eyelid pathology baguio2012
TRANSCRIPT
EYELID PATHOLOGY
FUNCTION
It offers mechanical protection to anterior globe
Spread the tear film over the conjunctiva and cornea with each blink.
Contain the meibomian oil gland which provide the lipid component of the tear film.
Prevent drying of the eyes. Contain the puncta through which the tears
flow into the lacrimal drainage system.
EYELID ABNORMALITIES
ABLEPHARON
• It is the absence of the eyelid• Synonymous with the term ablephary
Cryptophthalmos
* A condition characterized by the presence of an eyelid without a palpebral fissure
ANKYLOBLEPHARON
• It refers to an imperfectly separated eyelid• It is characterized by an adhesion between the
upper and lower lid margins• The horizontal diameter of the palpebral
fissure is lesser than normal
SYMBLEPHARON
* This is an adhesion between palpebral and bulbar conjunctiva
44- Posterior symblepharon
SYMBLEPHARON
LID COLOBOMA
* It is the failure of a part of the eyelid to develop
* It is a notching defect of its margin
2- Congenital coloboma of upper eyelid
BLEPHAROPHIMOSIS
It is a condition characterized by a decreased size of the palpebral fissure both vertical and horizontal
EPICANTHUS * It is the most common congenital abnormalities and is present among infants
It is characterized by the presence of a vertical skin fold in the medial canthal region that covers the medial angle and caruncle
It is also known as palpebranasal fold
1 - Bilateral Epicanthus
Epicanthus
BLEPHAROCHALASIS
*It is redundancy and loss of elasticity of skin of the eyelid
*It is the result of aging and repeated lid edema
blepharochalasis
BLEPHAROCHALASIS
EPIBLEPHARON
* It is the presence of an extra fold of skin at the lower eyelid
TELECANTHUS
• It is a condition characterized by a wide separation between the medial canthal ligaments
LID MARGIN ABNORMALITIES
• Entropion• Ectropion
ENTROPION
* It is a condition wherein the lid margin is turned inward
ENTROPION
ENTROPION
Symptoms of Entropion
• Foreign body sensation• Watering • Redness• Pain• Photophobia These symptoms are due to rubbing of ocular
surface by misdirected eyelashes
Classification
1. Congenital2. Acquired
2.1 Involutional2.2 Cicatricial 2.3 Spastic
CONGENITAL
• Inward rolling in of the lid margin due to abnormal development of tarsal plate
17- Congenital entropion of lower eye lid
INVOLUTIONAL
• Inward rolling of lid margin due to old age and instability of lid structures
Involutional Entropion
Involutional Entropion
CICATRICIAL
• Inward rolling of the lid margin due to scar tissue of the palpebral conjunctiva
SPASTIC
• Inward rolling of the lid margin due to spasm of the orbicularis oculi muscle
Entropion
Entropion
Entropion
Entropion
• Treatment– Lubrication– Taping the lid– Epilation– Horizontal lid tightening– Tarsal fracture procedure
Ectropion
ECTROPION
Classification
I. Acquired • Involutional or senile• Cicatricial • Paralytic• Mechanical II. Congenital
INVOLUTIONAL
• This is due to aging, there is laxity of the lid structures
Cicatricial Ectropion
• Is out-rolling of lid marging due to contraction of scar tissue on skin side. Commonly results from lid trauma, burns, chemical injuries and chronic inflammations of lid skin. Due to contraction of scar the lid skin shortens pulling the eyelid away from the eyeball
Cicatricial Ectropion
Ectropion Pre and Post-operative
Paralytic Ectropion • This condition is due to paralysis of the facial nerve due to
Bell palsy, surgery on parotid gland and trauma • Characterized by presence of other signs of facial palsy• Initially treated by conservative treatment by taping of lids,
lubricating eye drops, till there is recovery• Lateral tarsorrhaphy, by suturing freshened upper and lower
lids at outer canthus• Lagophthalmos due to weakness of superior orbicularis may
be treated by taping
Ectropion
Ectropion• Ectropion, or eversion of the lid margin, may be
congenital or acquired• The acquired forms are the result of
– Ageing changes (involutional)– Lumps (mechanical)– Scarring of the anterior lamella of the lid (cicatricial)
• Burn• Infection/ inflammation• Trauma
– Weakness of the orbicularis muscle (paralytic)
Ectropion
DISORDERS OF THE LASHES
• Trichiasis• Distichiasis• Madarosis• Poliosis• Pediculosis Palpebraum
TRICHIASIS
* Misdirection of lashes
TRICHIASIS
TRICHIASIS
DISTICHIASIS
* Presence of supernumerary rows of lashes
MADAROSIS
Absence of the lashes
MADAROSIS
POLIOSIS
Graying of the lashes
POLIOSIS
PEDICULOSIS PALPEBRAUM
• It is a condition wherein the eyebrow and lashes are infested by lice
ABNORMALITIES OF LID POSITION
BLEPHAROPTOSIS
* Drooping of the upper eyelid
PTOSIS
Marcus Gunn Jaw-Winking syndrome
- Also called Trigemino-oculomotor Synkineses - Autosomal dominant- In this congenital ptosis there is miswiring of the
nerve supply to the pterygoid muscle of the jaw and the levator of the eye so that the eyelid moves in conjugation with movements of the jaw.
Treatment Treatment is usually unnecessary but in severe
cases, surgery with a bilateral levator excision and frontalis brow suspension may be used.
