Lids & Lacrimal System. Nazeem Aghmed Desai B,Sc(UWC),B.Optom(RAU),CAS(NECO)
As ocularists we work with eyelids on a daily basis. This presentation is intended to familiarize us with some common eyelid conditions that we can detect and make appropriate referrals.
Blepharitis Critical signs: crusty, red, thickened eyelid margins prominent blood vessels on lid margin
Other signs Conjunctival injection Swollen eyelids Mild mucous discharge Superficial punctate keratopathy Corneal infiltrates phlyctenules
Symptoms Itching Burning Mild pain Foreign body sensation Tearing Crusting around eyes on awakening
Anterior Blepharitis I. Staphyloccocal Blepharitis II. Seborrheic Blepharitis
Anterior Blepharitis: Staphyloccocal Blepharitis Signs: Scaling at base of lashes Impaled cornflake
Source: Esen K. Akpek, M.D.
Seborrheic Blepharitis Signs: Scurfs or collarettes at base of lashes Patients might also have dandruff on scalp
Picture by Andrew A. Dahl, MD, FACS
Posterior Blepharitis/ Meibomianitis/Meibomitis Signs: Inspissated / Clogged or blocked meibomian glands Digital pressure will expell meibum Clear fluid graded 0 Slightly cloudy grade 1 Cloudy grade 3 Thick toothpaste like grade 4
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Angular blepharitis Picture :blepharitis.com.au
Complications of Blepharitis Ptylosis Madorosis Scarring of lid margin Poliosis
Madorosis & ptylosis
Pediculosis/ Phtriasis Infestation of eyelash by insect Also infects pubic area If seen in children must be reported to welfare organisation
Phthriasis Picture : Archivos de la Sociedad Española de Oftalmología versión impresa ISSN 0365-6691 Arch Soc Esp Oftalmol v.78 n.7 Madrid jul. 2003 http://dx.doi.org/10.4321/s0365-66912003000700005
Chalazion DEF: area of focal inflammation within the eyelid tarsus secondary to obstruction of a meibomian gland. Signs: -non infectious -inflammatory -slow onset -painless
Picture: dro.hs.columbia.edu
Hordeolum DEF: Acute infection; Can be external (stye: abscess of gland of Zeiss on the lid margin) Can be internal ( abscess of meibomian gland)
Critical Signs Visible or palpable, well-defined subcutaneous nodule within the eyelid Symptoms: Eyelid lump, swelling, pain, tenderness, erythema
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Other Signs Blocked meibomian orifice, eyelid swelling and erythema, localized eyelid tenderness, palpable preauricular node. associated blepharitis or acne rosacea.
Differential Diagnosis Preseptal cellulitis Sebaceous cell carcinoma (Should be suspected in a recurrent chalazion, thickening of both the upper and lower eyelids, and a chalazion associated with loss of the eyelashes)
Ectropion Critical Sign Outward turning of the eyelid margin. Symptoms tearing, eye or eyelid irritation May be asymptomatic
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Other Signs Superficial punctate keratitis (SPK) (may result from corneal exposure), conjunctival injection
Etiology Congenital Paralytic (Seventh-cranial-nerve palsy.) Involutional (Aging.) Cicatricial (e.g., from a chemical burn, surgery, eyelid laceration scar.) Mechanical (e.g., herniated orbital fat, eyelid tumor.) Allergic (Contact dermatitis.)
Entropion Critical Sign Inward turning of the eyelid margin. Symptoms Ocular irritation foreign-body sensation, tearing, red eye.
Other Signs Superficial punctate keratitis (SPK) (from eyelashes contacting the globe), conjunctival injection.
Etiology Involutional (Aging.) Cicatricial(Due to conjunctival scarring in ocular pemphigoid, Stevens- Johnson syndrome,chemical burns, trauma, trachoma, and others.) Spastic (Due to surgical trauma, ocular irritation, or blepharospasm.) Congenital
Trichiasis Critical Sign Misdirected eyelashes are found to be rubbing against the globe. Other Signs Superficial punctate keratitis (SPK), conjunctival injection.
Picture: www.revophth.com
Etiology Chronic blepharitis (Thickened, erythematous, inflamed eyelid margin with excess secretions and telangiectatic blood vessels running across it.) Entropion Idiopathic
Blepharospasm Critical Sign Bilateral episodic involuntary contractions of the orbicularis oculi muscles. Other Signs Disappears during sleep
Symptoms Uncontrolled blinking Twitching Closure of the eyelids Always bilateral
PICTURE:www.revoptom.com
Eyelid Myokemia Uncontrolled eyelid twitches Caused by: Too much caffine Lack of sleep Stress Ocular irritation Unilateral lower lid involvement
Floppy Eyelid Syndrome Critical Signs An upper eyelid which can be everted easily, without an accessory finger or cotton-tipped applicator exerting counter pressure.
Symptoms Chronically red, irritated eye, often worst upon awakening from sleep, mild mucus discharge. Patients are typically obese males Associated with sleep apnea
Other Signs A soft and rubbery superior tarsal plate, a superior tarsal papillary conjunctivitis, superficial punctate keratitis (SPK). NOTE: symptoms result from spontaneous eversion of upper eyelid during sleep, allowing the superior palpebral conjunctiva to rub against a pillow or mattress.
Canaliculitis Critical Signs Erythematous pouting punctum erythema of the skin surrounding the punctum. Mucopurulent discharge or concretions may be expressed from the punctum when pressure is applied over medial canthus
Other Signs A conjunctivitis confined to the nasal aspect of the eye Organism causing infection Streptothrix sp.
