Eyelid pathology baguio2012

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  • Lid lifted by cont of levator plus symp from smooth mu
  • Eyelid pathology baguio2012

    1. 1. EYELID PATHOLOGY
    2. 2. 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.
    3. 3. EYELID ABNORMALITIES
    4. 4. ABLEPHARON• It is the absence of the eyelid• Synonymous with the term ablephary
    5. 5. Cryptophthalmos * A condition characterized by the presence of an eyelid without a palpebral fissure
    6. 6. 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
    7. 7. SYMBLEPHARON * This is anadhesion betweenpalpebral and bulbarconjunctiva
    8. 8. 44- Posterior symblepharon
    9. 9. SYMBLEPHARON
    10. 10. LID COLOBOMA * It is the failure ofa part of the eyelidto develop * It is a notchingdefect of its margin
    11. 11. 2- Congenital coloboma of upper eyelid
    12. 12. BLEPHAROPHIMOSIS It is a conditioncharacterized by adecreased size of thepalpebral fissure bothvertical and horizontal
    13. 13. EPICANTHUS * It is the mostcommon congenitalabnormalities and ispresent among infants It is characterized bythe presence of avertical skin fold in themedial canthal regionthat covers the medialangle and caruncle It is also known aspalpebranasal fold
    14. 14. 1 - Bilateral Epicanthus
    15. 15. Epicanthus
    16. 16. BLEPHAROCHALASIS *It is redundancy and loss of elasticity of skin of the eyelid *It is the result of aging and repeated lid edema
    17. 17. blepharochalasis
    18. 18. BLEPHAROCHALASIS
    19. 19. EPIBLEPHARON * It is the presence ofan extra fold of skin atthe lower eyelid
    20. 20. TELECANTHUS• It is a condition characterized by a wide separation between the medial canthal ligaments
    21. 21. LID MARGIN ABNORMALITIES• Entropion• Ectropion
    22. 22. ENTROPION * It is a conditionwherein the lidmargin is turnedinward
    23. 23. ENTROPION
    24. 24. ENTROPION
    25. 25. Symptoms of Entropion• Foreign body sensation• Watering• Redness• Pain• PhotophobiaThese symptoms are due to rubbing of ocular surface by misdirected eyelashes
    26. 26. Classification1. Congenital2. Acquired 2.1 Involutional 2.2 Cicatricial 2.3 Spastic
    27. 27. CONGENITAL• Inward rolling in of the lid margin due to abnormal development of tarsal plate
    28. 28. 17- Congenital entropion of lower eye lid
    29. 29. INVOLUTIONAL• Inward rolling of lid margin due to old age and instability of lid structures
    30. 30. Involutional Entropion
    31. 31. Involutional Entropion
    32. 32. CICATRICIAL• Inward rolling of the lid margin due to scar tissue of the palpebral conjunctiva
    33. 33. SPASTIC• Inward rolling of the lid margin due to spasm of the orbicularis oculi muscle
    34. 34. Entropion
    35. 35. Entropion
    36. 36. Entropion
    37. 37. Entropion• Treatment – Lubrication – Taping the lid – Epilation – Horizontal lid tightening – Tarsal fracture procedure
    38. 38. Ectropion
    39. 39. ECTROPION
    40. 40. ClassificationI. Acquired• Involutional or senile• Cicatricial• Paralytic• MechanicalII. Congenital
    41. 41. INVOLUTIONAL• This is due to aging, there is laxity of the lid structures
    42. 42. 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
    43. 43. Cicatricial Ectropion
    44. 44. Ectropion Pre and Post-operative
    45. 45. 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
    46. 46. Ectropion
    47. 47. 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)
    48. 48. Ectropion
    49. 49. DISORDERS OF THE LASHES• Trichiasis• Distichiasis• Madarosis• Poliosis• Pediculosis Palpebraum
    50. 50. TRICHIASIS * Misdirection oflashes
    51. 51. TRICHIASIS
    52. 52. TRICHIASIS
    53. 53. DISTICHIASIS * Presence ofsupernumeraryrows of lashes
    54. 54. MADAROSIS Absence of thelashes
    55. 55. MADAROSIS
    56. 56. POLIOSIS Graying of thelashes
    57. 57. POLIOSIS
    58. 58. PEDICULOSIS PALPEBRAUM• It is a condition wherein the eyebrow and lashes are infested by lice
    59. 59. ABNORMALITIES OF LID POSITION
    60. 60. BLEPHAROPTOSIS * Drooping of theupper eyelid
    61. 61. PTOSIS
    62. 62. 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.