Ptosis
MARGIN-REFLEXDISTANCE
INTERPALPEBRALDISTANCE
LID CREASE POSTION
Ptosis
Ptosis
Ptosis
BLEPHAROSPASM
• It is the persistent, repetitive involuntary contractions of the orbicularis oculi muscle
• It is a bilateral conditions
MYOKYMIA
• It is the involuntary contraction of a few fibers of orbicularis oculi muscle
• It is eyelid twitching
BLEPHAROCLONUS
• It is an exaggerated form of reflex blinking• It is characterized by either increased
frequency of blinking or the closure phase is excessively prolonged
LAGOPHTHALMOS
• It is the inadequate closure of the lids while sleeping
LAGOPHTHALMOS
ORBITAL FAT HERNIATION
• It is the swelling or puffiness of the eyelids
ORBITAL FAT HERNIATION
HYPERTROPHY OF THE LIDS
• Immense overgrowth of the lids
HYPERTROPHY OF THE LIDS
LID INFLAMMATION
• Blepharitis
DEFINITION
• It is the inflammation of the lid margin
blepharitis
• Inflammation of the lid margin (crusting/redness of lids)
• Causes ‘gritty’/foreign body sensation, often concomitant with other ocular surface disease
• Associated with recurrent hordeolum (styes) or chalazia
• Improvement with warm compresses/lid hygeine, artificial tears, tetracycline
Types
1. Anterior a. Squamous b. Ulcerative
2. Posterior a. Meibomian seborrhoea b. Meibomianitis
ANTERIOR BLEPHARITIS
• It involves the outer parts of the eyelid• It is commonly caused by bacteria
SEBORRHEIC/SQUAMOUS
• It is characterized by the deposition of scales• Eyelashes fall• Hyperemic lid margin• Absence of ulcers
Squamous Blepharitis
Symptoms
• Burning, deposits / crusting along lid margins, grittiness , redness of lid margins, photophobia
• Symptoms are worse in the morning
ULCERATIVE
• It is characterized by the presence of infective materials such as yellow crusts or scales
• There is matting of the lashes• Presence of ulcers
Symptoms
• Redness of lid margins, burning, itching, watering and photophobia
• Signs: – Small ulcers at lid margins on removal of
discharge, this features differentiate it from conjunctivitis
Ulcerative Blepharitis
14- Ulcerative blepharitis
15- Ulcerative blepharitis
POSTERIOR BLEPHARITIS
• It involves the inner parts of the eyelids• It is due to problems in the oil glands
LID LUMPS
STYE
• It is a tender, painful red bump located at the base of an eyelash or inside the eyelid
• It is due to infection of the oil glands of the eyelid or from an infected hair follicle at the base of an eyelash
- It is an abscess in eyelash follicle.
painful -Most cases are
self limiting .
-Treatment requires the removal of the associated eyelash and application of hot compresses.
Internal hordeolum
an abscess in meibomian gland.
-Painful.
-May respond to topical antibiotics but incision by be necessary.
Hordeolum Internum
Chalazion -It is a granuloma
within the tarsal plate caused by obstructed meibomian gland.
-Painless.
-Symptoms are unsightly lid swelling which resolve within six months if the lesion persist we remove it surgically
Chalazion
-Is a viral infection of the skin or the mucous membranes, caused by pox virus.
-Can be presented with umbilicated lesion found on the lid margin.
-Cause irritation, redness, follicular conjuctivitis(small elevation of lymphoid tissue found on tarsal conjunctiva)
-Treatment requires excision of the lid lesion.
Molluscum contagiosum
• Painless, waxy, umbilicated nodule• Chronic follicular conjunctivitis
• May be multiple in AIDS patients• Occasionally superficial keratitis
Signs Complications
Histology of molluscum contagiosum
• Lobules of hyperplastic epithelium
• Circumscribed lesion• Surface covered by normal epithelium except in centre
• Intracytoplasmic (Henderson-Patterson) inclusion bodies• Deep within lesion bodies are small and eosinophilic• Near surface bodies are larger and basophilic
- Lipid containing bilateral lesions.
- Usually associated with hyperlipidemia .
- Removed for cosmetic reasons.
