condition.


There are a number of different reasons why nasolacrimal duct obstruction occurs. The epidemiological statistics have shown that of all the cases, 35% of them actually due to obstruction, 15% occur due to the improper formation of the opening of the lacrimal duct (punctual agenesis), 10% have some form of abnormal connection i.e. congenital fistula and 5% have defects in the structure of the head and face.


As such, congenital nasolacrimal duct obstruction does not differentiate between race and sex. It is typically seen in newborns.


Congenital nasolacrimal duct obstruction can result in numerous clinical presentations. These conditions bring with them a varying degree of morbidity and mortality.


The first condition that may occur is amniotocoele. Here, there is distension of the tear producing gland i.e. the lacrimal gland. Amniotic fluid enters the lacrimal sac and gets trapped within it. This can result in swelling of the lacrimal sac. Treating this can be done through inserting a small probe through the nasolacrimal duct.


Dacrocystitis is another condition that may develop where there is inflammation and distension of the lacrimal sac. It occurs in the neonatal period which is just after the baby has been born. In these patients as well, probing the lacrimal sac through the nasolacrimal duct is the treatment.


Finally, in newborns who have narrowing of the nasolacrimal duct, accumulation of pus or pus within the lacrimal sac may take place. This can manifest as constant watering of the eye or expulsion of pus from the eye. The treatment usually involves antibiotics, compression and massage of the lacrimal sac. If left untreated, newborns may have matted eyes every morning and excessive tearing of the eyes.



Clinical presentation

  • History forms an important part of making a diagnosis. There may be a family history of nasolacrimal duct problems and other abnormalities such as glaucoma. A detailed examination of the eye is useful in determining whether the patient has congenital nasolacrimal duct disease.
  • A special test known as the dye disappearance test is useful in determining whether there is any obstruction. In addition, tests to ascertain whether the patient has glaucoma need to be conducted.


Causes

Nasolacrimal duct obstruction is not very common but does have some recognised causes. The top three causes include :

  • genetic causes i.e. having a family history of nasolacrimal duct obstruction
  • premature birth
  • drug use by the mother during pregnancy

It is commonly accompanied by other eye abnormalities.



Treatment


  • 9 out of 10 cases resolve within the first year of life. If required, massage therapy over the lacrimal gland may be helpful.
  • In patients in whom this does not work, using a probe can cure up to 95% of cases. Other procedures include the insertion of a tube into the nasolacrimal gland or the insertion of a balloon catheter.
  • Special surgical procedures include a dacrocystorhinostomy - a procedure that helps restore normal tear flow.


Acquired (ADULT-ONSET) Nasolacrimal Duct Obstruction

Epiphora is the overflow of tears which is caused by an imbalance in tear production and tear drainage. Other than conditions that cause an abnormal increase in tear production, an abnormality in tear drainage is the most likely cause of epiphora. It may be either functional due to a displaced punctum, eyelid laxity, weak orbicularis, or facial nerve palsy or an anatomical obstruction may block the drainage of tears. Anatomical obstruction of the nasolacrimal duct may be congenital which occurs during the neonatal period or acquired which manifests during adulthood.


Classification of Acquired Nasolacrimal Drainage Obstruction (NLDO)

Acquired nasolacrimal drainage obstruction may be primary or secondary.

  • Primary acquired nasolacrimal drainage obstruction (PANDO) is caused by inflammation or fibrosis without any precipitating cause. The name was given by Linberg and McCormick in 1986.
  • Secondary acquired lacrimal drainage obstruction (SALDO) is further classified further based on aetiology as infectious, inflammatory, neoplastic, traumatic and mechanical. This classification was proposed by Bartley.

