Diseases of Lids Diseases of Lids

Anatomy of LidAnatomy of Lid

Hordeolum ExternumHordeolum Externum(Stye)(Stye)

Hordeolum Externum Hordeolum Externum (Stye)(Stye)

Definition: Localized suppurative Definition: Localized suppurative inflammation of gland of zeis at lid margin inflammation of gland of zeis at lid margin at ciliary follicle.at ciliary follicle.

EtiologyEtiology

Usually caused by staphylococcus Usually caused by staphylococcus aureusaureus

There is infection of hair follicle of There is infection of hair follicle of eyelash.eyelash.

It may complicate Acne Vulgeris in young It may complicate Acne Vulgeris in young adults.adults.

HistopathologyHistopathology

Purulent infection of follicle and its gland Purulent infection of follicle and its gland with cellulitis of surrounding connective with cellulitis of surrounding connective tissuetissue

Clinical PictureClinical Picture

Stye are frequently recurrent, appearing Stye are frequently recurrent, appearing in crops. in crops.

Recurrent lesion is particularly seen in Recurrent lesion is particularly seen in cases of debility, focal infections and cases 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 and feeling of fullness or heaviness and feeling of heatfeeling of heat

Tenderness (increase in pain on touching Tenderness (increase in pain on touching swelling/ affected area)swelling/ affected area)

Pain subsides on escape of pus Pain subsides on escape of pus

SignsSigns

Starts usually as Starts usually as edema of the lids edema of the lids with chemosiswith chemosis

Yellow pus point Yellow pus point appears on the lid appears on the lid margin around the margin around the root of a lash at the root of a lash at the most prominent part most prominent part of the swellingof the swelling

Signs … contdSigns … contd

Skin gives way and pus Skin gives way and pus drains with sloughingdrains with sloughing

Swelling subsides and Swelling subsides and cicatrix formcicatrix form

Spread of infection to Spread of infection to neighbouring lashes neighbouring lashes opposite lid margin and opposite lid margin and conjunctival sacconjunctival sac

Subsidence of Subsidence of inflammation may leave inflammation may leave area of induration area of induration

Hordeolum ExternumHordeolum Externum

Complications Complications

Cellulitis (particularly in cases of lesion at Cellulitis (particularly in cases of lesion at inner canthus)inner canthus)

Orbital thrombophebitis (leading to Orbital thrombophebitis (leading to cavernous sinus thrombosis and its cavernous sinus thrombosis and its complications)complications)

TreatmentTreatment

I.I. Systemic Systemic

a. Antibiotic a. Antibiotic

b. Anti-inflammatory analgesicb. Anti-inflammatory analgesic

c. Supportivec. Supportive

d Treatment of associated systemic d Treatment of associated systemic predisposing causepredisposing cause

TreatmentTreatment

II. LocalII. Local

a. Hot fomentationa. Hot fomentation

b. Local broad spectrum antibiotic drop b. Local broad spectrum antibiotic drop and ointmentand ointment

c. Evacuation of pus when pus points, c. Evacuation of pus when pus points, sometimes epilation may be required sometimes epilation may be required before evacuation of pus (lid margin/ before evacuation of pus (lid margin/ lesion should never be squeezed)lesion should never be squeezed)

Hordeolum Internum Hordeolum Internum

Hordeolum Internum Hordeolum Internum

Hordeolum Internum is a suppurative Hordeolum Internum is a suppurative inflammation of meibomian gland. inflammation of meibomian gland.

It may be due to secondary infection of It may be due to secondary infection of meibomian gland or it may start to begin meibomian gland or it may start to begin with as suppurative infection of with as suppurative infection of meibomian gland. meibomian gland.