Xanthelasma
• Usually bilateral and located medially
• Common in elderly or those with hypercholesterolaemia• Yellowish, subcutaneous plaques containing cholesterol and lipid
Adenoma of Meibomian Gland
• Blepharitis– Anterior– Posterior– Staphylococcal– Seborrhoeic– Meibomianitis
• Treatment– Lid hygiene– Tears– Antibiotics– Warm compresses
Eyelids inflammation
• Allergy– Acute allergic
blepharoconjuctivitis– Allergic
dermatoblepharitis
Eyelids inflammation
• Chalazion– Focal inflammation of the eye
lids which result from obstruction of the meibomian glands
– Chronic lipogranulomatous inflammatory changes
– Treatment• Warm compresses• Local antibiotic• Excision
Eyelids inflammation
• Hordeolum– Acute infection involving
the meibomian glands (internal) or the glands of Moll or Zeis (external)
– Overtime may evolve into chalazion
– Treatment• Warm compresses• Topical antibiotic
Eyelids inflammation
• Cysts– Cyst of Moll– Cyst of Zeiss– Sebaceous cyst– Hidrocystoma
Benign eyelid lesions
• Translucent• On anterior lid margin
Cyst of Moll
• Similar to cyst of Moll • Not confined to lid margin
Eyelid cysts
• Opaque• On anterior lid margin
Cyst of Zeis
Eccrine sweat gland hidrocystoma
Sebaceous cyst
• Cheesy contents • Frequently at inner canthus
• Tumors– Viral wart( papilloma)– Actinic keratosis– Seborrheic keratosis– Keratocanthoma– Nevi
• Junctional• Compound• Dermal
– Capillary hemangioma– Xanthelasma– Pyogenic granuloma
Benign eyelid lesions
Benign eyelid lesions
• Basal cell carcinoma• Squamous cell carcinoma• Meibomian gland carcinoma• Melanoma• Kaposi sarcoma• Merkel cell carcinoma
Malignant eyelid tumors
Basal cell carcinoma• Most common malignancy(90%)
of the eyelid• Usually located on the lower lid
and medial canthus• Pearly nodules which ulcerate
and have telangiectasias• Treatment
– Surgical excision– Cryotherapy– Radiation therapy
Squamous cell carcinoma
• Less common than BCC• May arise de-novo or
from pre-existing actinic keratosis
• May metastasize
BENIGN EYELID LESIONS1. Nodules
• Chalazion
• Acute hordeola
2. Cysts
•
• Cyst of Moll• Cyst of Zeiss• Sebaceous cyst• Hidrocystoma
3. Tumours
Xanthelasma
• Viral wart• Keratoacanthoma• Naevi• Capillary haemangioma• Port-wine stain• Pyogenic granuloma• Cutaneous horn
Molluscum contagiosum•
Signs of chalazion (meibomian cyst)
Painless, roundish, firm lesion within tarsal plate
May rupture through conjunctiva and cause granuloma
Histology of chalazion
Multiple, round spaces previously containing fat with surrounding granulomatous inflammation
Epithelioid Multinucleated cells giant cells
Treatment of chalazion
Injection of local anaestheticInsertion of clamp Incision and curettage
Acute hordeola
• Staph. abscess of meibomian glands
• Tender swelling within tarsal plate• May discharge through skin or conjunctiva
• Staph. abscess of lash follicle and associated gland of Zeis or Moll
• Tender swelling at lid margin
• May discharge through skin
Internal hordeolum ( acute chalazion )
External hordeolum (stye)
Viral wart (squamous cell papilloma)• Most common benign lid tumour
• Raspberry-like surface
Pedunculated
Sessile
Histology of viral wart
Finger-like projections of fibrovascular connective tissue
Epidermis shows acanthosis (increased thickness) and hyperkeratosis
Rete ridges are elongated and bent inwards
Seborrhoeic
• Common in elderly• Discrete, greasy, brown lesion• Friable verrucous surface• Flat ‘stuck-on’ appearance
Actinic
• Most common pre-malignant skin lesion• Rare on eyelids
• Affects elderly, fair-skinned individuals
• Flat, scaly, hyperkeratotic lesion
Keratoses
Keratoacanthoma
• Uncommon, fast growing nodule• Acquires rolled edges and keratin-filled crater
• Involutes spontaneously within 1 year
• Lesion above surface epithelium
• Central keratin-filled crater
• Chronic inflammatory cellular infiltration of dermis
Naevi• Appearance and classification determined by location within skin• Tend to become more pigmented at puberty
• Elevated
Intradermal
• May be non-pigmented
• No malignant potential
• Flat, well-circumscribed
• Low malignant potential
Junctional
• Has both intradermal and junctional components
Compound
• Pigmented
Capillary haemangioma
• Rare tumour which presents soon after birth
• Starts as small, red lesion, most frequently on upper lid
• Blanches with pressure and swells on crying
• Grows quickly during first year
• May be associated with intraorbital extension
• Begins to involute spontaneously during second year
Periocular haemangioma
• Steroid injection in most cases• Surgical resection in selected cases
• High-out heart failure
Treatment options
Occasional systemic associations
• Kasabach-Merritt syndrome - thrombocytopenia, anaemia and reduced coagulant factors
• Maffuci syndrome - skin haemangiomas, endrochondromas and bowing of long bones
Histology of capillary haemangioma
Lobules of capillaries Fine fibrous septae Lobules under high magnification
Port-wine stain (naevus flammeus)
• Rare, congenital subcutaneous lesion
• Segmental and usually unilateral
• Does not blanch with pressure
• Ipsilateral glaucoma in 30%
• Sturge-Weber or Klippel-Trenaunay-Weber syndrome in 5%
Associations
Progression of port-wine stain
Initially red and flat Subsequent darkening and hypertrophy of skin
Skin becomes coarse, nodular and friable
Pyogenic granuloma
• Usually antedated by surgery or trauma• Fast-growing pinkish, pedunculated or sessile mass• Bleeds easily
Cutaneous horn
• Uncommon, horn-like lesion protruding through skin• May be associated with underlying actinic keratosis or squamous cell carcinoma
EYELID PATHOLOGY
Ocular Diseases1Sy2010-2011
BLEPHAROCHALASIS
Entropion
- It is an inturning, usually of the lower lid towards the globe.
- Patients present with irritation caused by eyelashes rubbing on the cornea.
- more common in elderly, because orbcularis muscle become spasm.