Pathophysiology/Statistics

Although quite common, the frequency of nasolacrimal drainage obstruction is unknown. It has no racial predilection.
PANDO is more commonly seen in middle-aged and elderly females. This is due to the significantly smaller dimensions in the lower nasolacrimal fossa and middle nasolacrimal duct among women. Middle-aged women exhibit alterations in the dimensions of the bony nasolacrimal canal that coincides with osteoporotic changes elsewhere in the body, which supports the higher incidence of PANDO in women. Some suggest that sudden hormonal changes incite generalized de-epithelialization predisposing a narrow duct to be blocked by sloughed off debris.
SALDO is aetiologically classified as infectious, inflammatory, neoplastic, traumatic, and mechanical.
Infectious lacrimal drainage obstruction: Bacteria, viruses, fungi, and parasites that have all been implicated are as follows:

  • Bacterial Causes – Most common causes are Actinomyces, Propionibacterium, Fusobacterium, Bacteroides, Mycobacterium, and Chlamydia.
  • Viral Causes – Most commonly Herpes virus. Due to canalicular obstruction and damage.
  • Fungal Causes - Aspergillus, Candida, Pityrosporum, and Trichophyton. Usually cause obstruction due to dacryolith/stone or cast formation.
  • Parasitic Causes – Rare but can be caused by Ascaris lumbricoides entering through the valve of Hasner.


Inflammatory lacrimal drainage obstruction: May be endogenous or exogenous in origin.

  • Endogenous Causes – Most commonly due to Wegener granulomatosis and sarcoidosis. Other causes include cicatricial pemphigoid, sinus histiocytosis, Kawasaki disease, and scleroderma.
  • Exogenous Causes – Eye drops, radiation, systemic chemotherapy, and bone marrow transplantation all cause punctal and canalicular scarring, stenosis and occlusion in varying degrees.

Neoplastic lacrimal drainage obstruction: Neoplasms cause obstruction by primary growth, secondary spread, or metastatic spread.


Traumatic lacrimal drainage obstruction: May be iatrogenic or non-iatrogenic.

  • atrogenic Causes - Trauma and subsequent scarring due to overenthusiastic lacrimal probing, orbital decompression surgery, paranasal, nasal, and craniofacial surgery all cause obstruction.
  • Non-iatrogenic Causes - Either blunt or sharp injury to the canaliculus, lacrimal sac, and nasolacrimal duct results in post-traumatic dacryostenosis.

Mechanical lacrimal drainage obstruction

  • Intraluminal foreign bodies – Dacryoliths or casts due to infection or long-term use of topical medications.
  • External compression – Due to rhinoliths, nasal foreign bodies, or mucoceles. Dentigerous cyst in the maxillary sinus is also thought of as a culprit.

Symptoms/Presentation

  • Patients with NLDO most commonly present with epiphora, mucoid or purulent discharge with a painful, swollen medical canthus. They frequently have features of recurrent dacryocystitis, recurrent conjunctivitis, or ocular pemphigus. Some cases present with bloody tears and even epistaxis as in nasal, sinus or lacrimal sac tumours.
  • A thorough past ocular and medical history is in order to evaluate the cause of the disease. Always ask for previous eye surgery, lid surgery, use of antiglaucoma medications, or any other topical medications. Past medical history should all causes cited in the previous section.

On examination, the following findings may be present.

  • Gross observation shows overflowing tears, fluctuant tender mass over medial canthus, mucoid or purulent eye discharge. Regurgitation test results in mucoid reflux with lacrimal massage indicating lower system obstruction.
  • Slit lamp examination shows enhancement of tear meniscus height by fluorescein greater than 2 mm, punctal stenosis, canaliculitis, concretions expressed from the punctum

Investigations

  • Imaging studies may include dacryocystography, dacryoscintigraphy, CT scan, CT dacryocystography (CTDCG), nasal endoscopy, or Gadolinium-enhanced magnetic resonance dacryocystography.
  • Other tests include Schirmer test, Fluorescein dye disappearance test, lacrimal irrigation, probing of the canaliculi, Jones dye tests, microreflux test, Hornblass saccharine test
  • Diagnostic canalicular irrigation determines the level of canalicular obstruction staging it as partial obstruction, total common canalicular obstruction, total functional occlusion and complete nasolacrimal obstruction.

