eye

1. Diseases of Lids

4. Anatomy of Lid

5. Hordeolum Externum
(Stye)

6. Hordeolum Externum
(Stye)
Definition: Localized suppurative
inflammation of gland of zeis at lid
margin at ciliary follicle.

7. Etiology
 Usually caused by staphylococcus
aureus
 There is infection of hair follicle of
eyelash.
 It may complicate Acne Vulgeris in young
adults.

8. Histopathology
 Purulent infection of follicle and its gland
with cellulitis of surrounding connective
tissue

9. Clinical Picture
 Stye are frequently recurrent, appearing
in crops.
 Recurrent lesion is particularly seen in
cases of debility, focal infections and
diabetics.

10. Symptoms
 Severe pain which is sharp throbbing ,
feeling of fullness or heaviness and
feeling of heat
 Tenderness (increase in pain on touching
swelling/ affected area)
 Pain subsides on escape of pus

11. Signs
 Starts usually as
edema of the lids
with chemosis
 Yellow pus point
appears on the lid
margin around the
root of a lash at the
most prominent part
of the swelling

12. Signs … contd
 Skin gives way and pus
drains with sloughing
 Swelling subsides and
cicatrix form
 Spread of infection to
neighbouring lashes
opposite lid margin and
conjunctival sac
 Subsidence of
inflammation may leave
area of induration

13. Hordeolum Externum

14. Complications
 Cellulitis (particularly in cases of lesion at
inner canthus)
 Orbital thrombophebitis (leading to
cavernous sinus thrombosis and its
complications)

15. Treatment
I. Systemic
a. Antibiotic
b. Anti-inflammatory analgesic
c. Supportive
d Treatment of associated systemic
predisposing cause

16. Treatment
II. Local
a. Hot fomentation
b. Local broad spectrum antibiotic drop
and ointment
c. Evacuation of pus when pus points,
sometimes epilation may be required
before evacuation of pus (lid margin/
lesion should never be squeezed)

17. Hordeolum Internum

18. Hordeolum Internum
 Hordeolum Internum is a suppurative
inflammation of meibomian gland.
 It may be due to secondary infection of
meibomian gland or it may start to begin
with as suppurative infection of
meibomian gland.
 This condition is more symptomatic than
stye, the gland is larger and is located in
fibrous tarsal plate

19. Symptoms
 Pain, which may be severe throbbing
 Swelling , which is away from lid margin
 Pus pointing either at the lid margin or on
the palpabral conjunctiva

21. Signs
 Swelling of affected lid, due to associated
cellulitis
 Swelling is more marked about 4-5 mm
from lid margin
 Tenderness
 Palpabral conjunctiva over the swelling is
congested a pus point may be visible
 Pus point may be visible at the lid margin

22. Hordeolum Internum

23. Treatment of
Hordeolum Internum
 Medical treatment is similar to treatment of
Hordeoulm externum i.e.
Systemic
a. Antibiotic
b. Anti-inflammatory analgesic
Local
a. Hot fomentation
b. Local broad spectrum antibiotic drop and
ointment

24. Possible outcome of
Treatment
 It may resolve with evacuation of pus at the lid
margin
 It may burst on palpabral conjunctiva, leading
to infective bacterial conjunctivitis and
persistence of growth on palpabral conjunctiva,
resembling papilloma. It due to fungating mass
of granulation tissue sprouting through
opening. It causes irritation and conjunctival
discharge
 It turns into chronic granuloma i.e. Chalazion

25. Chalazion

26. Chalazion
 Chalazion is also called tarsal cyst or meibomian cyst
 Chalazion is chronic inflammatory inflammatory
granuloma of meibomian gland
 Seen in adults more often as multiple lesions occurring
in crops
 The glandular tissue is replaced by granulation tissue
consisting of gaint cells, polymorphonuclear cell,
plasma cells and histiocytes, indicating reaction to
chronic irritation. The opening of meibomian gland is
occluded leading to retention which acts as cause of
chronic irritation

27. Chalazion
Symptoms:
Hard painless swelling little away from lid
margin
Swelling increases gradually in size without
pain
Small chalazia are better felt than seen
Multiple lesions and large chalazion may
be associated with inability to open eye
fully

