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ANATOMI DAN

FISIOLOGI PALPEBRA
Anatomi
Terdiri atas :
• Skin :
– Paling tipis
– Jaringan longgar
– Tdk ada lemak subkutan
• Otot Protraktor (M.orbicularis oculi)
• Septum orbita, lemak orbita
• Otot Retraktor (M. Levator)
• Tarsus
• Konjungtiva
• Silia
• Glandula (Zeis, Moll, Meibom)
• Tarsus :
– Jar konektif padat  skeleton palpebra
– Tarsal plate palp superior : 10-12 mm
– Tarsal plate palp inferior : 4,5 mm
– Lebar : 29 mm
• Vaskularisasi :
– A/V oftalmika
– A/V lakrimalis
• Inervasi sensorik : N V
• Otot :
– M. Orbikularis okuli :
• Circular
• Fungsi : membuka/menutup
• inervasi : N VII
– M. Levator palpebra :
• Melekat pd batas atas tarsus &
pertengahan kulit
• Inervasi : N III
– M. Muller’s :
• Otot polos
• Insersi : tepi atas tarsus
Fungsi Palpebra

• Pelindung mekanik bola mata.


• Menghasilkan komponen lipid untuk
air mata.
• Membantu membasahi kornea.
Batas-Batas Palpebra
• Batas superior
daerah alis dan rima orbita
superior.
• Batas inferior
dari rima orbita inferior
sampai ke kulit nasojugal
dan lipatan malar.
• Lebar
horizontal fisura :30 mm
vertikal :8-10 mm.
Lipatan Palpebra Superior
• (Lid crease) :
terbentuk dari perlekatan
serabut aponeurosis levator
di lapisan subkutan.
• Lokasi:
7-11 mm di atas margo
palpebra.
Posisi Primer Palpebra

• Margo palpebra superior, 1-2 mm di


bawah limbus superior.
• Margo palpebra inferior pada limbus
inferior.
Margo Palpebra (1/2)
• Panjang 25-30 mm dan
lebar 2 mm.
• Papila lakrimal:
6 mm lateral dari sudut kantus
medial
• Gray Line  Pertemuan antara
– epitel berlapis gepeng
berkeratin di anterior,
– epitel berlapis gepeng tak
berkeratin dan epitel berlapis
silindris di posterior.
Margo Palpebra (2/2)

• Bagian anterior margo palpebra terdapat


otot Riolan.
• Palpebra superior:
silia uk.8-12 mm, jumlah 100-150
• Palpebra inferior:
silia uk.6-8 mm, jumlah 50-75
• Kel sebasea Zeiss dan kel Apokrin Moll.
7 Lapisan Palpebra

1. Kulit & jaringan


subkutan.
2. Otot protraktor.
3. Septum orbita.
4. Lemak orbita.
5. Otot retraktor.
6. Tarsus.
7. Konjungtiva.
Lipatan Palpebra
Occidental vs Oriental
Kulit & Jaringan Subkutan

• Sangat tipis dan elastis.


• Tidak mempunyai lapisan lemak subkutan
• Lapisan dermis:
– jaringan ikat longgar yang mengandung
serat elastin,pemb darah,limfe dan
saraf.
• Lapisan subkutan:
folikel rambut & kelenjar sebacea.
Otot Palpebra
• Otot Protraktor.
• Otot Retraktor.
Otot Protraktor Palpebra

• M.Orbikularis okuli, melingkari fisura


orbit.
• Dipersyarafi saraf otak VII.
• Tiga bagian :
– Orbikularis orbital,
– Orbikularis preseptal,
– Orbikularis pretarsal.
Otot Orbikularis Orbital
• Terbesar dan tertebal,
• Melapisi rima orbita.
• Berbatasan dengan :
– otot frontalis
– proserus
– korugator superfisialis
– temporalis
Otot Orbikularis Preseptal
• Terletak di atas septum orbita.
• Fungsi:
menutup palpebra &
berperan dalam pompa
lakrimalis.
• Serabut otot preseptal atas
dan bawah membentuk tendon di raphe
palpebra lateral.
Otot Orbikularis Pretarsal
• Bagian terkecil.
• Fungsi:
saat refleks mengedip dan berperan pada
pompa lakrimal.
• Dibagi 4 bagian:
bagian atas dan bagian bawah (superfisial
dan dalam)
• Otot tensor tarsi Horner.
• Dilateral bersatu membentuk tendon
kantus lateral.
Septum orbita
• Jaringan ikat berlapis berasal dari
periosteum pada rima orbita
superior-inferior di daerah arkus
marginalis.
• Fungsi:
sebagai barier antara orbita dan
palpebra
Lemak Orbita
• Normal:
letak di posterior septum orbita dan
anterior dari aponeurosis levator
• Dapat mengalami herniasi ke palpebra.
• Bantalan lemak sentral penting untuk
operasi palpebra elektif dan repair
laserasi palpebra
Otot Retraktor Palpebra

