DISEASES OF

THE EYELIDS
MIKAH TCHALE
 INTRODUCTION
 mobile tissue curtains placed in front of the eyelids
Position of the eyelids
 Upper eyelid → 1/6th of the cornea
 Lower eyelid → just touches the limbus
Palpebral aperture
 Vertically → 10-11mm
 Horizontally → 28-80mm
 EYELID CONTUSION
 Bruising of eyelid with edema & ecchymosis, usually 2˚ to blunt
trauma
 Posterior extension into the orbit should be evaluated
 Traumatic ptosis can occur → up to 6 months to recover
 Excellent prognosis
 Treatment
 Rule out open globe
 Cold compresses for up to 45 mins per hour while awake for 24-48
hours
 EYELID LACERATION
Cut in the eyelid involving skin & deeper structures
(muscle & fat) → penetrating trauma
Divided into
 No lid margin involvement
 Lid margin involvement
 Canthal angle involvement
TREATMENT
Tetanus Toxoid Vaccine (TTV) 0.5ml IM → tetanus
prophylaxis
For dirty wound → systemic antibiotics
 Doxycycline 250-500mg po QID x 7-10 days
 Penicillin V 500mg po QID x 7 days → animal or human bites
 Amoxicillin 500mg po TDS x 7 days
Surgical repair of eyelid laceration
 CHALAZION
aka tarsal or meibomian cyst
Chronic non-infective granulomatous inflammation of the
meibomian gland
CLINICAL PRESENTATION
 Px usually present with a painless swelling in the eyelid & a feeling
of heaviness
 Exam → small, firm to hard, non-tender swelling slightly away from
the lid margin
TREATMENT
Conservative treatment
 Hot compresses
 Topical antibiotics
 Oral NSAIDs e.g. Brufen 400mg tds x 5/7
Intralesional injection of long-acting steroid (triamcinolone)
Incision & curettage → conventional & effective tx
 EXTERNAL HORDEOLUM
(STYE)
Acute suppurative inflammation of gland of Zeiss or Moll
Predisposing factors
 Children & young adults
 Hyperopia
 Chronic blepharitis
 Diabetes mellitus
Causative organism → Staphylococcus aureus
Symptoms
 Acute pain
 Swelling of the eyelid
 Mild watering
 Photophobia
Signs
 Localised, hard, red, tender swelling at the lid margin associated
with marked edema
TREATMENT
Hot compresses
Antibiotic eye drops e.g. Genta 0.3% tds x 7/7
Antibiotic ointment nocte
Systemic NSAIDs e.g. Brufen 400mg tds x 5/7
Systemic antibiotics e.g. Amoxyl 500mg BD or tds x 7/7
Incision and drainage for large abscess (rare)
 INTERNAL HORDEOLUM
Suppurative inflammation of the meibomian gland
associated with blockage of the duct
Etiology
 1˚ staphylococcal infection of the meibomian gland
 Infected chalazion
Clinical presentation → same as external hordeolum,
except that pain is more intense
Treatment → same as external hordeolum
 BLEPHARITIS
Subacute/chronic inflammation of the eyelid margins
Extremely common
Clinical types
 Squamous/seborrhoeic blepharitis
 Ulcerative/staphylococcal blepharitis
 Mixed squamous with ulcerative blepharitis
 Posterior blepharitis/meibomitis
 Parasitic blepharitis
SQUAMOUS BLEPHARITIS
Associated with seborrhoea of scalp (dandruff)
Glands of Zeiss secrete abnormal excessive neutral lips →
irritating free fatty acids
Symptoms
 Px complains of deposition of whitish material at the lid margin
 Mild discomfort
 Irritation
 Occasional watering
 Hx of falling of eyelashes
Signs
 Accumulation of white dandruff-like scales on the eyelid margin
 On removing scales, underlying surface is hyperaemic (no ulcers)
 Lashes fall out easily
 Long-standing cases → thickened lid margin
TREATMENT
Lid hygiene → daily hot compresses to the eyelids
Cleansing of the eyelid margins with diluted baby shampoo
or soda or soap
Topical antibiotic oint qhs x 2-4 weeks
Artificial tears
ULCERATIVE BLEPHARITIS
Chronic staphylococcal infection of eyelid margins
Associated with tear film instability & dry eye
Sxs are worse in the morning
Predisposing factors
 Chronic conjunctivitis
 dacryocystitis
Symptoms
 Chronic irritation
 Itching
 Mild lacrimation
 Gluing of cilia
 photophobia
Signs
 Yellow crusts are seen at the root of cilia
