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diseases of lids

basics- blepharitis, hordeolums,chalazion,entropion, ectropion

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diseases of lids

  1. 1. Diseases of LidsDiseases of Lids -Dr Akshay Nayak-Dr Akshay Nayak
  2. 2. Anatomy of LidAnatomy of Lid
  3. 3. LID INFLAMMATIONLID INFLAMMATION  BlepharitisBlepharitis
  4. 4. DEFINITIONDEFINITION  It is the inflammation of the lid marginIt is the inflammation of the lid margin
  5. 5. blepharitisblepharitis  Inflammation of the lid marginInflammation of the lid margin (crusting/redness of lids)(crusting/redness of lids)  Causes ‘gritty’/foreign body sensation, oftenCauses ‘gritty’/foreign body sensation, often concomitant with other ocular surface diseaseconcomitant with other ocular surface disease  Associated with recurrent hordeolum (styes) orAssociated with recurrent hordeolum (styes) or chalaziachalazia
  6. 6. TypesTypes 1.1. AnteriorAnterior a. Squamousa. Squamous b. Ulcerativeb. Ulcerative 2. Posterior2. Posterior a. Meibomian seborrhoeaa. Meibomian seborrhoea b. Meibomianitisb. Meibomianitis
  7. 7. ANTERIORANTERIOR BLEPHARITISBLEPHARITIS  It involves the outer parts of the eyelidIt involves the outer parts of the eyelid  It is commonly caused by bacteriaIt is commonly caused by bacteria
  8. 8. SEBORRHEIC/SQUAMOSEBORRHEIC/SQUAMO USUS  It is characterized by the deposition ofIt is characterized by the deposition of scalesscales  Eyelashes fallEyelashes fall  Hyperemic lid marginHyperemic lid margin  Absence of ulcersAbsence of ulcers
  9. 9. Squamous BlepharitisSquamous Blepharitis
  10. 10. SymptomsSymptoms  Burning, deposits / crusting along lidBurning, deposits / crusting along lid margins, grittiness , redness of lidmargins, grittiness , redness of lid margins, photophobiamargins, photophobia  Symptoms are worse in the morningSymptoms are worse in the morning
  11. 11. ULCERATIVEULCERATIVE  It is characterized by the presence ofIt is characterized by the presence of infective materials such as yellow crustsinfective materials such as yellow crusts or scalesor scales  There is matting of the lashesThere is matting of the lashes  Presence of ulcersPresence of ulcers
  12. 12. SymptomsSymptoms  Redness of lid margins, burning, itching,Redness of lid margins, burning, itching, watering and photophobiawatering and photophobia  Signs:Signs:  Small ulcers at lid margins on removal ofSmall ulcers at lid margins on removal of discharge, this features differentiate it fromdischarge, this features differentiate it from conjunctivitisconjunctivitis
  13. 13. Ulcerative BlepharitisUlcerative Blepharitis
  14. 14. 14- Ulcerative blepharitis14- Ulcerative blepharitis
  15. 15. TreatmentTreatment  Discharge/ crust is removed from lidDischarge/ crust is removed from lid margins with 1:4 dilution baby shampoomargins with 1:4 dilution baby shampoo or luke warm 3% soda bicarbonate lotion.or luke warm 3% soda bicarbonate lotion. The loose discharge is then cleanedThe loose discharge is then cleaned cottoncotton  Diseased eyelashes are epilatedDiseased eyelashes are epilated  Appropriate antibiotic drops are usedAppropriate antibiotic drops are used  After control of infection, daily cleaning ofAfter control of infection, daily cleaning of lid margins with blend lotionlid margins with blend lotion
  16. 16. TreatmentTreatment  Improvement of local hygiene (rubbing ofImprovement of local hygiene (rubbing of eyes and touching of eyes with dirty handeyes and touching of eyes with dirty hand should be discouraged)should be discouraged)
  17. 17. Sequelae of UlcerativeSequelae of Ulcerative BlepharitisBlepharitis  Chronic course and associated chronicChronic course and associated chronic conjunctivitisconjunctivitis  Madarosis (Scanty eyelashes) due toMadarosis (Scanty eyelashes) due to falling of eyelashesfalling of eyelashes  Trichiasis (misdirected eyelashes) due toTrichiasis (misdirected eyelashes) due to contraction of scar tissuecontraction of scar tissue  Cicatrization of lid margins causingCicatrization of lid margins causing thickening and hypertrophy of tissue andthickening and hypertrophy of tissue and drooping of lids (Tylosis)drooping of lids (Tylosis)