This condition is more symptomatic than This condition is more symptomatic than stye, the gland is larger and is located in stye, the gland is larger and is located in fibrous tarsal plate fibrous tarsal plate

SymptomsSymptoms

Pain, which may be severe throbbing Pain, which may be severe throbbing Swelling , which is away from lid margin Swelling , which is away from lid margin Pus pointing either at the lid margin or on Pus pointing either at the lid margin or on

the palpabral conjunctiva the palpabral conjunctiva

Signs Signs

Swelling of affected lid, due to associated Swelling of affected lid, due to associated cellulitis cellulitis

Swelling is more marked about 4-5 mm Swelling is more marked about 4-5 mm from lid margin from lid margin

TendernessTenderness Palpabral conjunctiva over the swelling is Palpabral 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 margin Pus point may be visible at the lid margin

Hordeolum InternumHordeolum Internum

Treatment of Hordeolum Treatment of Hordeolum Internum Internum

Medical treatment is similar to treatment of Medical treatment is similar to treatment of Hordeoulm externum i.e.Hordeoulm externum i.e.

Systemic Systemic

a. Antibiotic a. Antibiotic

b. Anti-inflammatory analgesicb. Anti-inflammatory analgesic

LocalLocal

a. Hot fomentationa. Hot fomentation

b. Local broad spectrum antibiotic drop and b. Local broad spectrum antibiotic drop and ointmentointment

Possible outcome of Possible outcome of TreatmentTreatment

It may resolve with evacuation of pus at the lid It may resolve with evacuation of pus at the lid marginmargin

It may burst on palpabral conjunctiva, leading to It may burst on palpabral conjunctiva, leading to infective bacterial conjunctivitis and persistence infective bacterial conjunctivitis and persistence of growth on palpabral conjunctiva, resembling of growth on palpabral conjunctiva, resembling papilloma. It due to fungating mass of papilloma. It due to fungating mass of granulation tissue sprouting through opening. It granulation tissue sprouting through opening. It causes irritation and conjunctival discharge causes irritation and conjunctival discharge

It turns into chronic granuloma i.e. Chalazion It turns into chronic granuloma i.e. Chalazion

Chalazion Chalazion

ChalazionChalazion

Chalazion is also called tarsal cyst or meibomian cystChalazion is also called tarsal cyst or meibomian cyst Chalazion is chronic inflammatory inflammatory Chalazion is chronic inflammatory inflammatory

granuloma of meibomian gland granuloma of meibomian gland Seen in adults more often as multiple lesions occurring Seen in adults more often as multiple lesions occurring

in cropsin crops The glandular tissue is replaced by granulation tissue The glandular tissue is replaced by granulation tissue

consisting of gaint cells, polymorphonuclear cell, consisting of gaint cells, polymorphonuclear cell, plasma cells and histiocytes, indicating reaction to plasma cells and histiocytes, indicating reaction to chronic irritation. The opening of meibomian gland is chronic irritation. The opening of meibomian gland is occluded leading to retention which acts as cause of occluded leading to retention which acts as cause of chronic irritation chronic irritation

ChalazionChalazion

Symptoms:Symptoms:

Hard painless swelling little away from lid Hard painless swelling little away from lid margin margin

Swelling increases gradually in size without Swelling increases gradually in size without painpain

Small chalazia are better felt than seenSmall chalazia are better felt than seen

Multiple lesions and large chalazion may be Multiple lesions and large chalazion may be associated with inability to open eye fully associated with inability to open eye fully

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 hardOn conjunctival side it appears red or purple. In long On conjunctival side it appears red or purple. In long standing lesions it appears grey. In old lesion standing lesions it appears grey. In old lesion granulation tissue turns into jelly-like mass.granulation tissue turns into jelly-like mass.Chalazion may become smaller over the period of Chalazion may become smaller over the period of time , but complete resolution may occur only rarely time , but complete resolution may occur only rarely Sometimes the granulation tissue is formed in the duct Sometimes the granulation tissue is formed in the duct and project at the intermarginal strip as a reddish grey and project at the intermarginal strip as a reddish grey nodule nodule

