DISEASES OF THE LID AND CONJUNCTIVA.pptx

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1. DISEASES OF THE LID AND CONJUNCTIVA

2. The eyelid is divided into the upper lid and lower lid. Eyelids are folds of skin covering the eye. They are mobile curtains placed in front of the eyeballs There are essentially four layers:

3. 1. Cutaneous layer. It consists of skin, subcutaneous loose areolar tissue and the cilia or eyelashes Gross oedema 2. Muscular layer: This is found underneath the cutaneous layer Orbicularis oculi - concentric muscle fibres covering the lids, regions of the forehead and face around the orbital margins.Contraction firmly closes the lids. Nerve supply : Zygomatic branch of 7 th cranial nerve.

4. ii. Palpebral muscles: (a) Levator palpabrae superioris ( upperlid only) ( b) Muller’s muscle LPS is supplied by 3 rd nerve while the Muller’s muscle is supplied by the cervical sympathetic nerves. The palpebral muscles open the eyelids

5. 3. Fibrous layer i . orbital Septum: A thin membrane of connective tissue extending from the periosteum around the orbital margin. ii. Tarsal plate with meibomian glands: Fibrous skeleton of the lids.It extends from the medial to the latheral canthus . Meibomian glands are embedded within the structure

6. 4. Mucous Layer: This is formed by the palpebral conjunctiva lining the inner surface of the eyelid. The grey line is an important structure because it divides the eyelids into an anterior lamella composed of skin and orbicularis and a posterior lamella consisting of tarsal plate and conjunctiva

7. CONJUNCTIVA Thin, transparent mucous membrane which covers the inner surface of the eyelids Divided into 3: Palpebral conjunctiva-covers the under surface of the eyelid Forniceal conjunctiva-fold of conjunctiva at the fornix Bulbar conjunctiva-covers the anterior sclera

8. GLANDS IN THE EYELIDS AND CONJUNCTIVA There are three types of glands in the eyelids Meiboman glands: There are about 30-40 in the upper eyelid and 20-30 in the lower eyelid. They are arranged in vertical rows in the tarsal plates and are modified sebaceous glands that have openings on the eyelid border behind the posterior margin.

9. Glands of Zeis : These are sebaceous glands located in the lid margin and open into the hair follicle of the eyelashes

10. Glands of Moll: These are modified sweat glands located between the the cilia and the lid margin. They open into the ducts of the glands of Zeis or directly into the follicles of the cilia or on the surface of the lid margin.

11. Accessory lacrimal glands(glands of Krause and Wolfring ) located in the superior fornix

12. BLOOD SUPPLY Lacrimal and palpebral branches of ophthalmic Facial artery Superficial temporal artery Infraorbital artery Upper lid has two arterial arcades Lower lid has one arterial arcade

13. Nerve Supply Supratrochlear , supraorbital and lacrimal branches of ophthalmic division of V. nerve and Infraorbital branch of the maxillary division of V. nerve

14. Venous & Lymphatic Drainage Ophthalmic Vein Temporal vein Facial vein The upper lid and lateral canthus drain into the preauricular nodes whereas the lower lid and medial canthus drain into the submandibular nodes.

15. LYMPHATIC DRAINAGE

16. DISEASES OF EYELIDS HORDEOLUM Types a)External b) Internal

17. EXTERNAL HORDEOLUM(STYE) Inflammation of the eyelash follicle and its associated sebaceous gland (gland of Zeis ) Causative organism: Staphylococcus aureus Symptoms: Localized painful swelling of the lid Signs: Swelling, redness, oedema of the lid, tenderness, pus collection at the lid margin

18. MANAGEMENT Heat therapy: Hot moist compresses 3x a day Local and systemic Antibiotics Surgery if the above fails

19. INTERNAL HORDEOLUM Suppurative inflammation of the meibomian gland caused by staph Symptoms- more intense than external points inwards into tarsal conjunctiva Treatment-Systemic Antibiotics Hot compresses Surgery –Vertical incision

20. CHALAZION Painless chronic granulomatous inflammation of the meibomian gland Characterized by localized swelling on the lid Usually points inward into the conjunctiva. Swelling can press on the corneal which can then cause refractive error-Astigmatism TREATMENT- For cosmetic reasons Can disappear spontaneously Incision and Currettage (I&C)

