Lecture 2Lecture 2

DISEASES of DISEASES of EYELIDS,EYELIDS,

LACRYMAL SYSTEM & LACRYMAL SYSTEM & ORBITORBIT

Lecture is delivered byLecture is delivered by

Ph. D., associated professor Tabalyuk TetyanaPh. D., associated professor Tabalyuk Tetyana

EYELID ANATOMYEYELID ANATOMY

The eyelids layersThe eyelids layers::skinskinmusclemuscletarsustarsusconjunctivaconjunctiva

BLEPHARITISBLEPHARITISvery common chronic inflammation of the eyelid very common chronic inflammation of the eyelid

marginsmarginsClassificationClassification: : divided into anterior & divided into anterior &

posterior formsposterior forms: : the former may be the former may be staphylococcal or seborrhoeicstaphylococcal or seborrhoeic; ; a a mixed picture is typical, however.mixed picture is typical, however.

Causative factorsCausative factors::staphylococcalstaphylococcal:: chronic infection of the chronic infection of the

bases of the lashes – common in bases of the lashes – common in patients with eczemapatients with eczema

seborrhoeicseborrhoeic:: usually associated with usually associated with seborrhoeix dermatitis – involves seborrhoeix dermatitis – involves excess lipid production by eyelid excess lipid production by eyelid glands, converted to fatty acids by glands, converted to fatty acids by bacteriabacteria

posteriorposterior:: dysfunction of the meibomian dysfunction of the meibomian glands of the posterior lid margins – glands of the posterior lid margins – common in patients with acne rosaceacommon in patients with acne rosacea

Clinical features: Clinical features: usually worse in the usually worse in the morning, include grittiness, burning and morning, include grittiness, burning and redness, stickiness and crusting of the lids.redness, stickiness and crusting of the lids.SIGNSSIGNS::staphylococcalstaphylococcal:: dandruff-like scaling, mainly around the eyelash bases;seborrhoeicseborrhoeic:: greasy debris around the lashes greasy debris around the lashes causing them to adhere to one anothercausing them to adhere to one another;;posteriorposterior:: frothy tear film and pluggung of the frothy tear film and pluggung of the meibomian gland orificesmeibomian gland orifices

All types usually manifest hyperaemia of the lid margins and conjunctiva, and tear film instability

ComplicationsComplications::corneal epitheliopathycorneal epitheliopathyscarringscarringmarginal keratitismarginal keratitisreccurent bacterial conjunctivitisreccurent bacterial conjunctivitischalaziachalaziastyesstyesloss of lashes (madarosis)loss of lashes (madarosis)misdirection (trichiasis)misdirection (trichiasis)

ManagementManagement::

• lid margin hygiene using a weak solution or lid margin hygiene using a weak solution or baby shampoobaby shampoo

• tear substitutes (e.g. hypromellose, carbomers)tear substitutes (e.g. hypromellose, carbomers)

• antibiotic ointment (e.g. fusidic acid, antibiotic ointment (e.g. fusidic acid, chloramphenocol)chloramphenocol) rubbed into the lid marginsrubbed into the lid margins

• systemic tetracyclinesystemic tetracycline

Meibomian cyst (chalazion)Meibomian cyst (chalazion) a lesion consisting of lipogranulomatous a lesion consisting of lipogranulomatous

inflammation centred on a dysfuctional meibomian inflammation centred on a dysfuctional meibomian glandgland

Clinical featuresClinical features::

Extremely common, Extremely common, particularly in patients particularly in patients with posterior with posterior blepharitis.blepharitis.

A chronic, usually solitary, A chronic, usually solitary, painless, firm swelling in painless, firm swelling in the tarsal platethe tarsal plate;;

Can follow an acute Can follow an acute meibomian gland meibomian gland infection.infection.

May be assosiated with a May be assosiated with a secondary conjunctival secondary conjunctival granulomagranuloma

ManagementManagement:: spontaneous resolution spontaneous resolution may occur, although may occur, although usually only if the lesion is usually only if the lesion is small. Surgical incision and small. Surgical incision and curettage is often requiredcurettage is often required

INTERNAL HORDEOLUM (acute chalazion)INTERNAL HORDEOLUM (acute chalazion)an acute bacterial meibomian gland infectionan acute bacterial meibomian gland infection

Clinical featuresClinical features::An inflamed swelling within An inflamed swelling within

the tarsal plate which the tarsal plate which may be associated with may be associated with (mild) preseptal cellulitis(mild) preseptal cellulitis

ManagementManagement::Topical antibiotic ointment Topical antibiotic ointment

and systemic antibiotic and systemic antibiotic (e.g. flucloxacillin) for (e.g. flucloxacillin) for preseptal cellulitis.preseptal cellulitis.

