This PPT is very beneficial for Undergraduate Medical Students

1. Dr. Atul Kumar Anand
Senior Resident
AIIMS Patna

2. chronic inflammation of the lid margin.
appearing as a simple hyperemia or as a
true inflammation.
May be is associated with the secondary
changes in the conjunctiva and cornea.
extremely common disease.

3. Seborrhoeic or Squamous blepharitis
Ulcerative blepharitis
Posterior blepharitis or Meibomitis.
Parasitic blepharitis.

4. associated with
seborrhea of
scalp(dandruff)
symptoms
deposition of whitish
materials(scales) on
the lid margin.
itching , mild
discomfort, irritation,
occasional watering
and history of falling
eye lashes

5. Signs:
White scales on lid
margins, when
scales removed
underlying surface
hyperemeic (no
ulcer)
Lost eyelashes
replaced without
distortion

6. removal of the scales with lukewarm
solution of 3%sodium bicarbonate or baby
shampoo.
application of combined antibiotic and
steroid eye ointment in the lid margin.

7. Etiology
chronic staphylococcus infection of the lid
margin usually caused by coagulase
positive strains.
eye strain due to muscle imbalance and
refractive error is common predisposing
factor. Other factors include-chronic
conjunctivitis and dacryocystitis

9.  symptoms
 irritation, itching, mild lacrimation, gluing or
matting of cilia, photophobia.
 symptoms usually worse in morning.
 Signs

 yellow crust at root of cilia.
 when crust removed a small ulcer that bleeds
easily, is seen
 anterior lid margin may show dilated blood
vessels called rosettes.

10. Crust should be removed after
softening and hot compression
Antibiotic ointment on the lid margin twice
daily.
Instillation of eye drops.
Oral antibiotics (erythromycin or
tetracycline) and oral anti-inflammatory
drugs.

11. If ulcerative form not treated well may
cause:
Chronic conjunctivitis
Trichiasis
Madarosis
Tylosis (thicken & hypertrophied lid margin)
Epiphora
Ectropion

12. Chronic meibomitis
called MGD
common in middle aged with acene
rosacea and seborrhoeic dermatitis.
foam like secretion on the eyelid margins.
opening of meibomian gland become
prominent with thick secretions.
acute meibomitis
 mostly due to staphylococcal infection

15. Expression of the gland by repeated
vertical lid massage
Rubbing of antibiotic –steroid ointment at
the lid margin
Antibiotic eye drops(azithro)
Systemic antibiotic (tetracyclines 4-6
weeks or erythro)

16. Blepharitis acarica-
due to Demodex
follicularum
Phthiriasis
palpebram- due to
crab louse.
presence of nits at
the lid margins and
the root of the
eyelashes.

18. Removal of nits with forceps.
Rubbing of antibiotic ointment on lid
margins.

19. an acute supparative inflammation of gland
of Zeis or Moll.
etiology
eye strain.
habitual rubbing of eyes.
chronic blepharitis, diabetic mellitus
excessive intake of carbohydrate and
alcohol
Causative organism – staph. aureus.

20. symptoms
acute pain
swelling of lids
mild watering
photophobia

21. signs
stage of cellulitis-
localized , hard, red
, tender swelling on
the lid margin
Stage of abscess
formation-
visible pus point in
lid margin in
relation to base of
affected cilia.
Usually one stye
but may be multiple

22. Hot fomentation 2-3 times a day useful in
cellulitis stage.
Pus point formed – epilation of the
involved cilia.
Large abscess-surgical incision
Antibiotic eye drops and ointment to
control infection.
Anti-inflammatory and analgesics to
reduce edema and pain.

23. In the case of recurrent stye find and treat
the associated predisposing factors as
diabetes, refractive error or prevent
habitual eye rubbing

24. Chronic
granulomatous
inflammation of the
meibomian gland.
Also called tarsal or
meibomian cyst(not
a true cyst)

25. Mild grade of infection of the gland by
organisms of low virulence.
Proliferation of the epithelium and
infiltration of the walls of the ducts that
block the meibomian duct.
Retention of the secretion sebum in gland
cause enlargement of gland.

26. Painless swelling in
eyelid , feeling of
mild heaviness. No
signs or symptoms
of inflammation
Hard, non tender
swelling present
slightly away from
the lid margin.
On reverting the lid a
red purple or gray
area is seen on the
conjunctival side.

27. Usually points on
conjunctival side, but
rarely main bulk of
swelling project on
skin side.
Occasionally may
present on
intermarginal
strip(KA marginal
chalazion)
Single or multiple
chalazia on one or
more eyelids.