ChalazionChalazion

Adenoma of Meibomian Adenoma of Meibomian GlandGland

Treatment of Chalazion Treatment of Chalazion

Intralesional injection of Triamcinolone Intralesional injection of Triamcinolone Acetonide may help in resolution of Acetonide may help in resolution of chalazion chalazion

Incision & curette of chalazion is Incision & curette of chalazion is indicated in cases when it causes indicated in cases when it causes disfigurement and mechanical ptosis due disfigurement and mechanical ptosis due to its weight to its weight

Steps of operation Steps of operation

Explain about condition and operationExplain about condition and operation Informed consentInformed consent Topical anaesthesia and sub-muscular Topical anaesthesia and sub-muscular

infiltration of 2% Lignocaineinfiltration of 2% Lignocaine Application of chalazion clamp around the Application of chalazion clamp around the

nodule (this will provide field for bloodless nodule (this will provide field for bloodless operation, hard base and protect deeper operation, hard base and protect deeper soft structures). Lid is evertedsoft structures). Lid is everted

Infiltration of lignocaine around swelling Infiltration of lignocaine around swelling

Instruments Instruments

StepsSteps

Vertical incision on most prominent point/ Vertical incision on most prominent point/ point of greatest discolouration with point of greatest discolouration with sharp scalpel blade sharp scalpel blade

Semi-fluid/ cheesy contents are taken out Semi-fluid/ cheesy contents are taken out with small chalazion scoop (Curette) with small chalazion scoop (Curette)

Pseudocapsule/ cavity is excised or the Pseudocapsule/ cavity is excised or the cavity is cauterized with pure carbolic cavity is cauterized with pure carbolic acid or 10-20% trichloracetic acid acid or 10-20% trichloracetic acid

StepsSteps

Clamp is removed, and pressure is Clamp is removed, and pressure is applied on lid to stop bleeding or pressure applied on lid to stop bleeding or pressure bandage is applied for few hours bandage is applied for few hours

Swelling remains for few days after Swelling remains for few days after surgery as the cavity is filled by blood surgery as the cavity is filled by blood

Post-operatively analgesic may be Post-operatively analgesic may be needed systemically. Local antibiotic drop needed systemically. Local antibiotic drop and ointment for one to two weeks and ointment for one to two weeks

ChalazionChalazion

Very hard chalazion near canthi may be Very hard chalazion near canthi may be adenoma of gland and requires excisionadenoma of gland and requires excision

Recurrent lesion particularly in elderly Recurrent lesion particularly in elderly patients should be investigated for patients should be investigated for meibomian gland carcinoma (by biopsy) meibomian gland carcinoma (by biopsy)

BlepharitisBlepharitis

Blepharitis Blepharitis

Blepharitis is chronic inflammation of lid Blepharitis is chronic inflammation of lid margin occurring as true inflammation or margin occurring as true inflammation or as simple hyperaemia.as simple hyperaemia.

TypesTypes

1.1. Anterior Anterior

a. Squamous a. Squamous

b. Ulcerativeb. Ulcerative

2. Posterior 2. Posterior

a. Meibomian seborrhoea a. Meibomian seborrhoea

b. Meibomianitis b. Meibomianitis

CausesCauses

1.1. Following chronic Conjunctivitis Following chronic Conjunctivitis especially due to staphylococciespecially due to staphylococci

2.2. Parasitic infection, Blepharitis acarica Parasitic infection, Blepharitis acarica due to Demodex Folliculorum and due to Demodex Folliculorum and Phthiriasis Palpabrarum due to crab Phthiriasis Palpabrarum due to crab louse louse

Seborrhoeic or Squamous Seborrhoeic or Squamous Blepharitis Blepharitis

Is a form of anterior blebharitis characterized Is a form of anterior blebharitis characterized by deposition of white scales among the eye by deposition of white scales among the eye lashes. Eye lashes fall and replaced by lashes. Eye lashes fall and replaced by undistorted eyelashes. undistorted eyelashes.