 Small ulcers which bleed easily seen on removing the crusts
 Dilated blood vessels on the anterior lid margin (rosettes)
Complications
 Recurrent stye (very common)
 Chronic conjunctivitis
 Madarosis (sparseness/absence of lashes)
 Poliosis (greying of lashes)
 Tylosis (thickening of eyelids)
 Eversion of the punctum
 ectropion
TREATMENT
Same as in squamous blepharitis
TEO 1% BD x 1/12
Oral NSAIDs e.g. Brufen 400mg po TDS x 5/7
Systemic antibiotics
 Doxycycline 100mg po BD x 7/7, then 1 tab OD x 1/12
 Azithromycin 500mg po TDS x 14/7
 Erythromycin 250mg BD x 14/7 (children)
POSTERIOR BLEPHARITIS
Chronic meibomitis
Meibomian gland dysfunction → usually middle-aged
White frothy (foam-like) secretion → eyelid margins & canthi
Eyelid eversion → vertical yellowish streaks thru conjunctiva
At the lid margins → blocked openings of meibomian glands
with thick secretions
Signs
 Excessive & abnormal meibomian gland secretion
 Capping of meibomian gland orifices with oil globules
 Hyperemia of the posterior lid margin
 Pressure on the lid margin → turbid/tooth-paste like meibomian
fluid
 Tear film is oily & foamy
 Papillary conjunctivitis
 Corneal punctate epithelial erosions
TREATMENT
 Warm compresses & massaging the eyelid → express
accumulated meibum
 Physical expression of the glands by the clinician
 Antibiotic-steroid ointment on the lid margins
 Topical antibiotic eye drops 3-4x/day
 Systemic antibiotics
 Doxycycline 100mg BD x 1/52 then OD x 6-12 weeks
 Erythromycin 250mg BD (in children)
 TRICHIASIS
Inward misdirection of cilia with normal position of the
eyelid margin
Etiology
 Trachoma
 Ulcerative blepharitis
 Healed membranous conjunctivitis
 hordeolum
  Mechanical injuries
 Burns
 Operative scar on the lid margin
 Symptoms
 FB sensation
 Photophobia
 Irritation
 Pain
 Lacrimation
Signs
 Misdirected cilia touching the cornea
 Reflex blepharospasm
 Congested conjunctiva
Complications
 Recurrent corneal abrasions
 Superficial corneal opacities
 Corneal vascularisation
 Non-healing corneal ulcer
TREATMENT
Epilation → mechanical removal with forceps
Electrolysis
Cryoepilation
Surgical correction
Treat underlying condition
 ENTROPION
Inturning of the eyelid margin
TYPES
Congenital Entropion →rare
Cicatricial entropion → usually involve the upper eyelid
 Trachoma
 Membranous conjunctivitis
 Chemical burns
 Steven-Johnson syndrome
Spastic entropion
 Spasm of orbicularis muscle in pxs with chronic irritative corneal
conditions or after tight corneal bandaging
 Common in old people & usually involve the lower eyelid
Senile (involuntary) entropion
 Common type
 Elderly people & affects lower eyelid
Mechanical entropion
 Lack of support provided by the globe to the eyelid
 Pxs with phthisis bulbi, enophthalmos & after evisceration or
enucleation
SIGNS
Grade I → only posterior lid border is enrolled
Grade II → inturning up to the intermargin strup
Grade III → whole lid margin including anterior border is
inturned
Complications → same as trichiasis
TREATMENT
Congenital entropion → plastic reconstruction of the lid
crease
Surgical treatment
READING ASSIGNMENT
ECTROPION
 ETIOLOGY
 SIGNS AND SYMPTOMS
 COMPLICATIONS
 TREATMENT
 LAGOPHTHALMOS
Inability to voluntarily close the eyelids
Nocturnal lagophthalmos → physiologically some pple
sleep with their eyes open
Etiology
 Pxs with paralysis of orbicularis oculi muscle
 Cicatricial contraction of the eyelids
 Symblepharon
 Severe ectropion
 Proptosis
 Comatose pxs
Clinical presentation
 Incomplete closure of the palpebral aperture associated with
features of the causative disease
Complications
 Conjunctival & corneal xerosis
 Exposure keratitis
TREATMENT
Prevent exposure keratitis
 Artificial tears
 Antibiotic eye ointment during sleep & in comatose pxs
 Soft bandage contact lenses
Treat underlying disease
Tarsorrhaphy
 BLEPHAROSPASM