  18. 18. Posterior BlepharitisPosterior Blepharitis  Posterior blepharitisPosterior blepharitis Is caused by Meibomian gland dysfunction andIs caused by Meibomian gland dysfunction and alterations in secretions.alterations in secretions. Loss of tear film phospholipids that act asLoss of tear film phospholipids that act as surfactants results in increased tearsurfactants results in increased tear evaporation and osmolarityevaporation and osmolarity Post. Blep is more chronic and persistent thanPost. Blep is more chronic and persistent than anterioranterior
  19. 19. ComplicationsComplications  ChalazionChalazion  Tear film instabilityTear film instability  Papillary conjunctivitis and inferiorPapillary conjunctivitis and inferior corneal erosionscorneal erosions
  20. 20. TreatmentTreatment  Warm compressesWarm compresses  Systemic - Doxycycline 100 mgm twice xSystemic - Doxycycline 100 mgm twice x 1 week then once daily for 6 -12 weeks1 week then once daily for 6 -12 weeks or Tetracycline 250 mgm 4 times x 1or Tetracycline 250 mgm 4 times x 1 week then twice for 6 -12 weeksweek then twice for 6 -12 weeks  Associated tear film abnormality isAssociated tear film abnormality is treated with artificial tear dropstreated with artificial tear drops
  21. 21. LID LUMPSLID LUMPS
  22. 22. Hordeolum ExternumHordeolum Externum (Stye)(Stye) Definition: Localized suppurativeDefinition: Localized suppurative inflammation of gland of zeis at lidinflammation of gland of zeis at lid margin at ciliary follicle.margin at ciliary follicle.
  23. 23. EtiologyEtiology  Usually caused by staphylococcusUsually caused by staphylococcus aureusaureus  There is infection of hair follicle ofThere is infection of hair follicle of eyelash.eyelash.  It may complicate Acne Vulgeris in youngIt may complicate Acne Vulgeris in young adults.adults.
  24. 24. HistopathologyHistopathology  Purulent infection of follicle and its glandPurulent infection of follicle and its gland with cellulitis of surrounding connectivewith cellulitis of surrounding connective tissuetissue
  25. 25. Clinical PictureClinical Picture  Stye are frequently recurrent, appearingStye are frequently recurrent, appearing in crops.in crops.  Recurrent lesion is particularly seen inRecurrent lesion is particularly seen in cases of debility, focal infections andcases of debility, focal infections and diabetics.diabetics.
  26. 26. SymptomsSymptoms  Severe pain which is sharp throbbing ,Severe pain which is sharp throbbing , feeling of fullness or heaviness andfeeling of fullness or heaviness and feeling of heatfeeling of heat  Tenderness (increase in pain on touchingTenderness (increase in pain on touching swelling/ affected area)swelling/ affected area)  Pain subsides on escape of pusPain subsides on escape of pus
  27. 27. SignsSigns  Starts usually asStarts usually as edema of the lidsedema of the lids with chemosiswith chemosis  Yellow pus pointYellow pus point appears on the lidappears on the lid margin around themargin around the root of a lash at theroot of a lash at the most prominent partmost prominent part of the swellingof the swelling
  28. 28. Signs … contdSigns … contd  Skin gives way and pusSkin gives way and pus drains with sloughingdrains with sloughing  Swelling subsides andSwelling subsides and cicatrix formcicatrix form  Spread of infection toSpread of infection to neighbouring lashesneighbouring lashes opposite lid margin andopposite lid margin and conjunctival sacconjunctival sac
  29. 29. treatmenttreatment  Hot compressesHot compresses  Evacuation of pus by epilationEvacuation of pus by epilation  Antibiotic eye drops and eye ointmentAntibiotic eye drops and eye ointment  Systemic anti inflammatorySystemic anti inflammatory  Systemic antibioticsSystemic antibiotics  -Most cases are self limiting .-Most cases are self limiting .