Treatment

Medical Care

  • Topical antibiotics in early infections
  • Systemic antibiotics in chronic or severe infections

Surgical Care

  • External dacryocystorhinostomy
  • Endoscopic mechanical/nonlaser dacryocystorhinostomy
  • Endoscopic laser dacryocystorhinostomy
  • Endoscopic laser-assisted dacryocystorhinostomy
  • Conjunctivodacryocystorhinostomy (CDCR)
  • Balloon catheter dilatation
  • Inferior meatus surgery

Evaluation of Tearing

History of symptoms

unilateral vs. bilateral

  • nasal/sinus/facial fracture or surgery
  • bloody tears/pain w/o inflammation: rule out tumor
  • nasal polyps, sinusitis
  • hay fever
  • external ocular irritation
  • Bells palsy
  • epinephrine
  • phospholine iodide


Etiologies of Epiphora

  • surface irritation/reactive hypersecretion
  • outflow obstrutionn
  • Idiopathic hypersecretion
  • Inadequate Drainage
  • 5th nerve stimulation: external/corneal disease pseudoepiphora
    • dry eye syndrome
    • conjunctivitis
    • blepharitis
    • uveitis
    • entropion
    • trichiasis
    • thyroid eye disease
    • sinusitis
    • hay fever
    • dental problems
      • VII nerve aberrant regeneration
      • post-Bell’s palsy; crocodile tears
  • central nervous system
  • Inadequate Drainage
    • Stiff Lid
    • from burn, scar tissue, scleroderma
    • lacrimal pump dysfunction, punctal displacement
    • Punctal Problems
      • Agenesis
        • probe membranes, if none seen, do cut down (over probe)
        • can inject methylene blue inferior to medial canthal tendon
      • Stenosis
        • treat with dilation, ampullotomy (one-snip), may need silicone intubation
        • Eversion / Malpositions
        • rx with internal vertical shortening, may need horizontal lid shortening for laxity
        • transconjunctival cautery inferior to puncta in bedridden pt
    • Conjunctivochalasis
      • can occlude punctum
      • Rx: vasoconstrictor (Visine, etc) course then PF may be helpful
    • Canalicular Problems
      • Common Canaliculus Occlusion
      • trauma
      • meds: 5-FU, IDU, PI, eserine
      • viral infection
      • autoimmune (pemphigoid, Stevens-Johnson)
    • Canaliculitis
      • mostly actinomyces israelii, gm filamentous rod, yellow concretions (sulfur), other bact & fungi
      • Rx: compresses, antibiotics, curretage, canaliculotomy to remove concretions
    • Functional Occlusion
      • may be total occlusion if poor pump function
      • repeat probings
      • NLD Obstruction
    • Congenital

Examination of the Lacrimal System

  • check puncta for stenosis, position
  • conjunctivochalasis - is excess conjunctiva obstructing puncta opening
  • conjunctival injection
  • trichiasis
  • entropion
  • pseudoepiphora: tear evalaution (meniscus, tear break up time)
  • keratopathy
  • lid stiffness
  • lid laxity
  • pump function Lagophthalmos
  • check VII nerve
  • look up nose
  • Schirmer 1
  • push on sac, look for discharge
  • Basic Tear Secretion (BST)
    • tear strips after anesthesia


  • Dye Disappearance Test (DDT)
    • Fluorescein to both fornices, look with blue light for asymmetry after 5 min.
  • Primary Dye Test
    • Fluorescein to eyes, blow nose, dye present or absent
  • Irrigation (JONES I)
  • estimate flow through system
  • topical anesthesia
  • lower punctal dilation and irrigation, noting stenosis
  • drawing amount of flow 0-100%:
  • reflux around canula or out superior punctum without lacrimal sac distension = common canaliculus block, if same lacrimal sac distension likely complete nasolacrimal duct obstruction
  • if no reflux but w/pain lacrimal sac distention = nasolacrimal duct obstruction w with patent valve of Rosenmuller
  • if reflux and drainage to nose = partial nasolacrimal duct obstruction