- it may also caused by Conjuctival scarring distorting the lid (cicatrical entropion)
Treatment: Short term :include the application of lubricants to the
eye or taping of the eyelid. Permenant :surgery
Lower lid retractors
a. Inferior lid retractors:1. The inferior tarsal aponeurosis – capsulo-palpabral expansion of the inferior rectus muscle and is analogous to the levator aponeurosis 2. Inferior tarsal muscle is analogous to muller muscle
Entropion
Entropion is in-rolling of eye lid margin.Normal position of sharp posterior border of inter-marginal strip is essential for interigrity of the tear film and for maintenance of healthy ocular surface
Entropion is caused by disparity of length and tone of anterior skin muscle layer and posterior tarso-conjunctival layer of the eyelid
Symptoms of Entropion
• Foreign body sensation• Watering • Redness• Pain• Photophobia These symptoms are due to rubbing of ocular
surface by misdirected eyelashes
Involutional Entropion
This condition is due to old age, due to instability of lid structures There occurs:a. Weakness of the posterior retractor of the lid b. Laxity of medial and lateral canthal ligaments c. Atrophy of orbital pad of fat leading to enophthalmos
Involutional Entropion
• There occurs of over-ridding of preseptal orbicularis muscle over pretarsal orbicularis, that leads to forward rotation of tarsal plate
• Seen in lower lids
Treatment of Involutional Entropion
Principles of surgery 1. Reattachment of the retractor to tarsal plate2. Shortening of horizontal width of lid3. To induce scarring between the pre-tarsal
and pre-septal parts of orbicularis muscle
Surgical Procedures
1. Catgut suture application through2. Modified Bick operation: Horrizontal
shortening of lower lid with fixation to lateral canthal ligament and periosteum
3. Tucking of inferior lid retractors
Cicatricial Entropion
• Caused by contraction of scar tissue of the palpabral conjunctiva
• In this case there is relative shortening of inner layer i.e. tarso-conjunctiva
• Caused by scarring of palpabral conjunctiva by trachoma, trauma, chemical injuries (burns), pemphigus and Stevens-Johnson syndrome
Treatment
Principles of surgery1. Tarsal rotation (forwards)2. Lengthening of posterior lid lamina so that
eyelashes turn forwards Surgery a. Wedge resection (Tarsal paring)b. Tarsal fracture
Spastic Entropion
• This condition is due to spasm of orbicularis in presence of degeneration of the palpabral connective tissue separating orbicularis fibres. The spasm is induced by local irritation in inflammatory and traumatic conditions.
• Factors that prevent in-rolling of lid margin: a. intact inferior lid aponeurosis which maintains orbicularis in position that it presses against lower tarsus b. contraction of palpabral head of inferior rectus
Mechanism
• Degeneration of aponeurosis, the strong contraction of orbicularis is associated with turning inwards of lid margin
• Senile degeneration of tarsal muscle of Muller fails to anchor the lower border of tarsal plate to bony orbit
• Orbicularis rides up on tarsal plate towards lid margin
• Horizontal lid laxity
Clinical picture
• Condition is found in elderly patients • Tight bandaging may cause spastic entropion • Narrowness of palpabral aperture • Seen in lower lids
Treatment of Spastic Entropion
• Removal of cause i.e removal of cause of irritation, tight bandaging
• Treatment of surface disorder by artificial tears and control of conjunctival infection and lid inflammation with antibiotic
• Fixing of lower lid after everting it with adhesive tape
• Injection of Botulinum toxin into pre-tarsal orbicularis to weaken it
Surgical treatment
• Producing a ridge of fibrous tissue in the orbicularis to prevent its fibres from sliding in vertical direction
Congenital Entropion
• This condition is due to dysgenesis of lower lid retractor or due to abnormal development of tarsal plate.
• This condition must be differentiated from epiblepharon (due to anomalous fold of skin pushing lashes upwards onto the eyeball)
• Treatment of abnormality
Entropion
Lower lid retractors
a. Inferior lid retractors:1. The inferior tarsal aponeurosis – capsulo-palpabral expansion of the inferior rectus muscle and is analogous to the levator aponeurosis 2. Inferior tarsal muscle is analogous to muller muscle
Entropion
Entropion is in-rolling of eye lid margin.Normal position of sharp posterior border of inter-marginal strip is essential for interigrity of the tear film and for maintenance of healthy ocular surface
Entropion is caused by disparity of length and tone of anterior skin muscle layer and posterior tarso-conjunctival layer of the eyelid
Treatment of Involutional Entropion
Principles of surgery 1. Reattachment of the retractor to tarsal plate2. Shortening of horizontal width of lid3. To induce scarring between the pre-tarsal
and pre-septal parts of orbicularis muscle
Surgical Procedures
1. Catgut suture application through2. Modified Bick operation: Horrizontal
shortening of lower lid with fixation to lateral canthal ligament and periosteum
3. Tucking of inferior lid retractors
Cicatricial Entropion
• Caused by contraction of scar tissue of the palpabral conjunctiva
• In this case there is relative shortening of inner layer i.e. tarso-conjunctiva
• Caused by scarring of palpabral conjunctiva by trachoma, trauma, chemical injuries (burns), pemphigus and Stevens-Johnson syndrome
Treatment
Principles of surgery1. Tarsal rotation (forwards)2. Lengthening of posterior lid lamina so that
eyelashes turn forwards Surgery a. Wedge resection (Tarsal paring)b. Tarsal fracture
Spastic Entropion
• This condition is due to spasm of orbicularis in presence of degeneration of the palpabral connective tissue separating orbicularis fibres. The spasm is induced by local irritation in inflammatory and traumatic conditions.
