Eyelid Anatomy Lecture 2 PDF

 Upper and lower lids are 2 mobile muco-cutaneous folds covering of the orbital content.  Edges of eye lid meets when the eye is closed. ANTERIOR  Rounded with 2 to 3 rows of lashes (upper 100, lower 50). BORDER POSTERIOR  Right angled wit...

 Upper and lower lids are 2 mobile muco-cutaneous folds covering of the orbital content.  Edges of eye lid meets when the eye is closed. ANTERIOR  Rounded with 2 to 3 rows of lashes (upper 100, lower 50). BORDER POSTERIOR  Right angled with orifices of Meibomian glands just anterior to it. BORDER  Modified sebaceous (Zeis) & sweat (Moll’s) glands:  Evacuate their secretion in the lash follicles.  The lid fits on the globe: FOR UPPER LID  2 mm below upper limbus. FOR LOWER LID  Nearly just on ower limbus.  Lacrimal portion of lid margin:  The minute part medial to the puncti & is round allover with absent lashes. ①  Thin, loose, elastic & distensible.  Contains: ① Sebaceous & sweat glands. ② ② Hair follicles. ③ Pigment cells. ① Palpebral part of orbicularis oculi (7th Nerve) ② Insertion of levator palpebrae superiosis (3rd Nerve) ③ ③ Muller’s (superior tarsal) muscle {invoulantary smooth Ms with $ innervation}  Loose CT containing main vessels, nerves & lymphatics of lids.  Traversed by the levator fibers ④  It is the targeted sight of injection in local infiltration anesthesia & marked as the grey line on the lid margin.  Condensed fibrous tissue which forms skeleton of lids  Traversed by meibomian glands (30 lower & 40 upper).  It is connected to: ⑤ ① Medially by orbital margins ② Laterally by (medial & lateral palpebral ligaments) ③ Superiorly & inferiorly through orbital septum. ⑥  ① ②  Adhesion between both lid margins.  Full thickness defect of lid & lid margin.  It may lead to exposure keratitis ⇨ need surgical repair. ③ ④  Skin fold at the side of the nose covering  Increased distance between both medial medial canthus & caruncle canthi ⇨ pseudo-convergent squint ⇨ Pseudo-convergent squint  ⑤ ⑥ ① Narrowing of the normal width of the palpebral fissure (25-30 mm) to (18-20 mm) ② Ptosis WILL BE DISCUSSED IN NEXT PAGE. ③ Epicanthus inversus ④ Telecanthus ⑤ LL ectropion ① Congenital ectropion. ② Congenital entropion. ③ Distichiasis: Extra row of lashes in the site of miebomian gland ducts. ① CONGENITAL ECTROPION ② CONGENITAL ENTROPION ③ DISTICHIASIS   Dropping of upper lid below its normal level which normally covers the upper 1/6 of cornea (2 mm).  Usually: Bilateral & Hereditary.  Types: MYOGENIC  Poor development of levator muscle. NEUROGENIC  Poor development of nerve supply.  Rare form in which the ptosed lid is re-elevated from the dropped position with jaw movement (mastication).  Due to faulty innervation between the oculomotor supplying the levator & the mandibular division of trigeminal supplying the pterygoid muscle. ① OPENING OF MOUTH ② CONTRALATERAL JAW MOVEMENT   Oculomotor (3rd) nerve palsy ⇨ levator paralysis.  sympathetic paralysis (Horner’ s syndrome) ⇨ muller’s muscle paralysis ① Ptosis. NEUROGENIC ② Miosis. (PARALYTIC) ③ Anhydrosis. ④ Enophthalmous. ⑤ Face flushing. ① Myasthenia gravis MYOGENIC ② Myotonic dystrophy rare. ③ Chronic progressive external ophthalmoplegia (cpeo). MECHANICAL  Heaviness (chalazion or tumor). SENILE  Aponeurotic defects. (INVOLUTIONAL)  Ipsilateral lack of lid support : microphthalmous, empty socket, or PSEUDO PTOSIS enophthalmous.  Contralateral lid retraction.  