Eyelid Disorders PDF

UNIT 5 PART 1: DISORDERS OF THE EYELIDS + ORBIT: BLEPHARITIS: inflammation of the eyelid margins - Condition can be chronic - Can be recurrent and therefore difficult to manage 1. Anterior Lid Margin Disease 2. Posterior Lid Margin Disease 3. Mixed Lid Margin Dise...

UNIT 5 PART 1: DISORDERS OF THE EYELIDS + ORBIT: BLEPHARITIS: inflammation of the eyelid margins - Condition can be chronic - Can be recurrent and therefore difficult to manage 1. Anterior Lid Margin Disease 2. Posterior Lid Margin Disease 3. Mixed Lid Margin Disease (both anterior + posterior lid margins affected) - Predisposing conditions include: § Dry eye syndrome (50% of staph belph + 25-20% of seborrheic bleph) § Acne Rosacea § Seborrhoeic dermatitis ANTERIOR BLEPHARITIS: v Assoc with bacterial colonisation: mainly staphylococcal v Assoc with seborrheic: disorder of the ciliary glands of zeiss v SYMPTOMS: v SIGNS: § Ocular discomfort Ø Aqueous tear deficiency § Soreness Ø Lid margin hyperaemia § Burning Ø Lid margin swelling § Itching Ø Lid margin crusting § Mild photophobia Ø Loss of lashes § Blurred vision Ø Inferior punctate epithelial erosion § CLs intolerance Ø Marginal keratitis Ø Mild papillary conjunctivitis If seborrheic: v Oily/greasy deposits on lid margins v Conjunctiva + Lid margin hyperaemia v Seborrhoeic dermatitis involved – oily skin + flaking from scalp/brows POSTERIOR BLEPHARITIS: Meibomian gland dysfunction v Retention of secretions of meibomian glands + Blockage of meibomian glands orifices v CAUSES: Ø Direct bacterial colonisation of eyelids – causes direct microbial invasion of tissues Ø Immune mediated damage Ø Damage caused by production of bacterial toxins, waste products + enzymes v SYMPTOMS: v SIGNS: Ø Irritation Ø Watering Ø Burning Ø Photophobia Ø Foreign body sensation Ø Erythema (reddening of the skin) Ø Worse in the morning Ø Telangiectasia (dilated blood vessels) Ø Foamy meibomian gland secretions Ø Short TBUT Ø Accompanying MGD can be marginal keratitis – small white cell precipitates are seen (do not stain) With acne rosacea: Ø Acneiform spots esp around the nose Ø Facial flushing Ø Erythema Ø Telangiectasia Ø Rhinophyma (enlargement + thickening of nasal soft tissues Eyelash Abnormalities: Ø Madarosis (loss of eyelashes) Ø Poliosis (whitening of lashes) Ø Trichiasis (misdirection of lashes) Complications of Blepharitis: v Epiphora v Dry eyes v Conjunctivitis v Chalazion formation v Trichiasis v Ectropian v Entropian v Corneal disease: punctate epithelial erosion, marginal infilatrates, recurrent erosions, marginal ulcers, pannus, keratitis, CLs intolerance TREATMENT: 1) LID HYGEINE: § clean the lids with cotton buds/flannel to mechanically remove crusts, can use baby shampoo or solutions of bicarbonate of soda § use of cleaning wipes § 2x a day initially + reduced to once daily when symptoms improve § Avoid cosmetics 2) WARM COMPRESS: § 2x daily for 10 mins 3) OCULAR LUBRICANTS: § Symptomatic relief from dry eyes, trichiasis + entropian 4) TOPICAL ANTIBIOTICS: § Chloramphenicol: used 2x daily after deposit removal if there is marked lid infection 5) ORAL TETRACYCLINES: § If not responding to lid hygiene, esp in those pxs with acne rosacea 6) TOPICAL STEROIDS: § Reserved for severe cases of bleph or with complications with marginal keratitis Internal + External Hordoleum: § Hordeolum (stye) – localised infection or inflammation of the eyelid margin § EXTERNAL HORDOLEUM: involves the eyelash follicle + assoc glands of Moll and Zeiss -presents as a tender inflamed swelling of lid margin -occasionally multiple abscesses may present across the entire eyelid margin -always points towards the skin side of the lid margin § INTERNAL HORDOLEUM: involves the meibomian glands - presents as a tender inflamed swelling within the tarsal plate -more painful than a stye -can