• Factors that prevent in-rolling of lid margin: a. intact inferior lid aponeurosis which maintains orbicularis in position that it presses against lower tarsus b. contraction of palpabral head of inferior rectus
Mechanism
• Degeneration of aponeurosis, the strong contraction of orbicularis is associated with turning inwards of lid margin
• Senile degeneration of tarsal muscle of Muller fails to anchor the lower border of tarsal plate to bony orbit
• Orbicularis rides up on tarsal plate towards lid margin
• Horizontal lid laxity
Clinical picture
• Condition is found in elderly patients • Tight bandaging may cause spastic entropion • Narrowness of palpabral aperture • Seen in lower lids
Treatment of Spastic Entropion
• Removal of cause i.e removal of cause of irritation, tight bandaging
• Treatment of surface disorder by artificial tears and control of conjunctival infection and lid inflammation with antibiotic
• Fixing of lower lid after everting it with adhesive tape
• Injection of Botulinum toxin into pre-tarsal orbicularis to weaken it
Surgical treatment
• Producing a ridge of fibrous tissue in the orbicularis to prevent its fibres from sliding in vertical direction
Congenital Entropion
• This condition is due to dysgenesis of lower lid retractor or due to abnormal development of tarsal plate.
• This condition must be differentiated from epiblepharon (due to anomalous fold of skin pushing lashes upwards onto the eyeball)
• Treatment of abnormality
Entropion
Lower lid retractors
a. Inferior lid retractors:1. The inferior tarsal aponeurosis – capsulo-palpabral expansion of the inferior rectus muscle and is analogous to the levator aponeurosis 2. Inferior tarsal muscle is analogous to muller muscle
Entropion
Entropion is in-rolling of eye lid margin.Normal position of sharp posterior border of inter-marginal strip is essential for interigrity of the tear film and for maintenance of healthy ocular surface
Entropion is caused by disparity of length and tone of anterior skin muscle layer and posterior tarso-conjunctival layer of the eyelid
Involutional Entropion
This condition is due to old age, due to instability of lid structures There occurs:a. Weakness of the posterior retractor of the lid b. Laxity of medial and lateral canthal ligaments c. Atrophy of orbital pad of fat leading to enophthalmos
Involutional Entropion
• There occurs of over-ridding of preseptal orbicularis muscle over pretarsal orbicularis, that leads to forward rotation of tarsal plate
• Seen in lower lids
Treatment of Involutional Entropion
Principles of surgery 1. Reattachment of the retractor to tarsal plate2. Shortening of horizontal width of lid3. To induce scarring between the pre-tarsal
and pre-septal parts of orbicularis muscle
Surgical Procedures
1. Catgut suture application through2. Modified Bick operation: Horrizontal
shortening of lower lid with fixation to lateral canthal ligament and periosteum
3. Tucking of inferior lid retractors
Cicatricial Entropion
• Caused by contraction of scar tissue of the palpabral conjunctiva
• In this case there is relative shortening of inner layer i.e. tarso-conjunctiva
• Caused by scarring of palpabral conjunctiva by trachoma, trauma, chemical injuries (burns), pemphigus and Stevens-Johnson syndrome
Treatment
Principles of surgery1. Tarsal rotation (forwards)2. Lengthening of posterior lid lamina so that
eyelashes turn forwards Surgery a. Wedge resection (Tarsal paring)b. Tarsal fracture
Spastic Entropion
• This condition is due to spasm of orbicularis in presence of degeneration of the palpabral connective tissue separating orbicularis fibres. The spasm is induced by local irritation in inflammatory and traumatic conditions.
• Factors that prevent in-rolling of lid margin: a. intact inferior lid aponeurosis which maintains orbicularis in position that it presses against lower tarsus b. contraction of palpabral head of inferior rectus
Mechanism
• Degeneration of aponeurosis, the strong contraction of orbicularis is associated with turning inwards of lid margin
• Senile degeneration of tarsal muscle of Muller fails to anchor the lower border of tarsal plate to bony orbit
• Orbicularis rides up on tarsal plate towards lid margin
• Horizontal lid laxity
Clinical picture
• Condition is found in elderly patients • Tight bandaging may cause spastic entropion • Narrowness of palpabral aperture • Seen in lower lids
Treatment of Spastic Entropion
• Removal of cause i.e removal of cause of irritation, tight bandaging
• Treatment of surface disorder by artificial tears and control of conjunctival infection and lid inflammation with antibiotic
• Fixing of lower lid after everting it with adhesive tape
• Injection of Botulinum toxin into pre-tarsal orbicularis to weaken it
Surgical treatment
• Producing a ridge of fibrous tissue in the orbicularis to prevent its fibres from sliding in vertical direction
Congenital Entropion
• This condition is due to dysgenesis of lower lid retractor or due to abnormal development of tarsal plate.
