Diseases of eyelid.pptx

The eyelids are mobile tissue curtains placed in front of the eyeballs. These act as shutters protecting the eyes from injuries and excessive light. These also perform an important function of spreading the tear film over the cornea and conjunctiva and also help in drainage of tears by lacrimal pump system.

1. DISEASES OF EYELID MS. MEGHNA VERMA ASSISSTANT PROFESSOR DEPARTMENT OF OPTOMETRY RAMA UNIVERSITY

2. CONTENTS Anatomy of eyelid Glands of eyelid Congenital anomalies of eyelids Oedema of eyelids Inflammatory anomalies of eyelids Anomalies in eyelid margin and lashes Tumours of eyelids

3. GROSS ANATOMY OF EYELID Introduction. The eyelids are mobile tissue curtains placed in front of the eyeballs. These act as shutters protecting the eyes from injuries and excessive light. These also perform an important function of spreading the tear film over the cornea and conjunctiva and also help in drainage of tears by lacrimal pump system. Parts of eyelid . Each eyelid is divided by a horizontal furrow into an orbital and tarsal part. Position of lids . When the eye is open, the upper lid covers about one-sixth of the cornea and the lower lid just touches the limbus . Canthus . The two lids meet each other at medial and lateral angles (or outer canthus and inner canthus ). Palpebral aperture . It is elliptical space b/w the upper and the lower lid. When the eyes are open it measures about 10-11 mm vertically in the centre & 28-30 mm horizontally. Eye lid margin . It is about 2-mm broad and is divided into two parts by the punctum . The medial, lacrimal portion is rounded and devoid of lashes or glands and lateral, ciliary portion.

4. MICROSCOPIC ANATOMY OF EYELID from anterior to posterior, consists of 7 layers- The skin The subcutaneous areolar tissue The layer of striated muscle Submuscular areolar tissue Fibrous layer Layer of non-striated muscle fibres Conjunctiva

5. GLANDS OF EYELID The meibomian gland /the tarsal gland Glands of Zeis Glands of moll G lands of wollfring

6. CONGENITAL ANOMALIES OF EYELIDS Congenital ptosis Abnormal drooping of the upper eyelid is called ptosis. Normally, upper lid covers about upper one-sixth of the cornea, i.e., about 2 mm. Therefore, in ptosis it covers more than 2 mm .

7. Congenital coloboma It is a rare condition characterised by a full thickness triangular gap in the tissues of the lids. Epicanthus It is a semicircular fold of skin which covers the medial canthus .

8. Distichiasis Distichiasis is a rare anomaly in which an extra row of cilia. These cilia are usually directed backwards and when rubbing the cornea, should be electro-epilated. Cryptophthalmos It is a very rare anomaly in which lids fail to develop and the skin passes continuously from the eyebrow to the cheek hiding the eyeball.

9. Microblepharon In it, eyelids are abnormally small. It is usually associated with microphthalmos .

10. INFLAMMATORY DISORDERS OF EYELIDS BLEPHARITIS It is an acute or chronic inflammation of the lid margins. It can be divided into following clinical types: Seborrhoeic or squamous blepharitis Staphylococcal or ulcerative blepharitis Mixed staphylococcal with seborrhoeic blepharitis Posterior blepharitis or meibomitis Parasitic blepharitis

11. 1. Squamous blepharitis CAUSES It is usually associated with seborrhoea of scalp (dandruff). In it, Zeiss glands secrete abnormal excessive neutral lipids. SYMPTOMS Deposition of whitish material at the lid margin, mild discomfort, irritation, occasional watering and a history of falling of eyelashes. SIGNS Accumulation of white dandruff-like scales on lid margin & lashes. The lashes fall out easily but are usually replaced.

12. 2. Ulcerative blepharitis CAUSES It is a staphylococcal infection of the lid margin. The disorder may continue throughout life. Chronic conjunctivitis and Dacryocystitis may act as predisposing factors. SYMPTOMS Chronic irritation, itching, mild lacrimation, gluing of cilia & photophobia. The symptoms are worse in the morning than noon. SIGNS Yellow crusts are seen at the root of cilia. Small ulcers, which bleed easily, seen on removing the crusts. COMPLICATIONS Chronic conjunctivitis, Madarosis , trichiasis , poliosis and tylosis .

