PHATOLOGY THE EYELIDS, LACRIMAL

GLANDS
 DESEASES OF LIDS

The eyelids are important both in providing physical

protection to the eyes and in ensuring a normal tear film and
tear drainage. Diseases of the eyelids can be divided into
those associated with:

•abnormal lid position

•inflammation of the lid
•lid lumps
•abnormalities of the lashes
ABNORMALITIES OF LID POSITION
ENTROPION
 ECTROPION

The malposition of the lids everts the puncta and prevents drainage of the
tears, leading to epiphora. It also exposes the conjunctiva. This again results in an
irritable eye.
Treatment is surgical.
 BLEPHARITIS
This is a very common condition of chronic eyelid inflammation. The
condition causes squamous debris, inflammation of the lid margin, skin and eyelash
follicles (anterior blepharitis). The meibomian glands may be affected independently
(meibomian gland disease or posterior blepharitis).
SYMPTOMS 1) tired, sore eyes, worse in the morning; 2) crusting of the
lid margin.
SIGNS 1) scaling of the lid margins; 2) debris in the form of a rosette
around the eyelash, the base of which may also be ulcerated, a sign of
staphylococcal infection;3) a reduction in the number of eyelashes;4) obstruction
and plugging of the meibomian ducts;5) cloudy meibomian secretions;6) injection of
the lid margin;7) tear film abnormalities.
TREATMENT
This is often difficult and must be long term. For anterior blepharitis, lid
toilet with a cotton bud wetted with bicarbonate solution or diluted baby shampoo
helps to remove squamous debris from the eye. Similarly, abnormal meibomian
gland secretions can be expressed by lid massage after hot bathing. Staphylococcal
lid disease may also require therapy with topical antibiotics (fusidic acid gel) and,
occasionally, with systemic antibiotics.
Meibomian gland function can be improved by oral tetracycline. Topical
steroids may improve an anterior blepharitis but frequent use is best avoided.
Posterior blepharitis can be associated with a dry eye which requires treatment with
artificial tears.
CYSTS
 This is a common frond-like lid lesion with a fibrovascular core and
thickened squamous epithelium. It is usually asymptomatic but can be excised
for cosmetic reasons with cautery to the base.
-eruptie veziculoasa, unilaterala, ce respecta
teritotiul nervului oftalmic asociata cu
adenopatie regionala.
Placardele eritematoase initiale se transforma
in vezicule cu lichid clar care ulterior devine
tulbure. Dupa uscarea continutului se formeaza
o crusta.
TRATAMENT:
-combaterea infectiei
-stimularea imunitatii
-calmarea durerilor
 SQUAMOUS CELL CARCINOMA

This is a less common but more malignant tumour which can

metastasize to the lymph nodes. It can arise de novo or from pre-malignant
lesions. It may present as a hard nodule or a scaly patch. Treatment is by
excisional biopsy with a margin of healthy tissue.
UV exposure is an important risk factor for both basal cell and
squamous cell carcinoma.
TRICHIASIS
 DESEASES OF LACRIMAL ORGANS

Disorders of the lacrimal system are common and may produce chronic
symptoms with a significant morbidity. The lacrimal glands normally produce about
1.2iµl of tears per minute. Some are lost via evaporation.
The remainder are drained via the naso-lacrimal system. The tear film is
reformed with every blink.

Abnormalities are found in:

1) tear composition;
2) the drainage of tears.
AQUEOUS INSUFFICIENCY—DRY EYE
 OBSTRUCTION OF TEAR DRAINAGE (INFANT)

The naso-lacrimal system develops as a solid cord which subsequently

canalizes and is patent just before term.
Congenital obstruction of the duct is common. The distal end of the naso-
lacrimal duct may remain imperforate, causing a watering eye. If the canaliculi also
become partly obstructed the non-draining pool of tears in the sac may become
infected and accumulate as a mucocoele or cause dacrocystitis.
Diagnostically the discharge may be expressed from the puncta by pressure over
the lacrimal sac. The conjunctiva, however, is not inflamed. Most obstructions
resolve spontaneously in the first year of life.
If epiphora persists beyond this time, patency can be achieved by passing
a probe via the punctum through the naso-lacrimal duct to perforate the occluding
membrane (probing). A general anaesthetic is required.
 OBSTRUCTION OF TEAR DRAINAGE (ADULT)