  30. 30. Hordeolum InternumHordeolum Internum
  31. 31. Hordeolum InternumHordeolum Internum  Hordeolum Internum is a suppurativeHordeolum Internum is a suppurative inflammation of meibomian gland.inflammation of meibomian gland.  It may be due to secondary infection ofIt may be due to secondary infection of meibomian gland or it may start to beginmeibomian gland or it may start to begin with as suppurative infection ofwith as suppurative infection of meibomian gland.meibomian gland.  This condition is more symptomatic thanThis condition is more symptomatic than stye, the gland is larger and is located instye, the gland is larger and is located in fibrous tarsal platefibrous tarsal plate
  32. 32. SymptomsSymptoms  Pain, which may be severe throbbingPain, which may be severe throbbing  Swelling , which is away from lid marginSwelling , which is away from lid margin  Pus pointing either at the lid margin or onPus pointing either at the lid margin or on the palpabral conjunctivathe palpabral conjunctiva
  33. 33. SignsSigns  Swelling of affected lid, due to associatedSwelling of affected lid, due to associated cellulitiscellulitis  Swelling is more marked about 4-5 mmSwelling is more marked about 4-5 mm from lid marginfrom lid margin  TendernessTenderness  Palpabral conjunctiva over the swelling isPalpabral conjunctiva over the swelling is congested a pus point may be visiblecongested a pus point may be visible  Pus point may be visible at the lid marginPus point may be visible at the lid margin
  34. 34. Hordeolum InternumHordeolum Internum
  35. 35. Treatment ofTreatment of Hordeolum InternumHordeolum Internum  Medical treatment is similar to treatment ofMedical treatment is similar to treatment of Hordeoulm externum i.e.Hordeoulm externum i.e. SystemicSystemic a. Antibiotica. Antibiotic b. Anti-inflammatory analgesicb. Anti-inflammatory analgesic LocalLocal a. Hot fomentationa. Hot fomentation b. Local broad spectrum antibiotic drop andb. Local broad spectrum antibiotic drop and ointmentointment
  36. 36. Possible outcome ofPossible outcome of TreatmentTreatment  It may resolve with evacuation of pus at the lidIt may resolve with evacuation of pus at the lid marginmargin  It may burst on palpebral conjunctiva, leadingIt may burst on palpebral conjunctiva, leading to infective bacterial conjunctivitisto infective bacterial conjunctivitis  It turns into chronic granuloma i.e. ChalazionIt turns into chronic granuloma i.e. Chalazion
  37. 37. ChalazionChalazion
  38. 38. ChalazionChalazion  Chalazion is also called tarsal cyst or meibomian cystChalazion is also called tarsal cyst or meibomian cyst  Chalazion is chronic inflammatory inflammatoryChalazion is chronic inflammatory inflammatory granuloma of meibomian glandgranuloma of meibomian gland  Seen in adults more often as multiple lesions occurringSeen in adults more often as multiple lesions occurring in cropsin crops  The opening of meibomian gland is occluded leading toThe opening of meibomian gland is occluded leading to retention which acts as cause of chronic irritationretention which acts as cause of chronic irritation
  39. 39. ChalazionChalazion  Signs:Signs: Painless swelling 4-5 mm away from lid margin.Painless swelling 4-5 mm away from lid margin. Swelling is hardSwelling is hard On conjunctival side it appears red or purple. In longOn conjunctival side it appears red or purple. In long standing lesions it appears grey.standing lesions it appears grey. Chalazion may become smaller over the period ofChalazion may become smaller over the period of time ,but complete resolution may occur only rarelytime ,but complete resolution may occur only rarely
