Eyelids Flashcards
Functions of EL
• act as shutters protecting the eyes from injuries and excessive light
• helps in spreading the tear film over the cornea and conj
• also help in drainage of tears
Structure
Gray line divides the eyelid into an anterior strip and a posterior strip
layers of each eyelid
1) skin : thinnest and elastic
2) subcut areolar tissue: very loose connective tissue containing no fat
3) striated muscle layer
• orbicularis oculi - also called as muscle of rion
three parts - orbital, preseptal, pretarsal
it helps in closure of eyelids and is supplied by zygomatic br of facial nerve. therefore in facial nerve palsy it presents as lagophthalmos with or without complicated exposure keratitis
• LPS - upper eyelid only
helps in raising the upper eyelid. supplied by oculomotor nerve and in its palsy presents with ptosis
4) sub muscular areolar tissue - nerves and vessels lie here.
therefore, it is the site of anesthesia
5) fibrous layer - tarsal plate and septum orbitale
in the substance of tarsal plate lies meibomian gland in parallel rows
6) layer of non striated muscle
• Mullers muscle -
UL - arises from lps
LL - arises from prolongation of inf rectus
supplied by sympathetic fibers and leads to horners synd
7) conjunctiva - three parts - marginal tarsal orbital
GLANDS:
• MG (Tarsal Glands) - arranged vertically in the substance of tarsal plate.
UL - 30-40 LL - 20-30
mod sebaceous glands which open posterior to the ant surface of lid margin
• ZG -
mod sebaceous glands open in the base of lash follicles
• Glands of Moll
mod sweat glands which do not directly open onto the lid surface but joun ZG ducts to open at the base of lash follicles
Bacterial Ulcerative Blepharitis
Etiology
aka chronic anterior Blepharitis
aka staphylococcal Blepharitis
aka ulcerative blepharitis
chronic inflammation of the anterior part of lid margin.
causative organisms - coag positive staph, strep, propionibact acnes and moraxella
no predisposing factors seen
symptoms -
chronic irritation,
itching,
mild lacrimation,
gluing of cilia,
mild photophobia
signs -
• yellow crusts at the root of the cilia which glue them together
• small ulcers which bleed easily on removal of crusts
• red thickened EL margin with dilated red blood vessels
• mild papillary conjunctivitis and conjunctival hyperemia
complications
• lash abnormalities - madarosis, trichiasis, poliosis
• tylosis - thickening of lid margins
• recurrent styes
• eversion of punctum leading to epiphora
• eczema of skin and ectropion
• tear film instability
• secondary inflammatory and mechanical changes in cornea and conjunctiva
Rx
1) lid hygiene - 2x daily
• warm compresses for 5-10 min to soften crusts
• removal of crusts with cotton bud dipped in baby shampoo or 3% sodium bicarbonate
• avoid rubbing
2) antibiotics
• eye ointment immediately after removal
• antibiotic eye drops 3-4 times a day
• systemic (erythromycin, doxy) in cases complicated with external hordeolum and abscess
3) topical steroids : fluorometholone in patients with papillary conjunctivitis, marginal keratitis
4) ocular lubricants: tear film instability and dry eye
Seborrhoeic / Squamous Blepharitis
Etiology: ass with seborrhoea of scalp (dandruff)
anterior blepharitis with some spill over posteriorly
ZG secrete abnormal excessive neutral lipids which are split by cornyebact acne into irritating free fatty acids
deposition of whitish material (soft scales)
irritation
occasional watering of eyes
falling of eyelashes
• white dandruff like scales seen on lid margin. no ulcers on removal
• lashes fall off easily and get replaced quickly
• lid margin is thickened
Rx
1) General measures and balanced diet
2) treatment of underlying seborrhoea of scalp
3) local measures - removal of scales with cotton buds dipped in lukewarm solution of 3% sodium bicarbonate or baby shampoo or ab and steroid eye ointment
4) ab may be required in mixed seborrhoeic and bact blepharitis
Posterior Meibomitis
Signs
inflammation of meibomian glands
1) chronic meibomitis or meibomitis gland dysfunction (mgd)
- middle aged people esp those with acne rosacea and / or seborrhoeic dermatitis
c/f
# Symptoms
chronic irritation
itching
mild lacrimation
burning
grittiness
worse in the morning
• White frothy (foam like) secretions seen on lid margin and canthi
• Opening of meibomian glands become prominent with thick secretions which can be expressed out by pressure giving a toothpaste apperance
• Vertical yellowish streaks shining through conjunctiva seen on eversion
• hyperemia and telangiectasia of post lid margin
• oily and foamy tear film
• secondary changes - papillary conjunctivitis and inf corneal punctate epi erosions
2) Acute Meibomitis
staph inf characterised by
painful swelling
pressure - pus bead followed by serosanguinous discharge
Rx
1) lid hygiene -
• warm compresses
• expression of accumulated secretions
2) topical ab
• eye ointment
• eye drops 3-4 times a day
3) systemic ab
- doxy 100 mg bd for 1 week and od for 6-12 weeks
4) lubricants
5) topical steroids: fluorometholone with papillary conjunctivitis
Parasitic Blepharitis
signs
Etiology - infestation with lice
• phthiriasis palpebrarum - phthirus pubis - std
• pediculosis - infestation by pediculus humanus corporis or capitis ( head louse )
• demodex blepharitis
- demodex folliculorum - ant blepharitis
- demodex brevis - post blepharitis
c/f
# symptoms
chronic irritation
itching
burning
mild lacrimation
lid margins inflammed
lice seen at the root of the lashes on slit lamp ex
nits (eggs) opalescent pearls adherent to the base of cilia
conjunctival congestion and follicles
Rx
1) mechanical removal
2) ab ointment and yellow mercuric oxide 1% to lid margins
3) delousing the pt.