  • Secondary Dye Test = Informal Jones II
    • irrigate, dye present in nose = functional nasolacrimal duct obstruction, patent canalicular system, functional pump; or absent
  • Probing
    • diagnostic probing of adult upper system (puncta, canaliculi, lac sac) ok to find level of obstruction, not to probe NLD
  • Dacryocystogram (DCG)
    • good for anatomy, not physiology evaluation
  • CT

Lacrimal System Infections

Dacryoadenitis

Symptoms include pain, tenderness and swelling of the lateral aspect of the eyelid
May occur with systemic diseases such as Sjogren's, sarcoidosis, syphilis, TB, lymphoma, and benign lymphoid hyperplasia
May occur in patients with mums, EBV, zoster




Canaliculitis

Canaliculitis is a clinical condition that is characterized by infection of the canaliculi in the eye. It commonly affects individuals over the age of 50 years. It is caused due to obstruction within the canaliculus, the presence of a foreign body or the presence of diverticulum which harbours bacteria within it.


History and examination

Patients often complain of a long-standing history of one eye being red and inflamed. The inner aspect of the eye constantly displays a thick discharge which can be clear or rather discoloured.
On examination, the lacrimal punctum is swollen and inflamed. The swelling is due to accumulation of fluid and is called oedema. The area is tender to touch. When gently compressed, the cloudy, purulent discharge is expressed through the punctum.



Diagnosis

Diagnosis is through clinical history and examination in most cases. If a probe is passed through the lacrimal punctum, a grating sensation is experienced due to the presence of sulphur stones (concretions) within it.

Laboratory investigations are conducted on the discharge. Tests are conducted to ascertain the type of infection that is affecting the canaliculus. Staining may be performed with a different stains and microscopic assessment may reveal the presence of organisms such as Actinomyces or aspergillus.



Treatment

The treatment of canaliculitis is fairly straightforward and involves the application of warm compressions, massage of the local area and antibiotic creams and ointments applied locally. These treatments may or may not help the patient. In the event of this being the case, patients may require to undergo a surgical procedure to help clear the infection. This is usually offered when irrigation with a sterile solution and broad-spectrum antibiotics is ineffective. Procedures can include deployment of the canaliculus through a procedure called canaliculotomy.

The procedure is fairly straightforward and is performed by making a tiny incision on the conjunctival aspect of the canaliculus. The sulphur concretions are then removed and antibiotics are used to clear any residual infection.



Conclusion

Canaliculitis is a rare condition that affects individuals over the age of 50 years. It is characterised by bacterial or fungal infections within the canaliculi and the formation of concretions that are rich in sulphur. Treatments can include topical antibiotics and drainage, though in some cases surgical treatment may be required.

Symptoms include pain, swelling, tenderness of the INNER canthus of the eye

Etiology is usually actinomycetes



Dacryocystitis

Symptoms: acute onset, tearing (from nasolacrimal duct obstruction), redness, purulent discharge, tender swollen lacrimal sac

An infection within the "tear duct" causes a painful swelling in the inner corner of the eyelids.

If the tearing causes severe symptoms, surgery can be performed to create a new tear duct. This operation is called "dacryocystorhinostomy." (see below). Small silicone tubes my be placed in the tear system to keep the new tear duct open while healing occurs. Surgical elimination of the obstruction by creating a new tear duct is necessary to eliminate the tearing and infection that can result from such a blockage




Acute Dacryocystitis

many etiologies, all cause nasolacrimal duct obstruction with obstruction of drainage from lacrimal sac to nose

  • chronic tear stasis causes 2o infxn
  • edema, erythema below medial canthal tendon w/lac sac distention
  • +/- pain
  • rule out ethmoidal sinusitis, don't probe

Treatment

  • warm compresses
  • oral/IV abx (Keflex, Augmentin), topical only limited value
  • Incision Drainage localized abscess

Complications

  • mucocele, chronic conjunctivitis, orbital cellulitis
  • most need DCR after acute infection subsides


Chronic Dacryocystitis

  • distended lac sac with minimal inflammation suppurative discharge from punctum c/w nasolacrimal duct obstruction
  • probe/irrigate upper system only
  • dacryoliths from Actinomyces, Candida, topical meds, can cause lacrimal colic if impacted in NLD
  • Treatment usually needs DCR for resolution