  40. 40. ChalazionChalazion  -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
  41. 41. ChalazionChalazion Symptoms:Symptoms: Hard painless swelling little away from lidHard painless swelling little away from lid marginmargin Swelling increases gradually in size withoutSwelling increases gradually in size without painpain Small chalazia are better felt than seenSmall chalazia are better felt than seen Multiple lesions and large chalazion mayMultiple lesions and large chalazion may be associated with inability to open eyebe associated with inability to open eye fullyfully
  42. 42. Signs of chalazion (meibomian cyst) Painless, roundish, firm lesion within tarsal plate May rupture through conjunctiva and cause granuloma
  43. 43. Treatment of ChalazionTreatment of Chalazion  Intralesional injection of TriamcinoloneIntralesional injection of Triamcinolone Acetonide may help in resolution ofAcetonide may help in resolution of chalazionchalazion  Incision & curette of chalazion isIncision & curette of chalazion is indicated in cases when it causesindicated in cases when it causes disfigurement and mechanical ptosis duedisfigurement and mechanical ptosis due to its weightto its weight
  44. 44. Treatment of chalazion Injection of local anaesthetic Insertion of clamp Incision and curettage
  45. 45. EntropionEntropion
  46. 46. Functions of lidsFunctions of lids 1.1. Protection of eyeProtection of eye 2.2. Act as lacrimal pumpAct as lacrimal pump
  47. 47. EntropionEntropion Entropion is in-rolling of eye lid margin.Entropion is in-rolling of eye lid margin. Normal position of sharp posterior border ofNormal position of sharp posterior border of inter-marginal strip is essential for interigrity ofinter-marginal strip is essential for interigrity of the tear film and for maintenance of healthythe tear film and for maintenance of healthy ocular surfaceocular surface Entropion is caused by disparity of length andEntropion is caused by disparity of length and tone of anterior skin muscle layer and posteriortone of anterior skin muscle layer and posterior tarso-conjunctival layer of the eyelidtarso-conjunctival layer of the eyelid
  48. 48. Symptoms of EntropionSymptoms of Entropion  Foreign body sensationForeign body sensation  WateringWatering  RednessRedness  PainPain  PhotophobiaPhotophobia These symptoms are due to rubbing ofThese symptoms are due to rubbing of ocular surface by misdirected eyelashesocular surface by misdirected eyelashes
  49. 49. ClassificationClassification 1.1. InvolutionalInvolutional 2.2. CicatricialCicatricial 3.3. SpasticSpastic 4.4. CongenitalCongenital
  50. 50. Involutional EntropionInvolutional Entropion This condition is due to old age, due toThis condition is due to old age, due to instability of lid structuresinstability of lid structures There occurs:There occurs: a.a. WeaknessWeakness of the posterior retractor ofof the posterior retractor of the lidthe lid b.b. LaxityLaxity of medial and lateral canthalof medial and lateral canthal ligamentsligaments c.c. AtrophyAtrophy of orbital pad of fat leading toof orbital pad of fat leading to enophthalmosenophthalmos
  51. 51. Involutional EntropionInvolutional Entropion