    63. 63. PtosisMARGIN-REFLEX INTERPALPEBRALDISTANCE DISTANCE LID CREASE POSTION
    64. 64. Ptosis
    65. 65. Ptosis
    66. 66. Ptosis
    67. 67. BLEPHAROSPASM• It is the persistent, repetitive involuntary contractions of the orbicularis oculi muscle• It is a bilateral conditions
    68. 68. MYOKYMIA• It is the involuntary contraction of a few fibers of orbicularis oculi muscle• It is eyelid twitching
    69. 69. 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
    70. 70. LAGOPHTHALMOS• It is the inadequate closure of the lids while sleeping
    71. 71. LAGOPHTHALMOS
    72. 72. ORBITAL FAT HERNIATION• It is the swelling or puffiness of the eyelids
    73. 73. ORBITAL FAT HERNIATION
    74. 74. HYPERTROPHY OF THE LIDS• Immense overgrowth of the lids
    75. 75. HYPERTROPHY OF THE LIDS
    76. 76. LID INFLAMMATION• Blepharitis
    77. 77. DEFINITION• It is the inflammation of the lid margin
    78. 78. 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
    79. 79. Types1. Anterior a. Squamous b. Ulcerative2. Posterior a. Meibomian seborrhoea b. Meibomianitis
    80. 80. ANTERIOR BLEPHARITIS• It involves the outer parts of the eyelid• It is commonly caused by bacteria
    81. 81. SEBORRHEIC/SQUAMOUS• It is characterized by the deposition of scales• Eyelashes fall• Hyperemic lid margin• Absence of ulcers
    82. 82. Squamous Blepharitis
    83. 83. Symptoms• Burning, deposits / crusting along lid margins, grittiness , redness of lid margins, photophobia• Symptoms are worse in the morning
    84. 84. 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
    85. 85. 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
    86. 86. Ulcerative Blepharitis
    87. 87. 14- Ulcerative blepharitis
    88. 88. 15- Ulcerative blepharitis
    89. 89. POSTERIOR BLEPHARITIS• It involves the inner parts of the eyelids• It is due to problems in the oil glands
    90. 90. LID LUMPS
    91. 91. 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
    92. 92.  - 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.
    93. 93. Internal hordeolum an abscess in meibomian gland. -Painful. -May respond to topical antibiotics but incision by be necessary.
    94. 94. Hordeolum Internum
    95. 95. 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
    96. 96. Chalazion
    97. 97.  -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.
    98. 98. Molluscum contagiosum Signs Complications• Painless, waxy, umbilicated nodule • Chronic follicular conjunctivitis• May be multiple in AIDS patientsOccasionally superficial keratitis •
    99. 99. Histology of molluscum contagios • Lobules of hyperplastic epithelium • Intracytoplasmic (Henderson-Patterson• Circumscribed lesion inclusion bodies• Surface covered by normal Deep within lesion bodies are small an • epithelium except in centre eosinophilic • Near surface bodies are larger and basophilic
    100. 100.  - Lipid containing bilateral lesions. - Usually associated with hyperlipidemia . - Removed for cosmetic reasons.