External Hordeolum
acute suppurative inflammation of the lash follicle and its associated glands of zeis or moll
Etiology
predisposing factors
• age - children and young adults and pt with eye strain due to refractive errors or muscle imbalance
• habitual rubbing of eyes
• dm
• excessive intake of alcohol, carbohydrates
Causative organism : Staph
c/f
painful swelling
mild lacrimation
photophobia
signs
• stage of cellulitis - localised firm tender swelling at the lid margin with no pus point
• stage of abscess - visible pus point on the lid margin associated with the particular cilia
Rx
1) warm compresses during stage of cellulitis
2) evacuation of pus done by epilating the cilia after a pus point is formed
3) ab and eye ointment
4) surgical incision is done rarely
5) syst anti inflammatory and analgesics
6) early syst ab for quick recovery
7) recurrent styes find out the underlying cause
Chalazion
aka tarsal cyst
aka meibomian cyst
chronic non suppurative non infective lipogranulomatous inflammation of the meibomian gland
- commonest lid lump
Etio - age, habitual rubbing, dm, excessive carb and alcohol
Pathogenesis
organisms of low virulence
↓
mild grade infection
↓
proliferation of epi and infiltration of walls of ducts
↓
blockage of ducts
↓
secretions are retained (sebum)
↓
enlargement of gland and fatty secretions act like an irritant
↓
lipogranulomatous inflammation
c/f
symptoms -
painless swelling which increases in size,
mild heaviness of lids,
blurring of vision (astigmatism induced by the large chalazion)
watering ( eversion of lower punctum by large chalazion on LL )
signs
• nodule away from the lid margin - firm non tender
• UL»_space; LL
• reddish purple area on eversion of lid
• projection rarely towards skin side
compli
• resolution - rarely
• slow increase in size
• fungating mass of granulation tissue may be formed when it bursts on the conjunctival side
• calcification
• secondary infection —-> int hordeolum
• malig change to MG adenocarcinoma may be seen in elderly
Rx
1) conservation management: if it is soft small and recent, resolution may occur and can be helped by hot fomentation, topical eye ointment eye drops and anti inflammatory drugs
2) intralesional injection of triamcinolone
done when i&c may cause damage
3) i&c - definitive treatment
• surface anesthesia - xylocaine
• vertical incision is made on the conjunctival side (protect meibomian glands) and horizontal on the skin side to minimise scaring
• contents curretted out with a chalazion scoop
• carbolic acid cautery
• neutralization with methylated spirit is done to prevent recurrence
• patching for 6-12 hrs
• post op - conservation management
4) diathermy - marginal chalazion
5) oral tetracycline - prophylaxis in recurring chalazion
Internal Hordeolum
suppurative inflammation of the meibomian gland associated with the blockage of ducts
etio
predisposing - age, habitual rubbing, dm, excessive carb and alcohol
secondary infection in chalazion
c/f
intense pain
swelling
mild watering
photophobia
signs
• swelling is away from the lid margin
• point of maximum tenderness is seen on the tarsal conjunctiva and not on the root of cilia
Rx
1) warm compresses
2) drainage by vertical incision on the tarsal conjunctiva
3) ab and eye ointments
4) syst ab
5) syst anti-inflammatory and analgesics
Trichiasis
inward misdirection of cilia with normal lid margin
d/d : pseudotrichiasis seen in entropion
Etio
• ulcerative blepharitis
• ext hordeolum
• cicatrising trachoma
• burns
• mechanical injuries
• steven johnson synd
• herpes zoster ophthalmicus
c/f
• foreign body sensation
• excessive lacrimation
• irritation
• pain
• photophobia
signs
• misdirected cilia
• reflex blepharospasm and photophobia seen when cornea is abraded
• congested conjunctiva
compli
• recurrent corneal abrasions
• corneal opacity
• non healing corneal ulcer
Rx
1) epilation of the misdirected eyelashes with epilation forceps
however it is temporary and pt needs to do this every month
2) electroepilation - destroying lash follicles with the help of electric current
3) cryoepilation done with cryoprobe (-20°c)
disadv include - permanent removal of the lashes and depigmentation of skin
4) argon laser ablation
5) surgical correction
Entropion (overview)
refers to inward rolling and turning of the lid margin
types
• congenital
• involutional (senile)