  52. 52. Surgical ProceduresSurgical Procedures 1.1. Catgut suture application throughCatgut suture application through 2.2. Modified Bick operationModified Bick operation: Horizontal: Horizontal shortening of lower lid with fixation toshortening of lower lid with fixation to lateral canthal ligament and periosteumlateral canthal ligament and periosteum 3.3. Tucking of inferior lid retractorsTucking of inferior lid retractors
  53. 53. Cicatricial EntropionCicatricial Entropion  Caused byCaused by contraction of scar tissuecontraction of scar tissue ofof the palpebral conjunctivathe palpebral conjunctiva  In this case there is relative shortening ofIn this case there is relative shortening of inner layer i.e. tarso-conjunctivainner layer i.e. tarso-conjunctiva  Caused by scarring of palpebralCaused by scarring of palpebral conjunctiva byconjunctiva by trachoma, trauma,trachoma, trauma, chemical injuries (burns), pemphigus andchemical injuries (burns), pemphigus and Stevens-Johnson syndromeStevens-Johnson syndrome
  54. 54. TreatmentTreatment Principles of surgeryPrinciples of surgery 1.1. Tarsal rotationTarsal rotation (forwards)(forwards) 2.2. Lengthening of posterior lid lamina soLengthening of posterior lid lamina so that eyelashes turn forwardsthat eyelashes turn forwards SurgerySurgery a.a. Wedge resection (Tarsal paring)Wedge resection (Tarsal paring) b.b. Tarsal fractureTarsal fracture
  55. 55. Spastic EntropionSpastic Entropion  This condition is due toThis condition is due to spasm of orbicularisspasm of orbicularis inin presence of degeneration of the palpabralpresence of degeneration of the palpabral connective tissue separating orbicularis fibres.connective tissue separating orbicularis fibres.  The spasm is induced byThe spasm is induced by local irritationlocal irritation inin inflammatory and traumatic conditions.inflammatory and traumatic conditions.
  56. 56. Clinical pictureClinical picture  Condition is found inCondition is found in elderlyelderly patientspatients  Tight bandaging may cause spasticTight bandaging may cause spastic entropionentropion  Narrowness of palpebral apertureNarrowness of palpebral aperture  Seen inSeen in lower lidslower lids
  57. 57. Treatment of SpasticTreatment of Spastic EntropionEntropion  Removal of causeRemoval of cause i.e removal of cause ofi.e removal of cause of irritation, tight bandagingirritation, tight bandaging  Treatment of surface disorder byTreatment of surface disorder by artificialartificial tears and control of conjunctival infectiontears and control of conjunctival infection and lid inflammation with antibioticand lid inflammation with antibiotic  Fixing of lower lid after everting it withFixing of lower lid after everting it with adhesive tapeadhesive tape  Injection ofInjection of Botulinum toxinBotulinum toxin into pre-tarsalinto pre-tarsal orbicularis to weaken itorbicularis to weaken it
  58. 58. Surgical treatmentSurgical treatment  Producing a ridge of fibrous tissue in theProducing a ridge of fibrous tissue in the orbicularis to prevent its fibres fromorbicularis to prevent its fibres from sliding in vertical directionsliding in vertical direction
  59. 59. Congenital EntropionCongenital Entropion  This condition is due toThis condition is due to dysgenesis ofdysgenesis of lower lid retractor or due to abnormallower lid retractor or due to abnormal development of tarsal plate.development of tarsal plate.
