Diseases of Lids Power point copy of Lecture taken by Prof Sanjay Shrivastava For Junior Final Year students of Gandhi Medical College, Bhopal (M.P.)

Anatomy of Lid

Hordeolum Externum(Stye)

Hordeolum Externum (Stye)Definition: Localized suppurative inflammation of gland of zeis at lid margin at ciliary follicle.

EtiologyUsually caused by staphylococcus aureusThere is infection of hair follicle of eyelash.It may complicate Acne Vulgeris in young adults.

HistopathologyPurulent infection of follicle and its gland with cellulitis of surrounding connective tissue

Clinical PictureStye are frequently recurrent, appearing in crops. Recurrent lesion is particularly seen in cases of debility, focal infections and diabetics.

SymptomsSevere pain which is sharp throbbing , feeling of fullness or heaviness and feeling of heatTenderness (increase in pain on touching swelling/ affected area)Pain subsides on escape of pus

SignsStarts usually as edema of the lids with chemosisYellow pus point appears on the lid margin around the root of a lash at the most prominent part of the swelling

Signs contdSkin gives way and pus drains with sloughingSwelling subsides and cicatrix formSpread of infection to neighbouring lashes opposite lid margin and conjunctival sacSubsidence 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)

TreatmentSystemic a. Antibiotic b. Anti-inflammatory analgesicc. Supportived Treatment of associated systemic predisposing cause

TreatmentII. 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

SymptomsPain, 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 TendernessPalpabral conjunctiva over the swelling is congested a pus point may be visiblePus point may be visible at the lid margin

Hordeolum Internum

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 TreatmentIt may resolve with evacuation of pus at the lid marginIt 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

Chalazion

ChalazionChalazion is also called tarsal cyst or meibomian cystChalazion is chronic inflammatory inflammatory granuloma of meibomian gland Seen in adults more often as multiple lesions occurring in cropsThe 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

ChalazionSymptoms: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

ChalazionSigns: 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

Chalazion

Adenoma of Meibomian Gland

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 operationInformed consentTopical anaesthesia and sub-muscular infiltration of 2% LignocaineApplication of chalazion clamp around the nodule (this will provide field for bloodless operation, hard base and protect deeper soft structures). Lid is evertedInfiltration of lignocaine around swelling

Instruments

StepsVertical 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

StepsClamp 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

ChalazionVery hard chalazion near canthi may be adenoma of gland and requires excisionRecurrent lesion particularly in elderly patients should be investigated for meibomian gland carcinoma (by biopsy)

Blepharitis

Blepharitis Blepharitis is chronic inflammation of lid margin occurring as true inflammation or as simple hyperaemia.

TypesAnterior a. Squamous b. Ulcerative2. Posterior a. Meibomian seborrhoea b. Meibomianitis

CausesFollowing chronic Conjunctivitis especially due to staphylococciParasitic infection, Blepharitis acarica due to Demodex Folliculorum and Phthiriasis Palpabrarum due to crab louse

Seborrhoeic or Squamous Blepharitis Is a form of anterior blebharitis characterized by deposition of white scales among the eye lashes. Eye lashes fall and replaced by undistorted eyelashes. On removal of scales, lid margins appear hyperaemic. Ulcers are absent. Condition is metabolic associated with dandruff of the scalp Usually associated with seborrhoeic dermatitis involving scalp, nasolabial folds and retroauricular areas

Squamous Blepharitis

Symptoms Burning, deposits / crusting along lid margins, grittiness , redness of lid margins, photophobiaSymptoms are worse in the morning

Seborrhoeic or Squamous BlepharitisSkin condition also requires treatment.Cleaning of lid margin with baby shampoo. In case of bacteria infection, local antibiotic drops and ointment. Associated tear film dysfunction, if present is treated with artificial tear drops

Staphylococcal or Ulcerative Blepharitis Ulcerative blepharitis is infective condition commonly due to staphylococcal infection Lid margins are covered with infective material (yellow crusts or dry brittle scales) matting eyelashes. On removal of discharge small ulcers which bleed are found along lid margins around bases of the eyelashes

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

Treatment Discharge/ crust is removed from lid margins with 1:4 dilution baby shampoo or luke warm 3% soda bicarbonate lotion. The loose discharge is then cleaned cotton Diseased eyelashes are epilated Appropriate antibiotic drops are used After control of infection, daily cleaning of lid margins with blend lotion

TreatmentImprovement of local hygiene (rubbing of eyes and touching of eyes with dirty hand should be discouraged)

Sequelae of Ulcerative Blepharitis Chronic course and associated chronic conjunctivitis Madarosis (Scanty eyelashes) due to falling of eyelashesTrichiasis (misdirected eyelashes) due to contraction of scar tissueCicatrization of lid margins causing thickening and hypertrophy of tissue and drooping of lids (Tylosis)

Sequelae of Ulcerative BlepharitisCicatrization 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

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 Blepharitisb. 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 instabilityPapillary conjunctivitis and inferior corneal erosions

TreatmentWarm 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 weeksAssociated tear film abnormality is treated with artificial tear drops

Entropion

Lower lid retractorsInferior 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 EntropionForeign body sensationWatering RednessPainPhotophobia These symptoms are due to rubbing of ocular surface by misdirected eyelashes

ClassificationInvolutionalCicatricial Spastic Congenital

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 EntropionThere occurs of over-ridding of preseptal orbicularis muscle over pretarsal orbicularis, that leads to forward rotation of tarsal plate Seen in lower lids

Involutional Entropion

Involutional Entropion

Treatment of Involutional Entropion Principles of surgery Reattachment of the retractor to tarsal plateShortening of horizontal width of lidTo induce scarring between the pre-tarsal and pre-septal parts of orbicularis muscle

Surgical Procedures Catgut suture application throughModified Bick operation: Horrizontal shortening of lower lid with fixation to lateral canthal ligament and periosteum 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

TreatmentPrinciples of surgeryTarsal rotation (forwards)Lengthening of posterior lid lamina so that eyelashes turn forwards Surgery Wedge resection (Tarsal paring)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 marginSenile degeneration of tarsal muscle of Muller fails to anchor the lower border of tarsal plate to bony orbitOrbicularis rides up on tarsal plate towards lid margin Horizontal lid laxity

Clinical pictureCondition is found in elderly patients Tight bandaging may cause spastic entropion Narrowness of palpabral aperture Seen in lower lids

Treatment of Spastic EntropionRemoval of cause i.e removal of cause of irritation, tight bandagingTreatment of surface disorder by artificial tears and control of conjunctival infection and lid inflammation with antibioticFixing 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

Ectropion

Ectropion Ectropion is out-rolling of lid marginSymptoms 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

ClassificationI. Acquired Involutional or senileCicatricial ParalyticMechanical II. Congenital

Functions of lidsProtection of eyeAct as lacrimal pump

Effect of age Slowly there is relaxation of lid structures (canthal ligament and orbiularis)

Involutional EctropionStages:Early stage: in mild cases on looking up the puncta is not apposed to bulbar conjunctiva 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 Ectropion3. 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

SignsSigns as described with three stages earlierIn ling standing cases the exposed conjunctiva becomes dry, thickened, red , un-sightly. Cornea may suffer from imperfect closure of the lidsDiagnosis 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

TreatmentSurgical 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)

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

TreatmentPrinciple 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

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 palsyInitially treated by conservative treatment by taping of lids, lubricating eye drops, till there is recoveryLateral tarsorrhaphy, by suturing freshened upper and lower lids at outer canthusLagophthalmos due to weakness of superior orbicularis may be treated by taping