13. 3. Mixed staphylococcal with seborrhoeic blepharitis This type of blepharitis is usually associated with both type of bacteria, staphylocccal as well seborrhoeic . 4. Parasitic blepharitis This type of blepharitis associated with Demodex folliculorum infection. In chronic condition, it is characterized by presence of nits (lice) at the lid margin and at roots of eyelashes .

14. 5. Posterior blepharitis Acute meibomitis occurs mostly due to staphylococcal infection. In chronic posterior blepharitis , it is also called a meibomian gland dysfunction due to seborrhoeic bacteria.. It is characterized by white foam-like secretion on the eyelid margins & canthus . At the lid margin, openings of the meibomian glands opening become prominent.

15. TREATMENT OF BLEPHARITIS General measures include improvement of health and diet. Associated seborrhoea of the scalp should be adequately treated. Local measures include removal of scales & crusts from the lid margin with the help of 3 percent soda bicarb or baby shampoo with hot compresses. Antibiotic ointment should be applied at the lid margin, immediately after removal of scales and crusts, at least twice daily. Avoid rubbing of the eyes or fingering of the lids. Oral antibiotics such as erythromycin or tetracyclines may be useful. Oral anti-inflammatory drugs like ibuprofen help in reducing the inflammation. If nits at the lid margin & lashes than removal with forceps and shampoo and massage with antibiotic ointment.

16. STYE It is an acute inflammation of Zeiss glands or Moll glands. PREDISPOSING FACTORS It is more commonly infection. There is no age bar. Increase chances of stye , patients with eye strain or refractive errors. Habitual rubbing of the eyes or fingering of the lids and nose, chronic blepharitis and diabetes mellitus. Metabolic factors, chronic debility, excessive intake of carbohydrates & alcohol. CAUSES Commonly involved is Staphylococcus aureus .

17. SYMPTOMS Acute pain associated with swelling of lid, mild watering & photophobia. SIGNS Cellulitis stage - localised, hard, red, tender swelling at the lid margin. Abscess stage - a visible pus point on the lid margin of affected cilia.

18. TREATMENT Hot compresses 2-3 times a day are very useful. When the pus is filled, it may be drained by epilating the involved cilia. Antibiotic eye drops and eye ointment (at bed time) should be applied to control infection. Anti-inflammatory drugs to reduce oedema. Analgesics may be used for relieve pain. Systemic antibiotics may be used for early control of infection. In recurrent stye , try to find out and treat the associated cause first.

19. CHALAZION It is also called a tarsal cyst or meibomian cyst. It is a chronic inflammation of the meibomian gland. PREDISPOSING FACTORS It is more commonly infection. There is no age bar. Increase chances of stye , patients with eye strain or refractive errors. Habitual rubbing of the eyes or fingering of the lids and nose, chronic blepharitis and DM. Metabolic factors, chronic debility, excessive intake of carbohydrates & alcohol.

20. SYMPTOMS Painless swelling in the lid and mild heaviness. SIGNS Small, firm to hard, non-tender swelling of meibomian gland. On everting the lid, by means, conjunctival side seen a red, purple or grey area. Frequently, multiple chalazion may be seen involving one or more eyelids . COMPLICATIONS A large chalazion of the upper lid induced astigmatism. A large chalazion of the lower lid may cause ectropion . After long time chalazion , meibomian gland carcinoma may be seen because of meibomian cyst.

21. TREATMENT Treatment in the form of hot fomentation, topical antibiotic eye drops and oral anti-inflammatory drugs . Incision and curettage is the conventional and effective treatment for chalazion .

22. INTERNAL HORDEOLUM It is a suppurative inflammation of meibomian gland associated with blockage of the duct. CAUSES It may occur as primary staphylococcal infection of the meibomian gland or due to secondary infection in a chalazion . SYMPTOMS Painfull swelling of lid and heaviness . SIGNS On everting the lid, swelling is away from the lid margin & pus usually points on the tarsal conjunctiva and not on the root of cilia. Sometimes, pus point may be seen at the opening of meibomian gland. TREATMENT When the pus is formed, it should be drained by a vertical incision from the tarsal conjunctiva. Hot fomentation, topical antibiotic eye drops and oral anti-inflammatory drugs may be used.