28. Chalazion
 Signs:
Painless swelling 4-5 mm away from lid margin.
Swelling is hard
On conjunctival side it appears red or purple. In long
standing lesions it appears grey. In old lesion
granulation tissue turns into jelly-like mass.
Chalazion may become smaller over the period of
time , but complete resolution may occur only rarely
Sometimes the granulation tissue is formed in the duct
and project at the intermarginal strip as a reddish grey
nodule

29. Chalazion

30. Adenoma of Meibomian
Gland

31. Treatment of Chalazion
 Intralesional injection of Triamcinolone
Acetonide may help in resolution of
chalazion
 Incision & curette of chalazion is
indicated in cases when it causes
disfigurement and mechanical ptosis due
to its weight

32. Steps of operation
 Explain about condition and operation
 Informed consent
 Topical anaesthesia and sub-muscular
infiltration of 2% Lignocaine
 Application of chalazion clamp around
the nodule (this will provide field for
bloodless operation, hard base and
protect deeper soft structures). Lid is
everted
 Infiltration of lignocaine around swelling

33. Instruments

34. Steps
 Vertical incision on most prominent point/
point of greatest discolouration with
sharp scalpel blade
 Semi-fluid/ cheesy contents are taken out
with small chalazion scoop (Curette)
 Pseudocapsule/ cavity is excised or the
cavity is cauterized with pure carbolic
acid or 10-20% trichloracetic acid

35. Steps
 Clamp is removed, and pressure is
applied on lid to stop bleeding or
pressure bandage is applied for few
hours
 Swelling remains for few days after
surgery as the cavity is filled by blood
 Post-operatively analgesic may be
needed systemically. Local antibiotic
drop and ointment for one to two weeks

36. Chalazion
 Very hard chalazion near canthi may be
adenoma of gland and requires excision
 Recurrent lesion particularly in elderly
patients should be investigated for
meibomian gland carcinoma (by biopsy)

37. Blepharitis

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

39. Types
1. Anterior
a. Squamous
b. Ulcerative
2. Posterior
a. Meibomian seborrhoea
b. Meibomianitis

40. Causes
1. Following chronic Conjunctivitis
especially due to staphylococci
2. Parasitic infection, Blepharitis acarica
due to Demodex Folliculorum and
Phthiriasis Palpabrarum due to crab
louse

41. Seborrhoeic or
Squamous Blepharitis
 Is a form of anterior blebharitis characterized
by deposition of white scales among the eye
lashes. Eye lashes fall and replaced by
undistorted eyelashes.
 On removal of scales, lid margins appear
hyperaemic. Ulcers are absent.
 Condition is metabolic associated with dandruff
of the scalp
 Usually associated with seborrhoeic dermatitis
involving scalp, nasolabial folds and
retroauricular areas

42. Squamous Blepharitis

43. Symptoms
 Burning, deposits / crusting along lid
margins, grittiness , redness of lid
margins, photophobia
 Symptoms are worse in the morning

44. Seborrhoeic or
Squamous Blepharitis
 Skin condition also requires treatment.
 Cleaning of lid margin with baby
shampoo. In case of bacteria infection,
local antibiotic drops and ointment.
Associated tear film dysfunction, if
present is treated with artificial tear drops

45. Staphylococcal or
Ulcerative Blepharitis
 Ulcerative blepharitis is infective
condition commonly due to
staphylococcal infection
 Lid margins are covered with infective
material (yellow crusts or dry brittle
scales) matting eyelashes. On removal of
discharge small ulcers which bleed are
found along lid margins around bases of
the eyelashes

46. Symptoms
 Redness of lid margins, burning, itching,
watering and photophobia
 Signs:
 Small ulcers at lid margins on removal of
discharge, this features differentiate it from
conjunctivitis

47. Ulcerative Blepharitis

48. Treatment
 Discharge/ crust is removed from lid
margins with 1:4 dilution baby shampoo
or luke warm 3% soda bicarbonate lotion.
The loose discharge is then cleaned
cotton
 Diseased eyelashes are epilated
 Appropriate antibiotic drops are used
 After control of infection, daily cleaning of
lid margins with blend lotion