• cicatricial
• spastic
• mechanical
Symptoms
foreign body sensation
irritation
lacrimation
photophobia
Signs
• inturning of lid margin
grade 1 - only the post lid border is rolled
grade 2 - inturning up to inter marginal strip
grade 3 - whole lid margin is turned including the anterior border
• signs of causative disease
• signs of complications
- corneal abrasions
- superficial corneal opacity
- corneal ulcer
- corneal vascularization
Congenital
congenital
- LL»_space; UL
Etiology
• LL cong entropion - due to improper dev
• UL cong entropion - secondary to mechanical effects of microphthalmos
Rx
- excision of a strip of skin and muscle with plastic reconstruction of lid crease (HOTZ procedure)
cicatricial Entropion
Upper lid
causes
- trachoma, chemical burns, membranous conjunctivitis, SJ synd
Sx
1) Anterior Lamellar Resection
- mild
- elliptical strip of skin and orbicularis oculi is resected 3mm away from lid margin
2) Tarsal wedge resection
- moderate
- tarsal plate is also removed along with skin and muscle
3) Tarsal Fracture / transposition of tarsoconjunctival wedge
MODIFIED KETSSEY’S OP
- mild to moderate
- involves horizontal tarsal fracture and eversion of the distal tarsus
- mattress sutures are then passed from the upper cut end of the tarsal plate and emerges on the skin
4) posterior Lamellar Graft
- severe
- scarred or contracted tarsus is replaced by plg (preserved sclera, ear cartilage, hard palate)
Senile Entropion
only the LL
Etiology
• horizontal laxity of the lid
• vertical lid instability
• over riding of preseptal orbicularis
• laxity of orbital septum
Sx
1) Transverse Suture and Everting Suture
2) Weis Operation
3) Plication of LL retractors (Jones Operation)
4) Quickert Procedure
5) Lateral Tarsal Strip (LTS)
Transverse suture and Everting suture
- temporary so indicated in very old patients
- TS: applied to full thickness of the lids to prevent overriding of preseptal muscles
- ES: passed from lower level in the inferior fornix and emerge out from the skin near lash line
2) Weis Operation
- long term cure
- incision is given involving skin orbicularis and tarsal plate below lid margin
- mattress sutures are passed from the lower cut end of the tarsus to emerge on the skin
3) Plication of LL retractors Jones Operation
- severe
- LL retractors are exposed via horizontal incision and shortened and sutures are used to create a barrier to prevent over riding of preseptal muscles
4) Quickert Procedure
- combines horizontal lid shortening with weis op
5) LTS
- lateral canthal tightening procedure where lts is excised
senile Entropion
only the LL
Etiology
• horizontal laxity of the lid
• vertical lid instability
• over riding of preseptal orbicularis
• laxity of orbital septum
Sx
1) Transverse Suture and Everting Suture
2) Weis Operation
3) Plication of LL retractors (Jones Operation)
4) Quickert Procedure
5) Lateral Tarsal Strip (LTS)
Transverse suture and Everting suture
- temporary so indicated in very old patients
- TS: applied to full thickness of the lids to prevent overriding of preseptal muscles
- ES: passed from lower level in the inferior fornix and emerge out from the skin near lash line
2) Weis Operation
- long term cure
- incision is given involving skin orbicularis and tarsal plate below lid margin
- mattress sutures are passed from the lower cut end of the tarsus to emerge on the skin
3) Plication of LL retractors Jones Operation
- severe
- LL retractors are exposed via horizontal incision and shortened and sutures are used to create a barrier to prevent over riding of preseptal muscles
4) Quickert Procedure
- combines horizontal lid shortening with weis op
5) LTS
- lateral canthal tightening procedure where lts is excised
mechanical and spastic entropion
mechanical
- lack of support by the globe eg enophthalmos, after enucleation and evisceration
Rx: underlying treatment
spastic entropion
Etiology - lower eyelid
• irritative inflammation of lid margin, conjunctiva and cornea
• ocular trauma
• tight bandaging
• degeneration
Rx
- underlying cause
- supportive - lubricants, bandage contact lens (BCL)
- adhesive tape
- botulinum toxin inj
Ectropion
outward turning of the lid margin
types
- congenital
- involutional
- cicatricial
- mechanical
- paralytic
c/f
symptoms
• epiphora
• d/t ass chr conjunctivitis - irritation discomfort mild photophobia
signs