Usually in young females with young emotional troubles suspected if HYSTERICAL there is ⇨ trembling of ptotic lid & absence of forehead frowning. TRAUMATIC  Injury of levator or its nerve supply oculomotor  Primary weakness of levator muscle  Aponeurotic defects (attenuation, dehiscence, or disinsertion) from the tarsus. SENILE (INVOLUTIONAL)  ① Mild ptosis not covering the pupil ⇨ No symptoms. ② Lid covers the pupil ⇨ Visual disturbance. ③ Cosmetic disfigurement is the most common complaint. ①  Ask for → age of onset, history of trauma, & any family history. ②  Pseudo - Ptosis ③  To exclude → visual deprivation amblyopia  On attempt to elevate the ptotic lid → elevation of eyebrow & wrinkling of skin of forehead due to → hyper action of frontalis muscle.  Frontalis muscle: primarily elevates the forehead & eyebrows & accessory lid elevator providing 3-5 mm of elevation.  Frontalis elevation is measured by marking the brow position in relaxed primary position → then marking the position after ④ asking the patient to raise his brows as much as he can→ the difference is calculated.  Skin fold in the skin of the upper lid which is formed by ⑤ attachment of the levator to the undersurface of the skin → absent in congenital ptosis ⑥  If corneal anesthesia is present → surgical correction is CI   The head is lifted backwards→ allowing the eye on looking ⑦ downwards to visualize→ object in front of the patient while bypassing the ptotic lid barrier  Upward & outward movement of the globe with sleep. ⑧  If absent→ under correction of ptosis is aimed to partially protect the cornea. ① Epicanthus ⑨ ② Blepharophymosis. ③ Marcus Gunn. ① Marginal reflex distance (MRD):  The distance between the upper lid margin & the corneal reflex. It normally measures 4 mm. ② Vertical fissure height:  The distance between both lid margins passing through the centre of the pupil.  Normally measures 10 mm  According to measurement degree of ptosis is determined: ⑩ MILD PTOSIS MODERATE PTOSIS SEVERE PTOSIS 2 mm 3 mm 4 mm  ③ Assessment of levator function: a. patient is asked to look downwards b. pressure is applied to both eyebrows to neutralize the lifting action of the frontalis muscle c. patient is asked to look upward after ruler is placed to measure the excursion ˂4 mm Poor levator function 4-6 mm Fair levator function 7-10 mm Good levator function ˃ 11 mm Excellent  INDICATIONS: ① Congenital ptosis. ② Acquired ptosis (except Myasthenic ptosis, hysterical & pseudo-ptosis).  CONTRAINDICATIONS: ① 3rd N. palsy before treatment of squint to avoid → diplopia. ② Corneal anesthesia & absent Bell’s phenomena as ptosis here acts as corneal protector.   TIMING OF SURGERY FOR CONGENITAL PTOSIS:  Mild to moderate cases PRE-SCHOOL AGE  If pupil is uncovered (5 YEARS)  Absent torticolis YOUNGER AGE  Pupil is blocked → will result in amblyopia (6 MONTHS)  Presence of ocular torticolis  SURGICAL CHOICES: FRONTALIS (BROW) FASANELLA-SERVAT LEVATOR RESSECTION SUSPENSION {HESS OR SLING OPERATION OPERATIONS} Mild ptosis Moderate or severe ptosis + Severe ptosis INDICATION + good levator action good levator action + poor levator action  Muller’s ms + part of  Resection of a pre-  Upper lid is suspended upper tarsus are determined part of from its tarsus to the transconjunctivaly levator and advancement occipitofrontalis ms excised. & suturing of remaining Using: muscle to strengthen it & ① Exogenous material elevate the lid. (silk or prolene) It is either through: ② Indogenous maerial ① Transcutaneous approach (fascia lata). TECHNIQUE → (Everbuch’ s) ② Transconjunctival approach → (Blascovics) DEFINITION  Mal-direction of 4 lashes or less to rub against cornea or conjunctiva.  Permanent destruction of these lash follicles by: ① Diathermy (thermal coagulation) ② Electrolysis (electrical denaturation) Follicle Proteins ③ Cryo-coagulation (freezing & destruction)  After application of any of the above → lash must be removed without TREATMENT resistance (proving that the follicle was successfully destroyed).  Simple epilation:  Not a permanent treatment as → lash regrows after 4-6 weeks.  