23. ANOMALIES IN THE EYE LASHES AND EYELID MARGIN TRICHIASIS It refers to inward misdirection of cilia (Lashes). The inward turning of lashes along with the lid margin ( entropion ) is called pseudotrichiasis . CAUSES Trachoma, ulcerative blepharitis , conjunctivitis, stye , mechanical injuries, burns. SYMPTOMS Foreign body sensation and photophobia, irritation, pain and lacrimation . SIGNS Misdirected cilia touching the cornea. Reflex blepharospasm and photophobia occur when cornea is abraded. Conjunctiva may be congested .

24. COMPLICATIONS Recurrent corneal abrasions, superficial corneal opacities, corneal vascularisation and non-healing corneal ulcer. TREATMENT Epilation (mechanical removal with forceps), is a temporary method. Electrolysis , is a method of destroying the lash follicle by electric current using anaesthesia, through a fine needle inserted into the lash root & removed with forceps. Cryoepilation , is also an effective method of treating trichiasis . After infiltration anaesthesia, using cryoprobe is applied. Drawback is depigmentation of the skin. Surgical correction , When many cilia are misdirected operative treatment similar to cicatricial entropion should be employed.

25. ENTROPION It is inward turning of the lid margin. Types Congenital entropion . Cicatricial entropion . Spastic entropion Senile entropion Mechanical entropion

26. 1. Congenital entropion It is a rare condition seen since birth & associated with microphthalmos . 2. Cicatricial entropion It usually involving the upper lid. Causes are trachoma, membranous conjunctivitis, chemical burns and Stevens-Johnson syndrome. 3. Spastic entropion It occurs due to spasm of the orbicularis muscle & usually involves the lower lid. 4. Senile entropion It affects the lower lid in elderly people. weakening of capsulopalpebral fascia, degeneration of palpebral connective tissue separating the orbicularis muscle fibres and horizontal laxity of the lid. 5. Mechanical entropion It occurs due to lack of support provided by the globe to the lids and associated with phthisis bulbi , enophthalmos and after enucleation or evisceration operation.

27. SYMPTOMS Foreign body sensation, irritation, lacrimation and photophobia. SIGNS On examination, lid margin is found inward turned. Depending upon the degree of inturning it can be divided into three grades:- In grade I, only the posterior lid border is inrolled . Grade II, inturning up to the inter-marginal strip. Grade III, the whole lid margin including the anterior border is inturned . COMPLICATIONS These are similar to trichiasis .

28. TREATMENT Congenital entropion requires plastic reconstruction of the lid crease. Cicatricial entropion , is treated by a plastic operation, which is based on any of the following ( i ) Altering the direction of lashes, (ii) Transplanting the lashes, (iii) Straightening the distorted tarsus. Spastic entropion . ( i ) Treat the cause of blepharospasm . (ii) Adhesive plaster pull on the lower lid may help during acute spasm. (iii) Injection of botulinum toxins in the orbicularis muscle to relieve the spasm. Senile entropion , used surgical pocedures .

29. ECTROPION Outward turning of the lid margin is called ectropion . Types Senile entropion . Cicatricial entropion . Spastic entropion Paralytic entropion Mechanical entropion

30. Senile ectropion It involves only the lower lids and due to senile laxity of the tissues of the lids and decrease tone of the orbicularis muscle. 2. Cicatricial ectropion It occurs due to scarring of the skin and can involve both the lids. Common causes are: thermal burns, chemical burns, lacerating injuries and skin ulcers. 3. Spastic ectropion It is a rare, seen in children & adults due to spasm of the orbicularis . 4. Paralytic ectropion It results due to paralysis of the seventh nerve, occurs in the lower lids. Common causes Bell’s palsy, head injury and infections of the middle ear. 5. Mechanical ectropion It occurs in conditions where either the lower lid is pulled down (tumours) or pushed down (proptosis and chemosis of the conjunctiva).

31. SYMPTOMS Epiphora is the main symptom. Irritation, discomfort and mild photophobia. SIGNS Lid margin is outward rotate. Depending upon the degree, ectropion can be divided into three grades:- In grade I ectropion only punctum is everted . In grade II lid margin is everted and palpebral conjunctiva is visible. Grade III the fornix is also visible. COMPLICATIONS Dryness and thickening of the conjunctiva and corneal ulceration (exposure keratitis). Eczema and dermatitis may occur due to prolonged epiphora .

32. TREATMENT Cicatricial ectropion , depending upon the degree it can be corrected by i . V-Y operation, Z- plasty and skin grafting. Paralytic ectropion , can be corrected by a lateral tarsorrhaphy or palpebral sling operation . Mechanical ectropion , corrected by treating the underlying cause. Spastic ectropion , corrected by treating the cause of blepharospasm .