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

50. Sequelae of Ulcerative
Blepharitis
 Chronic course and associated chronic
conjunctivitis
 Madarosis (Scanty eyelashes) due to
falling of eyelashes
 Trichiasis (misdirected eyelashes) due to
contraction of scar tissue
 Cicatrization of lid margins causing
thickening and hypertrophy of tissue and
drooping of lids (Tylosis)

51. Sequelae of Ulcerative
Blepharitis
 Cicatrization of lid margin may drag
conjunctiva on posterior border of
intermarginal strip disturbing angle of
posterior edge leading to epiphora ,
eversion of puncta
 Epiphora leads to eczematous condition
of skin, scarring of skin leads to ectropion
. This further aggravate epiphora

52. Posterior Blepharitis
 Posterior blepharitis i.e. inflammation of
meibomian duct opening at intermarginal strip
and posterior border may cause tear film
instability and inferior punctate keratitis
 It occurs in two clinical forms
a. Meibomian seborrhoea – characteristic
appearance of oil droplet at the opening of
meibomian duct opening at intermarginal strip.
Tear film is oily and foamy. Frothy discharge
accumulate on the lid margin. Foam like
discharge can be expressed from these lesions

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

55. Complications
 Chalazion
 Tear film instability
 Papillary conjunctivitis and inferior
corneal erosions

56. Treatment
 Warm compresses
 Systemic - Doxycycline 100 mgm twice x
1 week then once daily for 6 -12 weeks
or Tetracycline 250 mgm 4 times x 1
week then twice for 6 -12 weeks
 Associated tear film abnormality is
treated with artificial tear drops

57. Entropion

58. Lower lid retractors
a. Inferior lid retractors:
1. The inferior tarsal aponeurosis –
capsulo-palpabral expansion of the
inferior rectus muscle and is analogous
to the levator aponeurosis
2. Inferior tarsal muscle is analogous to
muller muscle

59. Entropion
Entropion is in-rolling of eye lid margin.
Normal position of sharp posterior border of
inter-marginal strip is essential for interigrity of
the tear film and for maintenance of healthy
ocular surface
Entropion is caused by disparity of length and
tone of anterior skin muscle layer and posterior
tarso-conjunctival layer of the eyelid

60. Symptoms of Entropion
Foreign body sensation
Watering
Redness
Pain
Photophobia
These symptoms are due to rubbing of
ocular surface by misdirected eyelashes

61. Classification
1. Involutional
2. Cicatricial
3. Spastic
4. Congenital

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

63. Involutional Entropion
 There occurs of over-ridding of preseptal
orbicularis muscle over pretarsal
orbicularis, that leads to forward rotation
of tarsal plate
 Seen in lower lids

64. Involutional Entropion

65. Involutional Entropion

66. Treatment of
Involutional Entropion
Principles of surgery
1. Reattachment of the retractor to tarsal
plate
2. Shortening of horizontal width of lid
3. To induce scarring between the pre-
tarsal and pre-septal parts of orbicularis
muscle

67. Surgical Procedures
1. Catgut suture application through
2. Modified Bick operation: Horrizontal
shortening of lower lid with fixation to
lateral canthal ligament and periosteum
3. Tucking of inferior lid retractors

68. Cicatricial Entropion
 Caused by contraction of scar tissue of
the palpabral conjunctiva
 In this case there is relative shortening of
inner layer i.e. tarso-conjunctiva
 Caused by scarring of palpabral
conjunctiva by trachoma, trauma,
chemical injuries (burns), pemphigus and
Stevens-Johnson syndrome

69. Treatment
Principles of surgery
1. Tarsal rotation (forwards)
2. Lengthening of posterior lid lamina so
that eyelashes turn forwards
Surgery
a. Wedge resection (Tarsal paring)
b. Tarsal fracture

70. Spastic Entropion
 This condition is due to spasm of orbicularis in
presence of degeneration of the palpabral
connective tissue separating orbicularis fibres.
The spasm is induced by local irritation in
inflammatory and traumatic conditions.
 Factors that prevent in-rolling of lid margin:
a. intact inferior lid aponeurosis which
maintains orbicularis in position that it presses
against lower tarsus
b. contraction of palpabral head of inferior
rectus