28. Rarely complete
spontaneous
resolution.
Slowly increase in size
and become very
large.
Blurring of vision due
to induced
astigmatism.
Evertion of punctum or
ectropion leading to
epiphora.

29. Secondary infection
may led to formation of
hordeolum
internum(infected
chalazion)
Calcification may
occur.
Malignant change into
meibomian gland
carcinoma may be
occasionally seen in
elderly people.
D/D- meibomian cell
carcimoma

30. Conservative : hot fomentation, antibiotic
E/D
Intralesional injection-triamcinolone
acetonide in small chalazion.
Incision & curettage – vertical incision
on conjuctival side (or horizontal incision
on skin side to have an invisible scar)

31. Acute Suppurative inflammation of the
meibomian gland.
Etiology
Primary staphylococcal infection of the
meibomian gland .
Secondary infection of chalazion.
(infected chalazion)

32. Similar to stye (external hordeolum)
Pain is more intense as gland embedded in
dense fibrous tissue.
Treatmemt : same as stye except if
pus is formed incision exactly as chalazion

33. Swelling away from the lid margin.
Pus usually point on the tarsal conjunctiva
, seen as yellowish area on everting the lid
Not on root of cilia.

35. Viral infection of lids.
Commonly affecting children.
Caused by large pox virus.
Lesion are multiple, pale, waxy,
umblicated swelling scattered over the
skin near the lid margin.

37. Incision of skin lesion.
Interior cauterized with tincture of iodine or
carbolic acid.

38. Trichiasis
Distichiasis
Madarosis
Poliosis

39.  Inward misdirection of cilia rubbing the eyeball with
normal position of lid margin
 Etiology: cicatrising trachoma, ulcerative
blepharitis, stye, burn, injury, operative scar
 Symptoms: FB sensation, irritation, lacrimation,
pain, & photophobia
 Signs: O/E misdirected cilia rubbing cornea
conjunctival congestion,
 Complication: recurrent corneal abrasion,
superficial corneal opacity, corneal vascularization
non healing corneal ulcer

40. • Posterior misdirection of normal lashes
• Most frequently affects lower lid
Signs Complications
• Inferior punctate epitheliopathy
• Corneal ulceration and pannus

41. Epilation - but recurrences within few
weeks
Electrolysis - but frequently require repeated
treatments, 2mA current for 10 seconds
Diathermy -30mA current for 10 seconds
Cryotherapy – cryoprobe(-20C) for 20 seconds
Laser ablation- for few scattered lashes
Surgery - for localized crop resistant to other
methods

42. signs
• Second row of lashes arising
from meibomian gland orifices
• Congenital
• Occasionally dominantly inherited
Treatment
• Division into anterior and posterior
lamellae
• Cryotherapy to posterior lamella
• Reapposition of lamellae

43. Adhesion of lid to eyeball (due to adhesion
between palpebral & bulbar conjunctiva)
Etiology : any cause which produce raw
surface on opposed area of palpebral & bulbar
conjunctiva will lead to adhesion after healing,
e.g. chemical or thermal burn, S J syndrome,
conjunctival ulceration, membranous
conjunctivitis, ocular pemphigus

44. Restricted ocular motility (resulting diplopia),
inability to close lids(lagophthalmos) & cosmetic
disfigurement
 Fibrous adhesion between palpebral & bulbar
conjunctiva may be present in anterior part(anterior
symblepheron) or fornix(posterior symblepheron) or
whole lid(total symblepheron)
 Complication: dryness, exposure keratitis

45. Prophylaxsis: during raw surface adhesion
prevented by frequent sweeping of glass rod
coated with lubricant & large sized bandage
contact lens(bcl)
Curative: release of adhesion
(symblepharectomy), raw area covered with
mobilizing adjacent conjunctiva, buccal mucous
graft, amniotic membrane graft, BCL

46.  Adhesion between margins of upper & lower lids.
 Congenital or due to healing of burn ulcer or
wound of lid margin
 Partial or complete
 May be a/w symblepheron
 treated by separating the lids by excision of
adhesion & kept apart during healing process

47. Inability to voluntarily close the eyelids
Etiology: 7th nerve palsy(orbicularis oculi)
symblepheron, severe ectropion, proptosis,
cicatricial cotraction of lids, comatosed patient,
physiological in some person during sleep
 Causes conjunctival & corneal xerosis, exposure
keratitis
 Treatment: frequent use of artificial tears, gel during
sleep, treatment of cause, in severe cases
Tarsorraphy(adhesion created between part of lid
margins, aim to narrow down or almost close the
palpebral aperture)

48. Involuntary, sustained & forceful closure of
eyelids. May be of two types
Essential blepharospasm: idiopathic, occurs
spontaneously. Between 45-65 yrs of age, less
apparent when attention is diverted elsewhere.
 Treatment: botulinium toxin injected s/c over
orbicularis relieves spasm,(up to 10-12weeks) in
severe case facial denervation.

