TEXT BOOK OF DISEASES OF THE EYE

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Eye Lids
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TEXT BOOK OF DISEASES OF THE EYE

• The eye lid is made up of 4 layers. They are
  from without in-wards
• 1) Skin it is thin and characterized by absence
  of fat.
• 2) Muscle layer.
• a) Orbicular is oculi consists of horizontal
  concentric fibers it is supplied by the zygomatic
  branch of the facial nerve. When the orbicularis
  oculi contracts the lids are firmly closed.
• b) Levator palpebrae superiors. The muscle
  fibres are arranged vertically they end in an
  aponeurosis which is inserted .
• i) To the skin of the upper lid.
• ii) Upper border of the tarsus.
• iii) Conjunctiva at the fornix.
• It is supplied by the upper division of the 3rd
  cranial nerve.
• It raises the upper lid.
• c) Muller's muscle supplied by the sympathetic
  nerve.
• 3) Tarsus Consists of dense fibrous tissue.
  Embedded in it are enormously developed sebaceous
  glands-the meibomian (tarsal) glands.
• 4) Mucous layer formed by the palpebra
  conjunctiva.

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Glands of the eye lids

• Meibomian (tarsal) glands They are embedded
  in the tarsus and are modified sebaceous glands.
  They secrete an oily secretion. They open
  through vertically arranged ducts into the lid
  margin.
• Glands of Zeis they are sebaceous glands
  developed as outgrowth of the hair follicles of
  the eye lashes. They are situated at the lid
  margin.
• Glands of Moll these are modified sweat glands.
  The lid margin is covered with stratified
  epithelium which forms a transition between the
  skin and the conjunctiva. It consists of
• Eye lashes arranged in 2 3 rows anteriorly.
• Opening of the ducts of the meibomian gland
  posteriorly.
• Glands of Zeis and Moll.

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• DISEASES OF THE LIDS
• Oedema of lids this is common and owing to
  looseness of the tissue may be so great as to
  close the eye.
• ANATOMY AND DISEASES OF THE LIDS
• Causes
• Inflammatory oedema.
• Inflammation of the lids allergic dermatitis
  due to atropine ointment and cosmetics, stye,
  insect bite.
• Acute conjunctivitis.
• Acute dacryocystitis.
• Acute iridocyclitis.
• Panophthalmitis.
• Orbital cellulitis.
• Passive oederma due to circulatory obstruction.
• Nephritic syndrome.
• Cardiac failure.
• Cavernous sinus thrombosis.

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• INFLAMMATION OF THE LIDS-
• Blepharitis It is a chronic inflammation of the
  margin of the lid. The lid margin becomes
  thickened and red.
• VARIETIES AND ETIOLOGY
• 1) Squamous blepharitis there is encrustration
  of lid margin by white scales. It is of 2
  types.
• Oleosa Or seborrheic Often essentially
  metabolic associated frequently with seborrheic
  dermatitis of scalp (dandruff). Exacerbation and
  remission of the ocular lesions parallel those of
  lesions of the scalp.
• b) Siccaa Chemical irritants and cosmetics such
  as "surma", acne rosacea, uncorrected refractive
  error particularly astigmatism.

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• 2) Ulcerative blepharitis There is encrustation
  of the lid margin by yellow scales with
  underlying ulceration. The ulcers bleed on
  removing the scales. This distinguishes the
  condition from matting together of the lashes by
  conjunctival discharge in conjunctivitis removal
  of the crusts in conjunctivitis reveals normal
  lid margin. Ulcerative blepharitis is an
  infective condition caused by staphylococci.
• 3) Mixed blepharitis Staphylococci infection
  super imposed on Squamous blepharitis .
• 4) Margin is associated with angular
  conjunctivitis foamy discharge and excoriation
  of the skin of the lateral and medial canthi. It
  is caused by Morax Axenfeld bacillius.

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• TEXT BOOK OF DISEASES OF THE EYE
• The patients are usually children debilitated
  from
• 1) Living under poor hygienic conditions
  exposure to dust, smoke.
• 2) DISEASES exanthematous disease, upper
  respiratory infections, tuberculosis, diabetes.
• 3) Dietary deficiency malnutrition.
  Occasionally parasite causes blepharitis,
  blepharitis acarica.
• Symptoms
• Itching, soreness, lacrimation, photophobia.