Treatment of Obstruction

Traditional Surgical Treatments

Since its introduction in the early years of this century, Incisional dacryocystorhinostomy (DCR) has been the "traditional" procedure most often relied upon for relief of epiphora (chronic tearing) and nasolacrimal duct obstruction in adults. However, the high success rate (> 90%) for incisional DCR is balanced by a number of potential drawbacks:

  • Recovery time is significant
  • An incisional scar may develop due to invasive procedure
  • Potential for excess bleeding
  • May not be necessary for partial obstructions

Dacryocystorhinostomy (DCR)

  • goal: anastomosis between lacrimal sac and nasal cavity (middle meatus)
  • decreased success with prior nasal fractures, children, nasal mucosal disease, broad flat nasal bridge, and re-operation
  • Anesthesia Incision
    • General
          because of pt anxiety during bony excision
    • MAC with Local
          with 2% lidocaine/epinephrine with deep infiltration to bone
          pack middle turbinate of nose with nasal neosynephrine/Afrin/Cocaine mixture
  • avoid angular vessels, prevent bowstring contractures causing epicanthal folds
  • dissect skin from muscle with Tenzel periosteal elevators
  • spread orbicularis off periosteum with Steven’s or elevators just lateral to medial canthal tendon (push to bone, then spread)
  • vertically incise periosteum 2 mm medial to ant lacrimal crest, dissect away posteriorly, lacrimal sac reflected (supero)temporally
Procedures
Anophthalmos
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Blepharoplasty
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- Your eyes including your eyelids, are perhaps one of the first things people notice in you. This makes your eyes and eyelids one of the most important components for an appealing facial expression and aesthetic appearance. Any visible change in the shape or size of the orbital or periorbital region can spoil the look of your face.
- As you age and grow older, your eyelids may become ‘droopy’ or ‘baggy’ due to the stretching of your eyelid skin and gradually decreasing tone of your eyelid muscles. Your droopy eyelids and brow together cut a sorry figure for your face making you look tired, sleepy and haggard, further leading to eyelid or brow straining or both. In extreme cases, your saggy, baggy eyelids can even obstruct your vision, particularly peripheral vision causing difficulty in reading or driving.
- Blepharoplasty ensures cosmetic or functional corrections to the area around your eyes to enhance your look or to correct any abnormalities in function.
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Blepharospasm
- Blepharospasm is defined as an abnormal, involuntary, sustained and forceful closure or twitching of the eyelids. It is derived from the Greek word ‘blepharon’ which means eyelid, and ‘spasm’ which is an uncontrolled muscle contraction. Blepharospasm is usually associated with headache, eyebrow strain and occasionally loss of vision.
- Isolated blepharospasm is rare and represents a minority of patients presenting with blepharospasm. Blepharospasm is commonly associated with lower facial spasms as part of a syndrome or disease complex. Some examples are:
   - Meige Syndrome: Characterized by spasm of the eyelids and midface.
    - Brueghel’s Syndrome: Presents with blepharospasm and marked spasms in the lower face and neck.
    - Segmental Cranial Dystonia: In addition to the usual spasms of the eyelids and facial muscles it is associated with spasms along distribution of various cranial nerves, most frequently involving the Facial Nerve.
    - Generalized Dystonia: Presents with spasms across various body parts in addition to blepharospasm and facial spasms.
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Brow Lift
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Congenital
Congenital anomolies include :
- Eyelid Disorders
- Orbital Disorders
- Congenital Ptosis
- Congenital Nasolacrimal Duct Obstruction