  60. 60. EctropionEctropion
  61. 61. EctropionEctropion  Ectropion is out-rolling of lid marginEctropion is out-rolling of lid margin  Symptoms are:Symptoms are: Watering (due to eversion of punta)Watering (due to eversion of punta) Foreign body sensationForeign body sensation PainPain RednessRedness Photophobia (Due to involvement of cornea)Photophobia (Due to involvement of cornea) Symptoms are due to eversion of punta, andSymptoms are due to eversion of punta, and exposure of ocular surface, chronicexposure of ocular surface, chronic conjunctivitis caused by exposure and drying ofconjunctivitis caused by exposure and drying of surfacesurface
  62. 62. ClassificationClassification I. AcquiredI. Acquired  Involutional or senileInvolutional or senile  CicatricialCicatricial  ParalyticParalytic  MechanicalMechanical II. CongenitalII. Congenital
  63. 63. Involutional EctropionInvolutional Ectropion Effect of ageEffect of age Slowly there is relaxation of lid structures (canthalSlowly there is relaxation of lid structures (canthal ligament and orbiularis)ligament and orbiularis) Stages:Stages: 1.1. Early stage: inEarly stage: in mild cases on looking up the puncta ismild cases on looking up the puncta is not apposed to bulbar conjunctivanot apposed to bulbar conjunctiva 2.2. Progresses to moderate stage puncta are notProgresses to moderate stage puncta are not apposed to bulbar conjunctiva even in primary gazeapposed to bulbar conjunctiva even in primary gaze andand entire lid margin fall away from the globeentire lid margin fall away from the globe
  64. 64. Involutional EctropionInvolutional Ectropion 3. In3. In severe case lower lids are rolled outsevere case lower lids are rolled out andand palpabral conjunctiva (including tarso-palpabral conjunctiva (including tarso- conjunctiva and fornix are exposed)conjunctiva and fornix are exposed) Tears areTears are no longer drainedno longer drained into nose andinto nose and overflow onto the cheekoverflow onto the cheek
  65. 65. TreatmentTreatment  Surgical treatment:Surgical treatment: in mild to moderate cases,in mild to moderate cases, excisionexcision of 7 – 8of 7 – 8 mm long x 4 mm high conjunctival exicion 5mm long x 4 mm high conjunctival exicion 5 mm below lid margin (puncta), this puts backmm below lid margin (puncta), this puts back puncta in its normal positionpuncta in its normal position In more marked cases 5 mm full thicknessIn more marked cases 5 mm full thickness shortening/ resection of lid 5 mm from puncta,shortening/ resection of lid 5 mm from puncta, by giving inverted house shaped incisionby giving inverted house shaped incision ((modified Kuhnt Szymanowskimodified Kuhnt Szymanowski operation atoperation at lateral canthus orlateral canthus or modified Lazy Tmodified Lazy T operation atoperation at medial canthus)medial canthus)
  66. 66. Cicatricial EctropionCicatricial Ectropion  Is out-rolling of lid marging due toIs out-rolling of lid marging due to contraction of scar tissue on skin side.contraction of scar tissue on skin side. Commonly results from lid trauma, burns,Commonly results from lid trauma, burns, chemical injuries and chronicchemical injuries and chronic inflammations of lid skin. Due toinflammations of lid skin. Due to contraction of scar the lid skin shortenscontraction of scar the lid skin shortens pulling the eyelid away from the eyeballpulling the eyelid away from the eyeball
  67. 67. Cicatricial EctropionCicatricial Ectropion
  68. 68. Ectropion Pre andEctropion Pre and Post-operativePost-operative
  69. 69. TreatmentTreatment  Principle of surgery:Principle of surgery: release and relaxation of the scar tissuerelease and relaxation of the scar tissue and restoration (elongation) of skin byand restoration (elongation) of skin by blepharoplastyblepharoplasty Localized small scar may be treated byLocalized small scar may be treated by V-Y operationV-Y operation Large scar requiresLarge scar requires excision of scarexcision of scar tissuetissue and application of matching (wholeand application of matching (whole or spilt) skin graft.or spilt) skin graft.
  70. 70. Paralytic EctropionParalytic Ectropion  This condition is due toThis condition is due to paralysis of the facial nerveparalysis of the facial nerve due to Bell palsy, surgery on parotid gland and traumadue to Bell palsy, surgery on parotid gland and trauma  Characterized by presence of other signs of facialCharacterized by presence of other signs of facial palsypalsy  Initially treated by conservative treatment byInitially treated by conservative treatment by taping oftaping of lids, lubricating eye dropslids, lubricating eye drops, till there is recovery, till there is recovery  Lateral tarsorrhaphyLateral tarsorrhaphy, by suturing freshened upper and, by suturing freshened upper and lower lids at outer canthuslower lids at outer canthus  Lagophthalmos due to weakness of superior orbicularisLagophthalmos due to weakness of superior orbicularis may be treated bymay be treated by tapingtaping
  71. 71.  Thank youThank you

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