21. BLEPHARITIS A chronic bilateral inflammation of the eyelid margin Types: a) Anterior blepharitis ( i ) Squamous / seborrhoeic (ii) Ulcerative/staphylococcal b) Posterior blepharitis ( i ) Meibomian seborrhea (ii) Primary meibomitis

22. SQUAMOUS BLEPHARITIS Usually associated with dandruff of the hair and eyebrows Characterized by whitish scales around the roots of the lashes. Scales drop into the conjunctival sac to cause conjunctivitis aggravated by rubbing. The lid may be thickened Treatment Shampoo application Lid hygiene Topical antibiotics

23. ULCERATIVE/STAPHYLOCOCCAL BLEPHARITIS Lid margins are ulcerated and infection is more deep-seated and involves the hair follicles thereby destroying some of them. Cases are frequently seen in patients with atopic dermatitis. Staph aureus is the commonest cause. Sequelae : Madarosis , Trichiasis , Tylosis (hypertrophy of the lid margin), Ectropion TREATMENT- lid hygiene with shampoo Antibiotic ointment

24. MEIBOMIAN SEBORRHEA Characterized by burning sensation on waking up with frothy discharge at the inner canthi PRIMARY MEIBOMITIS Characterized by diffuse inflammation centered around the meibomian gland orifices TREATMENT Lid hygiene Topical and systemic antibiotics Topical weak steroids in chronic cases

25. PTOSIS (BLEPHAROPTOSIS) This is drooping of the upper eyelid below its normal eye position. May be unilateral/bilateral, partial/complete Causes A) CONGENITAL PTOSIS i )Simple ptosis - maldevelopment of levator muscle ii)Weakness of superior rectus iii)Marcus Gunn –Jaw syndrome- 5% of congenital ptosis . Retraction/wink of the lid at stimulation of ipsilateral pterygoid muscle by opening of the mouth, sucking or movement of the jaw towards the contralateral side iv) Blepharophimosis Syndrome

26. Blepharophimosis Syndrome Ptosis may be symmetrical/asymmetrical Telecanthus (lateral displacement of medial canthus ) Epicanthus inversus (lower lid fold larger than upper lid fold) Other features: ectropion , poorly developed nasal bridge and hypoplasia of superior orbital rims.

27. ACQUIRED PTOSIS CAUSES Neurogenic causes- 3 rd n palsy,Horner’s syndrome, Mis -direction of 3 rd nerve (Aberrant regeneration) Mechanical causes – Oedema /mass Myogenic causes- Myasthenia gravis, myotonic dystrophy, ocular myopthy Aponeurotic causes -dehiscence of or disinsertion of the levator muscle, Age related involutional ptosis caused degenerative levator aponeurosis PSEUDOTOSIS Lack of mechanical support from empty socket

28. TREATMENT Depends on the cause

29. Trichiasis - An acquired posterior misdirection of previously normal lashes Entropion - an inversion of the eyelid Ectropion -an outward turning of the eyelid

30. DISEASES OF THE CONJUNCTIVA CONJUNCTIVITIS Inflammation of the conjunctiva-commonest among all eye infections AETIOLOGICAL CLASSIFICATION i )Infective-Bacteria eg Staphlococcus epidermidis , Streptococcus pneumoniae , Haemophilus infuenza,Moraxella lacunata Viral eg Adenovirus( pharyngoconjunctival fever/ epidermic keratoconjunctivitis ), Enterovirus (acute haemorrhagic fever-Apollo) Fungal egCandida albicans Parasitic eg onchocerca volvulus , loaloa Chlamydial eg Chlamydia trachomatis

31. Parasitic eg onchocerca volvulus , loaloa Chlamydial eg Chlamydia trachomatis ii)Allergic-Seasonal allergic conjunctivitis Perenial allergic conjunctivitis Vernal allergic conjunctivitis Acute allergic conjunctivitis Atopic conjunctivitis Giant papillary conjunctivitis

32. iii) Traumatic Conjunctivitis Foreign bodies Chemicals

33. CLINICAL FEATURES Foreign body sensation/gritty sensation Photophobia Tearing Discharge-may be purulent, mucopurulent,stringy /rope-like in allergic conjunctivitis Redness Hyperaemia Chemosis Papillary hypertrophy Pseudoptosis

34. TREATMENT Conjunctival swab for m/c/s may be done Eye toileting with normal saline Topical antibiotics-

35. GONOCOCCAL CONJUNCTIVITIS It is usually bilateral. May rapidly cause blindness . May affect new born by direct infection from the mother through the vaginal discharge. Adults can get infection when they have gonococcal urethritis

