Lecture 2 DISEASES of EYELIDS, LACRYMAL SYSTEM

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Lecture 2DISEASES of
EYELIDS,LACRYMAL SYSTEM ORBIT

• Lecture is delivered by
• Ph. D., assistant of professor Tabalyuk Tetyana

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EYELID ANATOMY

• The eyelids layersskinmuscletarsusconjunctiva
  

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BLEPHARITISvery common chronic inflammation of
the eyelid margins

• Classification divided into anterior posterior
  forms the former may be staphylococcal or
  seborrhoeic a mixed picture is typical, however.
• Causative factors
• staphylococcal chronic infection of the bases of
  the lashes common in patients with eczema
• seborrhoeic usually associated with seborrhoeix
  dermatitis involves excess lipid production by
  eyelid glands, converted to fatty acids by
  bacteria
• posterior dysfunction of the meibomian glands of
  the posterior lid margins common in patients
  with acne rosacea

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Clinical features
usually worse in the morning, include grittiness,
burning and redness, stickiness and crusting of
the lids. SIGNS staphylococcal dandruff-like
scaling, mainly around the eyelash
bases seborrhoeic greasy debris around the
lashes causing them to adhere to one
another posterior frothy tear film and pluggung
of the meibomian gland orifices All types
usually manifest hyperaemia of the lid margins
and conjunctiva, and tear film instability
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Complicationscorneal epitheliopathyscarringmar
ginal keratitisreccurent bacterial
conjunctivitischalaziastyesloss of lashes
(madarosis)misdirection (trichiasis)
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Management

• lid margin hygiene using a weak solution or baby
  shampoo
• tear substitutes (e.g. hypromellose, carbomers)
• antibiotic ointment (e.g. fusidic acid,
  chloramphenocol) rubbed into the lid margins
• systemic tetracycline

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Meibomian cyst (chalazion) a lesion consisting
of lipogranulomatous inflammation centred on a
dysfuctional meibomian gland

• Clinical features
• Extremely common, particularly in patients with
  posterior blepharitis.
• A chronic, usually solitary, painless, firm
  swelling in the tarsal plate
• Can follow an acute meibomian gland infection.
• May be assosiated with a secondary conjunctival
  granuloma

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

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

• Clinical features
• An inflamed swelling within the tarsal plate
  which may be associated with (mild) preseptal
  cellulitis

• Management
• Topical antibiotic ointment and systemic
  antibiotic (e.g. flucloxacillin) for preseptal
  cellulitis.
• Hot bathing may promote discharge.
• Incision and curettage Incision and curettage may
  be required for a large abscess, or for secondary
  chronic lesion.

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

• Clinical features
• An acute painful inflamed swelling on the
  anterior lid margin, usually pointing through the
  skin

• Management
• Removal of the associated lash, and hot bathing.
• Topical antibiotic ointment.
• Large lesions may require incision

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Cysts of Zeis and Moll

• Clinical features
• A cysts of Zeis is a small, whitish, chronic,
  painless opaque nodule on the lid margin
• A cysts of Moll is similar but translucent

• Management
• simple excision

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MOLLUSCUM CONTAGIOSUM

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

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Benign tumours of the eyelids

• Squamous cell papilloma (viral wart)
• Basal cell papilloma (seborrhoeic keratosis)
• Keratoacanthoma
• Melanocytic naevus
• Capillary haemangioma (strawberry naevus)
• Plexiform neurofibroma

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Squamous cell papilloma(viral wart)

• Management
• Simple excision, cautery or laser ablation

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

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Basal cell papilloma (seborrhoeic keratosis)

• Management
• Simple excision or curettage

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

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Keratoacanthoma

• Remains static for several months before
  involution

• Clinical features
• An uncommon, fast-growing, firm, pinkish nodule
  that develops a keratin-filled crater and may be
  mistaken for a malignancy

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Melanocytic naevus

• Itradermal

• Intradermal naevus an elevated lesion with
  variable pigmentation. When located on the lid
  margin may be associated with protruding lashes.
  No malignant potential.
• Junctional naevus a flat well circumscribed
  lesion with a uniform brown colour, so-called
  because the naevus cells are located at the
  junction of the dermis and epidermis. Low
  malignant potential.
• Compound naevus usually elevated, with a
  homogeneous tan to brown colour. Consists of both
  intradermal and junctional components, the latter
  conferming a low malignant potential.

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Capillary haemangioma (strawberry naevus)

• Clinical features an irregular red lesion in an
  infant which may cause a mechanical ptosis and
  amblyopia.
• Management local steroids if necessary, but
  frequently undergoes gradual spontaneous
  involution.