• This condition must be differentiated from epiblepharon (due to anomalous fold of skin pushing lashes upwards onto the eyeball)
• Treatment of abnormality
Involutional Ectropion
Stages:1. Early stage: in mild cases on looking up the
puncta is not apposed to bulbar conjunctiva 2. Progresses to moderate stage puncta are
not apposed to bulbar conjunctiva even in primary gaze and entire lid margin fall away from the globe
Involutional Ectropion
3. In severe case lower lids are rolled out and palpabral conjunctiva (including tarso-conjunctiva and fornix are exposed)
Chronic exposure of lower puncta on everted lid leads to phimosis of puncta
Tears are no longer drained into nose and overflow onto the cheek
In long standing cases keratinization of the lid margin and palpabral conjunctiva takes place
Signs
• Signs as described with three stages earlier• In ling standing cases the exposed conjunctiva
becomes dry, thickened, red , un-sightly. Cornea may suffer from imperfect closure of the lids
• Diagnosis is confirmed if lower lids does not snap back into position after pulling it 6-7 mm away from globe. If canthal displacement is more than 2 mm on pulling lower lid laterally or medially , canthal laxity is diagnosed
• There is horizontal lengthening of the lids
Treatment
• Surgical treatment:in mild to moderate cases, excision of 7 – 8 mm long x 4 mm high conjunctival exicion 5 mm below lid margin (puncta), this puts back puncta in its normal positionIn more marked cases 5 mm full thickness shortening/ resection of lid 5 mm from puncta, by giving inverted house shaped incision (modified Kuhnt Szymanowski operation at lateral canthus or modified Lazy T operation at medial canthus)
Treatment
• Principle of surgery:release and relaxation of the scar tissue and restoration (elongation) of skin by blepharoplasty Localized small scar may be treated by V-Y operation Large scar requires excision of scar tissue and application of matching (whole or spilt) skin graft
Ectropion
• Treatment– Lubrication– Horizontal lid shortening or tightening– Punctal inversion
Disorders of Lashes
Treatment options for trichiasis
• Epilation• Electrolysis• Cryotherapy• Argon laser• Surgery
• Madarosis– Lid margin inflammation– Tumor– Cryotherapy, radiotherapy
or burns– Alopecia– Syphilis– Leprosy– SLE
• Poliosis– VKH– Sympathetic ophthalmia
Disorders of lashes
DISTICHIASIS
dermatochalasis
- excessive and lax eyelid skin and muscle is known as dermatochalasis. Gravity, loss of elastic tissue in the skin, and weakening of the connective tissues of the eyelid frequently contribute to this lax and redundant eyelid tissue. These findings are more common in the upper eyelids but can be seen in the lower eyelids as well.
- The patients who complain of dermatochalasis frequently complain of visual difficulties
- Causes:- The most common cause of dermatochalasis is the normal aging phenomenon - Patients with severe periorbital edema may develop dermatochalasis- Trauma can be associated with dermatochalasis - Chronic dermatitis - Thyroid eye disease - Chronic renal insufficiency - Amyloidosis- Genetics may play a role in some patients who develop dermatochalasis - Treatment:- Blepharoplasty is the procedure of choice for upper and/or lower eyelid
dermatochalasis
ptosis
This is an abnormally low position of the upper eyelid.PATHOGENESISIt may be caused by:Mechanical factors: (a) Large lid lesions pulling down the lid. (b) Lid oedema. (c) Tethering of the lid by conjunctival scarring. (d) Structural abnormalities including a disinsertion of
the aponeurosis of the levator muscle, usually in elderly patients.
2.Neurological factors: (a)Third nerve palsy (b)Horner’s syndrome, due to a sympathetic
nerve lesion (c)Marcus–Gunn jaw-winking syndrome. 3.Myogenic factors: (a)Myasthenia gravis (b)Some forms of muscular dystrophy. (c)Chronic external ophthalmoplegia.
SYMPTOMSPatients present because: they object to the cosmetic effect; vision may be impaired; there are symptoms and signs associated
with the underlying cause(e.g. asymmetric pupils in Horner’s syndrome,
diplopia and reduced eye movements in a third nerve palsy).
Ptosis
• Pseudoptosis– Orbital volume deficiency– Exophthalmos– Excess lid skin– Hypotropia
Ptosis• Acquired or Congenital
– Neurogenic• 3rd nerve palsy• 3rd nerve misdirection• Horner syndrome• Marcus Gunn jaw-winking syndrome
– Myogenic• Myasthenia gravis• Myotonic dystrophy• Ocular myopathies• Levator dystrophy• Aponeurotic (levator dehiscence)
– Mechanical– Traumatic
Ptosis
• Treatment– Ptosis crutch– Taping of the lid– Surgical
• Levator advancement• Muller’s muscle resection• Frontalis suspension
Signs : There is a reduction in size of the interpalpebral aperture. The upper lid margin, which usually overlaps the upper
limbus by 1–2imm, may be partially covering the pupil. The function of the levator muscle can be tested by
measuring the maximum travel of the upper lid from upgaze to downgaze (normally 15–18imm). Pressure on the brow (frontalis muscle) during this test will prevent its contribution to lid elevation.
If myasthenia is suspected the ptosis should be observed during repeated lid movement. Increasing ptosis after repeated elevation and depression of the lid is suggestive of myasthenia
MANAGMENT
It is important to exclude an underlying cause whose treatment could resolve the problem (e.g. myasthenia gravis). Ptosis otherwise requires surgical correction
In very young children this is usually deferred but may be expedited if pupil cover threatens to induce amblyopia.
- Eversion of the lid away from the globe.- Causes:- -age related orbicularis muscle laxity. -facial nerve palsy. -scarring of periorbital skin. - initial complaint of watery eye, because the mal
position of the lids everts the puncta and prevents drainge of the tears leading to epiphora(overflow of the tears over the cheeks )
-it also exposes the conjuctiva leading to irratable eye.