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• Sequelae or complications
• Chronic conjunctivitis.
• Marginal corneal ulcer.
• Styes.
• Permanent loss of a greater or losser number of
  lashes (madarosis ) due to destraction of root
  of the cilia.
• Tylosis usuall affects upper lid. There is
  hypertrophy of lid border causin this part to
  become rounded and thick and to droop on account
  of its own weight.
• Trichiasis.
• Entropion.
• Ectropion.

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• Treatment
• Improvement of general health and living
  condition.
• Treatment of seborrheic dermatitis o scalp with
  shampoo.
• Correction of refractive error.
• Removal of scales and crust with warm 3 soda
  bicarb solution.
• In cases of squamous blepharitis, dilute baby
  shampoo is applied on the lid margin with a swab
  stik. In more obstinate lesions, ointment of
  selenium oxide is used.
• allergy to chemical and cosmetic, 1
  hydrocortisone ointment is applied to the lid
  margin thrice a day.
• In cases of ulcerative blepharitis antibiotics
  such as chloromycetin, erythoromycin or
  tetracycline are applied to the lid margin. In
  more severe cases the antibiotic which has proved
  to be effective is given systemically, in
  addition to local treatment.
• In cases of angular blepharitis oxteracycline
  ointment is applied.

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• INFLAMMATION OF THE GLANDS OF THE LIDS
• 1) Eternal hordeolumor stye is a circumscribed,
  acute inflammation at the edge of the lid,
  caused by staphylococcal infection of the glands
  of Zeis usually ending in suppuration.
• Etiology
• Most common in children and young adults, often
  appear in crops. Frequently associated with
  blepharitis or lowered state of health
  diabetes mellitus, and uncorrected refractive
  error.
• Symptorns and Signs
• Red swelling appears in the lash line of the
  margin of the lid, accompanied by pain,
  tenderness and often by considerable oedema of
  the lids. Very soon a yellowish summit will be
  seen orderlid indicating suppuration.

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• Treatment
• Hot fomentation to hasten suppuration as soon
  as a yellow spot is seen, the pus should be
  evacuated by a horizontal incision at the lid
  margin or epilation.
• Antibiotics choromycetin ointment.
• Analgesics.
• Prophylaxis.
• Antibiotic ointment.
• Treatment of diabetes, blepharitis, correction of
  refractive errors.
• Avoidance of excess of sweets, oil in the diet.

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• 2) Hordeolum internum this is an acute
  suppurative inflammation of a meibomian gland due
  to staphylococcus. Sometimes it may be due to
  secondary infection of a chalazion.
• - Symptoms and Signs
• Symptoms are more violent than those of stye.
  Very soon pus points on the palpebral
  conjunctiva.
• ANATOMY AND DISEASES OF THE LIDS 33
  
  
  
• Treatment
• It may be removed by operation incision and
  curettage through the conjunctiva. A vertical
  incision is made through the palpebral
  conjunctiva and with a chalazion curette the
  contents are removed and the walls thoroughly
  scraped. Vertical incision is made to avoid
  cutting ducts of neighbouting meibomian glands
  and to prevent Entropion.
• Injection of cortisone into the chalazion can be
  used as an alternate fromof treatment.

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• Blepharospasm
• It is a condition in which there are involuntary
  and forcible eyelid closure (Refer Corneal ulcer
  for difference from photophobia).
• 1) Reflex sensory stimulation through branches of
  5th cranial nerve commonest.
• a) Phlyctenular keratoconjunctivitis.
• b) Foreign body on cornea.
• c) Membranous and pseudo membranous
  conjunctivitis.
• d) Acte iridocyclitis.
• 2) Excessive stimulation of retina.
• a) Bright light on sensitive eye.
• b) Dilated pupil.
• c) Albinism.
• 3) Essential Blepharospasm without any cause.
• 4) Hysteria.

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• Trichiasis - is an inversion of a varying
  number of eye lashes so that they rub against the
  conjunctiva or cornea.
• The margin of the lid may have a normal
  position, the displacement affecting only the
  lashes or the margins may be turned inward
  (Entropion ) as well as the lashes.
• Etiology same as Entropion.
• Signs and symptoms (same for Entropion).
• The misdirected lashes cause mechanical
  irritation and injury to cornea with ulceration
  pain, lacrimation, photophobia, Blepharospasm,
  vascularisation and opacities of cornea.
• Treatment
• If only a few cilia involved epilation or
  electrolysis to destroy the hair follicles. If
  extensive surgical treatment as for cicatricial
  Entropion.

