Lid diseases i


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Lid diseases i

  1. 1. Diseases of Lids
  2. 2. Anatomy of Lid
  3. 3. Hordeolum Externum(Stye)
  4. 4. Hordeolum Externum(Stye)Definition: Localized suppurative inflammation of gland of zeis at lid margin at ciliary follicle.
  5. 5. Etiology  Usually caused by staphylococcus aureus  There is infection of hair follicle of eyelash.  It may complicate Acne Vulgeris in young adults.
  6. 6. Histopathology  Purulent infection of follicle and its gland with cellulitis of surrounding connective tissue
  7. 7. Clinical Picture  Stye are frequently recurrent, appearing in crops.  Recurrent lesion is particularly seen in cases of debility, focal infections and diabetics.
  8. 8. 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
  9. 9. 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
  10. 10. 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
  11. 11. Hordeolum Externum
  12. 12. Complications Cellulitis (particularly in cases of lesion at inner canthus) Orbital thrombophebitis (leading to cavernous sinus thrombosis and its complications)
  13. 13. TreatmentI. Systemic a. Antibiotic b. Anti-inflammatory analgesic c. Supportive d Treatment of associated systemic predisposing cause
  14. 14. 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)
  15. 15. Hordeolum Internum
  16. 16. 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
  17. 17. 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
  18. 18. 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
  19. 19. Hordeolum Internum
  20. 20. Treatment ofHordeolum 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
  21. 21. Possible outcome ofTreatment  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
  22. 22. Chalazion
  23. 23. 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
  24. 24. 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
  25. 25. 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
  26. 26. Chalazion
  27. 27. Adenoma of MeibomianGland
  28. 28. 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
  29. 29. 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
  30. 30. Instruments
  31. 31. 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
  32. 32. 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
  33. 33. 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)
  34. 34. Blepharitis
  35. 35. Blepharitis Blepharitis is chronic inflammation of lid margin occurring as true inflammation or as simple hyperaemia.
  36. 36. Types1. Anterior a. Squamous b. Ulcerative2. Posterior a. Meibomian seborrhoea b. Meibomianitis
  37. 37. Causes1. Following chronic Conjunctivitis especially due to staphylococci2. Parasitic infection, Blepharitis acarica due to Demodex Folliculorum and Phthiriasis Palpabrarum due to crab louse
  38. 38. Seborrhoeic orSquamous 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
  39. 39. Squamous Blepharitis
  40. 40. Symptoms Burning, deposits / crusting along lid margins, grittiness , redness of lid margins, photophobia Symptoms are worse in the morning
  41. 41. Seborrhoeic orSquamous 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
  42. 42. Staphylococcal orUlcerative 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
  43. 43. 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
  44. 44. Ulcerative Blepharitis
  45. 45. Treatment Discharge/ crust is removed from lid margins with 1:4 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
  46. 46. Treatment Improvement of local hygiene (rubbing of eyes and touching of eyes with dirty hand should be discouraged)
  47. 47. Sequelae of UlcerativeBlepharitis  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)
  48. 48. Sequelae of UlcerativeBlepharitis  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
  49. 49. 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
  50. 50. 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
  51. 51. Complications Chalazion Tear film instability Papillary conjunctivitis and inferior corneal erosions
  52. 52. 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
  53. 53. Entropion
  54. 54. Lower lid retractors a. 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
  55. 55. 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
  56. 56. Symptoms of EntropionForeign body sensationWateringRednessPainPhotophobiaThese symptoms are due to rubbing of ocular surface by misdirected eyelashes
  57. 57. Classification 1. Involutional 2. Cicatricial 3. Spastic 4. Congenital
  58. 58. 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
  59. 59. 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
  60. 60. Involutional Entropion
  61. 61. Involutional Entropion
  62. 62. Treatment ofInvolutional Entropion Principles of surgery 1. Reattachment of the retractor to tarsal plate 2. Shortening of horizontal width of lid 3. To induce scarring between the pre- tarsal and pre-septal parts of orbicularis muscle
  63. 63. 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
  64. 64. 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
  65. 65. TreatmentPrinciples of surgery1. Tarsal rotation (forwards)2. Lengthening of posterior lid lamina so that eyelashes turn forwardsSurgerya. Wedge resection (Tarsal paring)b. Tarsal fracture
  66. 66. 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
  67. 67. 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
  68. 68. Clinical picture  Condition is found in elderly patients  Tight bandaging may cause spastic entropion  Narrowness of palpabral aperture  Seen in lower lids
  69. 69. Treatment of SpasticEntropion  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
  70. 70. Surgical treatment  Producing a ridge of fibrous tissue in the orbicularis to prevent its fibres from sliding in vertical direction
  71. 71. 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
  72. 72. Ectropion
  73. 73. 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
  74. 74. Classification I. Acquired  Involutional or senile  Cicatricial  Paralytic  Mechanical II. Congenital
  75. 75. Functions of lids 1. Protection of eye 2. Act as lacrimal pump Effect of age Slowly there is relaxation of lid structures (canthal ligament and orbiularis)
  76. 76. Involutional Ectropion Stages: 1. Early stage: in mild cases on looking up the puncta is not apposed to bulbar conjunctiva 2. Progresses to moderate stage puncta are not apposed to bulbar conjunctiva even in primary gaze and entire lid margin fall away from the globe
  77. 77. 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
  78. 78. 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
  79. 79. 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)
  80. 80. 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
  81. 81. Cicatricial Ectropion
  82. 82. Ectropion Pre andPost-operative
  83. 83. 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
  84. 84. 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