Ophthalmic Education:

Principles and Guidelines of a Curriculum for Ophthalmic Education of Medical Students: Chapter IX. Diseases of Eyelid, Lacrimal System, and Orbit

On this page:

• Educational Goal
  
  
• Eyelid
  
  
• Lacrimal System
  
  
• Orbit
  
  
• Clinical Competencies

Educational Goal: 

Students should understand the normal anatomy of the adnexal structures and the presenting signs and symptoms of serious conditions associated with ocular and systemic morbidity, such as orbital cellulitis.

A. Eyelid.*  

1. Examination and Technique.**

a.  Assess the position of the upper eyelid by measuring the distance between the lid margin and the corneal light reflex (margin-reflex distance).**

b. Visual inspection of eyelids and periocular area.**

2. Normal anatomy.**

a. Anterior and posterior lamellae.***

b. Lid margin.** (REF. 2E Fig. 10, REF. 2E Fig. 12)

c. Orbital septum relationship to eyelid/orbit.**

d. Eyebrow.**

e. Levator aponeurosis.**

f. Blood supply – internal and external carotid circulation.***  

g. Sensory supply – V₁ and V₂ .*

h. Motor supply – cranial nerve III, cranial nerve VII, and upper eye lid sympathetic innervations.**

3. Eyelid Diseases.*

a. Malpositions.*                               

   i. Blepharoptosis.** (REF. 2B Slide 20)

   ii. Dermatochalasis.**

   iii. Entropion.* (REF. 2B Slide 18) (REF. 22 Fig. F17, F18, F19, F20)  

   iv. Ectropion.* (REF. 2B Slide 19) (REF. 22 Fig. F14, F15)  

   v. Retraction.* (REF. 11 Fig. 12–18)

   vi. Lagophthalmos.* (REF. 11 Fig. 12, 13)  

b. Inflammations.* 

   i. Chalazion.* (REF. 2E Fig. 13, 14)

   ii. Blepharitis.* (REF. 2E Fig.16, 18)

   iii. Meibomitis.** (REF. 22 Fig. B49)

c. Infections.*  

   i. Hordeolum.* (REF. 2E Fig. 11) (REF. 22 Fig. B43)

   ii. Preseptal cellulitis.** (REF. 22 Fig. H43)

   iii. Orbital cellulitis.* (REF. 2E Fig.19–23)

   iv. Herpes Zoster Ophthalmicus.** (REF. 2B Slide 23)  

d. Tumors.* 

   i. Benign.***  

   ii. Cysts.***  

   iii. Nevi.**

   iv. Papillomas.**

   v. Xanthelasma.*  (REF. 8 Fig 13-6)

   vi. Malignant.**

      (a) Basal cell carcinoma.** (REF. 2B Slide 21) (REF. 3 Case 20, Basal Cell Carcinoma, p. 40) (REF. 22 Fig. F02, F03)  

      (b) Squamous cell carcinoma.**

      (c) Eyelid trauma.** (REF. 2C Slide 32, 33) (REF. 22 Fig. F53, F54)

B. Lacrimal System.**

1. Examination technique.**

a. Visual inspection of medial canthal area.* (REF. 2C Slide 34)

2. Anatomy.** (REF. 1 Fig. 24)

a. Upper lacrimal system – puncta, canaliculi, and lacrimal sac.*  

b. Lower lacrimal system – bony and mucosal nasolacrimal duct.***

3. Lacrimal diseases.**

a. Congenital nasolacrimal duct obstruction.**

b. Acquired nasolacrimal duct obstruction.**

c. Dacryocystitis.** (REF. 2E Slide 25) (REF. 22 Fig. F13)

d. Lacrimal trauma.**

C.  Orbit.*

1. Examination technique.*

a. Observe laterally and superiorly to compare both eyes to identify axial proptosis.*  

b. Exophthalmometer.***  

2. Anatomy.**

a. Seven bones comprise four walls: floor, medial and lateral walls, and roof.*** (REF. 4 Fig. 5.1)

b. Orbital septum relationship to orbit.**

c. Contents of orbit: extraocular muscles, lacrimal system, ophthalmic artery, cranial nerves (II, IV, V, VI, sympathetic, and parasympathetic).**  

d. Relationship of orbit to surrounding structures:  sinuses, cranial cavity.**

3. Orbital diseases.*  

a. Orbital cellulitis - life threatening condition requiring urgent referral.* (REF. 2E Slide 19-23)  

b. Thyroid eye disease (Graves’ ophthalmopathy).* (REF. 2F Slide 64, 74)

c. Orbital inflammatory disease.**

d. Orbital tumors.***    

   i. Muscle.*** (REF. 10 Fig 26-1 Rhabdomyosarcoma in a 4-year-old boy presenting with right upper eyelid ptosis of 3 weeks duration and a palpable subcutaneous mass)         

   ii. Vascular.*** (REF. 10 Fig. 26-5 Capillary hemangioma in a 2-month-old girl involving the right upper eyelid and orbit with displacement of the globe and induction of 8D of astigmatic error)    

   iii. Neural.*** (REF. 11 Fig. 8a-8f )    

      (a) Clinical photograph of a child with a right optic nerve glioma displaying proptosis and esotropia.***    

      (b) Fundoscopic view of the same patient.***

      (c) fMRI imaging studies.***    

   iv. Lacrimal.*** (REF. 11 Fig. 5-17 a, b, c)    

      (a) Proptosis and downward displacement of the left eye in a man with benign mixed tumor of the lacrimal gland.***    

      (b) Axial CT scan.*** (REF. 22 Fig. F25, F26, F27, F28, F29)     

      (c) Coronal CT study.***    

   v. Metastatic.*** (REF. 10 Fig. 26-2 Bilateral orbital metastases of neuroblastoma presenting with bilateral ecchymosis in a 2-year old child)

      (a) Orbital trauma.*** (REF. 2C Slide 36-38)

      (b) Blowout fracture.*** (REF. 2C Slide 29, 30) (REF. 22 Fig. F38, F39, F40, F41, F42)

Clinical Competencies

Students should:

• Understand structure and function of eyelids, commonly associated malpositions, and acquired disorders.*  
• Understand tear production and drainage.**
• Understand orbital structure and common abnormalities.**
• Understand the importance of orbital cellulitis as a potentially life threatening condition that requires emergent attention.**

* Basic Level: Necessary in the education of medical students worldwide.

** Standard Level: A higher level of ophthalmic understanding than the basic curriculum of most international medical students.

*** Advanced Level: Advanced cognitive and clinical skills more appropriate for students who seek further training in ophthalmology, which may be covered in an ophthalmology elective in medical school.

(Also see: More on Educational Priorities)

Next: X. Ocular Manifestations of Systemic Diseases

Also see:

• Table of Contents of the "Principles and Guidelines of a Curriculum for Ophthalmic Education of Medical Students"
  
  
• Education of Medical Students in Ophthalmology
  
  
• Resources for Ophthalmic Education of Medical Students