Diseases Of The Lids

Diseases of the Lids

INFLAMMATORY DISORDERS

Blepharitis

Squamous blepharitis

• It is usually associated with seborrhoea of scalp (dandruff). In it, glands of Zeis secrete abnormal excessive neutral lipids which are splitted by corynebacterium acne into irritating free fatty acids.
• Characterised by accumulation of whitish soft scales along the lid margin.

Ulcerative blepharitis

• Chronic staphylococcal infection of the lid margin.
• Characterised by yellow crusts at the root of cilia.
• Small ulcers, which bleed easily are seen on removing the crusts. Anterior lid margin shows dilated blood vessels (rosettes).
• Complications and sequelae are:
– Recurrent styes (very common)
– Recurrent conjunctivitis (common)
– Marginal keratitis (common)
– Madarosis, poliosis, tylosis and eversion of punctum.

Diseases of the LidsPosterior blepharitis (Meibomltis)

• A meibomian gland dysfunction, seen more commonly in patients with acne rosacea and seborrhoeic dermatitis.
• Foam in the tears (meibomian seborrhoea) is characteristic feature.

Stye (Hordeolum externum)

• An acute staphylococcal infection of gland of Zeis and lash follicle.
• Recurrent styes are more common in patients with asthenopia, diabetes meUitus and chronic blepharitis.

Chalazion (Meibomian cyst)

• A chronic non-infective lipo-granulomatous inflammation of the meibomian gland with blockage of duct and collection of sebaceous material.
• Characterised by painless tarsal swelling which often may be multiple (most common lid swelling).
• Incision and curettage of chalazion (most common mode of therapy) is done from the conjunctival side by a vertical incision.

Hordeolum internum

• An acute primary staphylococcal infection of meibomian gland or secondary infection in a chalazion.
• Symptoms are similar to stye except that pain is more intense, due to the swelling being embedded deeply in the dense fibrous tissue.
• It can be differentiated from hordeolum externum by the facts that in it, the point of maximum tenderness and swelling is away from the lid margin and that pus usually points on the conjunctival side and not on the root of cilia.

Molluscum contagiosum

• A viral infection (large pox virus) commonly affecting children with small, pale umbilicated lid nodules.
• Complications: ipsilateral chronic follicular conjunctivitis and epithelial keratitis.

DISORDERS OF EYE LASHES AND LID MARGIN

Trichiasis

An inward misdirection of eye lashes with normal position of lid margin

Causes: trachoma (commonest), ulcerative blepharitis, healed membranous conjunctivitis, hordeolum externum, mechanical injuries, burns and operative scar on the lid margin.

Treatment

Epilation is easy but temporary method, as recurrences occur within 3-6 weeks.
Electrolysis: A current of 2 mA is passed for 10 seconds into the lash root. Recurrences are not rare.
Cryoepilation: The cryoprobe with -20°C is applied for 20-25 seconds. It is the best method for segmental trichiasis. Its main disadvantage is depigmentation of the skin.
Argon laser destruction is effective but may need to be repeated.

Entropion

An inward turning of lid margin.
1. Congenital entropion
A rare condition seen since birth. Lower lid retractors not well developed.

2. Cicatricial entropion

• Common variety, more frequently involves the upper lid
Causes – scarring of palpebral conjunctiva in trachoma (most common), membranous conjunctivitis, chemical bums, pemphigus and Stevens-Johnson syndrome

3. Involutional (senile) entropion
• Common variety, affects the lower lid in elderly.
• Etiological factors
– Weakening or dehiscence of capsulopalpebral fascia (lower lid retractors).
– Degeneration of palpebral connective tissue allowing preseptal fibres to override the pretarsal fibres
– Horizontal laxity of the lid.

4. Spastic entropion
• Occurs following spasm of orbicularis due to chronic ocular irritation or following tight bandaging
• More common in elderly and frequently involves lower lid.

5. Mechanical entropion
Occurs due to lack of support provided by the globe to lids as in phthisis bulbi, enophthalmos, after enucleation or evisceration operation.

Ectropion

• Out rolling or outward turning of the lid margin.
• Epiphora is the main symptom in ectropion.

1. Involutional (senile) ectropion
• Most common variety, involves the lower lid.
• Occurs due to following age-related changes:
– Senile laxity of the lid tissues
– Loss of the tone of orbicularis muscle
– Weakness of medial and lateral canthal tendons

2. Cicatricial ectropion. Occurs due to skin scarring as in thermal bums, chemical bums, lacerating injuries and skin ulcers

3. Paralytic ectropion. Occurs in facial nerve palsy in lower lid.

Symblepharon
• Adhesions of the lids with the eyeball
• Causes: Chemical burns, thermal bums, membra¬nous conjunctivitis, ocular pemphigus, Stevens- Johnson syndrome
Types: Anterior, posterior and total

Ankyloblepharon
• Refers to adhesions between upper and lower lid margins.
• Usually associated with symblepharon.

Lagophthalmos
• Inability to voluntarily close the eye-lids
Causes: orbicularis paralysis, severe ectropion, symblepharon, marked proptosis, overcorrection of ptosis and comatosed patient

Blepharospasm
• Essential (spontaneous) blepharospasm is a rare idiopathic condition occurring in elderly patients
• Reflex blepharospasm occurs in conditions of chronic ocular irritations
Treatment: Eliminate the cause of reflex blepharospasm
– Botulinum toxin injection into the orbicularis muscle.
– Facial denervation in severe cases

Ptosis
Drooping of the upper lid more than the normal (2mm).