36. Incubation period –usually between 1-3days after birth Clinical features- Copious ,purulent eye discharge, swollen eye lids and redness Organisms can penetrate intact cornea causing perforation. Treatment Prophylaxis –Treat the mother before delivery At birth-Topical intensive antibiotics therapy-freshly prepared Penicillin( xtal pen) Systemic Antibiotics

37. COMPLICATIONS Corneal ulceration→Perforation Endophthalmitis Panophthalmitis Phthisis bulbi Leucoma

38. OPHTHALMIA NEONATORUM Defined as conjunctival inflammation that occurs during the first month of life Causes : N.gonorrhoea , C. trachomatis and miscellaneous –chemicals eg Silver Nitrate PROPHYLAXIS Antenatal diagnosis and treatment of maternal genital infections and their sexual partners. Disinfection of conjunctivae immediately after birth-use of Tetracycline ointment/Erythromycin ointment

39. TREATMENT OF EXPOSED OF INFANTS Eye toileting Topical antibiotics every hour for the first 24hrs, then every 3hr on the next day then 6hrly for the next 10 days. Systemic Antibiotics – i.m Ceftriazone 100mg/kg as a single dose.

40. VIRAL CONJUNCTIVITIS Various viruses can cause conjunctivitis ACUTE FOLLICULAR CONJUNCTIVITIS i )Acute herpetic conjunctivitis caused by herpes simplex virus(HSV) ii)Epidemic Keratoconjunctivitis (EKC) caused by adenovirus type 8 iii) Pharyngo-conjunctival fever(PCF) caused by adenovirus types 3 and 7 ACUTE HAEMORRHAGIC CONJUNCTIVITIS ( APOLLO XI CONJUNCTIVITIS ) Causative organism- Enterovirus

41. CLINICAL FEATURES Commonest conjunctival reaction-follicle formation with regional lymph nodes enlargement Chemosis Discharge Redness Conjunctival membrane formation

42. Often there is a tendency for corneal involvement thus called keratoconjunctivitis Corneal lesions: a) superficial punctate keratitis (SPK) b)Superficial erosion c)Corneal stroma opacity

43. TREATMENT Usually self limiting Treat secondary bacterial infection with topical antibiotics

44. ALLERGIC CONJUNCTIVITIS An inflammation of the conjunctiva as a result of reaction to allergens. 1 SEASONAL ALLERGIC (hay fever conjunctivitis) It is seasonal occurring in warm weather- Triggered by airborne antigens such as mould spores, pollen, grass, weeds, hair, feathers etc Presentation :acute itching, watery discharge and redness Treatment: Topical mast cell stabilizer Topical antihistamine

45. PERENIAL ALLERGIC CONJUNCTIVITIS Occurs all the year round ACUTE ALLERGIC CONJUNCTIVITIS It frequently affects young children after playing with animals/in the grass Presents with sudden onset of severe chemosis and swelling of the eyelids. TREATMENT: reassurance

46. VERNALKERATOCONJUNCTIVITS This is a chronic conjunctivitis. Cause is unknown but may be due to hypersensitivity reaction of the conjunctiva It usually affects children from about the age of 2years and runs a course of 5-20years and a positive family history

47. CLINICAL FEATURES Intense ocular itching, tearing, photophobia, foreign body sensation, thick mucous discharge .May occur throughout the year 3 clinical types: a)Palpebral VKC b) Limbal VKC c) Mixed

48. Corneal changes in VKC Punctate epitheliopathy Macroerosions Plaque Subepithelial scarring Pseudogerontonxon

49. TREATMENT Topical steroids Sodium Chromoglycate Lodoxamide Acetylcysteine Severe cases may need depot preparation of Steroid subconjunctival -(Depot medrol )

50. PTERYGIUM A degenerative disease of the conjunctiva. A triangular sheet of fibrovascular tissue that invades the cornea Typically affects patients who have been living in hot climates. May be due to irritation from exposure to uv rays. Found in out door workers, farmers, cattle rearers

51. TREATMENT Surgical excision-indications Cosmesis Visual impairment Complications-recurrence prevention- use of topical/ subconj steroids β-irradiation Use of 5-Fluoro uracil , Mitomycin C

52. PINGUECULA It is a common lesion which consists of a yellow-white deposit on the bulbar conjunctiva TREATMENT Surgery is rarely needed