point inwards towards the conjunctiva or outwards towards the skin Staphylococcus Aureus infection – implicated in many cases Staphylococcal blepharitis, diabetes, seborrhoea increase the risk of developing a hordoleum Chalazia may form after resolution of the internal stye or may occur spontaneously: painless bump in the lid caused by blockage of meibomian gland ducts SIGNS: v Lid erythema v Lid oedema v Epiphora v Pre-septal cellulitis v Secondary conjunctivitis MANAGEMENT: EXTERNAL HORDOLEUM: v Spontaneous resolution v Warm compress can help speed up v Removal of infected eyelash can also speed up the resolution v Topical antibiotics – chloramphenicol for recurrent lesions Consider referral to GP: v If px has a fever v If px has tender preauricular lymph nodes v Pre-septal cellulitis is present INTERNAL HORDOLEUM: v Mostly spontaneous resolution v Broad spectrum antibiotic during the acute inflammatory phase v If lump persists after acute episode then requires incision and cutterage under local anaesthetic TRICHIASIS: misdirection of eyelashes towards the globe -different to pseudotrichiasis in which the eyelashes are turned inwards secondary to entropian -PRIMARY CAUSES: v Ageing v Congenital v Scarring of the posterior lid lamella (superior or inferior) SIGNS: v Several condition predispose a px to trichiasis: v Conjunctival injections Blepharitis v Pain Epiblepharon v Foreign body sensation Past herpes zoster ophthalmicus infection v Tear film abnormalities Trachoma v Posterior lamellar scarring v Involutional entropian Ocular ciatrical pemphigoid v Punctate epitheliopathy Stevens Johnson Syndrome v Microbial keratitis Vernal Keratoconjunctivitis v Scarring Chemical burns MANAGEMENT: v Removal of the offending eyelash – epilation may need to be repeated 4-6 weeks v Tackling any underlying condition v If due to entropian, the eyelid should be taped for temporary relief of symptoms v Therapeutic contact lenses v Ocular lubricants TRACHOMA: 6 million people are blind with trachoma; endemic in Africa, ME, Asia v Caused by infection with bacterium Chlamidya Trachomatis v Incubation period of 5-12 days v Begins slowly as conjunctivitis which leads to tarsal conjunctival scarring v Scarring distorts the upper tarsal plate + leads to entropian and trichiasis v Eyelashes may turn in and rub against the cornea: Cause eye ulcers, further scarring, visual loss + blindness ENTROPIAN: inversion of the eyelid with the lid margin turned inwards toward the globe Involutional, Cicatrical, Spastic, Congenital INVOLUTIONAL - Related to ageing - Most common - Typically on the lower lid - F>M, people with involutional entropian have smaller than normal tarsal plates CICTRICAL - Scarring + contration of conjunctival tissue which pulls the lids margin inwards towards the globe - Trauma, chemical burns, OCP, infections or local response to topical medication - Involutional entropian – lids are lax so easy to evert BUT not in ciatrical SPASTIC - results from ocular irritation - infection, inflammation or traumatic processes - usually resolves spontaneously once cause has been eliminatedc CONGENITAL - very rare - results from improper development of lower lid retractor aponeurosis insertion in lower border of tarsal plate - causes instability in eyelid with consequent entropian SYMPTOMS: - redness - irritation - eye discomfort + pain: due to eyelashes rubbing against the cornea + conjunctiva SIGN: - corneal and or conjunctival epithelial disturbance by the lashes - conjunctival hyperaemia MANAGEMENT: - Surgery: remove part of the lower lid, strengthen the canthal tendons or inferior lid retractors - Ocular lubricants - Bandage contact lens to prevent eyelashes rubbing against conjunctiva - Taping the lower lid to the cheek ECTROPIAN: outward rotation of eyelid margin - Occurs in 4% of population over 50 years