Diseases of Lids

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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.)

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Anatomy of Lid
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Hordeolum Externum(Stye)
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Hordeolum Externum (Stye)

• Definition Localized suppurative inflammation of
  gland of zeis at lid margin at ciliary follicle.

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Etiology

• Usually caused by staphylococcus aureus
• There is infection of hair follicle of eyelash.
• It may complicate Acne Vulgeris in young adults.

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Histopathology

• Purulent infection of follicle and its gland with
  cellulitis of surrounding connective tissue

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Clinical Picture

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

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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

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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

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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

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Hordeolum Externum
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Complications

• Cellulitis (particularly in cases of lesion at
  inner canthus)
• Orbital thrombophebitis (leading to cavernous
  sinus thrombosis and its complications)

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Treatment

• Systemic
• a. Antibiotic
• b. Anti-inflammatory analgesic
• c. Supportive
• d Treatment of associated systemic predisposing
  cause

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Treatment

• II. Local
• a. Hot fomentation
• b. Local broad spectrum antibiotic drop and
  ointment
• c. Evacuation of pus when pus points, sometimes
  epilation may be required before evacuation of
  pus (lid margin/ lesion should never be squeezed)

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Hordeolum Internum
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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

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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

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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

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Hordeolum Internum
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Treatment of Hordeolum Internum

• Medical treatment is similar to treatment of
  Hordeoulm externum i.e.
• Systemic
• a. Antibiotic
• b. Anti-inflammatory analgesic
• Local
• a. Hot fomentation
• b. Local broad spectrum antibiotic drop and
  ointment

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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

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Chalazion
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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

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Chalazion

• Symptoms
• Hard painless swelling little away from lid
  margin
• Swelling increases gradually in size without pain
• Small chalazia are better felt than seen
• Multiple lesions and large chalazion may be
  associated with inability to open eye fully

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Chalazion

• Signs
• Painless swelling 4-5 mm away from lid margin.
  Swelling is hard
• On 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

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Chalazion
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Adenoma of Meibomian Gland
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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

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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

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Instruments
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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

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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

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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)

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Blepharitis
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Blepharitis

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

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Types

• Anterior
• a. Squamous
• b. Ulcerative
• 2. Posterior
• a. Meibomian seborrhoea
• b. Meibomianitis

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Causes

1. Following chronic Conjunctivitis especially due
   to staphylococci
2. Parasitic infection, Blepharitis acarica due to
   Demodex Folliculorum and Phthiriasis Palpabrarum
   due to crab louse

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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

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Squamous Blepharitis
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Symptoms

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

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Seborrhoeic or Squamous Blepharitis

• Skin 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

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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

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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

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Ulcerative Blepharitis
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Treatment

• Discharge/ crust is removed from lid margins with
  14 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

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Treatment

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

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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)

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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

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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

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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

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Complications

• Chalazion
• Tear film instability
• Papillary conjunctivitis and inferior corneal
  erosions

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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

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Entropion
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Lower lid retractors

• 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

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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

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Symptoms of Entropion

• Foreign body sensation
• Watering
• Redness
• Pain
• Photophobia
• These symptoms are due to rubbing of ocular
  surface by misdirected eyelashes

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Classification

1. Involutional
2. Cicatricial
3. Spastic
4. Congenital

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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

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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

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Involutional Entropion
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Involutional Entropion
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Treatment of Involutional Entropion

• Principles of surgery
• Reattachment of the retractor to tarsal plate
• Shortening of horizontal width of lid
• To induce scarring between the pre-tarsal and
  pre-septal parts of orbicularis muscle

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Surgical Procedures

1. Catgut suture application through
2. Modified Bick operation Horrizontal shortening
   of lower lid with fixation to lateral canthal
   ligament and periosteum
3. Tucking of inferior lid retractors

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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

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Treatment

• Principles of surgery
• Tarsal rotation (forwards)
• Lengthening of posterior lid lamina so that
  eyelashes turn forwards
• Surgery
• Wedge resection (Tarsal paring)
• Tarsal fracture

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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

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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

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Clinical picture

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

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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

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Surgical treatment

• Producing a ridge of fibrous tissue in the
  orbicularis to prevent its fibres from sliding in
  vertical direction

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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

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Ectropion
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Ectropion

• Ectropion is out-rolling of lid margin
• Symptoms are
• Watering (due to eversion of punta)
• Foreign body sensation
• Pain
• Redness
• Photophobia (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

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Classification

• I. Acquired
• Involutional or senile
• Cicatricial
• Paralytic
• Mechanical
• II. Congenital

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Functions of lids

• Protection of eye
• Act as lacrimal pump
• Effect of age
• Slowly there is relaxation of lid structures
  (canthal ligament and orbiularis)

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Involutional Ectropion

• Stages
• 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

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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

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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

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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 position
• In 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)

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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

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Cicatricial Ectropion
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Ectropion Pre and Post-operative
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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

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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