Hot bathing may promote Hot bathing may promote discharge.discharge.

Incision and curettage Incision and curettage Incision and curettage Incision and curettage may be required for a may be required for a large abscess, or for large abscess, or for secondary chronic secondary chronic lesion.lesion.

EXTERNAL HORDEOLUM (stye)EXTERNAL HORDEOLUM (stye)a small abscess of an eyelash folliclea small abscess of an eyelash follicle

Clinical featuresClinical features::An acute painful inflamed An acute painful inflamed

swelling on the anterior swelling on the anterior lid margin, usually lid margin, usually pointing through the skinpointing through the skin

ManagementManagement::Removal of the Removal of the

associated lash, and associated lash, and hot bathing.hot bathing.

Topical antibiotic Topical antibiotic ointment.ointment.

Large lesions may Large lesions may require incisionrequire incision

Cysts of Zeis and Cysts of Zeis and MollMoll

Clinical featuresClinical features::

A cysts of Zeis is a A cysts of Zeis is a small, whitish, small, whitish, chronic, painless chronic, painless opaque nodule on opaque nodule on the lid marginthe lid margin

A cysts of Moll is A cysts of Moll is similar but similar but translucenttranslucent

ManagementManagement::

simple excisionsimple excision

MOLLUSCUM CONTAGIOSUMMOLLUSCUM CONTAGIOSUM

Clinical featuresClinical features:: single or multiple, small, single or multiple, small, pale, waxy umbilicated nodules, which may pale, waxy umbilicated nodules, which may cause a secondary chronic ipsilateral follicular cause a secondary chronic ipsilateral follicular conjunctivitis. These virally transmitted lesions conjunctivitis. These virally transmitted lesions are common and more severe, in AIDS are common and more severe, in AIDS patients.patients.

ManagementManagement:: expression or cautery.expression or cautery.

Benign tumours of the Benign tumours of the eyelidseyelids

Squamous cell papilloma (viral wart)Squamous cell papilloma (viral wart)Basal cell papilloma (seborrhoeic Basal cell papilloma (seborrhoeic

keratosis)keratosis)KeratoacanthomaKeratoacanthomaMelanocytic naevusMelanocytic naevusCapillary haemangioma (strawberry Capillary haemangioma (strawberry

naevus)naevus)Plexiform neurofibromaPlexiform neurofibroma

Squamous cell papillomaSquamous cell papilloma(viral wart)(viral wart)

Clinical featuresClinical features::

The most common The most common benign tumour of the benign tumour of the eyelid which may be eyelid which may be broad-based (sessile) broad-based (sessile) or pedunculatedor pedunculated

ManagementManagement::

Simple excision, cautery Simple excision, cautery or laser ablationor laser ablation

Basal cell papillomaBasal cell papilloma (seborrhoeic keratosis)(seborrhoeic keratosis)

Clinical featuresClinical features::

This common tumour This common tumour usually found in the usually found in the elderly, is a slowly-elderly, is a slowly-enlarging brownish enlarging brownish papillary lesion with a papillary lesion with a greasy friable surfacegreasy friable surface

ManagementManagement::

Simple excision or Simple excision or curettagecurettage

KeratoacanthomKeratoacanthomaa

Clinical featuresClinical features::An uncommon, fast-An uncommon, fast-

growing, firm, growing, firm, pinkish nodule pinkish nodule that develops a that develops a keratin-filled keratin-filled crater and may be crater and may be mistaken for a mistaken for a malignancymalignancy

Remains static for Remains static for several months several months before before involutioninvolution

Melanocytic naevusMelanocytic naevus

Itradermal Itradermal Intradermal naevusIntradermal naevus – an elevated lesion with variable – an elevated lesion with variable

pigmentation. When located on the lid margin may be pigmentation. When located on the lid margin may be associated with protruding lashes. No malignant associated with protruding lashes. No malignant potential.potential.

Junctional naevusJunctional naevus – a flat well circumscribed lesion with a – a flat well circumscribed lesion with a uniform brown colour, so-called because the naevus cells uniform brown colour, so-called because the naevus cells are located at the junction of the dermis and epidermis. are located at the junction of the dermis and epidermis. Low malignant potential.Low malignant potential.

Compound naevusCompound naevus – usually elevated, with a – usually elevated, with a homogeneous tan to brown colour. Consists of both homogeneous tan to brown colour. Consists of both intradermal and junctional components, the latter intradermal and junctional components, the latter conferming a low malignant potential.conferming a low malignant potential.

Capillary Capillary haemangiomhaemangiomaa (strawberry (strawberry

naevus)naevus)

Clinical featuresClinical features:: an irregular red lesion in an infant an irregular red lesion in an infant which may cause a mechanical ptosis and amblyopia.which may cause a mechanical ptosis and amblyopia.