Just a temporary measure to relieve corneal or conjunctival irritation  Before intra-ocular surgery as lash may act as a source of infection.   Mal-direction of More than 4 lashes to rub against cornea or conjunctiva. DEFINITION  Condition is either alone or with entropion. ① Entropion due to cicatrization in stage IV of trachoma → commonest cause. ETIOLOGY ② Spastic entropion in old persons or due to tight bandaging. ③ Blepharitis specially the ulcerative form. ④ Scars of the lid following burn, injury or operation. ① Foreign body sensation ③ Lacrimation SYMPTOMS ② Photophobia ④ Blepharospasm CONJUNCTIVAL CORNEAL ① Chronic conjunctivitis ① Recurrent corneal ulceration COMPLICATIONS ② Conjunctival ulcer ending in corneal opacities ③ Epithelial plaque ② Superficial vascularization ③ Epithelial plaque ① Trichiasis alone:  Upper lid → Van Millingen’s operation → a buccal mucous membrane graft is placed in grey line to displace the lashes away from cornea  Lower lid → Webster operation → a buccal mucus membrane graft is placed in an incision in the sulcus subtarsalis to straighten the tarsus & lengthen the palpebral conjunctiva TREATMENT ② Trichiasis with entropion:  lower lid → Webster operation also.  upper lid → Snellen’s operation also indicated in cicatricial entropion  Wedge resection of the tarsus & suturing it after removal of the Wedege to → straighten the tarsus deformity  This leads to → eversion of the lid margin thus displace the lashes Away from the cornea.   Rare.  One or more extra rows of eyelashes are present at → the opening of DEFINITION meibomian glands.  Directed backwards to rub against cornea → epithelial erosion. DEFINITION  Whitening of the lashes DEFINITION  Permanent absence of eye lashes due to destruction of the lash follicles. TYPES  Partial or total. ① Inflammation: Stye, ulcerative blepharitis, & trachoma. LOCAL ② Traumatic: Burns. ③ Iatrogenic: during lash Electrolysis or diathermy. CAUSES ① Alopecia. GENERAL ② Myxedema. ③ Syphilis and leprosy.  Treatment of the cause TREATMENT  Artificial lashes.   Rolling of the lid margin & the tarsal plate inwards towards the eyeball. ① Severe irritation & foreign body sensation ② Recurrent corneal ulceration ③ Corneal opacities with visual deficit as an end result. 1 Due to scarring in the palpebral conjunctiva POST-INFLAMMATORY POST-TRAUMATIC CAUSES  Trachoma.  Injuries and chemical burns.  Membranous conjunctivitis.  Complication to previous lid operation. ① Cicatricial entropion of UL ⇨ Snellen’s operation. TREATMENT ② Cicatricial entropion of LL ⇨ Webster's Operation. 2 Due to weak support of the lid in presence of blepharospasm as in: ① Enophthalmos: Especially senile enophthalmos due to absorption of CAUSES orbital fat. ② Prolonged eye bandage.  Treat the cause: TREATMENT ① Treat blepharospasm. ② Remove eye bandage.   Correction of spastic entropion: TEMPORARY METHODS ① Painting the skin of the lid with collodion. ② T -shaped adhesive plaster. ③ Alcohol injection: Subcutaneous injection of 1 cc of 70 % alcohol along the edge of the lid. ④ Lateral canthotomy: Division of the lateral canthus with scissors. PERMANENT METHODS ① Lateral canthoplasty: Lateral canthotomy and covering the raw area with bulbar conjunctiva. ② Skin and muscle operation: An elliptical piece of skin and spastic orbicularis muscle 3mm to lid margin (Riolan) is removed. 3 SITE  Usually occurs in the lower lid. ① Loss of the subcutaneous elastic tissue of the lid. ② A redundant loose skin of the lid. CAUSES ③ Senile loss of orbital fat.  Any slight increase in the tone of the orbicularis muscle or long continued bandaging of the eyes may produce entropion in an old patient. TEMPORARY METHODS as spastic entropion. PERMANENT METHODS TREATMENT Wheeler's operation → a band of orbicularis muscle from the anterior surface of the tarsal plate is → dissected→ overlapped→ reattached to the tarso -orbital fascia just below the tarsus 4  Due to lack of support to the eye lid (without blepharospasm): ① Empty socket: After enucleation. ② Shrunken (atrophic) globe. ③ Enophthalmos. 