49. Reflex blepherospasm: precipitated by sensory
stimulus.
 Commonly caused by bright light, eyelid or
corneal(keratitis, corneal FB) irritation.
 Treatment : removal of sensory stimulus i.e. treat the
cause.

50. Abnormal drooping(low position) of upper
lid is ptosis
Normally upper lid covers 2mm or 1/6th of
superior cornea

51. Congenital :
Simple
Complicated – a/w ocular motor
anomalies, Blepharophimosis syndrome,
Marcus Gunn ptosis
Acquired :
Neurogenic: Third nerve palsy, Horner
syndrome, Marcus Gunn jaw-winking ptosis

52. Myogenic: Myasthenia gravis, Myotonic
dystrophy
 Aponeurotic:
Mechanical:

53. Lack of lid support Contralateral lid retraction
Ipsilateral hypotropia Brow ptosis - excessive
eyebrow skin
Dermatochalasis - excessive
eyelid skin

54. • Distance between upper lid
margin and light reflex (MRD)
• Mild ptosis (2 mm of droop)
• Moderate ptosis (3 mm)
• Severe ptosis (4 mm or more)

55. • Reflects levator function
• Normal (15 mm or more)
• Good (8 mm or more)
• Fair (5-7 mm)
• Poor (4 mm or less)

56.  Distance between upper
and lower lid margins
 Normal upper lid margin
rests about 2 mm below
upper limbus.
• Normal lower lid margin
rests 1 mm above lower
limbus or just touches the
limbus
•In male 7-10mm
•In female 8-12mm
• Amount of unilateral ptosis is determined by comparison

57. Upper lid crease Pretarsal show
• Distance between lid margin and lid
crease in down-gaze
• Normal - females 10 mm; males 8 mm
• Absence in congenital ptosis indicates
poor levator function
• High crease suggests an aponeurotic
defect
• Distance between lash line and skin fold
in primary position of gaze

58. Upward & outward rotation of globe on attempted lid closure
Good
 Poor - risk of postoperative
corneal exposure

59. Severe unilateral ptosis and
defective adduction Normal abduction
Defective elevation Defective depression

60. • Caused by oculosympathetic
palsy
• Usually unilateral mild
ptosis and miosis
• Normal pupillary reactions
• Slight elevation of lower lid
• Iris hypochromia if
congenital or longstanding
• Anhydrosis if lesion is below
superior cervical ganglion

61. • Accounts for about 5% of all cases of congenital ptosis
• Retraction or ‘wink’ of ptotic lid in conjunction with
stimulation of ipsilateral pterygoid muscles.
Branch of mandibular neve is misdirected to levetor muscle
Contralateral movement of jaw
Opening of mouth

62. Diplopia
Ptosis
 Insidious, bilateral but
asymmetrical
• Worse with fatigue and in up gaze
•
anti-acetylcholine receptor antibody
Ptosis & failure of convergence
 Intermittent and usually
vertical
 Treatment : steroid,
immunosuppresive
plasmapheresis

64. Facial weakness and
ptosis
Release of grip difficult
 Muscle wasting
• Involvement of tongue and pharyngeal
• muscles
• Ophthalmoplegia - uncommon
 Hypogonadism
• Frontal baldness in males
• Intellectual deterioration
• Presenile stellate cataracts

65. Simple congenital ptosis
• Occasionally associated with weakness of superior rectus
 Unilateral or bilateral ptosis of
varying severity
Frequent absence of upper lid crease
 In downgaze ptotic eyelid is
slightly higher
Usually poor levator function

66. • Rare congenital disorder
• Dominant inheritance
• Short horizontal palpebral aperture
• Moderate to severe symmetrical ptosis
• Telecanthus (lateral displacement
of medial canthus)
• Epicanthus inversus (lower lid
fold larger than upper)
• Lateral inferior ectropion
• Poorly developed nasal bridge
and hypoplasia of superior orbital
rims

67. Aponeurotic ptosis
• Causes - involutional, postoperative and blepharochalasis
• Weakness of levator aponeurosis
Mild
Severe
High upper lid crease Good levator function
Absent upper lid crease Deep sulcus