- treatment: surgical
Ectropion
Ectropion • Ectropion is out-rolling of lid margin• Symptoms are:
Watering (due to eversion of punta)Foreign body sensationPain
RednessPhotophobia (Due to involvement of cornea)Symptoms are due to eversion of punta, and exposure of ocular surface, chronic conjunctivitis caused by exposure and drying of surface
Sequelae of Ulcerative Blepharitis
• Chronic course and associated chronic conjunctivitis
• Madarosis (Scanty eyelashes) due to falling of eyelashes
• Trichiasis (misdirected eyelashes) due to contraction of scar tissue
• Cicatrization of lid margins causing thickening and hypertrophy of tissue and drooping of lids (Tylosis)
Sequelae of Ulcerative Blepharitis
• Cicatrization of lid margin may drag conjunctiva on posterior border of intermarginal strip disturbing angle of posterior edge leading to epiphora , eversion of puncta
• Epiphora leads to eczematous condition of skin, scarring of skin leads to ectropion . This further aggravate epiphora
Blepharitis is an inflammation of the eyelids and occurs in two forms, anterior (outside of the eyelid) and posterior (inner eyelid). Both types of blepharitis can cause a burning or foreign body sensation, excessive tearing, itching, sensitivity to light, red and swollen eyelids, redness of the eye, blurred vision, frothy tears, dry eye, flaking at the base of the lashes, or crusting of the eyelashes upon awakening.
Common causes for anterior blepharitis are bacteria (Staphylococcus) and scalp dandruff while posterior forms are caused by problems with the oil glands in the eyelid. Treatment for both forms involves keeping eyelids clean and free of crusts. Warm compresses should be applied to loosen crusts, followed by a light scrubbing with a cotton swab and a mixture of water and baby shampoo.
Because blepharitis rarely goes away completely, most patients must maintain an eyelid hygiene routine for life. If the blepharitis is severe, an eye-care professional may also prescribe antibiotics or steroid eyedrops.
Blepharitis
Posterior Blepharitis
• Posterior blepharitis i.e. inflammation of meibomian duct opening at intermarginal strip and posterior border may cause tear film instability and inferior punctate keratitis
• It occurs in two clinical forms a. Meibomian seborrhoea – characteristic appearance of oil droplet at the opening of meibomian duct opening at intermarginal strip. Tear film is oily and foamy. Frothy discharge accumulate on the lid margin. Foam like discharge can be expressed from these lesions
Posterior Blepharitis
b. Meibomianitis – There is inflammation and obstruction of meibomian glands. Characterized by diffuse thickening of posterior border of lid margin which becomes rounded. On lid massage toothpaste like thick material can be expressed out. Due to duct blockade cyst formation may be present
Complications
• Chalazion • Tear film instability• Papillary conjunctivitis and inferior corneal
erosions
Treatment
• Warm compresses • Systemic - Doxycycline 100 mgm twice x 1
week then once daily for 6 -12 weeks or Tetracycline 250 mgm 4 times x 1 week then twice for 6 -12 weeks
• Associated tear film abnormality is treated with artificial tear drops
Blepharitis
Inflammation of the eyelid margins. It is a chronic disease. Symptoms: - tired, itchy, sore eye, worse in the morning.- Crusting of the lid margin. Classified into: anterior and posterior . Both forms are strongly associated with
seborrhoeic dermatitis, atopic eczema and acne rosacea.
Anterior Blepharitis
Is when the inflammation is located in the outside surface the lid margin, specifically in lash line.
Signs are:-Redness and scaling of the lid margin.-Debris in the form of a collarette around the eyelashes.-Reduction in the number of eyelashes.-Some lash bases may ulcerated- sign of staphylococcal
infection. In severe diseasesthe cornea is affected (blepharokeratitis) Small infiltrate ulcers may form in the peripheral cornea
(marginal teratitis)due to immune complex response to staphlococcal exotoxins .
Posterior blepharitis
Have another name which is meibomian gland dysunction.
Signs are:- Obstruction and plugging of the meibomian
orifices.- Thickened , cloudy, expressed meibomian
secretion.- Injection of the lid margin and conjuctiva.- Tear film abnormalities and punctate keratitis.
Treatment
Anterior blepharitis:• Cleaning with a cotton bud wetted with bicarbonate or diluted baby
shampoo to remove squamous debris from lash line .• Topical steroid: used infrequently.• Topical (fusidic acid) +- systemic antibioticin staphylococcal lid
disease . Posterior blepharitis:• Hot compressors and lid massage.• Oral tetracycline.• Artificial tears to prevent dryness
Hordeolum Externum(Stye)
Hordeolum Externum (Stye)
Definition: Localized suppurative inflammation of gland of zeis at lid margin at ciliary follicle.
Etiology
• Usually caused by staphylococcus aureus• There is infection of hair follicle of eyelash.• It may complicate Acne Vulgeris in young
adults.
Histopathology
• Purulent infection of follicle and its gland with cellulitis of surrounding connective tissue
Clinical Picture
• Stye are frequently recurrent, appearing in crops.
• Recurrent lesion is particularly seen in cases of debility, focal infections and diabetics.