• Otot rektraktor palpebra superior:


m. levator dan aponeurosisnya dan
m.tarsalis superior (muller).
• Otot retraktor palpebra inferior:
fasia kapsulopalpebral dan
m.tarsalis inferior.
• Dipersarafi: saraf simpatis.
Otot Retraktor Palpebra
Superior (1/2)

• M.Levator palpebra :
otot utama dan berfungsi mengangkat
palpebra superior sekitar 15 mm.
• M.Muller :
fungsi memberi tambahan tonus dan
hilang bila kelelahan atau paralisis dan
palpebra turun 2 mm.
• Bila mengalami overstimulasi :
terjadi retraksi 2-3 mm di atas normal.
Otot Retraktor Palpebra
Superior (2/2)

• Origo m Levator: di atas anulus Zinn


• Komponen otot 20mm dan komponen
aponeurosis 14-20 mm.
• Lig.Whitmall:
Letak di daerah transisi m.levator dan
aponeurosis levator
• Fungsi lig.Whitmall:
pendukung palpebra superior dan jaringan orbita
superior
Otot Retraktor Palpebra Inferior
(1/2)

• Palpebra inferior membuka secara


pasif karena tarikan m.rektus
inferior.
• Fasia kapsulopalpebral analog dengan
aponeurosis levator.
• Dua bagian kepala kapsulopalpebra
membentuk lig.Lockwood.
Otot Retraktor Palpebra Inferior
(2/2)
• M.Tarsalis inferior analog dengan
m Muller.
• Ligamentum suspensorium forniks
Tarsus (1/2)
• Terdiri dari jaringan padat.
• fungsi : sebagai rangka palpebra.
• Ukuran tarsus superior:
lebar :10 mm di sentral
panjang :25-29mm
tebal :1 mm.
• Ukuran tarsus inferior:
lebar :3.5-4 mm di sentral,
panjang :25-29 mm
tebal :1 mm.
Tarsus (2/2)

Tda kelenjar Meibom:


• 30-40 di palpebra
superior
• 20-30 di palpebra
inferior
Konjungtiva
• Konjungtiva palpebra.
• Konjungtiva forniks.
• Konjungtiva bulbi.
• Plika semilunaris.
Vaskularisasi
• Suplai vaskular padat dan banyak
sirkulasi kolateral.
• Mempercepat penyembuhan.
• Mudah terjadi perdarahan saat
prosedur operasi.
Vaskularisasi Arteri

• Dari a.karotis interna melalui


a.oftalmika dan a.infraorbita.
• A.karotis eksterna melalui
a.fasialis dan a.temporalis
superfisialis.
• Membentuk sirkulasi kolateral
yang besar.
Vaskularisasi Vena
• Terdiri dari arkade palpebra
superior dan arkade palpebra
inferior.
• Vena palpebra superior dan
inferior menuju v.angularis di
kantus medial.
• Vena angularis membentuk
anastomosis dengan sinus
kavernosus.
Sistim Limfatik

• Menuju nodus limfatikus


preaurikular dan submandibular.
• Menerima drainase dari sistem
superfisial dan profunda.
• Pleksus superfisial : menerima
aliran limfa dari kulit dan otot
orbikularis.
• Pleksus profunda : dari tarsus
dan konjungtiva.
Sistem Limfatik

• Aspek medial palpebra superior


inferior,sentral palpebra inferior
dan konjungtiva menuju nodus
limfatikus submandibularis.
• Palpebra superior,aspek lateral
palpebra inferior dan konjungtiva
menuju nodus imfatikus preaurikular
Persarafan (1/2)

• 2 saraf motorik untuk gerakan


palpebra.
• N.III: mempersarafi m.levator
palpebra untuk mengangkat palpebra
superior dan m.rektus inferior.
• N.VII mempersarafi m.orbikularis
okuli.
Persarafan (2/2)