ManagementManagement:: local steroids if necessary, but local steroids if necessary, but frequently undergoes gradual spontaneous frequently undergoes gradual spontaneous involution.involution.

Plexiform Plexiform neurofibromaneurofibroma

Typically occurs in neurofibromatosis-1, Typically occurs in neurofibromatosis-1, characteristically giving rise to an S-shaped lid characteristically giving rise to an S-shaped lid margin and ptosismargin and ptosis

Premalignant and malignant Premalignant and malignant tumours of the eyelidstumours of the eyelids

Actinic (solar) keratosisActinic (solar) keratosisBasal cell carcinomaBasal cell carcinomaSquamous cell carcinomaSquamous cell carcinomaSebaceous gland carcinomaSebaceous gland carcinoma

ManagementManagement: : Surgical excision with a wide clearance margin Surgical excision with a wide clearance margin

is the treatment of choice for most lid is the treatment of choice for most lid malignanciesmalignancies

Radiotherapy in selected casesRadiotherapy in selected cases

ActinicActinic(solar) (solar)

keratosiskeratosis

Clinical featuresClinical features:: although rare, this is most common although rare, this is most common premalignant lid condition and is strongly associated premalignant lid condition and is strongly associated with excessive sun exposure in light-skinned with excessive sun exposure in light-skinned individuals. It is usually presents as a persistent scaly individuals. It is usually presents as a persistent scaly plaque, which must be biopsied.plaque, which must be biopsied.

Basal cell Basal cell carcinomacarcinoma

Clinical featuresClinical features:: most common eyelid malignancy, is locally most common eyelid malignancy, is locally invasive but does not metastasize. About 50 % involve the invasive but does not metastasize. About 50 % involve the lower lid, 30 % the medial canthal area.lower lid, 30 % the medial canthal area.

Nodule –ulcerativeNodule –ulcerative - a - a ««rodent ulcerrodent ulcer»», with rolled hyperkeratotic , with rolled hyperkeratotic edges and central granulation, gradually enlarging over 1-2 edges and central granulation, gradually enlarging over 1-2 years. A purely nodular appearance is common.years. A purely nodular appearance is common.

Sclerosing Sclerosing - a flat indurated plaque with poorly demarcated - a flat indurated plaque with poorly demarcated margins, often with loss of overlying lashes that may simulate margins, often with loss of overlying lashes that may simulate chronic blepharitischronic blepharitis

Squamosus Squamosus cell cell

carcinomacarcinoma

Clinical featuresClinical features:: is muchis much less common than basal cell less common than basal cell carcinoma. It grows more quiclkly and may carcinoma. It grows more quiclkly and may metastasize. It may arise de novo or from premalignant metastasize. It may arise de novo or from premalignant condition such as actinic keratosis.condition such as actinic keratosis.

NodularNodular – starts as a hyperkeratotic nodule or plaque – starts as a hyperkeratotic nodule or plaque which later develops crusting fissureswhich later develops crusting fissures

UlcerativeUlcerative – resembles a rodent ulcer – resembles a rodent ulcer

Sebaceous Sebaceous gland gland

carcinomacarcinoma

Clinical featuresClinical features:: this is rare but very aggressive this is rare but very aggressive tumour, which may originate in a meibomian or Zeus tumour, which may originate in a meibomian or Zeus gland as a film nodule either on the lid margin or gland as a film nodule either on the lid margin or within the tarsal plate, when it may be mistaken for within the tarsal plate, when it may be mistaken for an chalazion.an chalazion.

Entropion Entropion an inward-turning of the eyelidan inward-turning of the eyelid

ClassificationClassification::InvolutionalInvolutional – most common form, results from – most common form, results from

age-related changes in lower lidage-related changes in lower lidCicatrical Cicatrical – most frequently secondary to – most frequently secondary to

scarring of the upper conjunctiva, as on scarring of the upper conjunctiva, as on chronic trachomachronic trachoma

Spastic Spastic – lower lid, caused by spasm of the – lower lid, caused by spasm of the orbicularis muscle due to ocular irritation or orbicularis muscle due to ocular irritation or essentialessential

Congenital Congenital – very rare, only involves the lower – very rare, only involves the lower lid. Caused the hypertrophy of skin and lid. Caused the hypertrophy of skin and orbicularisorbicularis

Management Management :: surgical correctionsurgical correction

::

Ectropion Ectropion an outward-turning of the eyelidan outward-turning of the eyelid