    101. 101. Xanthelasma• Common in elderly or those with hypercholesterolaemia• Yellowish, subcutaneous plaques containing cholesterol and lipid• Usually bilateral and located medially
    102. 102. Adenoma of Meibomian Gland
    103. 103. Eyelids inflammation• Blepharitis – Anterior – Posterior – Staphylococcal – Seborrhoeic – Meibomianitis• Treatment – Lid hygiene – Tears – Antibiotics – Warm compresses
    104. 104. Eyelids inflammation• Allergy – Acute allergic blepharoconjuctivitis – Allergic dermatoblepharitis
    105. 105. Eyelids inflammation• 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
    106. 106. Eyelids inflammation• 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
    107. 107. Benign eyelid lesions• Cysts – Cyst of Moll – Cyst of Zeiss – Sebaceous cyst – Hidrocystoma
    108. 108. Eyelid cysts Eccrine sweat gland Cyst of Moll hidrocystoma• Translucent • Similar to cyst of Moll• On anterior lid • Not confined to lid margin margin Cyst of Zeis Sebaceous cyst• Opaque • Cheesy contents• On anterior lid • Frequently at margin inner canthus
    109. 109. Benign eyelid lesions• Tumors – Viral wart( papilloma) – Actinic keratosis – Seborrheic keratosis – Keratocanthoma – Nevi • Junctional • Compound • Dermal – Capillary hemangioma – Xanthelasma – Pyogenic granuloma
    110. 110. Benign eyelid lesions
    111. 111. Malignant eyelid tumors• Basal cell carcinoma• Squamous cell carcinoma• Meibomian gland carcinoma• Melanoma• Kaposi sarcoma• Merkel cell carcinoma
    112. 112. 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
    113. 113. Squamous cell carcinoma• Less common than BCC• May arise de-novo or from pre-existing actinic keratosis• May metastasize
    114. 114. BENIGN EYELID LESIONS 1. Nodules • Chalazion • Acute hordeola • Molluscum contagiosum • Xanthelas ma 2. Cysts • Cyst of Moll • Cyst of Zeiss • Sebaceous cyst • Hidrocystoma 3. Tumours • Viral • wart • Keratoacantho • Capillary haemangioma Naevi ma • Port-wine stain • Pyogenic granuloma • Cutaneous horn
    115. 115. Signs of chalazion (meibomian cysPainless, roundish, firm lesion May rupture through conjunctivawithin tarsal plate and cause granuloma
    116. 116. Histology of chalazionMultiple, round spaces previously Epithelioid Multcontaining fat with surrounding cells giant cellsgranulomatous inflammation
    117. 117. Treatment of chalazion Insertion of clampInjection of local anaesthetic Incision and curettage
    118. 118. Acute hordeola Internal hordeolum External hordeolum (stye) ( acute chalazion )• Staph. abscess of meibomian Staph. abscess of lash follicle and • glands associated gland of Zeis or Moll• Tender swelling within tarsal•plate Tender swelling at lid margin• May discharge through skin • May discharge through skin or conjunctiva
    119. 119. Viral wart (squamous cell papilloma • Most common benign lid tumour • Raspberry-like surface Pedunculat Sess ed ile
    120. 120. Histology of viral wartFinger-like projections of Epidermis shows acanthosis (increasfibrovascular connective tissue thickness) and hyperkeratosis Rete ridges are elongated and bent in
    121. 121. Keratoses Seborrhoeic Actinic• Common in elderly • Affects elderly, fair-skinned individuals• Discrete, greasy, brown lesion • Most common pre-malignant skin lesio• Friable verrucous surface • Rare on eyelids• Flat ‘stuck-on’ appearance • Flat, scaly, hyperkeratotic lesion
    122. 122. Keratoacanthoma• Uncommon, fast growing nodule • Lesion above surface epithelium• Acquires rolled edges and keratin-filled crater • Central keratin-filled crater• Involutes spontaneously within 1 • Chronic inflammatory cellular infiltr year of dermis
    123. 123. Naevi • Appearance and classification determined by location within • Tend to become more pigmented at puberty Intradermal Junctional Compound• Elevated • Flat, well-circumscribed Has both intradermal • and junctional• May be non-pigmented Pigmented • components •• No malignant potential Low malignant potential
    124. 124. Capillary haemangioma• Rare tumour which presents soon after birth associated with intraorbi • May be extension• Starts as small, red lesion, most frequently on upper lid • Grows quickly during first year • crying• Blanches with pressure and swells on Begins to involute spontaneous during second year
    125. 125. Periocular haemangioma Treatment options • Steroid injection in most cases • Surgical resection in selected cases Occasional systemic associations • High-out heart failure • Kasabach-Merritt syndrom thrombocytopenia, anaem and reduced coagulant fa • Maffuci syndrome - skin haemangiomas, endrochondromas and bowing of long bones
