Eyelid pathology baguio2012

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.

ABLEPHARON
• It is the absence of the eyelid
• Synonymous with the term ablephary

Cryptophthalmos

* A condition
characterized
by the
presence of an
eyelid without a
palpebral
fissure

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

SYMBLEPHARON
* This is an
adhesion between
palpebral and bulbar
conjunctiva

LID COLOBOMA
* It is the failure of
a part of the eyelid
to develop

* It is a notching
defect of its margin

2- Congenital coloboma of upper eyelid

BLEPHAROPHIMOSIS
It is a condition
characterized by a
decreased size of the
palpebral fissure both
vertical and horizontal

EPICANTHUS
* It is the most
common congenital
abnormalities and is
present among infants
It is characterized by
the presence of a
vertical skin fold in the
medial canthal region
that covers the medial
angle and caruncle
It is also known as
palpebranasal fold

BLEPHAROCHALASIS

*It is redundancy and
loss of elasticity of skin
of the eyelid
*It is the result of
aging and repeated lid
edema

EPIBLEPHARON

* It is the presence of
an extra fold of skin at
the lower eyelid

TELECANTHUS
• It is a condition characterized by a wide
separation between the medial canthal
ligaments

LID MARGIN ABNORMALITIES
• Entropion
• Ectropion

ENTROPION
* It is a condition
wherein the lid
margin is turned
inward

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

Classification
1. Congenital
2. Acquired
2.1 Involutional
2.2 Cicatricial
2.3 Spastic

CONGENITAL
• Inward rolling in of the lid margin due to
abnormal development of tarsal plate

17- Congenital entropion of lower eye lid

INVOLUTIONAL
• Inward rolling of lid margin due to old age and
instability of lid structures

CICATRICIAL
• Inward rolling of the lid margin due to scar
tissue of the palpebral conjunctiva

SPASTIC
• Inward rolling of the lid margin due to spasm
of the orbicularis oculi muscle

Entropion
• Treatment
– Lubrication
– Taping the lid
– Epilation
– Horizontal lid tightening
– Tarsal fracture procedure

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

INVOLUTIONAL
• This is due to aging, there is laxity of the lid
structures

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

Ectropion Pre and Post-operative

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

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)

DISORDERS OF THE LASHES
• Trichiasis
• Distichiasis
• Madarosis
• Poliosis
• Pediculosis Palpebraum

TRICHIASIS

* Misdirection of
lashes

DISTICHIASIS
* Presence of
supernumerary
rows of lashes

MADAROSIS
Absence of the
lashes

POLIOSIS
Graying of the
lashes

PEDICULOSIS PALPEBRAUM
• It is a condition wherein the eyebrow and
lashes are infested by lice

BLEPHAROPTOSIS

* Drooping of the
upper eyelid

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.

Ptosis

MARGIN-REFLEX INTERPALPEBRAL
DISTANCE DISTANCE

LID CREASE POSTION

BLEPHAROSPASM
• It is the persistent, repetitive involuntary
contractions of the orbicularis oculi muscle
• It is a bilateral conditions

MYOKYMIA
• It is the involuntary contraction of a few
fibers of orbicularis oculi muscle
• It is eyelid twitching

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

LAGOPHTHALMOS
• It is the inadequate closure of the lids while
sleeping

ORBITAL FAT HERNIATION
• It is the swelling or puffiness of the eyelids

HYPERTROPHY OF THE LIDS
• Immense overgrowth of the lids

LID INFLAMMATION
• Blepharitis

DEFINITION
• It is the inflammation of the lid margin

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

Types
1. Anterior
a. Squamous
b. Ulcerative
2. Posterior
a. Meibomian seborrhoea
b. Meibomianitis

ANTERIOR BLEPHARITIS
• It involves the outer parts of the eyelid
• It is commonly caused by bacteria

SEBORRHEIC/SQUAMOUS
• It is characterized by the deposition of scales
• Eyelashes fall
• Hyperemic lid margin
• Absence of ulcers

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

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

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

POSTERIOR BLEPHARITIS
• It involves the inner parts of the eyelids
• It is due to problems in the oil glands

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

 - 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.

Internal hordeolum
 an abscess in
meibomian
gland.

 -Painful.

 -May respond
to topical
antibiotics but
incision by be
necessary.

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

 -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.

Molluscum contagiosum
Signs Complications

• Painless, waxy, umbilicated nodule
• Chronic follicular conjunctivitis
• May be multiple in AIDS patientsOccasionally superficial keratitis
•

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

 - Lipid
containing
bilateral lesions.

 - Usually
associated with
hyperlipidemia .

 - Removed for
cosmetic
reasons.