5  Usually affecting the whole lower eyelid. 6  In plump (fatty) infants due to increased subcutaneous fat in the cheeks and lids pushing LL margin inwards (it disappears after some time).  Rolling outwards of the eyelid from the globe.  It usually affects lower lid as it stands against gravity. SYMPTOMS  Constant epiphora due to eversion of the lacrimal punctum.  Depending on the degree of ectropion: ① Mild: Exposure of lower punctum. SIGNS ② Moderate: Exposure of tarsal conjunctiva. ③ Severe: Exposure of lower fornix. ① Epiphora, eczema & cicatricial ectropion (vicious circle). ② Conjunctival: Exposure conjunctivitis, hypertrophy of the palpebral conjunctiva & conjunctival xerosis. COMPLICATIONS ③ Corneal: Exposure keratitis, corneal xerosis & ulceration. Both conjuntival & corneal complications are results of lagophthalmous. 1  Spasm of the orbicularis muscle when the lids are well supported and the CAUSES overlying skin is firm e.g. in cases of proptosis. a) Removal of the cause of blepharospam is necessary. TREATMENT b) As a temporary measure well fitting bandage after manual correction of the ectropion. 2  Affects both upper & lower lids by scarring of the skin due to burns, CAUSES wounds or malignant ulcers ① V -Y operation: done in mild cases.  A ‘V’-shaped incision is made in the skin of the lower lid which includes the scar.  The skin is excised and the wound is sutured in Y -shaped pattern thus correcting the ectropion. TREATMENT ② Excision of scar tissue and application of skin graft:  Useful in cases of extensive scarring.  Split skin graft or full-thickness skin grafts are taken from the upper lid, behind the ear, inner side of upper arm or thigh. 3 CAUSES  Increased weight of lower lid by e.g. multiple chalazia. TREATMENT  Treat the cause e.g. curette or excision. 4 SITE  Occurs only in the lower lid.  Redundancy of the tissues and laxity of the fibers of orbicularis CAUSES palpebrum muscle and palpebral ligaments.  Conjunctivitis is treated if present.  The choice of treatment then depends on the degree of ectropion: ① Electrocautery Punctures:  The principle is to induce cicaterization at the site of electrocautery this will pull on the out-turned lid inwards. ② Suture repair( Snellen’s - Stellwag’s – Quickert):  The idea of this procedure is → formation of cicatricial bands along the suture tracks which will pull on conjunctiva and correct ectropion. TREATMENT ① If ectropion is most marked in→ middle portion of lower lid.  This may be corrected by horizontal shortening procedure of lower lid  A wedge resection of tarsus and skin 5 mm away from the punctum and resuturing it. ② If ectropion is severe and marked over → lateral half of lower lid.  The Dimmer's modification of Kuhnt Szymanowski’s operation is the surgical procedure of choice.  Principle:  Removal of the redundant skin.  Decrease the weight of lid by removal of a triangle of the tarsus. 5  Paralysis of the orbicularis oculi muscle due to a lower motor neuron CAUSES lesion of the facial nerve, e.g. Bell's palsy.  Trauma to orbicularis oculi muscle. ① Protection of the cornea:  By drops during the day and ointment during sleep. ② Medical treatment:  To help nerve regeneration by steroids, and facial massage (neuro- medical issue) ③ Lateral tarsorraphy: TREATMENT  Either temporary or permanent to narrow the palpebral fissure. 6  Rare.  