    126. 126. Histology of capillary haemangiomaLobules of capillaries Fine fibrous septae Lobules under high magnification
    127. 127. Port-wine stain (naevus flammeus) • Rare, congenital subcutaneous le • Segmental and usually unilateral • Does not blanch with pressure Associations • Ipsilateral glaucoma in 30% • Sturge-Weber or Klippel-Trenaunay-Weber syndrome in 5%
    128. 128. Progression of port-wine stainInitially red and flat Subsequent darkening Skin becomes coarse, and hypertrophy of skinnodular and friable
    129. 129. Pyogenic granuloma Cutaneous horn• Usually antedated by surgery or trauma • Uncommon, horn-like lesion protru through skin• Fast-growing pinkish, pedunculated or sessile mass • May be associated with underlying• Bleeds easily keratosis or squamous cell carcino
    130. 130. EYELID PATHOLOGY Ocular Diseases1 Sy2010-2011
    131. 131. BLEPHAROCHALASIS
    132. 132. 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
    133. 133. Lower lid retractorsa. 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
    134. 134. EntropionEntropion is in-rolling of eye lid margin.Normal position of sharp posterior border of inter-marginal strip is essential for interigrity of the tearfilm and for maintenance of healthy ocular surfaceEntropion is caused by disparity of length and tone ofanterior skin muscle layer and posterior tarso-conjunctival layer of the eyelid
    135. 135. Symptoms of Entropion• Foreign body sensation• Watering• Redness• Pain• PhotophobiaThese symptoms are due to rubbing of ocular surface by misdirected eyelashes
    136. 136. Involutional EntropionThis condition is due to old age, due toinstability of lid structuresThere occurs:a. Weakness of the posterior retractor of thelidb. Laxity of medial and lateral canthalligamentsc. Atrophy of orbital pad of fat leading toenophthalmos
    137. 137. 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
    138. 138. Treatment of Involutional EntropionPrinciples of surgery2. Reattachment of the retractor to tarsal plate3. Shortening of horizontal width of lid4. To induce scarring between the pre-tarsal and pre-septal parts of orbicularis muscle
    139. 139. Surgical Procedures1. Catgut suture application through2. Modified Bick operation: Horrizontal shortening of lower lid with fixation to lateral canthal ligament and periosteum3. Tucking of inferior lid retractors
    140. 140. 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
    141. 141. TreatmentPrinciples of surgery2. Tarsal rotation (forwards)3. Lengthening of posterior lid lamina so that eyelashes turn forwardsSurgerye. Wedge resection (Tarsal paring)f. Tarsal fracture
    142. 142. 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
    143. 143. 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
    144. 144. Clinical picture• Condition is found in elderly patients• Tight bandaging may cause spastic entropion• Narrowness of palpabral aperture• Seen in lower lids
    145. 145. 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
    146. 146. Surgical treatment• Producing a ridge of fibrous tissue in the orbicularis to prevent its fibres from sliding in vertical direction
    147. 147. 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
    148. 148. Entropion
    149. 149. Lower lid retractorsa. 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
    150. 150. EntropionEntropion is in-rolling of eye lid margin.Normal position of sharp posterior border of inter-marginal strip is essential for interigrity of the tearfilm and for maintenance of healthy ocular surfaceEntropion is caused by disparity of length and tone ofanterior skin muscle layer and posterior tarso-conjunctival layer of the eyelid
    151. 151. Treatment of Involutional EntropionPrinciples of surgery2. Reattachment of the retractor to tarsal plate3. Shortening of horizontal width of lid4. To induce scarring between the pre-tarsal and pre-septal parts of orbicularis muscle
    152. 152. Surgical Procedures1. Catgut suture application through2. Modified Bick operation: Horrizontal shortening of lower lid with fixation to lateral canthal ligament and periosteum3. Tucking of inferior lid retractors
    153. 153. 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
    154. 154. TreatmentPrinciples of surgery2. Tarsal rotation (forwards)3. Lengthening of posterior lid lamina so that eyelashes turn forwardsSurgerye. Wedge resection (Tarsal paring)f. Tarsal fracture
    155. 155. 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