33. SYMBLEPHARON In this condition, lids become adherent with the eyeball. In other words , adhesions between the palpebral and bulbar conjunctiva. ETIOLOGY It results from healing of the kissing raw surfaces upon the palpebral and bulbar conjunctiva. CAUSES Thermal or chemical burns, conjunctivitis, injuries, conjunctival ulcers and Stevens-Johnson syndrome. SYMPTOMS Difficulty in lid movements, diplopia, inability to close the lids, and cosmetic disfigurement. SIGNS Adhesion may be present only in the anterior part (anterior symblepharon ), or fornix (posterior symblepharon ) or the whole lid (total symblepharon ).

34. COMPLICATIONS Dryness, thickening, corneal ulceration and exposure keratitis. TREATMENT Prophylaxis. During the stage of adhesions, may be prevented by lubricant around the fornices several times a day. A large-sized, therapeutic, soft contact lens also helps in preventing the adhesions. Curative treatment consists of symblepharectomy .

35. ANKYLOBLEPHARON In this condition, the adhesions between upper lid margin and lower lid margin. CAUSES Chemical burns, thermal burns, ulcers and traumatic wounds of the lid margins. Ankyloblepharon may be complete or incomplete. It is usually associated with symblepharon . TREATMENT Lids should be separated by excision of adhesions between the lid margins and kept apart during healing process.

36. BLEPHAROPHIMOSIS In this condition, the palpebral aperture is decreased. ETIOLOGY It may be congenital or acquired, due to formation of a vertical skin fold at the lateral canthus . TREATMENT Usually no treatment is required. Canthoplasty operation is performed .

37. LA GOPHTHALMOS In this condition, inability to voluntarily close the eyelids . CAUSES Paralysis of orbicularis oculi muscle, symblepharon , severe ectropion , proptosis, over-resection of the levator muscle for ptosis. Physiologically some people sleep with their eyes open (nocturnal lagophthalmos). SYMPTOMS Incomplete closure of the palpebral aperture. COMPLICATIONS Conjunctival and corneal xerosis and exposure keratitis. TREATMENT Artificial tear drops should be instilled for prevent exposure keratitis & antibiotic eye ointment during sleep. Soft bandage contact lens may be used to prevent exposure keratitis.

38. BLEPHAROSPASM It refers to the involuntary and forceful closure of the eyelids. ETIOLOGY Blepharospasm occurs in two forms: 1. Essential blepharospasm - It is a rare idiopathic condition involving patients between 45 and 65 years of age. 2. Reflex blepharospasm - It usually occurs due to reflex stimulation such as : keratitis, corneal foreign body, corneal ulcers and iridocyclitis . CLINICAL FEATURES Oedema of the lids. TREATMENT In essential blepharospasm , Botulinum toxin, injected subcutaneously over the orbicularis muscle. In reflex blepharospasm , to treat the cause first.

39. PTOSIS Abnormal drooping of the upper eyelid is called ptosis. Normally, upper lid covers about upper one-sixth of the cornea, i.e., about 2 mm. Therefore, in ptosis it covers more than 2 mm.

40. CONGENITAL PTOSIS It is associated with congenital weakness (mal-development) of the LPS muscle. Simple congenital ptosis , not associated with any other anomaly. Congenital ptosis with associated weakness of superior rectus muscle. Blepharophimosis syndrome , includes congenital ptosis, telecanthus & epicanthus . Congenital synkinetic ptosis (Marcus Gunn jaw winking ptosis), retraction of the ptotic lid with jaw movements.

41. ACQUIRED PTOSIS It may be: Neurogenic ptosis , caused by third nerve palsy, Horner’s syndrome, migraine and multiple sclerosis. Myogenic ptosis, due to disorders of the LPS muscle. It may be seen in patients with myasthenia gravis, ocular myopathy , oculo -pharyngeal muscular dystrophy. Aponeurotic ptosis, due to defects of the levator aponeurosis in the presence of a normal functioning muscle. It includes (senile) ptosis, postoperative ptosis after cataract and retinal detachment surgery. Mechanical ptosis, due to excessive weight on the upper lid by lid tumours, multiple chalazia and lid oedema.