Differential Diagnosis Dacryocystitis (Much more swelling, tenderness, and pain. Swelling of the skin is more prominent than pouting of the punctum.) Nasolacrimal duct obstruction (Tearing, minimal to no erythema nor tenderness around the punctum.) Conjunctivitis (Conjunctival follicles and/or papillae, discharge. No pouting or punctal discharge.)
Dacryocystitis/ Inflammation of Lacrimal sac Critical Signs Erythematous, tender swelling over nasal aspect of lower eyelid extending around periorbital area nasally. mucopurulent discharge can be expressed from the punctum
Etiology Nasolacrimal duct obstruction, diverticulum of the lacrimal sac, dacryolith, nasal or sinus surgery, trauma
Differential Diagnosis All may produce inflammation of the periorbital area nasally. Facial cellulitis involving the medial canthus (Discharge cannot be ex- pressed from the punctum Acute ethmoid sinusitis (Pain, tenderness, and erythema over the nasal bone,frontal headache and nasal obstruction are common. Patients are often febrile.)
Acute frontal sinusitis (Inflammation predominantly involves the upper eyelid. The forehead is tender to palpation.) Sebaceous cyst
Sebaceous cyst
Congenital Nasolacrimal Duct Obstuction Nasolacrimal duct is last part of lacrimal drainage syst. to canalize. At birth lower end of nasolacrimal duct is freq. not canalized(near valve of Hasner). Most become patent spontaneously during first few weeks of life
Clinical Features Present within few weeks of birth with epiphora and mattering of eye Examination Gentle pressure over lacrimal sac causes reflux of purulent discharge from puncta NB. Consider congenital glaucoma in all infants with watery eye.
MASSAGE Treatment Index finger over common canaliculis to block exit of material through puncta Stroke downward firmly to increase hydrostatic pressure in lacrimal sac 10 strokes QID Sulphacetamide gtt QID
Probing Should be performed after age12 months 95% cases spontaneous canalization Probing within first 2yrs v high success rate & decreases with age If after 2 probings no change DCR @ age 3 to 4
Dacryoadenitis (Infection of the Lacrimal Gland) Critical Signs Erythema, swelling, and tenderness over the temporal one-third of the upper eyelid; may be associated with hyperemia of the lacrimal gland
Symptoms Unilateral pain, redness, and swelling over the outer one-third of the upper eyelid, often with tearing or discharge. Typically occurs in children and young adults
Other Signs Ipsilateral preauricular lymphadenopathy, ipsilateral conjunctival chemosis temporally fever, elevated white blood cell count (WBC).
Etiology Bacterial (e.g., Staph. aureus, N. gonorrhea, streptococci) Viral (e.g., mumps, infectious mononucleosis, influenza, herpes zoster)
Differential Diagnosis Chalazion Adenovirus conjunctivitis (May produce eyelid swelling and erythema along with preauricular lymphadenopathy and a discharge. Typically produces inferior tarsal conjunctival follicles.)
Preseptal cellulitis(erythema, edema, and warmth of the eyelid[s] Orbital cellulitis Malignant lacrimal gland tumor
Preseptal Cellulitis Critical Signs Eyelid erythema, edema warmth tenderness. No proptosis, No restriction of extraocular motility, No pain with eye movement.
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Other Signs Conjunctival chemosis, tightness of the eyelid skin, fluctuant lymphedema of the eyelids.
Preseptal cellulitis due to H. influenza generally occurs in children less than 5 years old characterized by excessive amount of upper- and lower- eyelid edema extending to cheeks. distinctive red-purple discoloration.
Differential Diagnosis Orbital cellulitis Allergic eyelid swelling Viral conjunctivitis with eyelid swelling Chalazion
Allergic Eyelid Swelling picture: Nazeem Desai
Ptosis
Etiology Most cases are benign Four entities must be ruled out in all cases: 1.Horners syndrome 2.Third nerve palsy 3.Myesthenia Gravis 4.Superior eyelid or orbital malignancy
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Malignant Tumors of the Eyelid Symptoms Asymptomatic mildly irritating eyelid lump
Signs Skin ulceration inflammation distortion of the normal eyelid anatomy
Etiology Basal-cell carcinoma most common malignant eyelid tumor Middle-aged to elderly patients. Two clinical presentations: 1.Nodular 2.Morpheaform
Basal cell carcinoma
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1. Nodular Indurated, firm mass, commonly with telangiectasia over the tumor margins Sometimes,center of lesion is ulcerated.
2. Morpheaform Firm flat, subcutaneous lesion indistinct borders. NOTE: Basal-cell carcinoma does not metastasize, but is highly locally invasive, particularly when in medial canthal region
Squamous-cell carcinoma Variable presentation, often appearing similar to basal cell carcinoma. Metastasis may occur, but uncommon. may appear as a scaly erythematous flat lesion or as a cutaneous horn.
Squamous cell carcinoma Picture:www.revophth.com
Picture:www.revophth.com
Sebaceous-gland carcinoma Usually middle-aged to elderly patients. Most arise from the meibomian glands. Must be considered in presence of recurrent "chalazion" or intractable blepharitis",as it may simulate each of these conditions.
Loss of eyelashes destruction of the meibomian gland orifices in region of tumor may occur. tumor may be multifocal, involving both the upper and lower eyelids. Metastasis or orbital extension can occur
Differential Diagnosis (Benign eyelid masses) Hordeolum Chalazion Cysts Molluscum contagiosum Nevus Xanthelasma Verrucae Papilloma
Molluscum contagiosum
Papiloma
Sebaceous cyst
Thank You I hope this will be useful.