    156. 156. 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
    157. 157. Clinical picture• Condition is found in elderly patients• Tight bandaging may cause spastic entropion• Narrowness of palpabral aperture• Seen in lower lids
    158. 158. 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
    159. 159. Surgical treatment• Producing a ridge of fibrous tissue in the orbicularis to prevent its fibres from sliding in vertical direction
    160. 160. 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
    161. 161. Entropion
    162. 162. Lower lid retractorsa. 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
    163. 163. EntropionEntropion is in-rolling of eye lid margin.Normal position of sharp posterior border of inter-marginal strip is essential for interigrity of the tearfilm and for maintenance of healthy ocular surfaceEntropion is caused by disparity of length and tone ofanterior skin muscle layer and posterior tarso-conjunctival layer of the eyelid
    164. 164. Involutional EntropionThis condition is due to old age, due toinstability of lid structuresThere occurs:a. Weakness of the posterior retractor of thelidb. Laxity of medial and lateral canthalligamentsc. Atrophy of orbital pad of fat leading toenophthalmos
    165. 165. 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
    166. 166. Treatment of Involutional EntropionPrinciples of surgery2. Reattachment of the retractor to tarsal plate3. Shortening of horizontal width of lid4. To induce scarring between the pre-tarsal and pre-septal parts of orbicularis muscle
    167. 167. Surgical Procedures1. Catgut suture application through2. Modified Bick operation: Horrizontal shortening of lower lid with fixation to lateral canthal ligament and periosteum3. Tucking of inferior lid retractors
    168. 168. 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
    169. 169. TreatmentPrinciples of surgery2. Tarsal rotation (forwards)3. Lengthening of posterior lid lamina so that eyelashes turn forwardsSurgerye. Wedge resection (Tarsal paring)f. Tarsal fracture
    170. 170. 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
    171. 171. 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
    172. 172. Clinical picture• Condition is found in elderly patients• Tight bandaging may cause spastic entropion• Narrowness of palpabral aperture• Seen in lower lids
    173. 173. 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
    174. 174. Surgical treatment• Producing a ridge of fibrous tissue in the orbicularis to prevent its fibres from sliding in vertical direction
    175. 175. 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
    176. 176. Involutional EctropionStages:2. Early stage: in mild cases on looking up the puncta is not apposed to bulbar conjunctiva3. Progresses to moderate stage puncta are not apposed to bulbar conjunctiva even in primary gaze and entire lid margin fall away from the globe
    177. 177. 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 punctaTears are no longer drained into nose and overflow onto the cheekIn long standing cases keratinization of the lid margin and palpabral conjunctiva takes place
    178. 178. 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
    179. 179. 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)
    180. 180. 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
    181. 181. Ectropion• Treatment – Lubrication – Horizontal lid shortening or tightening – Punctal inversion
    182. 182. Disorders of Lashes
    183. 183. Treatment options for trichiasis• Epilation• Electrolysis• Cryotherapy• Argon laser• Surgery
    184. 184. Disorders of lashes• Madarosis – Lid margin inflammation – Tumor – Cryotherapy, radiotherapy or burns – Alopecia – Syphilis – Leprosy – SLE• Poliosis – VKH – Sympathetic ophthalmia
    185. 185. DISTICHIASIS
    186. 186. 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
    187. 187. 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.
    188. 188. 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.
    189. 189. 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).
    190. 190. Ptosis• Pseudoptosis – Orbital volume deficiency – Exophthalmos – Excess lid skin – Hypotropia
    191. 191. 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
    192. 192. Ptosis• Treatment – Ptosis crutch – Taping of the lid – Surgical • Levator advancement • Muller’s muscle resection • Frontalis suspension
    193. 193. 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
    194. 194. 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.