ClassificationClassification::InvolutionalInvolutional – most common form, age- – most common form, age-

related tissue laxityrelated tissue laxityCicatrical Cicatrical – scarring resulting from burns or – scarring resulting from burns or

surgery (e.g. tumour resection)surgery (e.g. tumour resection)Mechanical Mechanical – excess lid weight (e.g. large – excess lid weight (e.g. large

tumour)tumour)Paralytic Paralytic –facial nerve palsy, associated with –facial nerve palsy, associated with

incomplete blinking and lid closureincomplete blinking and lid closureCongenital Congenital – may be part of – may be part of

blepharophimosis syndromeblepharophimosis syndromeManagement Management :: surgical correctionsurgical correction

::

Lacrymal system anatomyLacrymal system anatomy::

Larcymal Larcymal productive productive

part &part &

Lacrymal Lacrymal excretory excretory

partpart

Investigation of lacrymal systemInvestigation of lacrymal system

Functional ability of Functional ability of lacrymal excretory lacrymal excretory systemsystem – 1% Fluorecsein – 1% Fluorecsein is dropped into is dropped into conjunctival cavityconjunctival cavity

Positive canalicular test – Positive canalicular test – disapearing of S. disapearing of S. Fluorecsein from Fluorecsein from conjunctival cavity till 5 conjunctival cavity till 5 minutes, usually 1-2 minutes, usually 1-2 minutesminutes

Positive nose test – Positive nose test – appering of S. Fluorecsein appering of S. Fluorecsein in 5 minutesin 5 minutes

Shirmer testShirmer test

Reveals hyposecretion of Reveals hyposecretion of lacrymal gland – lacrymal gland – wetting of filter paper wetting of filter paper less then 15 mmless then 15 mm

DACRYOADENITIS – DACRYOADENITIS – inflammation of lacrymal inflammation of lacrymal

glandgland

Clinical featuresClinical features:: hyperemia, oedema and pain in hyperemia, oedema and pain in upper-external part of orbitupper-external part of orbit

Eyeball can be dislocated down and nasallyEyeball can be dislocated down and nasallyPrearicular lymph nodes are increased and painfullPrearicular lymph nodes are increased and painfullIncreased body temperatureIncreased body temperatureKey sign – S-like form of rima ophthalmicaKey sign – S-like form of rima ophthalmicaManagementManagement:: systemically antibiotics, sulfanilamids, systemically antibiotics, sulfanilamids,

salicilatessalicilatesIn abscess – incision and In abscess – incision and

DACRYOCYSTITIS – DACRYOCYSTITIS – inflammation of lacrymal inflammation of lacrymal

sacsac

EthiologyEthiology:: in infants – atresia of lower part of in infants – atresia of lower part of nasolacrymal ductnasolacrymal duct; ; in adults – stenosis of nasolacrymal in adults – stenosis of nasolacrymal ductduct

Clinical featuresClinical features:: exess tearing, pus discharge usually exess tearing, pus discharge usually from one eyefrom one eye

Key sign – pus discharge from lower lacrymal point in Key sign – pus discharge from lower lacrymal point in palpation of area of lacrymal sacpalpation of area of lacrymal sac

ManagementManagement:: in infants – massage of lacrymal sacin infants – massage of lacrymal sac

Syringing of lacrymal excretory waysSyringing of lacrymal excretory ways

DreanageDreanage of lacrymal excretory ways of lacrymal excretory ways

Chonic in adults – surgical - Chonic in adults – surgical - dacryocystorhinostomydacryocystorhinostomy

Orbital cellulitisOrbital cellulitis

SignsSigns::eyelids oedemaeyelids oedemachemosischemosisproptosisproptosislimiting of eye movementslimiting of eye movementsdecreasing of visual acuitydecreasing of visual acuitygeneral intoxication (headacke, general intoxication (headacke,

increased temperature, brain increased temperature, brain signs).signs).

Optic neuritis, papilloedema, Optic neuritis, papilloedema, central vein occlusion may central vein occlusion may occur with outcome in optic occur with outcome in optic atrophy.atrophy.

ManagementManagement::incision of orbit with drainageincision of orbit with drainageantibiotics systemicallyantibiotics systemicallyosmotherapyosmotherapy

Fissura orbitalis superior Fissura orbitalis superior syndromesyndromeTumour, haematoma, foreign body in Tumour, haematoma, foreign body in

the area of the area of fissura orbitalis superior fissura orbitalis superior usually causesusually causes::

ProptosisProptosisPtosisPtosisOphthalmoplegyOphthalmoplegyMydriasisMydriasisParalysis of accomodationParalysis of accomodationDecreasing of corneal sensitivity and skin Decreasing of corneal sensitivity and skin

sensitivity in the area of innervation of I sensitivity in the area of innervation of I branch n.trigeminusbranch n.trigeminus