On removal of scales, lid margins appear On removal of scales, lid margins appear hyperaemic. Ulcers are absent. hyperaemic. Ulcers are absent.

Condition is metabolic associated with dandruff Condition is metabolic associated with dandruff of the scalp of the scalp

Usually associated with seborrhoeic dermatitis Usually associated with seborrhoeic dermatitis involving scalp, nasolabial folds and involving scalp, nasolabial folds and retroauricular areasretroauricular areas

Squamous BlepharitisSquamous Blepharitis

Symptoms Symptoms

Burning, deposits / crusting along lid Burning, deposits / crusting along lid margins, grittiness , redness of lid margins, grittiness , redness of lid margins, photophobiamargins, photophobia

Symptoms are worse in the morning Symptoms are worse in the morning

Seborrhoeic or Seborrhoeic or Squamous BlepharitisSquamous Blepharitis

Skin condition also requires treatment.Skin condition also requires treatment. Cleaning of lid margin with baby Cleaning of lid margin with baby

shampoo. In case of bacteria infection, shampoo. In case of bacteria infection, local antibiotic drops and ointment. local antibiotic drops and ointment. Associated tear film dysfunction, if Associated tear film dysfunction, if present is treated with artificial tear drops present is treated with artificial tear drops

Staphylococcal or Staphylococcal or Ulcerative Blepharitis Ulcerative Blepharitis

Ulcerative blepharitis is infective condition Ulcerative blepharitis is infective condition commonly due to staphylococcal infection commonly due to staphylococcal infection

Lid margins are covered with infective Lid margins are covered with infective material (yellow crusts or dry brittle material (yellow crusts or dry brittle scales) matting eyelashes. On removal of scales) matting eyelashes. On removal of discharge small ulcers which bleed are discharge small ulcers which bleed are found along lid margins around bases of found along lid margins around bases of the eyelashes the eyelashes

Symptoms Symptoms

Redness of lid margins, burning, itching, Redness of lid margins, burning, itching, watering and photophobia watering and photophobia

Signs: Signs: Small ulcers at lid margins on removal of Small ulcers at lid margins on removal of

discharge, this features differentiate it from discharge, this features differentiate it from conjunctivitis conjunctivitis

Ulcerative BlepharitisUlcerative Blepharitis

Treatment Treatment

Discharge/ crust is removed from lid Discharge/ crust is removed from lid margins with 1:4 dilution baby shampoo margins 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 cleaned The loose discharge is then cleaned cotton cotton

Diseased eyelashes are epilated Diseased eyelashes are epilated Appropriate antibiotic drops are used Appropriate antibiotic drops are used After control of infection, daily cleaning of After control of infection, daily cleaning of

lid margins with blend lotion lid margins with blend lotion

TreatmentTreatment

Improvement of local hygiene (rubbing of Improvement of local hygiene (rubbing of eyes and touching of eyes with dirty hand eyes and touching of eyes with dirty hand should be discouraged) should be discouraged)

Sequelae of Ulcerative Sequelae of Ulcerative Blepharitis Blepharitis

Chronic course and associated chronic Chronic course and associated chronic conjunctivitis conjunctivitis

Madarosis (Scanty eyelashes) due to Madarosis (Scanty eyelashes) due to falling of eyelashesfalling of eyelashes

Trichiasis (misdirected eyelashes) due to Trichiasis (misdirected eyelashes) due to contraction of scar tissuecontraction of scar tissue

Cicatrization of lid margins causing Cicatrization of lid margins causing thickening and hypertrophy of tissue and thickening and hypertrophy of tissue and drooping of lids (Tylosis)drooping of lids (Tylosis)

Sequelae of Ulcerative Sequelae of Ulcerative BlepharitisBlepharitis

Cicatrization of lid margin may drag Cicatrization of lid margin may drag conjunctiva on posterior border of conjunctiva on posterior border of intermarginal strip disturbing angle of intermarginal strip disturbing angle of posterior edge leading to epiphora , posterior edge leading to epiphora , eversion of puncta eversion of puncta