• N.V :
untuk sensasi palpebra
• Palpebra superior dipersarafi
oleh cab.1 n.oftalmikus
• Cabang utama n. oftalmikus:
n.lakrimalis, n.supraorbita,
n.supratroklearis, dan
n.infratroklearis.
Eye Lids Diseases
Eyelid Diseases
• Infection
– Hordeolum
• Suppurative acute infection at eyelids gland
caused by Staphylococcus
– Hordeolum internum : at meibom gland
– Hordeolum eksternum : at zeis,mole gland

• Therapy :
– Systemic & local antibiotics
– Incision :
• mostly common on hordeolum externum
• Skin incision : margo
• Conjuctival incision : margo
• Complication : eyelids abscess
• Chalazion
– Chronic lipogranulomatous
inflammation of the meibom gland
– red-purple painless nodule at the
conjunctiva
– Therapy : incision
• Eyelids abscess
– originates from hordeolum or severe
eyebrow infections
– Therapy :
• Local and systemic antibiotics
• incision skin line
• Blepharitis
– bilateral
– chronic infection margin of the eye lid
– Squamous blepharitis (seborrhea) :
• signs : itching, burning, squamous seborrhoic at
the lash
• Th/ : cleaning with wet cotton, corticosteroid
ointment
– Ulcerated blepharitis :
• margo infection caused
by staphylococci at
children with bad
general condition
• clinical signs : red
palpebra, squamous
seborrhoic, ulceration
along margo covered by
crust,
• loss of eye lashes, margo
distortion (if chronic and
severe)
• Th/ : improving general
condition, clean the crust
with wet cotton,
antibiotic ointment
• Herpes Zoster Ophtalmica
– E/ : herpes zoster viral
– clinical signs : very pain and burning (caused by
disturbances of the first branch of nervus V)
– Th/ : analgetic, antiviral (acyclovir), antibiotic
(to prevent from secondary infection) and local
corticosteroid
• ALERGY
– Clinical signs : eye lids edema
– Type :
• anaphylactic and atopy (urticaria and
angioneurotic edema)
• contact allergy (cosmetic)
– Th/ :
• eliminate etiological agent
• local and systemic steroid ( depend on
the E/)
Tumor
– Benign :
• naevus
•verucca
• xanthelasma :
–yellowing plaque, irregular esp..
at medial
–Th/ : excision (for cosmetic
reason)
• milium :
– small and white papil (lenticular)
– caused by retention of sebacea gland
• Haemangiom (vascular tumor)
–Cavernous haemangiom :
• consists of the big branch of vein at
subcutan
• blueing
• change at vaso dilatation  bigger if
crying (Valsava test +)
– Capilary haemangiom :
• superficial
• consist of widing capillary
• red
– Th/ :
• cryocoagulation (if big and disturbing)
• steroid injection
• Neurofibromatosis (von
Recklinghausen disease)
• usually occur at temporal
– Malignant
• Basal Cell Ca at geriatric
• the most common eye lid malignancy (90-95%) on
lower eye lid (near medial cantus)
• clinical signs : ulcerative node, irregular,
pigmentation, metastation rare
• Th/ : excision and radio th/
– Nodular basal cell Ca
• firm, raised, pearly nodule
• central ulceration
– Morpheaform
• firm, slightly elevated
• characteristically : ulceration
– Squamous Cell Ca (Epithelioma)
• at geriatric
• esp. at superior palpebra
• metastation to preauricular nodes through lymphatic
system
• Th/ : wide excision
– Malignant Melanoma
• associated with conjuntival melanoma
• Th/ : radical operation --> excenteration
– Sebaceous Cell Ca
• at gland. Meibom
• recurrent Chalazion
• multifocal
• metastation : rare
• Th/ : wide excision
Eye Lid Malposition
• Entropion
– turning in of the eye lid margin  the
lashes touch the cornea (Trichiasis) 
corneal irritation  corneal ulcer
– unilateral or bilateral
• Congenital entropion
– Senile Entropion
• Th/ : blepharoplasty (reconstruction)