    195. 195. Ectropion- 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
    196. 196. 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
    197. 197. 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)
    198. 198. 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
    199. 199. Blepharitis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 cancause a burning or foreign body sensation, excessive tearing, itching, sensitivity tolight, red and swollen eyelids, redness of the eye, blurred vision, frothy tears, dryeye, flaking at the base of the lashes, or crusting of the eyelashes upon awakening. Common causes for anterior blepharitis are bacteria (Staphylococcus) and scalpdandruff while posterior forms are caused by problems with the oil glands in theeyelid. Treatment for both forms involves keeping eyelids clean and free of crusts.Warm compresses should be applied to loosen crusts, followed by a light scrubbingwith a cotton swab and a mixture of water and baby shampoo. Because blepharitis rarely goes away completely, most patients must maintainan eyelid hygiene routine for life. If the blepharitis is severe, an eye-careprofessional may also prescribe antibiotics or steroid eyedrops.
    200. 200. 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
    201. 201. Posterior Blepharitisb. Meibomianitis – There is inflammation andobstruction of meibomian glands.Characterized by diffuse thickening ofposterior border of lid margin which becomesrounded. On lid massage toothpaste like thickmaterial can be expressed out. Due to ductblockade cyst formation may be present
    202. 202. Complications• Chalazion• Tear film instability• Papillary conjunctivitis and inferior corneal erosions
    203. 203. 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
    204. 204. 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.
    205. 205. 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 .
    206. 206. 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.
    207. 207. 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
    208. 208. Hordeolum Externum (Stye)
    209. 209. Hordeolum Externum (Stye)Definition: Localized suppurative inflammation of gland of zeis at lid margin at ciliary follicle.
    210. 210. Etiology• Usually caused by staphylococcus aureus• There is infection of hair follicle of eyelash.• It may complicate Acne Vulgeris in young adults.
    211. 211. Histopathology• Purulent infection of follicle and its gland with cellulitis of surrounding connective tissue
    212. 212. Clinical Picture• Stye are frequently recurrent, appearing in crops.• Recurrent lesion is particularly seen in cases of debility, focal infections and diabetics.
    213. 213. 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
    214. 214. 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
    215. 215. 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
    216. 216. Hordeolum Externum
    217. 217. Complications• Cellulitis (particularly in cases of lesion at inner canthus)• Orbital thrombophebitis (leading to cavernous sinus thrombosis and its complications)
    218. 218. TreatmentI. Systemic a. Antibiotic b. Anti-inflammatory analgesic c. Supportive d Treatment of associated systemic predisposing cause
    219. 219. TreatmentII. 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)
    220. 220. Hordeolum Internum
    221. 221. 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
    222. 222. 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
    223. 223. 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
    224. 224. 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
    225. 225. 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
    226. 226. Chalazion (Eyelid Cyst) A chalazion is a tiny lump of the upper or lower eyelid caused byinflammation of a gland of the lid. It may be soft and fluid-filled or firmer. Achalazion is also referred to as a meibomian cyst, tarsal cyst, or conjunctivalgranuloma. The narrow opening through which a meibomian gland secretes its materialcan become clogged from narrowing of the opening or hardening of thesebaceous liquid near the opening. If this occurs, the gland will have a backupof the material it secretes and it will swell. Most chalazions are treated with warm compresses to the eyelid to promotehealing and circulation of blood to the inflamed area. Doctors may prescribean antibiotic drop or ointment to be used immediately after the compresses. Ifthe chalazion persists and is causing an unsightly lump, it can be removedsurgically through the inside of the lid.
    227. 227. Chalazion
    228. 228. 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
    229. 229. ChalazionSymptoms:Hard painless swelling little away from lid marginSwelling 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
    230. 230. 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
    231. 231. 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
    232. 232. 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
    233. 233. Instruments
    234. 234. 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
    235. 235. 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
    236. 236. 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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