Epiphora leads to eczematous condition Epiphora leads to eczematous condition of skin, scarring of skin leads to ectropion of skin, scarring of skin leads to ectropion . This further aggravate epiphora . This further aggravate epiphora

Posterior Blepharitis Posterior Blepharitis

Posterior blepharitis i.e. inflammation of Posterior blepharitis i.e. inflammation of meibomian duct opening at intermarginal strip meibomian duct opening at intermarginal strip and posterior border may cause tear film and posterior border may cause tear film instability and inferior punctate keratitis instability and inferior punctate keratitis

It occurs in two clinical forms It occurs in two clinical forms a. Meibomian seborrhoea – characteristic a. Meibomian seborrhoea – characteristic appearance of oil droplet at the opening of appearance of oil droplet at the opening of meibomian duct opening at intermarginal strip. meibomian duct opening at intermarginal strip. Tear film is oily and foamy. Frothy discharge Tear film is oily and foamy. Frothy discharge accumulate on the lid margin. Foam like accumulate on the lid margin. Foam like discharge can be expressed from these lesions discharge can be expressed from these lesions

Posterior BlepharitisPosterior Blepharitis

b. Meibomianitis – There is inflammation b. Meibomianitis – There is inflammation and obstruction of meibomian glands. and obstruction of meibomian glands. Characterized by diffuse thickening of Characterized by diffuse thickening of posterior border of lid margin which posterior border of lid margin which becomes rounded. On lid massage becomes rounded. On lid massage toothpaste like thick material can be toothpaste like thick material can be expressed out. Due to duct blockade cyst expressed out. Due to duct blockade cyst formation may be present formation may be present

Complications Complications

Chalazion Chalazion Tear film instabilityTear film instability Papillary conjunctivitis and inferior Papillary conjunctivitis and inferior

corneal erosions corneal erosions

TreatmentTreatment

Warm compresses Warm compresses Systemic - Doxycycline 100 mgm twice x Systemic - Doxycycline 100 mgm twice x

1 week then once daily for 6 -12 weeks 1 week then once daily for 6 -12 weeks or Tetracycline 250 mgm 4 times x 1 or Tetracycline 250 mgm 4 times x 1 week then twice for 6 -12 weeksweek then twice for 6 -12 weeks

Associated tear film abnormality is Associated tear film abnormality is treated with artificial tear dropstreated with artificial tear drops

Entropion Entropion

Lower lid retractorsLower lid retractors

a.a. Inferior lid retractors:Inferior lid retractors:

1. The inferior tarsal aponeurosis – 1. The inferior tarsal aponeurosis – capsulo-palpabral expansion of the capsulo-palpabral expansion of the inferior rectus muscle and is analogous inferior rectus muscle and is analogous to the levator aponeurosis to the levator aponeurosis

2. Inferior tarsal muscle is analogous to 2. Inferior tarsal muscle is analogous to muller muscle muller muscle

Entropion Entropion

Entropion is in-rolling of eye lid margin.Entropion is in-rolling of eye lid margin.

Normal position of sharp posterior border of Normal position of sharp posterior border of inter-marginal strip is essential for interigrity of inter-marginal strip is essential for interigrity of the tear film and for maintenance of healthy the tear film and for maintenance of healthy ocular surfaceocular surface

Entropion is caused by disparity of length and Entropion is caused by disparity of length and tone of anterior skin muscle layer and posterior tone of anterior skin muscle layer and posterior tarso-conjunctival layer of the eyelid tarso-conjunctival layer of the eyelid

Symptoms of EntropionSymptoms of Entropion

Foreign body sensationForeign body sensation Watering Watering RednessRedness PainPain Photophobia Photophobia

These symptoms are due to rubbing of These symptoms are due to rubbing of ocular surface by misdirected eyelashes ocular surface by misdirected eyelashes