The tear drainage system may become blocked at any point, although the
most common site is the naso-lacrimal duct. Causes include infection or direct
trauma to the naso-lacrimal system.
HISTORY The patient complains of a watering eye sometimes associated
with stickiness. The eye is white. Symptoms may be worse in the wind or in cold
weather.There may be a history of previous trauma or infection.
SIGNS A stenosed punctum may be apparent on slit lamp examination.
Epiphora is unusual if one punctum continues to drain. Acquired obstruction beyond
the punctum is diagnosed by syringing the naso-lacrimal system with saline using a
fine cannula inserted into a canaliculus. A patent system is indicated when the
patient tastes the saline as it reaches the pharynx. If there is an obstruction of the
naso-lacrimal duct then fluid will regurgitate from the non-canulated punctum. The
exact location of the obstruction can be confirmed by injecting a radio-opaque dye
into the naso-lacrimal system (dacrocystogram); X-rays are then used to follow the
passage of the dye through the system.
TREATMENT
It is important to exclude other ocular disease that may contribute to
watering such as blepharitis. Repair of the occluded naso-lacrimal duct requires
surgery to connect the mucosal surface of the lacrimal sac to the nasal mucosa by
removing the intervening bone (dacryocystorrhinostomy). The operation can be
performed through an incision on the side of the nose but it may also be performed
endoscopically through the nasal passages thus avoiding a scar on the face.
INFECTIONS OF THE NASO-LACRIMAL SYSTEM
DESEASES OF CONJUNCTIVA
BACTERIAL CONJUNCTIVITIS
VIRAL CONJUNCTIVITIS
CHLAMYDIAL INFECTIONS
ALLERGIC CONJUNCTIVITIS
CONJUNCTIVAL DEGENERATIONS
 CONJUNCTIVAL TUMOURS

These are rare.

They include:
1) Squamous cell carcinoma. An irregular raised area of conjunctiva which
may invade the deeper tissues.
2) Malignant melanoma. The differential diagnosis from benign pigmented
lesions (for example a naevus) may be difficult. Review is necessary to assess
whether the lesion is increasing in size. Biopsy, to achieve a definitive diagnosis,
may be required.
 DESEASES OF CORNEA

The features of corneal disease are different and include the following:
1) Epithelial and stromal oedema may develop causing clouding of the
cornea.
2) Cellular infiltrate in the stroma causing focal granular white spots.
3) Deposits of cells on the corneal endothelium (termed keratic
precipitates or KPs, usually lymphocytes or macrophages).
4) Chronic keratitis may stimulate new blood vessels superficially, under
the epithelium (pannus) or deeper in the stroma. Stromal oedema, which causes
swelling and separates the collagen lamellae, facilitates vessel invasion.
5) Epithelial erosions are punctate or more extensive patches of epithelial
loss which are best detected using fluorescein dye and viewed with a blue light.
HERPES SIMPLEX KERATITIS
HERPES ZOSTER OPHTHALMICUS
BACTERIAL KERATITIS
 EPISCLERITIS

This inflammation of the superficial layer of the sclera causes mild

discomfort. It is rarely associated with systemic disease. It is usually self-limiting
but as symptoms are tiresome, topical anti-inflammatory treatment can be given.
In rare, severe disease, systemic non-steroidal anti-inflammatory treatment may
be helpful.
 SCLERITIS

This is a more severe condition than episcleritis and may be associated

with the collagen-vascular diseases, most commonly rheumatoid arthritis.
It is a cause of intense ocular pain. Both inflammatory areas and
ischaemic areas of the sclera may occur. Characteristically the affected sclera is
swollen.The following may complicate the condition: scleral thinning
(scleromalacia), sometimes with perforation; keratitis; uveitis; cataract formation;
glaucoma.
Treatment may require high doses of systemic steroids or in severe cases
cytotoxic therapy and investigation to find any associated systemic disease.
Scleritis affecting the posterior part of the globe may cause choroidal
effusions or simulate a tumour.
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