Orbits, eyelids and lacrimal pathways

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Orbits, eyelids and lacrimal pathways


Tears have fascinated humanity since antiquity. They have been addressed in poetry, literature and religious writings, paintings, music and cinema.

There are three basic types of tears:

Basal production that lubricates the eye conjunctiva and is part of our immune barriers
Reflex tears for flushing out external irritants
Emotional tears



The lacrimal gland lies at upper external corner of the orbit, responsible for 90% of tear secretion. The remaining 10% is produced by accessory glands placed in the eyelids. Tears leave the conjunctival surface through two holes, the lacrimal punctum.

These holes drain to a lacrimal sac and then to a duct by which the fluid is conveyed into the cavity of the nose. There are a few valves along this pathway to avoid fluid reflux back to the eye.

An excess of tears, during reflex or emotional tears, causes the nose to run, and when exceeding the lachrymal draining capacity, tears will fall from the eyelid onto the cheek. The medical term for this tearing overflow is epiphora.

Watery eyes

Having watery eyes affects daily activities, such as reading, driving, outdoor walking, watching television or computer work. It may be caused by an excess of basal tear production or their insufficient drainage.

Let me talk about the latter one, because those are the cases I get referred to.


An obstruction in the nasolacrimal system will result in a stagnation of tears and epiphora. Stagnation provides a favorable environment for infectious organisms to propagate and debris to form, leading to a local infection, named dacryocystitis.

There can be obstructions at any level of the nasolacrimal system, for several reasons: local debris, local trauma, lachrymal stones and systemic diseases such as auto-immune diseases.

In adults, dacryocystitis it occurs usually above 40 years old, and females represent around 70% of all cases, because their lacrimal conduit tend to be narrower.


During acute infection episodes, it may be necessary to use antibiotic therapy. In chronic dacryocystitis it is almost always managed surgically.

Whatever the case, it is highly recommended to visit an Ophthalmologist before referring to a surgeon.

Surgery is usually performed under general anesthesia, and the approach can be done entirely inside the nose using an endoscope, or combined with a small skin incision. A silicone tube is placed in the lachrymal conduit and left there during a few weeks to prevent re-occlusion.

When for some reason, it is not possible to restore the duct, due to trauma, oncological cases or very fibrotic ducts, a new channel can be opened in the inner corner of the eye with a Jones tube.

Patients leave hospital the same or the next day and should avoid strenuous activities, to prevent unnecessary nose bleeding.

For patients unfit for general anesthesia, there are other possible surgical approaches and managements.


Orbital tumors

A wide spectrum of tumors and pseudotumors (inflammatory disorders) involve the orbit. Their approach may require a handful of different medical fields, with Ophthalmology as pivotal speciality. My role as Maxillofacial Surgeon is to perform biopsies, tumor removal, orbital decompression, orbital and eyelid reconstruction.  

Orbital tumors and inflammatory diseases do not have specific symptoms. They may present with proptosis (eye bulgidng), eye redness, eye pain, visual impairment, diplopia (double vision), eyelid ptosis, epiphora (constant basal tearing), headaches and/or nasal obstruction. 

Imaging with CT scan and MRI are key for evaluation. While fine needle biopsy may be faster and cheaper to obtain, and useful for benign/malignant differatiation of orbital masses, a final diagnosis usually requires an open biopsy, in particular for bone, neural tumors and lymphomas.  

The most common orbital tumoral masses include: 

  • Vascular malformations are one of the most frequent benign tumors involving the orbital tissues. Surgery is done when the lesion is symptomatic and interventional (neuro)radiology may be called for vascular diagnostic angiography, and in some cases with therapeutic vascular embolization. 
  • Mesenchimal tumors encompass wide variety of tumors, usually benign such as lipomas. Within this group, the solitary fibrous tumors, are locally aggressive and therefore should be removed. Distant metastasis are very rare.  
  • Shwannoma or neurilemmomas are benign tumors that arise from neural cells. If asymptomatic, can be monitored regularly. Gliomas and meningiomas must be surgically address, with Neurosurgery cooperation. 
  • Tumors from the orbital bone, when benign and symptomatic they are surgically removed, trying to preserve the eye structure. When malignant, a prompt and radical excision is needed. 
  • Lymphoma (in particular MALT lymphoma) are not infrequent, and required a biopsy for confirmation. Its treatment is based on drugs managed by a Haematologist. 
  • Eyelid and facial skin tumors can invade the orbit with and should therefore surgically removed. A new drug, directed to basal cell carcinoma, enlarges the treatment portfolio for selected patients with irresectable or potentially eye losing resection surgery. Its prescription must be approved and directed by an oncology board. Radiotherapy is also frequently prescribed some of orbital invading tumors from the skin. 
  • Lesions from the lacrimal sac and nasal sinus can also invade the orbit and should be referred to a surgeon.   
  • Lacrimal gland tumors are rare, but must also be surgically removed.  

Inflammatory diseases

There are two main categories of inflammatory orbital diseases: 

  • Non-specific or Idiopatic, previously known as inflammatory pseudotumor, because its clinical presentation resembles an orbital tumor. The biopsy is fundamental, but even with highly experienced Pathologist, it may be difficult to differentiate it from a lymphoma. Searching for a specific underlying cause may reveal an Ig4 immue-medidated syndromes or other rheumatological diseases such as sarcoidosis or lupus, and must be refered  to and auto-immune diseases specialist. 
  • Graves’ disease is an autoimmune disease which deserves a topic on its own. 

Graves' disease

It is an autoimmune mediated thyroid hyperfunction. Approximatively 25% to 30% will develop an inflammatory orbit and eye disease, named Graves´ orbitopathy, Graves´ ophtalmopathy or thyroid eye disease. It is classified in three severity categories: mild, moderate and sight-threatening. It impacts negatively the quality of life, even in mild and moderate disease. 