ClassificationClassification

1.1. InvolutionalInvolutional

2.2. Cicatricial Cicatricial

3.3. Spastic Spastic

4.4. Congenital Congenital

Involutional Entropion Involutional Entropion

This condition is due to old age, due to This condition is due to old age, due to instability of lid structures instability of lid structures There occurs:There occurs:a. Weakness of the posterior retractor of a. Weakness of the posterior retractor of the lid the lid b. Laxity of medial and lateral canthal b. Laxity of medial and lateral canthal ligaments ligaments c. Atrophy of orbital pad of fat leading to c. Atrophy of orbital pad of fat leading to enophthalmos enophthalmos

Involutional EntropionInvolutional Entropion

There occurs of over-ridding of preseptal There occurs of over-ridding of preseptal orbicularis muscle over pretarsal orbicularis muscle over pretarsal orbicularis, that leads to forward rotation orbicularis, that leads to forward rotation of tarsal plate of tarsal plate

Seen in lower lids Seen in lower lids

Involutional EntropionInvolutional Entropion

Involutional EntropionInvolutional Entropion

Treatment of Treatment of Involutional Entropion Involutional Entropion

Principles of surgery Principles of surgery

1.1. Reattachment of the retractor to tarsal Reattachment of the retractor to tarsal plateplate

2.2. Shortening of horizontal width of lidShortening of horizontal width of lid

3.3. To induce scarring between the pre-To induce scarring between the pre-tarsal and pre-septal parts of orbicularis tarsal and pre-septal parts of orbicularis muscle muscle

Surgical Procedures Surgical Procedures

1.1. Catgut suture application throughCatgut suture application through

2.2. Modified Bick operation: Horrizontal Modified Bick operation: Horrizontal shortening of lower lid with fixation to shortening of lower lid with fixation to lateral canthal ligament and periosteum lateral canthal ligament and periosteum

3.3. Tucking of inferior lid retractors Tucking of inferior lid retractors

Cicatricial Entropion Cicatricial Entropion

Caused by contraction of scar tissue of Caused by contraction of scar tissue of the palpabral conjunctiva the palpabral conjunctiva

In this case there is relative shortening of In this case there is relative shortening of inner layer i.e. tarso-conjunctiva inner layer i.e. tarso-conjunctiva

Caused by scarring of palpabral Caused by scarring of palpabral conjunctiva by trachoma, trauma, conjunctiva by trachoma, trauma, chemical injuries (burns), pemphigus and chemical injuries (burns), pemphigus and Stevens-Johnson syndrome Stevens-Johnson syndrome

TreatmentTreatment

Principles of surgeryPrinciples of surgery

1.1. Tarsal rotation (forwards)Tarsal rotation (forwards)

2.2. Lengthening of posterior lid lamina so Lengthening of posterior lid lamina so that eyelashes turn forwards that eyelashes turn forwards

Surgery Surgery

a.a. Wedge resection (Tarsal paring)Wedge resection (Tarsal paring)

b.b. Tarsal fracture Tarsal fracture

Spastic Entropion Spastic Entropion

This condition is due to spasm of orbicularis in This condition is due to spasm of orbicularis in presence of degeneration of the palpabral presence of degeneration of the palpabral connective tissue separating orbicularis fibres. connective tissue separating orbicularis fibres. The spasm is induced by local irritation in The spasm is induced by local irritation in inflammatory and traumatic conditions. inflammatory and traumatic conditions.

