Diseases of Lids

Power point copy of Lecture taken by

Prof Sanjay Shrivastava
For Junior Final Year students of
Gandhi Medical College, Bhopal (M.P.)

Anatomy of Lid

Hordeolum Externum
(Stye)

Hordeolum Externum (Stye)

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

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

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

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

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

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

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

Hordeolum Externum

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

Treatment
I.

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

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)

Hordeolum Internum

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

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

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

Hordeolum Internum

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

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

Chalazion

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

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

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

Chalazion

Adenoma of Meibomian Gland

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

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

Instruments

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

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

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)

Blepharitis

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

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

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

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

Squamous Blepharitis

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

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

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

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

Ulcerative Blepharitis

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

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

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)

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

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

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

Complications
Chalazion
Tear film instability
Papillary conjunctivitis and inferior corneal
erosions

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

Entropion

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

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

Symptoms of Entropion

Foreign body sensation

Watering
Redness
Pain
Photophobia
These symptoms are due to rubbing of
ocular surface by misdirected eyelashes

Classification
1.
2.
3.
4.

Involutional
Cicatricial
Spastic
Congenital

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

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

Involutional Entropion

Involutional Entropion

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 pretarsal and pre-septal parts of orbicularis
muscle

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

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

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

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

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

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

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

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

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

Ectropion

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

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

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)

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

Involutional Ectropion
3. In severe case lower lids are rolled out and
palpabral conjunctiva (including tarsoconjunctiva 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

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

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)

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

Cicatricial Ectropion

Ectropion Pre and Post-operative

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 VY operation
Large scar requires excision of scar tissue
and application of matching (whole or
spilt) skin graft

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