diseases of lids

Diseases of LidsDiseases of Lids
-Dr Akshay Nayak-Dr Akshay Nayak

LID INFLAMMATIONLID INFLAMMATION
 BlepharitisBlepharitis

DEFINITIONDEFINITION
 It is the inflammation of the lid marginIt is the inflammation of the lid margin

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

TypesTypes
1.1. AnteriorAnterior
a. Squamousa. Squamous
b. Ulcerativeb. Ulcerative
2. Posterior2. Posterior
a. Meibomian seborrhoeaa. Meibomian seborrhoea
b. Meibomianitisb. Meibomianitis

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

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

Squamous BlepharitisSquamous Blepharitis

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

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

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

Ulcerative BlepharitisUlcerative Blepharitis

14- Ulcerative blepharitis14- Ulcerative blepharitis

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

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)

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)

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

ComplicationsComplications
 ChalazionChalazion
 Tear film instabilityTear film instability
 Papillary conjunctivitis and inferiorPapillary conjunctivitis and inferior
corneal erosionscorneal erosions

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

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.

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.

HistopathologyHistopathology
 Purulent infection of follicle and its glandPurulent infection of follicle and its gland
with cellulitis of surrounding connectivewith cellulitis of surrounding connective
tissuetissue

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.

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

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

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

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 .

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

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

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

Treatment ofTreatment of
 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

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

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

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

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

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

Signs of chalazion (meibomian cyst)
Painless, roundish, firm lesion
within tarsal plate
May rupture through conjunctiva
and cause granuloma

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

Treatment of chalazion
Injection of local anaesthetic Insertion of clamp Incision and curettage

Functions of lidsFunctions of lids
1.1. Protection of eyeProtection of eye
2.2. Act as lacrimal pumpAct as lacrimal pump

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

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

ClassificationClassification
1.1. InvolutionalInvolutional
2.2. CicatricialCicatricial
3.3. SpasticSpastic
4.4. CongenitalCongenital

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

Involutional EntropionInvolutional Entropion

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

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

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

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.

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

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

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

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.

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

ClassificationClassification
I. AcquiredI. Acquired
 Involutional or senileInvolutional or senile
 CicatricialCicatricial
 ParalyticParalytic
 MechanicalMechanical
II. CongenitalII. Congenital

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

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

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)

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

Cicatricial EctropionCicatricial Ectropion

Ectropion Pre andEctropion Pre and
Post-operativePost-operative

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.

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

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