Factors that prevent in-rolling of lid margin: Factors that prevent in-rolling of lid margin: a. intact inferior lid aponeurosis which maintains a. intact inferior lid aponeurosis which maintains orbicularis in position that it presses against lower orbicularis in position that it presses against lower tarsus tarsus b. contraction of palpabral head of inferior rectus b. contraction of palpabral head of inferior rectus

Mechanism Mechanism

Degeneration of aponeurosis, the strong Degeneration of aponeurosis, the strong contraction of orbicularis is associated contraction of orbicularis is associated with turning inwards of lid marginwith turning inwards of lid margin

Senile degeneration of tarsal muscle of Senile degeneration of tarsal muscle of Muller fails to anchor the lower border of Muller fails to anchor the lower border of tarsal plate to bony orbittarsal plate to bony orbit

Orbicularis rides up on tarsal plate Orbicularis rides up on tarsal plate towards lid margin towards lid margin

Horizontal lid laxity Horizontal lid laxity

Clinical pictureClinical picture

Condition is found in elderly patients Condition is found in elderly patients Tight bandaging may cause spastic Tight bandaging may cause spastic

entropion entropion Narrowness of palpabral aperture Narrowness of palpabral aperture Seen in lower lids Seen in lower lids

Treatment of Spastic Treatment of Spastic EntropionEntropion

Removal of cause i.e removal of cause of Removal of cause i.e removal of cause of irritation, tight bandagingirritation, tight bandaging

Treatment of surface disorder by artificial Treatment of surface disorder by artificial tears and control of conjunctival infection tears and control of conjunctival infection and lid inflammation with antibioticand lid inflammation with antibiotic

Fixing of lower lid after everting it with Fixing of lower lid after everting it with adhesive tape adhesive tape

Injection of Botulinum toxin into pre-tarsal Injection of Botulinum toxin into pre-tarsal orbicularis to weaken it orbicularis to weaken it

Surgical treatment Surgical treatment

Producing a ridge of fibrous tissue in the Producing a ridge of fibrous tissue in the orbicularis to prevent its fibres from orbicularis to prevent its fibres from sliding in vertical direction sliding in vertical direction

Congenital Entropion Congenital Entropion

This condition is due to dysgenesis of This condition is due to dysgenesis of lower lid retractor or due to abnormal lower lid retractor or due to abnormal development of tarsal plate.development of tarsal plate.

This condition must be differentiated from This condition must be differentiated from epiblepharon (due to anomalous fold of epiblepharon (due to anomalous fold of skin pushing lashes upwards onto the skin pushing lashes upwards onto the eyeball)eyeball)

Treatment of abnormality Treatment of abnormality

Ectropion Ectropion

Ectropion Ectropion

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 sensationPain Pain

RednessRednessPhotophobia (Due to involvement of cornea)Photophobia (Due to involvement of cornea)Symptoms are due to eversion of punta, and Symptoms are due to eversion of punta, and exposure of ocular surface, chronic conjunctivitis exposure of ocular surface, chronic conjunctivitis caused by exposure and drying of surface caused by exposure and drying of surface

ClassificationClassification

I. Acquired I. Acquired Involutional or senileInvolutional or senile Cicatricial Cicatricial ParalyticParalytic Mechanical Mechanical

II. Congenital II. Congenital

Functions of lidsFunctions of lids

1.1. Protection of eyeProtection of eye

2.2. Act as lacrimal pump Act as lacrimal pump

Effect of age Effect of age

Slowly there is relaxation of lid Slowly there is relaxation of lid structures (canthal ligament and structures (canthal ligament and orbiularis)orbiularis)

Involutional EctropionInvolutional Ectropion

Stages:Stages:

1.1. Early stage: in mild cases on looking up Early stage: in mild cases on looking up the puncta is not apposed to bulbar the puncta is not apposed to bulbar conjunctiva conjunctiva

2.2. Progresses to moderate stage puncta Progresses to moderate stage puncta are not apposed to bulbar conjunctiva are not apposed to bulbar conjunctiva even in primary gaze and entire lid even in primary gaze and entire lid margin fall away from the globe margin fall away from the globe

Involutional EctropionInvolutional Ectropion

3. In severe case lower lids are rolled out and 3. In severe case lower lids are rolled out and palpabral conjunctiva (including tarso-palpabral conjunctiva (including tarso-conjunctiva and fornix are exposed) conjunctiva and fornix are exposed)