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• TEXT BOOK OF DISEASES OF THE EYE
• Treatment - is the same as same as for stye
  except that the incision should be made exactly
  as for chalazion i.e. a vertical incision on the
  palpebral conjunctiva. This is to avoid cutting
  ducts of neighbouring meibomian glands and to
  prevent Entropion.
• chalazion - This is a chronic granulomatous
  enlargement of one of the meibomain glands.
• Etiology Pathology
• It occurs most frequently in adults. The
  meibomian duct becomes obstructed through
  proliferation of its epithelium and consequently
  the gland enlarges. The fatty secretion escapes
  into the surrounding tissue and excites a foreign
  body reaction (lipogranuloma) which consists of
  lymphocytes, epitheloid cells and giant cells.
  The blood supply is cut off by the surrounding
  fibrous tissue leading to degeneration of
  contents jelly like mass.

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• Symptoms chalazion may cause
• 1) Cosmetic disfigurement lid swelling.
• 2) Conjunctiva irrition.
• Signs
• The process develops slowly. After weeks or
  months it presents a circumscribed swelling which
  feels hard, not adherent to skin. On everting
  the lid, its situation is usually shown by a
  purple discolouration of the conjunctiva.

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• Complications
• It may be secondarily infected forming an
  internal hordeolum.
• In old people, recurrent chalazion may lead to
  the development of Meibomian gland carcinoma.
• Mechanical ptosis in cases of large chalazion.
• The chalazion may press on the cornea causing
  astigmatism.
• The chalazion may burst either on the skin
  surface or on the conjunctival surface, with
  granulation tissue protruding.
• The granuloma may protrude through a duct of the
  meibomian gland on the lid margin marginal
  chalazion.

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• Entropion is a rolling of the margin of the
  lid and with it the lashes.
• Etiology and Varieties
• I) Cicatricial entopion due to cicatricial
  changes in the conjunctiva and distortion of the
  tarsal plate, most commonly affects the upper
  lid .
• a) Old case of trachoma .
• b) Blepharitis
• c) Burns and other injuies to the lids
• d) Operation upon the lids
• e) Diphtheritic conjunetivitis

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• II) Spastic entropion
• Due to spasm of the palpebral portion of the
  orbicularis muscle, most commonly affecting lower
  lid, strong contraction of the circularly
  arranged fibers tends not only to approximate the
  lid margins but also to turn them inwards of
  outwards according to the degree of mechanical
  support afforded by the globe and orbital
  contents. If the support is insufficient
  intropion is produced
• i) Atrophy or absence of eye ball
• ii) Old persons ( senile entropion) owing to
  absence of orbital fat.
• iii) Tight bandaging after surgical operation of
  the eye.
• iv) Blepharospasm
• Symptoms and signs same as for trichiasis .

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• Treatment
• I) Cicatricial entrpion The principles
  governing various operation are
• i) Altering the direction of eyelashes
• a) Snellen,s operation
• b) Jaesch Arlt operation
• ii) Straightening of the distorted tarsus.
• II) Spastic entropion
• i) Pull the lower lid down and out and apply
  leucoplast which should extend below the
  mandible.
• ii) Injection of alcohol is made close to the
  lateral 3rd of the lid margin .
• Plastic surgery of lower lid - modified
  wheeler's operation
• Ectropion It is a rolling out of the margin of
  the lid
• Etiology and varieties
• Cicartical Ectropion due to cicatricial
  changes in the skin of the lids- Blepharitis,
  burns, operations on the lids, leprosy.
• Both upper and lower lids may be affected.

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• 2) Senile ectropion the lower lid is affected
  in old age due to laxity of the tissue of the lid
  and due to loss of tone of the orbicularis
  muscle.
• 3) Paralytic ectropion it occurs as a result
  of weakness of the orbicularis muscle due to
  facial nerve paralysis . The lower lid is
  affected.
• Symptoms Epiphora due to eversion of lacrimal
  punta.
• Complications
• 1) Xerosis of conjunctiva
• 2) Chronic conjunctivitis and exposure keratitis
  particularly in Ectropion of upper lid.
• Treatment
• 1) In mild cases row of heat cautery applied to
  the palpebral conjunctiva below the lek margin .
  As a result of fibrosis of conjunctiva ectropion
  is corrected .
• 2) Lateral tarsorrhaphy
• 3) In severe case, platstic surgery Kuhnt
  Szymanowski operation.

