lid diseases i
DESCRIPTION
eyeTRANSCRIPT
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