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Plexiform neurofibroma

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

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Premalignant and malignant tumours of the eyelids

• Actinic (solar) keratosis
• Basal cell carcinoma
• Squamous cell carcinoma
• Sebaceous gland carcinoma
• Management
• Surgical excision with a wide clearance margin is
  the treatment of choice for most lid malignancies
• Radiotherapy in selected cases

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Actinic(solar) keratosis

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

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Basal cell carcinoma

• Clinical features most common eyelid malignancy,
  is locally invasive but does not metastasize.
  About 50 involve the lower lid, 30 the medial
  canthal area.
• Nodule ulcerative - a rodent ulcer, with
  rolled hyperkeratotic edges and central
  granulation, gradually enlarging over 1-2 years.
  A purely nodular appearance is common.
• Sclerosing - a flat indurated plaque with poorly
  demarcated margins, often with loss of overlying
  lashes that may simulate chronic blepharitis

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Squamosus cell carcinoma

• Clinical features is much less common than basal
  cell carcinoma. It grows more quiclkly and may
  metastasize. It may arise de novo or from
  premalignant condition such as actinic keratosis.
• Nodular starts as a hyperkeratotic nodule or
  plaque which later develops crusting fissures
• Ulcerative resembles a rodent ulcer

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Sebaceous gland carcinoma

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

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Entropion an inward-turning of the eyelid

• Classification
• Involutional most common form, results from
  age-related changes in lower lid
• Cicatrical most frequently secondary to
  scarring of the upper conjunctiva, as on chronic
  trachoma
• Spastic lower lid, caused by spasm of the
  orbicularis muscle due to ocular irritation or
  essential
• Congenital very rare, only involves the lower
  lid. Caused the hypertrophy of skin and
  orbicularis
• Management surgical correction

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Ectropion an outward-turning of the eyelid

• Classification
• Involutional most common form, age-related
  tissue laxity
• Cicatrical scarring resulting from burns or
  surgery (e.g. tumour resection)
• Mechanical excess lid weight (e.g. large
  tumour)
• Paralytic facial nerve palsy, associated with
  incomplete blinking and lid closure
• Congenital may be part of blepharophimosis
  syndrome
• Management surgical correction

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Lacrymal system anatomy

• Larcymal productive part
• Lacrymal excretory part

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Investigation of lacrymal system

• Functional ability of lacrymal excretory system
  1 Fluorecsein is dropped into conjunctival
  cavity
• Positive canalicular test disapearing of S.
  Fluorecsein from conjunctival cavity till 5
  minutes, usually 1-2 minutes
• Positive nose test appering of S. Fluorecsein
  in 5 minutes

• Shirmer test
• Reveals hyposecretion of lacrymal gland wetting
  of filter paper less then 15 mm

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DACRYOADENITIS inflammation of lacrymal gland

• Clinical features hyperemia, oedema and pain in
  upper-external part of orbit
• Eyeball can be dislocated down and nasally
• Prearicular lymph nodes are increased and
  painfull
• Increased body temperature
• Key sign S-like form of rima ophthalmica
• Management systemically antibiotics,
  sulfanilamids, salicilates
• In abscess incision and

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DACRYOCYSTITIS inflammation of lacrymal sac

• Ethiology in infants atresia of lower part of
  nasolacrymal duct in adults stenosis of
  nasolacrymal duct
• Clinical features exess tearing, pus discharge
  usually from one eye
• Key sign pus discharge from lower lacrymal
  point in palpation of area of lacrymal sac
• Management in infants massage of lacrymal sac
• Syringing of lacrymal excretory ways
• Dreanage of lacrymal excretory ways
• Chonic in adults surgical - dacryocystorhinostom
  y

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Orbital cellulitis

• Signs
• eyelids oedema
• chemosis
• proptosis
• limiting of eye movements
• decreasing of visual acuity
• general intoxication (headacke, increased
  temperature, brain signs).
• Optic neuritis, papilloedema, central vein
  occlusion may occur with outcome in optic
  atrophy.
• Management
• incision of orbit with drainage
• antibiotics systemically
• osmotherapy

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Fissura orbitalis superior syndrome

• Tumour, haematoma, foreign body in the area of
  fissura orbitalis superior usually causes
• Proptosis
• Ptosis
• Ophthalmoplegy
• Mydriasis
• Paralysis of accomodation
• Decreasing of corneal sensitivity and skin
  sensitivity in the area of innervation of I
  branch n.trigeminus

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