DEFINITION  Incomplete closure of palpebral fissure when the lids are closed. ① Congenital deformity of the lids e.g lid coloboma. ② Ectropion. ETIOLOGY ③ Proptosis. ④ Absence of reflex blinking in extremely ill patients. ⑤ Paralysis of orbicularis oculi muscle e.g facial palsy. ① Epiphora. ② Conjunctiva: Chronic conjunctivitis and conjunctival xerosis. ③ Cornea: Exposure keratopathy CLINICAL PICTURE  Corneal exposure during sleep leads to → dryness of its lower third.  The upper part of cornea is protected by the upper lid as the eyes roll up during sleep (Bell's phenomenon). ① Treatment of → the cause e.g. facial palsy. ② Protection of the cornea during the day by → glasses or contact lenses. TREATMENT ③ Protection of the cornea during sleep by → applying ointment at night. ④ Tarsorrhaphy: It may be lateral or median; temporary or permanent.  DEFINITION  Adhesions between bulbar and palpebral conjunctiva.  Apposition of 2 raw surfaces facing each other which ends in adhesion ① Burns and caustics. ETIOLOGY ② Post inflammatory e.g. trachoma and diphtheria. ③ Post operative e.g. pterygium operation. ④ Ocular cicatricial pemphigoid. ① Diplopia due to limitation of ocular motility. CLINICAL PICTURE ② Disfugerment (bad cosmetic appearance). (3DS) ③ Diminution of vision in case of→ corneal involvement. ① Anterior: Between lid margin and cornea. ② Posterior: At the→ fornix (trachoma). ③ Total: Between the lid and globe (burns). TYPES ① Prophylaxis: either by applying ointment or contact shell use. ② Cutting the adhesions by→ passing a glass rod through the fornices several times a day TREATMENT ③ Mucous membrane graft: To cover→ the two opposite surfaces. ④ Keratoplasty: If we end having a dense visually significant corneal opacity.   Chronic inflammation of the lid margin.  One of the most common external eye diseases in clinical practice. ① Squamous blepharitis. ② Ulcerative blepharitis. ③ Parasitic blepharitis. ④ Angular blepharoconjunctivitis. A. Predisposing Factors that cause hyperemia of the lid margin: ① External irritants: such as dust, wind, heat and smoke. ② Eye strain: refractive errors, over-work of fine nature particularly in poor illumination conditions and insomnia. ③ Metabolic disturbances: e.g. DM, debility & avitaminosis. ④ Allergic conditions affecting the lid margin B. Exciting Factors that act on the predisposed lid-margin → blepharitis: SQUAMOUS BLEPHARITIS  Seborrhoea, dandruff of the scalp and rosacea  Usually by bacteria (staph aureus) and can be as part of a chronic ULCERATIVE BLEPHARITIS blepharitis which flares up suddenly and acutely from time to time.  Less commonly: viruses such as Herpes Simplex or Varicella Zoster  Demodex blepharitis:  Demodex brevix and demodex follicularum which lives in hair and eyelash follicles and in the meibomian glands.  Risk factors: increasing age, rosacea & DM PARASITIC BLEPHARITIS  Phthiriasis palpebrarum:  Infestation of the eyelashes with Phthirus pubis (pubic lice).  It is classed as STD so patients should undergo diagnostic tests for other STDs.  Morax Axenfeld diplobacilli, infection usually starts at lateral ANGULAR angle due to relative tear deficiency with absence of lysozymes. BLEPHAROCONJUNCTIVITIS  The organism produces a strong→ proteolytic enzyme (which is inhibited by the lysozyme of tears). ① Chronic conjunctivitis. ② Madarosis due to destruction of the hair follicles. ③ Trichiasis due to healing of the ulcers by fibrosis. ④ Tylosis: Thickening and hypertrophy of the lid margin. ⑤ Epiphora: due to destruction of the sharp posterior lid margin initiating (vicious circle) of: epiphora → eczema → ectropion → epiphora. ⑥ Ectropion. ⑦ Punctate keratitis → affecting lower third of the cornea. ⑧ Marginal corneal ulcer.  