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• SYMBLEPHARON
• is a cicatricial attachment between the
  conjunctiva of the lid and the eye ball, it may
  affect both lids, but usually the lower,
  sometimes it includes part of the cornea.
• Tyes
• 1) Anterior- when extending bridge like from lid
  to globe, leaving a free portion of the
  conjunctiva corresponding to the fornix .
• 2) Posterior- When it involves only the fornix.
• 3) Total When the lids are adherent to the
  globe throughout.
• Etiology
• It is caused by the junction of 2 opposing
  granulating surfaces raw surfaces hence it occurs
  after.
• 1) injuries especially burns from lime, acids,
  and molten metal.
• 2) Operations.
• 3) Trachoma, rarely diphtheritic conjunctigitis.

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• Symptoms
• 1) It often interferes with movement of eye ball
  producing diplopia.
• 2) Traction upon the adherent parts causes
  irrition
• 3) In extensive cases the cornea is involved and
  vision is affected.
• 4) If there is inability to close , lagoph
  thalmos.
• 5) Cosmetic disfigurement.
• Treatment
• 1) Prophylactic - use of contact shell in fresh
  cases of alkali burns, after operations on lids.
• 2) Curative.
• a) If anterior and not extensive, the band is
  divided and the 2 raw surfaces kept from uniting
  by separating them daily with a glass rod smeared
  with antibiotic ointment .
• b) In more sever cases of anterior symblepharon,
  in posterior and total symblepharon the
  separated raw surfaces must be cobered with
  conjunctiva or with grafts of mucous membrane
  from the lip to keep them from uniting .

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• Lagophthalmos
• This is the condition of incomplete closure of
  the palpebral aperture when an attempt is made
  to shut the eyes.
• Causes
• 1) Exophthalomos as in Graves' disease,
  proptosis due to orbital tumour.
• 2) Facial never paralysis .
• 3) Cicatricial ectropion of upper lid .
• 4) Symblepharon.
• 5) Laxity of the tissue and absence of reflex
  blinking in people who are extremely ill coma,
  keratomalacia etc.
• Complications
• 1) Parenchymatous xerosis of conjunctiva.
• 2) Chronic conjunctivitis and exposure keratitis
  
• Treatment
• 1) Of the cause whenever possible.
• 2) Application of a bland or antibiotic ointment
  to protect cornea.
• 3) Lateral or median tarsorrhaphy to protect the
  cornea.

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• 1) Distichiasis It is a condition in which
  there is an extra posterior row of eye lashes.
  The posterior row occupies the position of the
  opening of Meibomian glands, these lashes may
  irritate the cornea.
• 2) Coloboma of the lid It is a triangular gap
  in the lid magin, generally affecting the upper
  lid. It may form part of Golden Har's syndrome-
  accessory auricles, dermolipoma at the limbus,
  hypoplasia of the maxilla and anomalies of the
  vertebral column.
• ptosis or blepharoptosis is a drooping of the
  upper lid usually due to defective development or
  paralysis of the levator palpebrae superioris
  (L.P.S.).
• All degrees o ptosis occur- partial or complete.
  When severe it interferes with vision by covering
  the pupil.
• 1) Patients attempt to raise the lid by forced
  action of the occipito frontalis muscle,
  wrinkling the skin of the forehead and raising
  the brow.
• 2) When condition is severe and bilateral they
  favour exposure of the pupil by throwing the head
  backwards.

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• Etiology Classification
• 1) Congenital ptosis
• a) With normal superior rectus funtction.
• b) With superior rectus weakness- developmentally
  superior rectus is closely related to L.P.S.
• Marcus Gunn or jaw-winking ptosis.
• 2) Acquired ptosis
• Neurogenic due to lesion of 3rd never nucleus,
  3rd nerve trunk in its intracranial or orbital
  course as in cases of brain tumour, meningitis,
  aneurysm etc.
• - Horner's syndrome due to affection of
  sympathetic nerves.
• b) Myogenic Myasthenia gravis.
• c) Mechanical ptosis - due to increased weight
  of lid as in trachomatous ptosis, tylosis ,
  tumours of upper lid or lack of support of upper
  lid as phthisis bulbi etc.
• d) Traumatic ptosis.