• outward turning of lid margin
grade
- grade 1 - only the punctum is everted
- grade 2 - the lid margin is everted and palpebral conjunctiva is visible
- grade 3 - fornix is also visible
• etiological condition signs
skin scars
seventh nerve palsy
• associated complications
- dryness and exposure keratitis
- thickening of conjunctiva and corneal ulceration
- eczema and dermatitis
Congenital and Involutional Ectropion
Congenital
- rare so occurs with other ocular malformations
- both lids
Rx
- mild - no rx
- moderate and severe - cicatricial ectropion with horizontal lid tightening and full thickness skin graft to vertically lengthen anterior lamella
Involutional
- commonest
- only lower lids
Etio
- horizontal lid laxity
- medial canthal tendon laxity - punctum moves till limbus (mild) or pupil (severe)
- lateral canthal tendon laxity
- dehiscence or disinsertion of lower lid retractors
Rx
1) Medial conjunctivoplasty
-mild
- excising a spindle shaped piece of conjunctiva and sub conj tissue
2) horizontal lid shortening
- moderate
- full thickness pentagonal excision
3) bryon smith’s modified kuhnt szymanowski op
- severe
- full thickness pentagonal excision is combined with triangular excision of the skin from the area just lateral to lateral canthus
4) lateral tarsal strip
Paralytic Ectropion
- seventh nerve paralysis
causes - bells palsy, middle ear infection, parotid surgery, head injury
Rx
1) often resolves in cases of bells palsy in 6 months so temp measures should be taken
- topical lubricants
- taping temp side of eyelid
- suture tarsorrhaphy
permanent measures
• horizontal lid tightening
• palpebral sling op - fascia lata sling is passed all around lid margins
cicatricial and mechanical ectropion
cicatricial ectropion
- both lids
causes - thermal burns, chemical burns, lacerating injuries, scarring, medications
Rx
1) V-Y op
- mild
- v shaped Incision is made, skin is undermined and sutured in a y shaped pattern
2) z plasty - mild to moderate
3) excision of scar tissue and full thickness skin grafting
mechanical ectropion
- LL is pulled down (tumours)
- LL is pulled out and down (proptosis)
Rx : underlying cause
symblepharon
lids become adherent with the eyeball as a result of adhesions between palpebral and bulbar conjunctiva
Etiology
- abnormal healing
causes
• thermal burns
• chemical burns
• membranous conjunctivitis
• SJ syndrome
• injuries
c/f
- restricted ocular mobility
- diplopia
- lagophthalmos
- cosmetic disfigurement
types
~ anterior - only in ant part
~ post - in the fornices
~ total - whole of the lid
complications
- dryness
- keratinization of conjunctiva
- corneal ulceration
- thickening
Rx
Prophylaxis
- sweeping a glass rod coated with lubricant several times a day
- therapeutic soft contact lens
Curative
symblepharectomy
- mobilising the surrounding conjunctiva
- conjunctival or buccal mucosal graft
- amniotic membrane transplantation
Lagophthalmos
inability to close the eyelids voluntarily
causes
- paralysis of oo (7th nerve palsy)
- marked proptosis
- cicatricial ectropion
- surgical overcorrection of proptosis
- comatose pt
- symblepharon
c/f
- inability to close
- dryness of conj and cornea
- clinical signs of causative ds
compli
- exposure keratitis
- dessication of cornea and conj
- corneal ulcer perforation
Rx
1) measures to prevent exposure keratopathy
• artificial tear drops
• antibiotic eye ointment
• eyelid taping during sleep and in comatosed pt
• bandage contact lens BCL
• tarsorrhaphy
2) to treat the cause
Tarsorrhaphy
- adhesions are created between a part of lid margins to narrow down / close the palpebral aperture
1) temporary
indications - seventh nerve palsy to protect cornea, to assist healing of corneal ulcer, and skin grafts
median or paramedian
i) Incision - 5 mm Incision is taken for paramedian 3mm away on either sides of the mid line.
2mm deep Incision is made in the grey line and marginal epithelium is excised
ii) suturing
sutured with double armed 6-0 silk sutures passed through a rubber bolster
2) Permanent
indications - unresolving cases of established seventh nerve palsy, established cases of neuroparalytic keratitis with severe corneal anesthesia
technique
- performed at lat canthus
- excise a triangular flap of skin and orbicularis from lower lid and corresponding triangular tarsoconjunctival flap from upper lid
- overlapped