In Graves´orbitopathy there is an abnormal growth of adipose (fat) and muscle inside the orbit, which is a bony non-distensible cavity. Graves`s disease is classified in three severity categories: mild, moderate and sight-threatening. It impacts negatively the quality of life, even in mild and moderate disease. The growing tissues push the eye outward through the orbital natural opening, leading to proptosis (eye bulging), eyelid retraction and incapacity of eyelid closure leading to corneal dryness and consequently a corneal ulcer (sore). Besides changing the light refraction and visual power, it represents an open door for a severe eye infection.  

The impaired muscle activity and unbalanced eye axis may lead to double vision. Optic nerve compressing by the growing surrounding tissues is a sight-threatening event and needs expeditious medical and surgical care. 

Patient will probably present other hyperthyroidism signs such as tachycardia, excessive sweating, diarrhea, enlarged neck. 

General recommendations: 

The first and important active behaviour patient can do on their own: quit smoking and adopt a healthy lifestyle to reduce cholesterol. 

Thyroid hormonal control is of paramount importance, as well eye ointment with artificial tears and gels when dry eye is present, therefore prompt counselling with Endocrinologist and an Ophthalmologist.  

According to your disease activity and severity, the multidisciplinary medical team may decide for corticoid treatment and/or immunomodulatory drugs or in very selected cases radiotherapy. 

In case of sight threatening Graves’ ophthalmopathy, without sufficient response to medication, it must be quickly referred to a surgeon, for a prompt orbital decompression to reduce the pressure on the optic nerve. It is usually done endoscopically through the nose, but in severe cases can also include external approach to the lateral orbital wall.  

In case of inactive or stable disease, rehabilitative surgery may include eyelid surgery and orbital decompression as needed or required. 


If you think you might have Graves´ disease or orbital tumor, please write to us so we can provide your multidisciplinary evaluation.  



Orbital fat graft




Orbits, eyelids and lacrimal pathways Lisboa near me

MD, DSS, Miguel Lopes Oliveira

Maxillofacial Surgeon

At Faces, we offer a wide range of specialized services in facial health. Our highly qualified team is ready to meet your individual needs. In our clinic, you will find a global and comprehensive approach to facial and neck surgery, achieving results beyond restoration.

We provide treatments for conditions such as temporomandibular joint dysfunction, orthognathic surgery, salivary gland problems, neck conditions, snoring and sleep apnea, tear duct and eyelid issues, facial fat grafting, and trauma-related injuries.

Our dedicated team is here to answer all your questions and provide the most suitable treatment for you. Schedule a consultation with us today and discover how we can help you.

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Pedro Costelas
Pedro Costelas
Recentemente fui submetido a uma cirurgia Maxilofacial para retirar um tumor benigno, tendo a mesma sido efetuada pelo Dr. Miguel Oliveira. A cirurgia não podia ter corrido melhor só tendo a agradecer ao Dr Miguel o seu grande profissionalismo e o interesse que demonstrou em resolver o meu problema, que tanto me preocupava. A intervenção correu muito bem, assim como a posterior recuperação. A cicatriz mal se nota pelo excelente trabalho efetuado pelo Dr. Miguel. Mais uma vez o meu Muito Obrigado por tudo!!!
Teresa Canário
Teresa Canário
Fui intervencionada recentemente a um enorme lipoma pelo Dr. Miguel Oliveira e não quero deixar de destacar o extremo profissionalismo, simpatia, empatia com que conduziu todo o meu processo. De destacar ainda a forma descontraída com que sempre me tratou, o que ajudou em muito a que eu acreditasse que estava realmente nas mãos certas. O resultado foi perfeito, a cicatriz é quase invisível e ninguém acredita que daquele tão pequeno espaço saiu um lipoma tão grande. Quero agradecer profundamente ao Dr. Miguel por todo o seu excelente trabalho!
Tânia Calisto
Tânia Calisto
O Dr. MIGUEL foi impecável. Super atencioso, simpático e prestável. Foi muito esclarecedor.
Anabela Correia
Anabela Correia
O Dr. Miguel Oliveira é um profissional de excelência. A cirurgia reconstrutiva q fez ao olho esquerdo do meu pai fIcou PERFEITA. O meu pai tem 82 anos e foi alvo de violência q o deixou com várias lesões no rosto em especial na zona ocular e o Dr. Miguel foi de uma atenção, empatia e perfeccionismo inexcedível. Obgada.
Mariana Rosa
Mariana Rosa
Excelente médico, sempre disponível fossem que horas fossem. Durante a recuperação ligou várias vezes para acompanhar ao máximo a recuperação apesar de não estar perto. Aconselho!
Mario Reis
Mario Reis
As consultas e a cirurgia com o Dr. Miguel Oliveira decorreram de forma tranquila, serena, com toda a informação. A intervenção evidenciou elevado nível de competência profissional. Grato pelos serviços profissionais prestados.
maria anjos
maria anjos
Sempre considerei que profissionalismo e competência é o que devemos valorizar em qualquer área mas sobretudo na saúde. Quando nada o fazia prever foi-me diagnosticado um carcinoma mucoepidermoide. Em boa hora conheci o Dr. Miguel Oliveira e desde o primeiro momento senti uma enorme confiança. Fui operada e até hoje continuo a ser acompanhada por ele. Embora ainda não se possa cantar vitória, o certo é que até agora tem tudo corrido bem. Bem haja Sr. Dr. Miguel Oliveira.
pedro brandao
pedro brandao
Consulta que demonstrou confiança serenidade e competência no diagnóstico clínico .Fui recebido a horas e decorreu com a urbanidade que esperava.

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