Xanthelasma

• Common in elderly or those with
hypercholesterolaemia
• Yellowish, subcutaneous plaques
containing cholesterol and lipid
• Usually bilateral and located medially

Eyelids inflammation
• Blepharitis
– Anterior
– Posterior
– Staphylococcal
– Seborrhoeic
– Meibomianitis
• Treatment
– Lid hygiene
– Tears
– Antibiotics
– Warm compresses

• Allergy
– Acute allergic
blepharoconjuctivitis
– Allergic
dermatoblepharitis

• 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

• 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

Benign eyelid lesions
• Cysts
– Cyst of Moll
– Cyst of Zeiss
– Sebaceous cyst
– Hidrocystoma

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

Benign eyelid lesions
• Tumors
– Viral wart( papilloma)
– Actinic keratosis
– Seborrheic keratosis
– Keratocanthoma
– Nevi
• Junctional
• Compound
• Dermal
– Capillary hemangioma
– Xanthelasma
– Pyogenic granuloma

Malignant eyelid tumors
• Basal cell carcinoma
• Squamous cell carcinoma
• Meibomian gland carcinoma
• Melanoma
• Kaposi sarcoma
• Merkel cell carcinoma

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

Squamous cell carcinoma
• Less common than BCC
• May arise de-novo or
from pre-existing actinic
keratosis
• May metastasize

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

Signs of chalazion (meibomian cys

Painless, roundish, firm lesion May rupture through conjunctiva
within tarsal plate and cause granuloma

Histology of chalazion

Multiple, round spaces previously Epithelioid Mult
containing fat with surrounding cells giant cells
granulomatous inflammation

Treatment of chalazion

Insertion of clamp
Injection of local anaesthetic Incision and curettage

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

Viral wart (squamous cell papilloma
• Most common benign lid tumour
• Raspberry-like surface

Pedunculat Sess
ed ile

Histology of viral wart

Finger-like projections of Epidermis shows acanthosis (increas
fibrovascular connective tissue thickness) and hyperkeratosis
Rete ridges are elongated and bent in

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

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

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

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

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

Histology of capillary haemangioma

Lobules of capillaries Fine fibrous septae
Lobules under high magnification

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%

Progression of port-wine stain

Initially red and flat Subsequent darkening Skin becomes coarse,
and hypertrophy of skinnodular and friable

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

EYELID PATHOLOGY

Ocular Diseases1
Sy2010-2011

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

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

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

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

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

Treatment of Involutional Entropion
Principles of surgery
2. Reattachment of the retractor to tarsal plate
3. Shortening of horizontal width of lid
4. To induce scarring between the pre-tarsal
and pre-septal parts of orbicularis muscle

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

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

Treatment
Principles of surgery
2. Tarsal rotation (forwards)
3. Lengthening of posterior lid lamina so that
eyelashes turn forwards
Surgery
e. Wedge resection (Tarsal paring)
f. Tarsal fracture

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

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

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

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

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

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

Involutional Ectropion
Stages:
2. Early stage: in mild cases on looking up the
puncta is not apposed to bulbar conjunctiva
3. Progresses to moderate stage puncta are
not apposed to bulbar conjunctiva even in
primary gaze and entire lid margin fall away
from the globe

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

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

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)

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

Ectropion
• Treatment
– Lubrication
– Horizontal lid shortening or tightening
– Punctal inversion

Treatment options for trichiasis
• Epilation
• Electrolysis
• Cryotherapy
• Argon laser
• Surgery

Disorders of lashes
• Madarosis
– Lid margin inflammation
– Tumor
– Cryotherapy, radiotherapy
or burns
– Alopecia
– Syphilis
– Leprosy
– SLE
• Poliosis
– VKH
– Sympathetic ophthalmia

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

ptosis

 This is an abnormally low position of the upper eyelid.
PATHOGENESIS
It 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.

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.

SYMPTOMS
Patients 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).

Ptosis
• Pseudoptosis
– Orbital volume deficiency
– Exophthalmos
– Excess lid skin
– Hypotropia

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

Ptosis
• Treatment
– Ptosis crutch
– Taping of the lid
– Surgical
• Levator advancement
• Muller’s muscle resection
• Frontalis suspension

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

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.


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

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

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)

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

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 can
cause a burning or foreign body sensation, excessive tearing, itching, sensitivity to
light, red and swollen eyelids, redness of the eye, blurred vision, frothy tears, dry
eye, flaking at the base of the lashes, or crusting of the eyelashes upon awakening.

 Common causes for anterior blepharitis are bacteria (Staphylococcus) and scalp
dandruff while posterior forms are caused by problems with the oil glands in the
eyelid. Treatment for both forms involves keeping eyelids clean and free of crusts.
Warm compresses should be applied to loosen crusts, followed by a light scrubbing
with a cotton swab and a mixture of water and baby shampoo.

 Because blepharitis rarely goes away completely, most patients must maintain
an eyelid hygiene routine for life. If the blepharitis is severe, an eye-care
professional may also prescribe antibiotics or steroid eyedrops.

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

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

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

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

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.

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 .

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.

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

Hordeolum Externum
(Stye)

Hordeolum Externum (Stye)
Definition: Localized suppurative inflammation
of gland of zeis at lid margin at ciliary follicle.

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

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

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

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

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

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

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

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

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)

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

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

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

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

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

Chalazion (Eyelid Cyst)
 A chalazion is a tiny lump of the upper or lower eyelid caused by
inflammation of a gland of the lid. It may be soft and fluid-filled or firmer. A
chalazion is also referred to as a meibomian cyst, tarsal cyst, or conjunctival
granuloma.

 The narrow opening through which a meibomian gland secretes its material
can become clogged from narrowing of the opening or hardening of the
sebaceous liquid near the opening. If this occurs, the gland will have a backup
of the material it secretes and it will swell.

 Most chalazions are treated with warm compresses to the eyelid to promote
healing and circulation of blood to the inflamed area. Doctors may prescribe
an antibiotic drop or ointment to be used immediately after the compresses. If
the chalazion persists and is causing an unsightly lump, it can be removed
surgically through the inside of the lid.

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

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

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

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

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

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

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

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)

Eyelid pathology baguio2012

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