ANGULAR BLEPHARO- SQUAMOUS BLEPHARITIS ULCERATIVE BLEPHARITIS PARASITIC BLEPHARITIS CONJUNCTIVITIS ETIOLOGY PREDISPOSING As before FACTORS EXCITING Seborrhoea staphylococcus aureus Phthiriasis pubis Morax Axenfeld diplobacilli FACTORS C/P SYMPTOMS ① Itching. ② Burning. ③ Lacrimation. ④ Photophobia. ① Zeis glands secrete excessive sebum ① Yellow crusts at the base of ① Demodex blepharitis ① Red fissured and edematous lid which is splitted by corynebacterium lashes gluing them together.  Redness of the lid margins cylindrical scaling margin localized to the angle. acne into irritating free fatty acids → ② Minute ulcers of the lid around the lashes. ② Macerated skin. small, white scales (dried scales) margin which bleed easily ② Phthiriasis palpebrarum: ③ Conjunctivitis. between lashes. when crusts are removed  The lashes are covered with nits ④ Discharge. ② Usually associated with seborrhoeic ③ Differential Diagnosis:  Lid margin is hyperaemic with reddish- dermatitis (dandruff of the scalp).  Dried discharge in brown crusts. SIGNS ③ Removal of scales reveals a conjunctivitis which leave  Diagnosis of disease is difficult due to hyperemic lid margin without an intact lid margin when parasite's small size and translucent nits, ulceration. removed. which makes them barely visible & ocular ④ The eyelashes fall out readily but are symptoms may evolve for months before replaced without distortion. the diagnosis is established.  An associated localized or generalized itching of hair- bearing areas of the body is suggestive of associated phthiriasis pubis.  ANGULAR BLEPHARO- SQUAMOUS BLEPHARITIS ULCERATIVE BLEPHARITIS PARASITIC BLEPHARITIS CONJUNCTIVITIS TREATMENT ① Attention to the general health. ② Treatment of seborrhea of scalp. GENERAL TTT ③ Change of unhygienic atmosphere. ④ Correction of any refractive errors. ⑤ Avoidance of excess carbohydrates in the diet. ① Lid hygiene: ① Phthiriasis palpebrum a) Frequent massage to evacuate ① Dilute Acetic acid 2 to loosen the nits. meibomian secretions. ② Yellow oxide of mercury ointment 1% b) Meticulous removal of scales by applied to the lid. It destroys →the larvae. scrubbing the lid margins with ③ Mechanical removal is the most effective. ① General treatment of baby shampoo or 3% Sodium ④ Treatment is continued for 3 weeks. seborrhea. bicarbonate lotion. ① Boric acid 4% lotion. ② Remove scales with 3% ② Demodex blepharitis: ② Zinc preparations such as Zinc sodium bicarbonate or ② Elimination of infection:  Eyelid cleanser that contains tea tree oil Sulphate 0.25 % drops to neutralize LOCAL TTT diluted baby shampoo. a) Organisms are hidden in the hair twice daily in order to eradicate the the proteolytic enzyme. ③ Rub antibiotic ointment into follicles and meibomian glands, Demodex mites. ③ Antibiotic drops or ointment to kill the lid margin. so treatment must be prolonged.  Complete coverage of the eyelash base by the organism. ④ The treatment must be b) Rub Gentamycin ointment into the the tea tree oil lid cleanser is necessary to prolonged (2-3 weeks). lid margin after careful removal of be effective so that mites are unable to lay scales and crusts. eggs and hatch more Demodex mites.  Patients should be instructed to use the wipes on their eyelashes, forehead, eyebrows, and cheeks as the mites live in all of those areas   Very common type of blepharitis that results from Meibomian Gland DEFINITION Dysfunction (MGD) which normally produce oil for the tear film.  The oil that is produced is usually a clear runny oil.  For reasons not fully understood, inflammation occurs in the glands causing production of thickened poor quality oil that causes blockages in ETIOLOGY meibomian ducts and openings near the posterior boarder of lid margin.  Meibomian Gland Dysfunction: is more common as we age, but is also associated with other skin conditions such as Rosacea.  Examining the posterior eyelid margin shows→ The meibomian glands may appear capped with oil, be dilated, or be visibly obstructed. The secretions of glands are usually turbid and thicker than normal.  