Congenital ptosis
• Congenital weakness of levator palpebrae superioris (LPS) muscle.
• It is the most common congenital anomaly of the lid.
• May be associated with:
– Weakness of superior rectus muscle.
– Marcus Gunn Jaw winking (synkinetic ptosis).
• Blepharophimosis, telecanthus and epicanthus inversus (blepharophimosis syndrome).

Acquired ptosis

1. Neurogenic ptosis. Third nerve palsy, ophthalmoplegic migraine, multiple sclerosis. Homer’s syndrome occurs in: cervical adenitis, thyroid operation. aortic aneurysm, syringomyelia, Pancoast’s syndrome, trauma, cervical cord tumours and multiple sclerosis.

2 Myogenic ptosis. Myasthenia gravis, dystrophica myotonica,ocular myopathy, oculopharyngeal muscular dystrophy, trauma to LPS muscle.

3. Aponeurotic ptosis. Involutional (senile) ptosis, post-cataract operation, blepharochalasis, traumatic dehiscence or disinsertion of the aponeurosis.

4. Mechanical ptosis. Lid tumours, multiple chalazia, lid oedema.

Causes of pseudoptosis
• Microphthalmos
• Anophthalmos
• Enophthalmos
• Phthisis bulbi

Degree of ptosis
• Mild-2 mm
• Moderate – 3 mm
• Severe – 4 mm or more

Levator function by Burke’s method
• Normal-15 mm
• Good – 8 mm or more
• Fair – 5-7 mm
• Poor – 4 mm or less

Special tests
• Tensilon (edrophonium) test for suspected myasthenia
• Phenylepherine test for suspected Homer’s syndrome.

Treatment

1. Fasanella – Servat operation – for mild ptosis.

2 Levator resection – for moderate and severe ptosis.
• Blaskovics’ operation (conjunctival approach)
• Everbusch’s operation (skin approach)

3. Frontalis sling operation (Brow suspension)
• For severe ptosis with no levator function
• Materials used – autogenous fascia lata (best), supramid, prolene, silicone.

TUMOURS OF THE LIDS

Benign tumours
1. Simple papilloma
• Most common tumour
• Usually occurs at the lid margin

2. Xanthelasma
• Creamy-yellow plaque like lesion
• Occurs on upper and lower lids near the inner can thus
• More common in middle aged women, diabetics and those with high cholesterol level.

3. Capillary haemangioma
• A childhood tumour, may occur pari-passi or as a part of Sturge Weber syndrome
• In many cases self-resolution may occur by the age of 5 years

4. Neurofibroma
• Lids and orbits commonly affected
• Solitary neurofibroma or as a part of neurofibromatosis

Precancerous conditions
• Solar keratosis
• Carcinoma in situ
• Xeroderma pigmentosa

Malignant tumours

1. Basal cell carcinoma
• Commonest malignant tumour of the lids, seen in elderly people.
• Locally malignant.
• Sites: Lower lid – 50% (most common)
– Medial can thus -25%
– Upper lid- 10-15%
– Outer canthus – 5%
• Presentations
– Noduloulcerative (most common)
– Nonulcerative nodular
– Sclerosing type
– Pigmented basal cell carcinoma
• Most common histological pattern is solid basal cell carcinoma with characteristic peripheral palisaded appearance
• Treatment: of choice is local excision
– Radiotherapy only in unoperable cases.

2. Squamous cell carcinoma
• Second commonest malignant tumour of the eye lids
• Incidence is much less than the basal cell carcinoma
• Common site – lid margin
• Presentations
– An ulcerated growth with elevated and indurated margins (common)
– Fungating or polypoidal growth (rare)
• Metastasis: preauricular and submandibular lymph nodes
• Characteristic histological feature is whorled arrangement forming horn pearls which may contain laminated keratin in the centre.

3. Sebaceous gland carcinoma
• Arises from meibomian glands (most common), sebaceous glands of eyebrows and caruncle.
• May be mistaken for chalazion.

4. Malignant melanoma (melanocarcinoma)
• May arise from a pre-exiting naevus, but usually arises de-novo from the melanocytes present in the skin.
• Metastasis: locally, lymphatics and blood stream.
• Radioresistent, so surgery is treatment of choice.

MISCELLANEOUS POINTS

• Blepharophimosis may be associated with Down’s syndrome, Microphthalmos, Edward’s syndrome and Waardenburg’s syndrome.
• Ptosis associated with lower lid of the affected side being at a higher level than the lower lid of the normal side is seen in Homer’s syndrome.
• Epicanthus may be associated with Down’s syndrome.
• Blepharitis acaria is caused by Demodex follicularium.
• A cutaneous hom of eye lids is frequently associated with an underlying dysplastic (actinic keratosis) or neoplastic (squamous cell carcinoma) change.
• Ptosis associated with lid lag in down gaze is feature of congenital ptosis.
• The peculiarities of the skin of the eyelids are loose attachment, extreme thinness, and absence of hair.