– Acute spastic
• ocular inflamation
• ocular irritation
– Cicatricial entropion
• caused by cicatrix/shortening of the
tarsus
• E/ :
– trauma thermal, chemical burns and eye lid
injury
– infections : trachoma, herpes zoster
• Th/
– eye lid reconstruction
– trachoma --> Sie Boen Lian technique (SBL)
• Ectropion
– turning out of the eye lid margin 
conjunctiva is not well covering  thick,
red, chronic conjunctivitis
– Congenital ectropion
– Senile ectropion :
• caused by tissue relaxation loss of eye lid tone 
evertion of margin
• often seen in the lower eye lid
– Paralytic ectropion :
• caused by N.VII palsy  poor blinking &
lagophthalmos
– Cicatrical ectropion

• Th/ : blepharoplasty/reconstruction
• Mechanical
– caused by :
• bulky tumor of the eye lid
• fluid accumulation
• Simblepharon
– attachment of the eye lid to the eye
ball (usually with cornea)
– Th/ : simblepharectomy
• Lagophthalmos
– the eyelids aperture can not close
perfectly
– E/ : paralyze of N.VII, cicatrix,
proptosis, tumor
– complication : xerosis (dry eye)
• Ptosis
– the upper eye lid can not open perfectly
– unilateral/bilateral
– congenital ptosis
– acquired ptosis
• senile
• myogenic
• neurogenic (paralyze of N.III)
• trauma
• mechanic (tumor)
– Th/ :
• fasanela servat
– if some and the function of levator still good
• levator shortening
– skin approach or
conjunctival approach
LACRIMAL SYSTEM
• Secretory apparatus
– Lacrimal gland :
• located in superolateral quadrant of the
orbit
• exocrine gland
– Accesoryexocrine glands :
• Krause & Wolfring
• location in the superior fornix and above
the superior border of the tarsus
• Excretion section
– draining the tears into the nasal cavity
• Tear
– slightly alkaline
– containing NaCl, such a lyzozym
enzyme that bacteriostatic
– Normal : tear dampened the eye ball -
-> apart are evaporated and most of
the tear flows is actively pump by the
action of the orbicularis
muscles/blinking
– measure with Schirmer Test
5mm 25 mm
Normal 10 - 15 mm dalam 5’
Congenital abnormalities of
the nasolacrimal system

• Nasolacrimal duct obstruction


– complete absence or the puncta
– lacrimal cutaneus fistula
– nasolacrimal obstruction of the distal
end (the valve of Hasner) ---> very
often
• Punctum anomaly
– no punctum
– punctum evertion
• loose palpebra -----> facial paralysis
• cicatrix -----> old age
– Th/ : reconstruction
• Dry eye
– caused by decrease of producing tear
– occur at :
• conjunctival cicatrix caused by
trachoma/trauma
• Sjorgen syndrome
• Steven Johnson syndrome
• deficiency of Vit A
• lagophthalmos
• Epiphora
– the disturbance of tear excretion
– Occur on :
• lachrymal punctum position disturbance
• paralyze of M. orbicularis --> weaking
the canaliculi suction effect
• obstruction of nasolacrimal duct and sac
Determining of the lacrimal
system disturbances
• punctum inspection
• palpation at sac area
– on pressure --> discharge reflux
• Dye Disappereance Test (Jones
test)
• Anel test (irrigation test)
• probing with Bowman’s probe
• dacryosistography with contrast
• dacryoscintilography,
sophisticated, with radionuclides
(technetium-99)
• Management
– The upper system
• dilation ----> probing
• ampullotomy
• cilicon intubation
– Lower system
• dacryocystorrhinostomy (DCR)
Nasolacrimal Infection
• Acute dacrioadenitis
– signs :
• red painfull swelling with redness of the
outer of the upper eye lid , pseudo ptosis
(sometime)
– E/ :
• adult : gonorrhoica
• children : with another disease -->
parotitis
• Chronic dacrioadenitis
– slightly edema
– not pain
– often at TB, leukemia, trachoma
– Th/ : depend on the etiological agent
• Chronic dacriosistitis
– more common
– attributed to the nasolacrimal obstruction
– children and adult
– symptom :
• epiphora
• swelling at the site of the sac (distended sac)
• on pressure over the sac --> muco-pus or pus
regurgitates trough the puncta
– Th/ :
• topical and systemic antibiotic
• if obstruction --> dacriosistorinostomi
Nasolacrimal system tumor
• Lacrimal gland tumor
– benign
• adenoma
• limphangioma
– malignant
• mixed tumor
• sarcoma
– Th/
• operation
• radiation
• Lacrimal sac tumor
– benign
• squamous papiloma
– malignant
• epidermoid Ca
– Th/
• operation (cystectomy)
• radiation