Telangiectasias and lid scarring may also be present in this area. Chalazia may be a cause or consequence of MGD. SIGNS   Warm, wet compresses:  Applied to the eye for 5 to 10 minutes to soften eyelid debris, oils,  also to dilate meibomian glands  Immediately following this, the eyelid margins should be washed gently with a cotton applicator soaked in diluted baby shampoo:  To remove scale and debris.  Care should be taken not to use too much soap since it can result in dry eyes.  Gentle massage of eyelid margins:  To express oils from the meibomian glands.  Cotton applicator or finger is used to massage the lid margins in small circular patterns TREATMENT  Eye makeup:  Needs to be limited and all triggers removed.  Underlying conditions should be treated.  Topical antibiotic creams:  as bacitracin or erythromycin can be applied to the lid margin for 2 to 8 weeks.  Oral tetracyclines and macrolide antibiotics:  may be used to treat posterior blepharitis not responsive to eyelid hygiene or associated with rosacea.  These oral antibiotics are used for their anti- inflammatory and lipid regulating properties.  Short courses of topical steroids:  are beneficial in patients with ocular inflammation In all types of blepharitis, the tear film may show signs of rapid evaporation. This is best evaluated measuring the tear break-up time.   Acute suppurative inflammation of Zeis gland and the lash follicle, DEFINITION forming a small abscess. ① Infection of a Zeis gland by staphylococcus aureus. ETIOLOGY ② Predisposing factors: Diabetes, poor general condition, errors of refraction and co-existing blepharitis.  Symptoms: ① Swelling of the lid. ② Severe pain, first dull then throbbing. CLINICAL PICTURE  Signs: Diffuse, red-yellowish swelling: ① Related to a lash. ② Close to the lid margin. ③ Points on the skin side.  General: ① Wear glasses & avoid contact lenses ② Avoid wearing eye makeup ③ Hand sanitation before touching the stye ④ Eye lead cleansing ⑤ Systemic antibiotics & anti-inflammatory drugs. TREATMENT ⑥ For recurrent cases: Correct the underlying cause.  Local: ① Hot fomentations. ② Local antibiotic drops and ointment. ③ When pointing occurs, the pus must be evacuated by: a. Epilation of the related lash & applying pressure. b. Horizontal incision to avoid gapping (evacuation marvelously ↓ pain)   Acute suppurative inflammation of the meibomian gland caused by DEFINITION staphylococcus aureus.  It may be primary or it may occur on top of a chronic inflammation of the ETIOLOGY meibomian gland (chalazion).  Very painful even more than stye  Yellow spot (pus): CLINICAL PICTURE  Seen shining through conjunctiva on everting lid. TREATMENT  Vertical incision but through the conjunctival side. DEFINITION  Chronic non-specific inflammatory granuloma of a meibomian gland.  Granuloma (contains predominantly giant cells) produced by the retained ETIOLOGY contents of gland (irritant & excites granulomatous reaction) following obstruction of its duct by poliferation of epithelium or dry secretions.  Symptoms: ① Painless swelling felt under skin of lids.  It may be single or multiple. ② Pain occurs only when it becomes infected (acute chalazion). CLINICAL PICTURE  Signs: ① Small non-tender hard swelling in lid, slightly away from lid margin. ② There are no signs of acute inflammation. ③ On everting the lid, conjunctiva over swelling is highly vascularized & exhibits a greyish color. It may be yellowish when 2ry infected.  ① Spontaneous resolution is rare. ② Infection forming an acute chalazion. FATE OF ③ Marginal chalazion: the granulation tissue forms only in the duct and CHALAZION projects on the lid margin as a red nodule. ④ It may open through the conjunctiva. ① Very small chalazion:  Local antibiotic and steroid preparation. ② Marginal chalazion:  Scraping from lid margin. ③ Moderate or large chalazion:  Vertical incision and scraping through the conjunctival side. ④ Multiple chalazia:  Combined excision of tarsus and conjunctiva leaving the lower third of the tarsus (to avoid lid notching) with replacement by a mucous graft from the lip. ⑤ Recurrent chalazion of the same gland:  Excision biopsy to exclude malignant tumor. TREATMENT  HORDEOLUM EXTERNUM (SYTE) HORDEOLUM INTERNUM SUPPURATION OF Zies gland Meibomian gland RELATED TO Lash root Not related to lash root POINT ON The skin Palpebral conjunctiva White line DRAINAGE Horizontal Vertical conj. incision XANTHELASMA DERMATOCHALASIS BLEPHAROCHALASIS  SC deposits of cholesterol  Redundancy of upper  Recurrent attacks of upper in medial canthus region. eyelid skin in old age lid edema → redundancy of  Seen in diabetics and in associated with bulging of upper lid in young age. patients with hyper- orbital fat. cholesterolemia.  Treatment: Blepharoplasty. ① Distichiasis is a. Permanent absence of the eye lashes b. One or more extra row of eye lashes c. Misdirection of the eye lashes d. Whitening of eye lashes ② Meibomian glands are found in : a. The subcutaneous areolar layer of the lid b. The tarsus of the lid c. The submascular areolar tissue of the lid d. The palpebral conjunctiva ③ Paralytic ptosis is due to a. complete or partial 3rd nerve palsy b. 4th nerve palsy c. 6th nerve palsy d. 7th nerve palsy ④ Surgery of choice in cases where multiple ptosis operations have failed and levator action is poor a. fascia lata sling surgery b. skin muscle resection c. levator resection d. Fasanella-Servat operation ⑤ The common causes of cicatricial entropion include a. Trachoma stage IV b. Ulcerative blepharitis c. Burns d. Ocular pimphigoid ⑥ Sling surgery should be avoided in cases of ptosis with a. very poor levator action b. poor Bell’ s phenomenon c. weak Muller ’ s muscle d. multiple failed surgery ⑦ Treatment of trichiasis includes a. epilation b. electrolysis c. skin muscle resection d. all of the above ⑧ A patient complains of maceration of skin of the lids and conjunctiva redness at the inner and outer canthi. Conjunctival swab is expected to show: a. Slaphylococcus aureus. b. Streptococcus viridans. c. Streptococcus pneumonae d. Morax- Axenfeld diplobacilli ⑨ Chalazion is a chronic inflammatory granuloma of: a. Meibomian gland b. Zies’s gland c. Sweat gland d. Wolfring’s gland ⑩ Lagophthalmos can occur in all of the following except: A. 7th cranial nerve paralysis. B. 5th cranial nerve paralysis. C. Thyrotoxic exophthalmos. D. Symblepharon. ⑪ The clinical features of Symblepharon include: A. Ectropion. C. Chalazion. B. Lagophthalmos. D. Xanthelasma ⑫ Hordeolum externum is a suppurative inflammation of: A. Zeis gland. B. Meibomian gland. C. Moll's gland. D. Gland of Krause. ⑬ On removing yellow crusts on the lid margin, small ulcers bleed. What is the most probable diagnosis: A. Squamous blepharitis. B. Ulcerative blepharitis. C. Parasitic blepharitis. D. Hordeolum intemum. E. All of the above. ⑭ The most common complication of lagophthalmos is: A. Purulent conjunctivitis. B. Exposure keratitis. C. Entropion. D. Trichiasis. E. Chronic simple glaucoma. ⑮ Chalazion is: A. Acute suppurative inflammation of Meibomian glands. B. Chronic granulomatous inflammation of Meibomian glands. C. Retention cyst of the Meibomian glands. D. Neoplasm of the Meibomian glands. ⑯ Hordeolum internum is: A. Chronic inflammation of lid margin. B. Acute suppurative inflammation of Zeis gland and lash follicle. C. Incomplete closure of palpebral fissure. D. Chronic suppurative inflammation of Meibomian gland. E. Redundancy of upper eye lid skin in old age.