Brief on lid pathologies

1. Lid Pathologies

2. Skin comprises of -
• Epidermis -
Comprised of Keratinocytes, melanocytes, langerhans
cells , merkel cells
4 layers of epidermis -
Keratin layer / stratum corneum
Granular layer / str granulosum
Prickle cell layer / str spinosum
Basal cell layer / str basale

3. Stratum Corneum - flat cells devoid of nuclei
Str granulosum -
contains Keratohyaline granules
They cross link the keratin filaments - Barrier.
function
Stratum spinosum - prickle cell layer -
Polygonal cells, united by spiny appearing
desmosomes
Stratum basale -
columnar cell layer contain melanin derived from
adjacent melanocytes
Dermis -
connective tissue, blood vessels & lymphatics,
nerve fibers
Lies on Orbicularis Oculi muscle

5. Deep zone contains the adnexa
 Sebaceous glands
 Meibomian glands
 Glands of Zeiss
 Glands of Moll
 Eccrine Sweat glands
 Pilosebaceous units

6. • Blepharitis
• Chalazion
• Stye ( external hordeolum)
• Ectropion , Entropion
• Xanthelasma
• Seborrhoeic keratosis
• Acquired melanocytic nevus
• Freckle
• Congenital Melanocytic nevus

7. Benign adnexal tumors
Syringoma
Pilomatricoma
Miscellaneous benign -
Capillary hemangioma
Port wine stain
Pyogenic granuloma (Sturge weber syndrome)
Neurofibroma
Malignant tumors -
Basal cell Ca
( Nodular, NoduloUlcerative, Sclerosing)
Keratoacanthoma
Sebaceous gland carcinoma
Lentigo Maligna
Merkel cell ca
Kaposi sarcoma

8. • ✰ Subacute or Chronic inflammation of Lid
margins
types -
# Bacterial / chronic anterior blepharitis/
staphylococcal/ ulcerative ( staph > strepto,
P.acnes, moraxella)
# Seborrhoeic or Squamous ( d/t seborrhoea of
scalp/ dandruff)
# Mixed Staphylococcal with Seborrhoeic
# Posterior blepharitis / Meibomitis ( opening of
meibomian glands become prominent with thick secretions
on lid press)
# Parasitic blepharitis ( infestation of lashes by Lice)
( Demodex folliculorum )

9. C/f -
symptoms:
chronic irritation
itching
lacrimation
mild photophobia
gluing of cilia
signs:
yellow crusts at cilia root
inflammed and thickened lid
margins
conj hyperemia
small ulcers which bleed
easily

10. Management of Blepharitis

11. Chalazion

12. C/f —
symptoms —
Painless eyelid swelling
Progressive increase
Watering / epiphora
Heaviness in Lids
Blurrin of Vn ( due to
mass effect induced
astigmatism )
Signs -
Firm/hard non tender
nodule
Nodule away from lid
margin generally
Generally points towards
palpebral conjunctiva

13. Possible complications —
Progressive increase
secondary infection
Calcification
Metaplasia occasionally into Meibomian
gland adenoCa
Management —
Conservative mx ( for small/soft/recent )
: topical antibiotic, Hot
fomentation, Oral Nsaids
Intralesional Triamcinolone — when mass
located near puncta ( I&C may cause
damage here )
Incision and Curettage

14. Chalazion I&C :
Under topical Xylocaine and mass infiltration
with 2% xylocaine
Vertical incision on Conjunctival side
Contents removed with Chalazion Scoop
Eye patching with topical antibiotics - 6-12 hrs

15. Ref - Kanski

16. Stye / External Hordeolum
Acute suppurative
inflamm
Involves Lash follicle
and associated glands
of Zeis and Moll

17. Causative factors —
Habitual rubbing
Diabetes
children, young adults
pt with eye strain, refractive errors
causative organism — m/c Staphylococcus aureus
C/f —
acute pain , redness
lid swelling
watering
photophobia
Stages : stage of cellulitis —> stage of abscess
formation