Symptoms
• Severe pain which is sharp throbbing , feeling of fullness or heaviness and feeling of heat
• Tenderness (increase in pain on touching swelling/ affected area)
• Pain subsides on escape of pus
Signs
• Starts usually as edema of the lids with chemosis
• Yellow pus point appears on the lid margin around the root of a lash at the most prominent part of the swelling
Signs … contd
• Skin gives way and pus drains with sloughing
• Swelling subsides and cicatrix form
• Spread of infection to neighbouring lashes opposite lid margin and conjunctival sac
• Subsidence of inflammation may leave area of induration
Hordeolum Externum
Complications
• Cellulitis (particularly in cases of lesion at inner canthus)
• Orbital thrombophebitis (leading to cavernous sinus thrombosis and its complications)
Treatment
I. Systemic a. Antibiotic b. Anti-inflammatory analgesicc. Supportived Treatment of associated systemic predisposing cause
Treatment
II. Locala. Hot fomentationb. Local broad spectrum antibiotic drop and ointmentc. Evacuation of pus when pus points, sometimes epilation may be required before evacuation of pus (lid margin/ lesion should never be squeezed)
Hordeolum Internum
Hordeolum Internum
• Hordeolum Internum is a suppurative inflammation of meibomian gland.
• It may be due to secondary infection of meibomian gland or it may start to begin with as suppurative infection of meibomian gland.
• This condition is more symptomatic than stye, the gland is larger and is located in fibrous tarsal plate
Symptoms
• Pain, which may be severe throbbing • Swelling , which is away from lid margin • Pus pointing either at the lid margin or on the
palpabral conjunctiva
Signs
• Swelling of affected lid, due to associated cellulitis
• Swelling is more marked about 4-5 mm from lid margin
• Tenderness• Palpabral conjunctiva over the swelling is
congested a pus point may be visible• Pus point may be visible at the lid margin
Treatment of Hordeolum Internum
• Medical treatment is similar to treatment of Hordeoulm externum i.e.Systemic a. Antibiotic b. Anti-inflammatory analgesicLocala. Hot fomentationb. Local broad spectrum antibiotic drop and ointment
Possible outcome of Treatment
• It may resolve with evacuation of pus at the lid margin
• It may burst on palpabral conjunctiva, leading to infective bacterial conjunctivitis and persistence of growth on palpabral conjunctiva, resembling papilloma. It due to fungating mass of granulation tissue sprouting through opening. It causes irritation and conjunctival discharge
• It turns into chronic granuloma i.e. Chalazion
A chalazion is a tiny lump of the upper or lower eyelid caused by inflammation of a gland of the lid. It may be soft and fluid-filled or firmer. A chalazion is also referred to as a meibomian cyst, tarsal cyst, or conjunctival granuloma.
The narrow opening through which a meibomian gland secretes its material can become clogged from narrowing of the opening or hardening of the sebaceous liquid near the opening. If this occurs, the gland will have a backup of the material it secretes and it will swell.
Most chalazions are treated with warm compresses to the eyelid to promote healing and circulation of blood to the inflamed area. Doctors may prescribe an antibiotic drop or ointment to be used immediately after the compresses. If the chalazion persists and is causing an unsightly lump, it can be removed surgically through the inside of the lid.
Chalazion (Eyelid Cyst)
Chalazion
Chalazion• Chalazion is also called tarsal cyst or meibomian cyst• Chalazion is chronic inflammatory inflammatory granuloma of
meibomian gland • Seen in adults more often as multiple lesions occurring in
crops• The glandular tissue is replaced by granulation tissue
consisting of gaint cells, polymorphonuclear cell, plasma cells and histiocytes, indicating reaction to chronic irritation. The opening of meibomian gland is occluded leading to retention which acts as cause of chronic irritation
Chalazion
Symptoms:Hard painless swelling little away from lid
margin Swelling increases gradually in size without painSmall chalazia are better felt than seenMultiple lesions and large chalazion may be
associated with inability to open eye fully
Chalazion• Signs:
Painless swelling 4-5 mm away from lid margin. Swelling is hardOn conjunctival side it appears red or purple. In long standing lesions it appears grey. In old lesion granulation tissue turns into jelly-like mass.Chalazion may become smaller over the period of time , but complete resolution may occur only rarely Sometimes the granulation tissue is formed in the duct and project at the intermarginal strip as a reddish grey nodule
Treatment of Chalazion
• Intralesional injection of Triamcinolone Acetonide may help in resolution of chalazion
• Incision & curette of chalazion is indicated in cases when it causes disfigurement and mechanical ptosis due to its weight
Steps of operation
• Explain about condition and operation• Informed consent• Topical anaesthesia and sub-muscular
infiltration of 2% Lignocaine• Application of chalazion clamp around the
nodule (this will provide field for bloodless operation, hard base and protect deeper soft structures). Lid is everted
• Infiltration of lignocaine around swelling
Instruments
Steps
• Vertical incision on most prominent point/ point of greatest discolouration with sharp scalpel blade
• Semi-fluid/ cheesy contents are taken out with small chalazion scoop (Curette)
• Pseudocapsule/ cavity is excised or the cavity is cauterized with pure carbolic acid or 10-20% trichloracetic acid
Steps
• Clamp is removed, and pressure is applied on lid to stop bleeding or pressure bandage is applied for few hours
• Swelling remains for few days after surgery as the cavity is filled by blood
• Post-operatively analgesic may be needed systemically. Local antibiotic drop and ointment for one to two weeks
Chalazion
• Very hard chalazion near canthi may be adenoma of gland and requires excision
• Recurrent lesion particularly in elderly patients should be investigated for meibomian gland carcinoma (by biopsy)