old - 50% have bilateral SIGN: - Conjunctival hyperaemia - Corneal exposure - Tearing - Globe apposition - Keratinisation of the palpebral conjunctiva - Visual loss - Mucous discharge INVOLUTIONAL -due to ageing -most common -disinsertion of lower lid retractors -decreased tone of lower pre-septal/pre-tarsal orbicularis muscle in combination with medial/lateral canthal tendon laxity CICATRICAL -occurs from scarring of anterior lamella of the lid by conditions such as burns, trauma, chronic dermatitis -less common cause: tumors PARALYTIC -may occur due to 7th Nerve Palsy -Bell’s palsy, cerebellopontine angle tumors, herpes zoster oticus (viral ear infection), infiltrations/tumors of parotid gland MECHANICAL -lid tumors such as neurofibromas which evert the eyelid SYMPTOMS: - Irritated eyes - Red eyes - Tearing - Constant wiping of eyes which will increase the laxity of the eyelid – remind px to not rub MANAGEMENT: - Adv px to not rub to prevent further more lid laxity - Taping the lids closed at night - Therapeutic lids - when there is risk of corneal exposure - Tape the lateral canthus to the skin above and temporally to provide temporary relief – esp with 7th nerve - SURGERY: shorten lower lid/canthal plication under local anaesthetic PRE-SEPTAL CELLULITIS: common infection of eyelid + periorbital soft tissues - Acute eyelid erythema - Eyelid oedema - Mainly affecting children: 80% medial > superior > temporal - Stem from the basal layer – deepest layer of the skin - Most common among light skinned individuals with high uv exposure - Incidence of BCC increase with age – peaking in the seventh decade of life - M>F: 3:2 - More in immunocompromised who have been on immunosuppresants for many years THREE MAIN BCC TYPES: a) NODULAR – small, translucent, poorly defined borders, firm to touch b) ULCERATIVE – classic ulcerative presentation is a nodular lesion, reddish hue due to permanent blood vessels along the surface, pearly appearance, excavated centre c) MORPHEIC: firm, pale, waxy yellow plaque with indistinct borders which may spread underneath skin surface SIGNS: - May present as a change in lid contour/direction - Redirection/loss of eyelashes - Texture of surrounding skin may be lost - Secondary infection/inflammation may be evident - Referral necessary - If left untreated: can metastasise and can threaten sight MANAGEMENT: - Surgical removal - Skin grafting may be required if large - Cryotherapy - Radiation therapy - Early detection: good prognosis SQUAMOUS CELL CARCINOMA: - Rare - More aggressive malignancy than BCC - 2nd most common eyelid malignancy: 5% of all eyelid lesions - Mostly in the elderly - Fair skinned individuals - History of chronic sun exposure - Associaton with other pre-cancerous lesions: actinic keratosis, bowen dermatosis - Immunocompromised pxs - Px exposed to oil/tar - Xeroderma pigmentosa association BENIGN EYELID LESIONS: - Cysts from any of the glands around the eyelid margin - CYSTS OF MOLL: benign clear fluid-filled cysts occurring upper/lower lid margins - CYSTS OF ZEISS: small sebaceous glands assoc with lash follicles, blockage of lash follicles leads to accumulation of yellow/white sebaceous material - Removal of these two will only be for cosmetic purposes - MOLLUSCUM CONTAGIOSUM: benign skin lesion Contagious Spreads through direct contact Lesion can be single/multiple Dome shaped waxy nodule 2-3mm in diameter Release toxic viral products can lead to follicular conjunctivitis THYROID EYE DISEASES: - Most common present in women in their 4th to 6th decade - Graves Disease (autoimmune thyrotoxicosis) - SYSTEMIC SYMPTOMS: tremor, mood change/irritability, weight loss, tachycardia) - OCULAR SYMPTOMS: proptosis, lid retraction, lid lag, irritation due to corneal dryness, lid oedema, conjunctival chemosis, serious complication of optic nerve compression (