18. Rx —
Hot compress
antibiotics topical
Systemic Nsaids, analgesics
Epilation of involved cilia and Pus evacuation
Systemic antibiotics for infection control

19. Entropion

20. C/f —
Arise due to rubbing of
cilia against cornea &
Conjunctiva
Irritation
Grittiness/ FB sensation
Watering
Photophobia
Grades —
GD 1 : only posterior lid
border folled
2: inturning upto
interMarginal strip
Whole lid margin with
ant border inturned

21. Management —
Congenital :
Hotz procedure for senile entropion (excision of a
strip of skin & muscle f/b plastic reconstruction)
May resolve with time
Cicatricial :
Ant lamellar resection -
Tarsal wedge resection
Transposition of TarsoConjunctival wedge (modified
kessey’s operation) - tarsal fracture with eversion
Posterior lamellar graft
Senile : Weis operation ( full thickness horizontal lid
incision with everting sutures
Quickert procedure ( weis + horizontal tightening)

22. Jones (plication of lower lid retractors)
Transverse suturing and everting suture
weis -
Quickert -
Jones -

23. Tarsal wedge
resection
Anterior lamellar
resection.

24. ECTROPION
Outrolling of lid margin
Congenital (Down’s , epicanthus inversus, ankyloblepharon)
Involutional (horizontal laxity, medial lid laxity) - Lid fails to
snap back
Cicatricial (scarring in burns)
Paralytic (bell’s palsy)
Mechanical (tumors, proptosis)
c/f -
epiphora
irritation
discomfort, photophobia

25. Grades —
gd1 : only puncta everted
gd 2 : lid margin everted, palpebrap conj visible
gd 3: fornix visible
Management -
medial conjunctivoplasty
Horizontal lid shortening
Byron smith modified kuhnt szymanowski (penragonal full thickness
excision from lateral 1/3 eyelid, triangular skin excision lateral to lateral
canthus)
Paralytic ectropion oftens resolved - 6months (bell’s especially)
Topical rx - artificial tears ,
Lid taping , Suture tarsorrhaphy

26. Cicatricial ectropion —
VY operation
Z plasty ( Elschnig operation )
Scar tissue excision + full thickness grafting
VY plasty -
Z plasty -

27. Ptosis
Abnormal dropping of Upper eyelid
Normally covers 2 mm/ upper 1/6th cornea
1) Congenital
2) Acquired
Congenital seen in :
Simple congenital
Associated Sup rectus weakness
Blepharophimosis syndrome
Congenital Synkinetic / Markus gunn jaw winking
phenomenon

28. Acquired ptosis —
Neurogenic ( CN 3 palsy, ophthalmoplegic migraine ,
Horner’s, multiple sclerosis)
Myogenic (LPS muscle disorder, myoneural junction
diseases, myotonic dystrophy, thyrotoxicosis,
Lambert eaton myasthenic syndrome )
Aponeurotic
Mechanical (multiple chalazia, lid tumors, scarring, lid
edema )

30. Margin reflex distance (MRD) -
distance between upper lid margins and corneal light reflex
Normal MRD : 4-5 mm
Levator function assessment -
asked to look down ->and thumb of one hand is placed
firmly against the eyebrow of the palient (to block the action of
frontalis muscle) .
Then the patient is asked to look up and the amount of
upper lid excursion is measured wilh a ruler
Normal - 15 mm
Good - 8mm or more
Fair. - 5-7 mm
Poor. - <4 mm

31. Other tests —
Tensilon test (i.v Edrophonium 1ml(10mg) in myasthenia)
Phenylephrine test
Neurological Investigations
Photographic record
Management :
Fasanella servat operation (Tarso conjunctival
mullerectomy ) - for Horner’s
Frontalis sling ( Brow suspension) - for severe ptosis with
no Levator function - for neurogenic ptosis
(conservative Mx for 6 months in neurogenic ptosis
later Sx options)
Levator resection
( 1- conjunctival approach/ Blaskowich’s operation

32. Frontalis sling -

33. references :
google images
ncbi.nhm
kanski’s ophthalmology
Parson’s
A.K. Khurana’s textbook