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• Treatment
• 1) Medical in the acquired form cause is
  determined and treated Syphilis Inj.
  Penicillin I.M. Myashthenia gravis _
  Physostigmine
• 2) Surgical usually necessary for Congenital
  ptosis.
• If the levator palpebrae superioris is not
  completely paralysed this mucle may be shortened.
  Conjunctival approach Blaskowicz operation.
  Skin approach Everbusch's operation
• If the levator muscle is paralysed but the
  superior rectus is active, the latter muscle may
  be pressed into service to lift the lidMotais'
  operation .
• C) If both levator and superior rectus are
  paralysed, the action of the frontalis muscle may
  be utilized in raising the lid frontalis
  suspension the frontalis muscle is sutured to
  the tarsal plate using strips of fascia lata or
  4.O supramid suture . As a result contraction of
  frontalis muscle elevates the lid.

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• TUMOURS OF the eye lids
• 1) Benign tumouts of the lids are
• a) Papilloma
• Molluscum contagiosum is a small umbilicated ,
  nodular swelling, generally multiple due to a
  large pox virus. Histologically large
  eosinophilic intra cytoplasmic inclusion bodies
  occur (Henderson Paterson bodies). It produces
  follicular conjunctivitis and superficial
  punctuate keratitis.
• Treatment
• Excision of these nodules
• c) Naevus
• d) Xanthelasma or Xanthoma this is a raised
  yellow plague, most commonly found in the upper
  and lower lids near the inner canthus and often
  symmetrical in the 2lids on both sides. They are
  most common in
• 1) Elderly women
• 2) Diabetes mellitus
• 3) Excessive levels of blood cholesterol

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• Treatment They may be excised if causing
  cosmetic disfigurement .
• e) Haemangioma may occur in 2 forms.
• __ telangiectasis
• __ cavernous haemangioma
• It is seen usually in children and often follows
  the distribution of the 1st and 2nd division of
  5th cranial nerve. In Sturge Weber syndrome it
  is associated with haemangioma of the choroid ,
  buphthalmos and also with haemangioma of the
  leptomeninges, causing homonymous hemianopia or
  epilepsy. The intracranial causing lesion may be
  diagnosed on x-ray skull since there are often
  calcareous deposits underlying the cerebral
  cortex.
• f) Neurofibromatosis Von Reckinghausen's
  disease.
• The hypertrophied nerves can be felt through the
  skin as hard cords. It may be associated with
  café au lait spots elsewhere in the body ,
  buphthalmos, proptosis in some cases and
  enophthalmos in others.

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• 2) Malignant tumours of the lids are
• a) Rodent ulcer or basal cell carcinoma. It
  originates either from the basal layer of the
  epidermis or from the epithelium of the hair
  follicles and glands of the skin . It shows a
  predilection for the inner canthus. It starts as
  a small pimple which ulcerates and if the scab is
  removed it is found that the edges are raised and
  indurated. The ulcer spreads very slowly
  destroying the lids, orbital structures. It is
  locally malignant and the regional lymph nodes
  are not involved.
• b) Squamous cell carcinoma It originates at the
  lid margin which is the transition zone of the
  epithelium. It starts as a small nodule which
  ulcerates. The regional lymph nodes preauricular
  or submandibular become enlarged. Histologically
  it shows epitheliai pearls'
• C) Meibomian gland carcinoma it is an
  adenocarcinoma of the Meibormian gland. The upper
  lid is more commonly affected than the lower lid.
  In old people it may start as a recurrent
  chalazion. Therefore in this group of patients
  it is advisable to send the curettings of a
  chalazion for histopathological examination.

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• ????? ?????

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angular blepharitis
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chalazion
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hordeolum internum
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Trichiasis
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Blepharitis
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External hordeolum
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Lid diseases
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Ulcerative Blepharitis
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blepharospas
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eye lids
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Squamous Blepharitis
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angular blepharitis
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chalazion
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hordeolum internum
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Trichiasis
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Blepharitis
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External hordeolum
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Lid diseases
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Ulcerative Blepharitis
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blepharospas
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eye lids
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Squamous Blepharitis
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