71. Mechanism
 Degeneration of aponeurosis, the strong
contraction of orbicularis is associated
with turning inwards of lid margin
 Senile degeneration of tarsal muscle of
Muller fails to anchor the lower border of
tarsal plate to bony orbit
 Orbicularis rides up on tarsal plate
towards lid margin
 Horizontal lid laxity

72. Clinical picture
 Condition is found in elderly patients
 Tight bandaging may cause spastic
entropion
 Narrowness of palpabral aperture
 Seen in lower lids

73. Treatment of Spastic
Entropion
 Removal of cause i.e removal of cause of
irritation, tight bandaging
 Treatment of surface disorder by artificial
tears and control of conjunctival infection
and lid inflammation with antibiotic
 Fixing of lower lid after everting it with
adhesive tape
 Injection of Botulinum toxin into pre-tarsal
orbicularis to weaken it

74. Surgical treatment
 Producing a ridge of fibrous tissue in the
orbicularis to prevent its fibres from
sliding in vertical direction

75. Congenital Entropion
 This condition is due to dysgenesis of
lower lid retractor or due to abnormal
development of tarsal plate.
 This condition must be differentiated from
epiblepharon (due to anomalous fold of
skin pushing lashes upwards onto the
eyeball)
 Treatment of abnormality

76. Ectropion

77. Ectropion
 Ectropion is out-rolling of lid margin
 Symptoms are:
Watering (due to eversion of punta)
Foreign body sensation
Pain
Redness
Photophobia (Due to involvement of cornea)
Symptoms are due to eversion of punta, and
exposure of ocular surface, chronic
conjunctivitis caused by exposure and drying of
surface

78. Classification
I. Acquired
 Involutional or senile
 Cicatricial
 Paralytic
 Mechanical
II. Congenital

79. Functions of lids
1. Protection of eye
2. Act as lacrimal pump
Effect of age
Slowly there is relaxation of lid
structures (canthal ligament and
orbiularis)

80. Involutional Ectropion
Stages:
1. Early stage: in mild cases on looking up
the puncta is not apposed to bulbar
conjunctiva
2. Progresses to moderate stage puncta
are not apposed to bulbar conjunctiva
even in primary gaze and entire lid
margin fall away from the globe

81. Involutional Ectropion
3. In severe case lower lids are rolled out and
palpabral conjunctiva (including tarso-
conjunctiva and fornix are exposed)
Chronic exposure of lower puncta on everted lid
leads to phimosis of puncta
Tears are no longer drained into nose and
overflow onto the cheek
In long standing cases keratinization of the lid
margin and palpabral conjunctiva takes place

82. Signs
 Signs as described with three stages earlier
 In ling standing cases the exposed conjunctiva
becomes dry, thickened, red , un-sightly.
Cornea may suffer from imperfect closure of
the lids
 Diagnosis is confirmed if lower lids does not
snap back into position after pulling it 6-7 mm
away from globe. If canthal displacement is
more than 2 mm on pulling lower lid laterally or
medially , canthal laxity is diagnosed
 There is horizontal lengthening of the lids

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

84. Cicatricial Ectropion
 Is out-rolling of lid marging due to
contraction of scar tissue on skin side.
Commonly results from lid trauma, burns,
chemical injuries and chronic
inflammations of lid skin. Due to
contraction of scar the lid skin shortens
pulling the eyelid away from the eyeball

85. Cicatricial Ectropion

86. Ectropion Pre and
Post-operative

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

88. Paralytic Ectropion
 This condition is due to paralysis of the facial nerve
due to Bell palsy, surgery on parotid gland and trauma
 Characterized by presence of other signs of facial
palsy
 Initially treated by conservative treatment by taping of
lids, lubricating eye drops, till there is recovery
 Lateral tarsorrhaphy, by suturing freshened upper and
lower lids at outer canthus
 Lagophthalmos due to weakness of superior orbicularis
may be treated by taping