Eyelid pathology baguio2012

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


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


• 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


• 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


• 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



• 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


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


• 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



Entropion






Surgical Procedures








Treatment



Spastic Entropion



Mechanism





Clinical picture







Surgical treatment






Entropion



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


• There occurs of over-ridding of preseptal orbicularis muscle over pretarsal orbicularis, that leads to forward rotation of tarsal plate

• Seen in lower lids




Surgical Procedures








Treatment



Spastic Entropion



Mechanism





Clinical picture







Surgical treatment






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)

Health & Medicine

Eyelid pathology baguio2012