Chronic exposure of lower puncta on everted lid Chronic exposure of lower puncta on everted lid leads to phimosis of puncta leads to phimosis of puncta

Tears are no longer drained into nose and Tears are no longer drained into nose and overflow onto the cheek overflow onto the cheek

In long standing cases keratinization of the lid In long standing cases keratinization of the lid margin and palpabral conjunctiva takes place margin and palpabral conjunctiva takes place

SignsSigns

Signs as described with three stages earlierSigns as described with three stages earlier In ling standing cases the exposed conjunctiva In ling standing cases the exposed conjunctiva

becomes dry, thickened, red , un-sightly. Cornea becomes dry, thickened, red , un-sightly. Cornea may suffer from imperfect closure of the lidsmay suffer from imperfect closure of the lids

Diagnosis is confirmed if lower lids does not Diagnosis is confirmed if lower lids does not snap back into position after pulling it 6-7 mm snap back into position after pulling it 6-7 mm away from globe. If canthal displacement is away from globe. If canthal displacement is more than 2 mm on pulling lower lid laterally or more than 2 mm on pulling lower lid laterally or medially , canthal laxity is diagnosed medially , canthal laxity is diagnosed

There is horizontal lengthening of the lids There is horizontal lengthening of the lids

TreatmentTreatment

Surgical treatment:Surgical treatment:in mild to moderate cases, excision of 7 – 8 mm in mild to moderate cases, excision of 7 – 8 mm long x 4 mm high conjunctival exicion 5 mm long x 4 mm high conjunctival exicion 5 mm below lid margin (puncta), this puts back puncta below lid margin (puncta), this puts back puncta in its normal positionin its normal positionIn more marked cases 5 mm full thickness In more marked cases 5 mm full thickness shortening/ resection of lid 5 mm from puncta, by shortening/ resection of lid 5 mm from puncta, by giving inverted house shaped incision (modified giving inverted house shaped incision (modified Kuhnt Szymanowski operation at lateral canthus Kuhnt Szymanowski operation at lateral canthus or modified Lazy T operation at medial canthus) or modified Lazy T operation at medial canthus)

Cicatricial Ectropion Cicatricial Ectropion

Is out-rolling of lid marging due to Is 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 chronic chemical injuries and chronic inflammations of lid skin. Due to inflammations of lid skin. Due to contraction of scar the lid skin shortens contraction of scar the lid skin shortens pulling the eyelid away from the eyeball pulling the eyelid away from the eyeball

Cicatricial EctropionCicatricial Ectropion

Ectropion Pre and Post-Ectropion Pre and Post-operativeoperative

TreatmentTreatment

Principle of surgery:Principle of surgery:release and relaxation of the scar tissue release and relaxation of the scar tissue and restoration (elongation) of skin by and restoration (elongation) of skin by blepharoplasty blepharoplasty Localized small scar may be treated by Localized small scar may be treated by V-Y operation V-Y operation Large scar requires excision of scar Large scar requires excision of scar tissue and application of matching (whole tissue and application of matching (whole or spilt) skin graft or spilt) skin graft

Paralytic Ectropion Paralytic Ectropion

This condition is due to paralysis of the facial nerve This condition is due to paralysis of the facial nerve due to Bell palsy, surgery on parotid gland and trauma due to Bell palsy, surgery on parotid gland and trauma

Characterized by presence of other signs of facial Characterized by presence of other signs of facial palsypalsy

Initially treated by conservative treatment by taping of Initially treated by conservative treatment by taping of lids, lubricating eye drops, till there is recoverylids, lubricating eye drops, till there is recovery

Lateral tarsorrhaphy, by suturing freshened upper and Lateral tarsorrhaphy, by suturing freshened upper and lower lids at outer canthuslower lids at outer canthus

Lagophthalmos due to weakness of superior orbicularis Lagophthalmos due to weakness of superior orbicularis may be treated by taping may be treated by taping