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Dry Eye
What is Dry Eye?
- Dry eye is a reduction in your eye’s ability to produce sufficient natural tears.
- Insufficient tear production can lead to irritation and pain, and even scarring of the cornea (the transparent part of the eye that covers the pupil and iris).
- Many people will experience dry eye symptoms at some point in their lives.
- Often due to environmental factors such as indoor heating or air conditioning, it can also be caused by occupational factors such as prolonged computer use.
- Dry eye symptoms can affect anyone.
- Some of the symptoms of dry eye include a burning sensation or gritty feeling in the eyes. You may also experience decreased tolerance to contact lens wear or sensitivity to light.
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Eyelid Laxity
- Eyelids protect your eyes from any foreign bodies while keeping them lubricated throughout. Any alteration in the shape, position or function of your eyelids can predispose your eyes to a plethora of ailments or interfere with our vision.
Our eyelid is a complex structure consisting of three theoretical layers:
   - Anterior Layer contains the skin and orbicularis muscle
   - Middle Layer contains the orbital septum and eyelid retractors
   - Posterior Layer contains tarsus and conjunctiva.

- Eyelid malpositions include any unnatural or incorrect positioning and orientation of eyelids due to various factors that influence any of the three layers of the eyelids. They may be caused due to ageing, trauma, scarring, birth defects or medical disease involving any or all of the three layers.
- The most common forms of eyelid malposition are eyelid retraction, ptosis, entropion and ectropion.
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Face
The world of cosmetic surgery has advanced tremendously over the last two decades. New procedures have emerged that can make an individual look and feel younger in a matter of a few minutes. Amongst the vast number of cosmetic procedures currently available, the face lift is a commonly performed one that is sought after by both men and women. Here we shall take a look at this procedure in a little more detail.

- What is a face lift?    - A face lift is called a rhytidectomy in the world of medicine. It involves tightening the muscles of the face and smoothening of the skin so that the face appears younger.    - However, it must be remembered that a face-lift is not an anti ageing solution.
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Lacrimal System
- The lacrimal gland produces tears which enter into the "duct" that drain the tears from the eye into the nose. The most common symptoms are If one has a plugged up "tear duct," not only will tears spill over the eyelids and run down the face, but the stagnant tears within the system can become infected.    (1) excess tearing (tears may run down the face) and    (2) mucous discharge - This may lead to recurrent red eyes and infections. - The excessive tearing can also produce secondary skin changes on the lower eyelids.
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Lagophthalmos
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Latisse
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Orbital Tumors
- Orbital Tumor is any tumor that occurs within the orbit of the eye. The orbit is a bony housing in the skull about 2 inches deep that provides protection to the entire eyeball except the front surface. It is lined by the orbital bones and contains the eyeball, its muscles, blood supply, nerve supply, and fat.
- Tumors may develop in any of the tissues surrounding the eyeball and may also invade the orbit from the sinuses, brain, or nasal cavity, or it may metastasize (spread) from other areas of the body. Orbital tumors can affect adults and children. Fortunately, most are benign.
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Ptosis
- Ptosis is an abnormally low position (drooping) of the upper eyelid
- Ptosis occurs when the muscles that raise the eyelid (levator and Müller's muscles) are not strong enough to do so properly.
- It can affect one eye or both eyes and is more common in the elderly, as muscles in the eyelids may begin to deteriorate.
- Compare with dermatochalsis (extra skin and fat)
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Skin Rejuvination
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Skin Tumors
Cancer of the eyelid, like any other cancer, can be a worrying thing. Treatments are variable and depend on the type of cancer. In this article, we shall take a brief look at the different kinds of eyelid tumors.
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Symblepharon
A symblepharon is a fibrous tract that connects bulbar conjunctiva to conjunctiva on the eyelid.
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Thyroid
Graves' disease is an autoimmune disease.
It most commonly affects the thyroid, causing it to grow to twice its size or more (goiter), be overactive, with related hyperthyroid symptoms such as increased heartbeat, muscle weakness, disturbed sleep, and irritability. It can also affect the eyes, causing bulging eyes (exophthalmos).
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Trauma
Eye injuries are extremely common with over 2 million cases reported every year that require medical treatment. Blindness in one eye is most commonly due to cataract and this is followed closely by eye injuries. In addition, in children, injury to the eye is a recognized as the most common cause of blindness in one eye that is not due to a birth defect.
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