 Involuntary, sustained & forceful closure of the eyelids
 Two clinical forms
 Essential (spontaneous) blepharospasm
 rare, idiopathic condition involving pxs between 45 & 65 yrs
 Reflex blepharospasm → reflex sensory stimulation of 5th cranial nerve
 Phlyctenular keratitis
 Interstitial keratitis
 Corneal FB
 Corneal ulcer
 iridocyclitis
Clinical features
 Persistent epiphora
 Edema of the eyelids
 Entropion → long-standing cases
 Blepharophimosis → palpebral fissure is decreased
TREATMENT
Essential blepharospasm
 Subcutaneous injection of Botulinum toxin
 Facial denervation in severe cases
Reflex blepharospasm
 Treat the causative disease
 Treat the associated complications
 ACQUIRED PTOSIS
Abnormal dropping of the upper eyelid
Normal → 2mm of the cornea
More than 2mm → ptosis
ETIOLOGY
Neurogenic ptosis
 Innervational defects e.g. 3rd nerve palsy, Horner’s syndrome,
migraine & multiple sclerosis
Myogenic ptosis
 Acquired LPS muscle disorder
 Pxs with myasthenia gravis, dystropha myotonica, ocular
myopathy, trauma to the LPS muscle
Aponeurotic ptosis
 Defects of the levator aponeurosis in presence of a normal
functioning muscle
 Includes senile ptosis, post-operative ptosis
Mechanical ptosis
 Excessive weight on the upper eyelid → pxs with lid tumours,
multiple chalazia & lid edema
 Scaring (Cicatricial ptosis) → pxs with ocular pemphigoid &
trachoma
EVALUATION
 Complete ophthalmic hx → age of onset, family hx, hx of trauma, eye
surgery
 General observations
 Laterality → unilateral or bilateral
 Function of orbicularis oculi muscle
 Presence or absence of eyelid crease
 Jaw-winking phenomenon
 Bell’s phenomenon
 Associated weakness of any EOMs
Measurement of degree of ptosis
 Unilateral → difference between the vertical height of the palpebral
fissure of the 2 eyes
 Bilateral → measuring amount of cornea covered by the upper
eyelids then subtract 2mm
 Grading
 Mild → 2mm
 Moderate → 3mm
 Severe → 4mm
Assessment of levator function → Burke’s method
Special investigations
 Ice pack test
 Phenylephrine test → Horner’s syndrome
 Neurological investigations
Photographic record of the px
TREATMENT
 Treat the underlying cause
 Surgical procedures
 Fasanella-servat operation → mild ptosis & good levator fxn
 Levator resection
 Indicated for moderate to severe grades of ptosis
 Contraindicated for pxs of severe ptosis with poor levator fxn
 Frontalis sling operation (Brow suspension) → pxs having severe
ptosis with no levator fxn
 EYELID TUMOURS
PAPILLOMAS
Most common benign tumours
Two clinical forms
 Squamous papilloma
 Occurs in adults; Usually involving the eyelid margin
 Very slow growing or stationary
 Raspberry-like growth or as pedunculated lesion
 Tx → simple excision
 Seborrhoeic keratosis
 Middle aged & older people
 Surface is friable, verrucous & slightly pigmented
BASAL CELL CARCINOMA
Commonest malignant tumour of the eyelid (90%)
Seen in elderly people
Locally malignant
 Lower eyelid (50%)
 Medial canthus (25%)
 Upper eyelid (10-15%)
 Outer canthus (5-10%)
Clinical features
 It starts as a small nodule which undergoes central ulceration with
pearly rolled margins
Treatment
 Local surgical excision of the tumour along with 3mm surrounding
area of normal skin → treatment of choice
 Radiotherapy & cryotherapy → only in inoperable cases
SQUAMOUS CELL CARCINOMA
2nd commonest malignant tumour of the eyelid (5%)
Commonly arises from the lid margin in elderly pxs
Affect upper & lower eyelid equally
Metastasise in preauricular & submandibular lymph nodes
Clinical presentation
 Common → ulcerated growth with elevated & indurated margins
 Rare → polypoid/fungating verrucous lesion without ulceration
Treatment → same as Basal cell carcinoma
KAPOSI SARCOMA
Vascular tumour which typically affects people with
HIV/AIDS
Pink, red-violet to brown lesion
Treatment
 Radiotherapy
 Excision