42. CLINICAL EVALUATION [A] History - age of onset, family history, trauma history, eye surgery & degree of the ptosis. [B] Examination 1. Inspect pseudoptosis - common causes are: microphthalmos , enophthalmos and phthisis bulbi . 2. Observe the following points i . ptosis is unilateral or bilateral. ii. Function of orbicularis oculi muscle. iii. Eyelid crease is present or absent. iv. Jaw-winking phenomenon is present or not. v. Associated weakness of any extraocular muscle. vi. Bell’s phenomenon is present or absent.

43. 3. Measurement of amount of ptosis – Mild - 2 mm Moderate - 3 mm Severe - 4 mm 4. Assessment of levator function - Patient is asked to look down, and thumb of one hand is placed firmly against the eyebrow of the patient (to block the action of frontalis muscle) by the examiner. Then the patient is asked to look up and the amount of upper lid movement is measured with a ruler. Normal - 15 mm Good - 8 mm or more Fair - 5-7 mm Poor - 4 mm or less

44. 5. Photographic record of the patient should be maintained for comparison. Phenylephrine test is carried out in patients suspected of Horner’s syndrome. Neurological investigations may be required to find out the cause in patient with neurogenic ptosis. TREATMENT Congenital ptosis It almost always needs surgical correction. In severe ptosis, surgery should be performed at the earliest to prevent stimulus deprivation amblyopia. In mild and moderate ptosis, surgery should be delayed until the age of 3 to 4 years.

45. SURGERY FOR CONGENITAL PTOSIS 1. Fasanella-Servat operation - It is performed in mild ptosis and good levator function. 2. Levator resection - It is performed for moderate and severe grades of ptosis. It is contraindicated in patients having severe ptosis with poor levator function. 3. Frontalis sling operation (Brow suspension ) - It is performed in patients having severe ptosis with no levator function. B] Acquired ptosis Efforts should be made to find out the underlying cause and if possible treat it.

46. TUMOURS OF THE LIDS

47. PAPILLOMAS This type of tumour is most common, arising from the epithelium surface. These occur in two types - i . Squamous papillomas , occur in adults, as very slow growing, raspberry-like growths, usually involving the lid margin & treated by simple excision. ii. Seborrhoeic keratosis , occurs in middle-aged and older persons. Their surface is friable, verrucous and slightly pigmented.

48. XANTHELASMA These are creamy-yellow plaque-like lesions which frequently involve the skin of upper and lower lids around medial canthus . Xanthelasma occurs in middle-aged females (most common). Xanthelasma represents lipid deposits in histiocytes in the dermis of the lid. These may be associated with diabetes mellitus or high cholesterol levels. Excision treatment may be advised for cosmetic reasons.

49. NEUROFIBROMA Eyelids and orbits are commonly affected in neurofibromatosis.

50. BASAL-CELL CARCINOMA It usually seen in elderly people. It involves most commonly lower lid (50%) followed by medial canthus , upper lid and outer canthus . Clinical features It may present in four forms: Nodulo -ulcerative basal cell carcinoma is the most common. Non-ulcerated nodular basal cell carcinoma, rarely. Sclerosing type basal cell carcinoma, rare. Pigmented basal cell carcinoma, rare. Treatment Surgery. Local surgical excision of the tumour. Radiotherapy and cryotherapy should be given in non-operable cases.

51. SQUAMOUS CELL CARCINOMA It is the second most common type of tumour. It arises from the lid margin in elderly patients. It affects upper and lower lids equally. Clinical features . It may present in two forms, First, an ulcerated growth with elevated margins, is most common. Second, fungal lesion without ulceration, is a rare. Treatment Surgery. Local surgical excision of the tumour. Radiotherapy and cryotherapy should be given in non-operable cases.

52. SEBACEOUS GLAND CARCINOMA It is a rare tumour arising from the meibomian glands. It usually start as a nodule and then grows to form a big growth (by chalazion ) Rarely, a diffuse tumour along the lid margin may be mistaken as chronic blepharitis . Surgical excision with reconstruction of the lids is the treatment.

53. MALIGNANT MELANOMA (MELANOCARCINOMA) It is a very rare tumour of the lid. It may arise from a pre-existing naevus , but usually arises from the melanocytes present in the skin. It appears as a flat or slightly elevated naevus which has irregular borders. It may ulcerate and bleed. The tumour spreads locally as well as to distant sites by lymphatics and blood stream. Treatment. Surgical excision with reconstruction of the lids.