68. Mechanical ptosis
Causes
Dermatochalasis Large tumours
Severe lid oedema Anterior orbital lesions

69. 1.Fasanella-Servat operation (conjunctiva –
Muller resection) : for mild ptosis as Horner’s
syndrome
2.Levator resection:
conjunctival approach(Blaskowics operation)
skin approach(Everbusch’s operation)
3.Frontalis sling operation(Brow suspension)

70. Fasanella-Servat procedure
Indicated for mild ptosis with good levator function
Excision of upper border of tarsus, lower border of Muller muscle
and overlying conjunctiva

71. Levator resection
Indicated for any ptosis provided levator function is at least 5 mm
Shortening of levator complex Amount determined by levator
function and severity of ptosis

72. Frontalis brow suspension
Main indications
• Severe ptosis with poor levator function ( 4 mm or less )
• Marcus Gunn jaw-winking syndrome
Attachment of tarsus to frontalis muscle with sling

74. 1. Ectropion outward turning of lid margin
• Involutional
• Cicatricial
• Paralytic
• Mechanical
• Congenital
2. Entropion
• Involutional or senile
• Cicatricial
• Spastic
• Congenital

75. • Affects lower lid of elderly patients
• May cause chronic conjunctival inflammation
and thickening

76. Horizontal lid shortening
Kuhnt-Szymanowski procedure

77.  Unilateral ectropion due to
 traumatic scarring
 Bilateral ectropion due to
severe
 dermatitis
• Contracture of skin pulling lid away from globe
• Unilateral or bilateral, depending on cause

78.  Exposure keratopathy
caused by
 lagophthalmos
Caused by facial nerve palsy which,
if severe, may give rise to the following
Epiphora caused by combination
of: Failure of lacrimal pump
 Increase in tear production

79.  Treatment
• Removal of the
cause, if possible
• Correction of significant
horizontal lid laxity
Mechanical lid
eversion by tumour

80.  Affects lower lid because
upper lid
 has wider tarsus and is
more stable
 If longstanding may result in
corneal
 ulceration

81.  Horizontal lid laxity
• Canthal tendon laxity
 Overriding of preseptal over
pretarsal orbicularis during
lid closure
• Weakness of lower lid retractors

82. • Inturning of entire lower eyelid and lashes
•When skin is pulled down lid also pulls away from globe
• Does not resolve spontaneously
• Absence of lower lid crease
• Very rare - not to be confused with epiblepharon

83. Clue for distinguishing malignant from
benign
show fixation to deeper structures
It is palpable.
enlargement of the regional lymph
nodes show metastasis spread
Upper eye lid and lateral canthus-
preaurical lymph nodes.lower lid and
medial canthus –submandibular lymph
nodes.

84. General inspection show-
Ulceration
Superficial Vascularisation.
Evidence of progressive growth in serial
examination
On slit lamp examination-localized
destruction of lashes and meibomian
gland orifice.

85. Common in elderly people.
Most common human malignancy.
90% in head and neck of which 10%in eye
lid.
Among eye lid tumors constitute 90%of
cases.

86. Lower eye lid - medial canthus- upper eye
lid- lateral canthus.

87. Slow growing , locally invasive but not
metastasing.
Tumor in medial canthus is complicated
since it is prone to involve the orbit and
sinuses.

88. Nodular BCC
Shiny , translucent,firm
raised , indurated nodule
with small dilated vessel
on the surface.
When hyperkeratosis
takes place it is
mistaken for actinic
keratosis.
When contain pigment
mistaken for malignant
melanoma

89. Called rodent ulcer
Raised rolled
boarder with
ulcerated center.
Dilated vessel may
occur in the lateral
margin of the tumor

90. Originate in
epidermis , invade
to dermis and
spread beneath
normal epithelium.
Flat indurated
plaque.

91. Less common
More aggressive than BCC with metastasis
to regional lymph nodes.
5-10% of eye lid malignancies.
Common in elderly people with fair
complexion and much exposure to sun.
Characterized by hard nodule, a roughened
scaly patch that develops into crusting
erosions

93. Rare, mainly affecting elderly.
Mainly arise from meibomian gland but nay
also arise from gland of zeis, the
sebaceous gland in the crauncle and eye
brow.
More common in upper lid in contrast to
BCC and SCC.
Can be misdiagnosed as chalazion.
Metastasis take place.

95. Rare
Lethal
Types-
Superficial
spreading
Nodular
Arising from lentigo
maligna.

97. Surgical excision.
Standard frozen section
Radiotherapy
Chemotherapy