Lids

Objectives

1. Recognize the main anatomical landmarks of the eyelid and its cranial nerves’ supply.
2. Identify eyelid and eyelash malposition and disorders.
3. Distinguish between different causes of eyelid inflammation and infection.
4. Recognize the most common lid tumors.

Anatomical Structure of the Eyelid

Lash Disorders

• Trichiasis: primary or secondary (entropion).
• Madarosis: local or systemic.
• Poliosis: Local (blepharitis) or systemic (VKH).
• Lid retraction: Thyroid eye disease.

Allergic Disorders

• Acute allergic edema: insect bite or other allergens. Unilateral or bilateral painless pitting edema.

• Contact dermatitis: Type 4 hypersensitivity reaction.

Topical medications, cosmetics.

Xanthelasma

• Elderly people or young’s with hyperlipidemia.
• Cholesterol and lipid form subcutaneous plaques.

Infections of the Eyelid

• Blepharitis

• Hordeolum:

  1. Externum (Stye)
  2. Internum

• Trachoma

Blepharitis

• Anterior, posterior, or mixed.

  • Symptoms: burning, grittiness, mild photophobia, crusting, and redness of lid margin.
  • Signs: lid margin (hyperemia, telangiectasia and tiny abscesses) scales and lashes (greasy and stuck together).

• Complications: Stye, tear film instability, hypersensitivity to staph. toxins, trichiasis, madarosis, and poliosis.

• Treatment:

  1. Lid hygiene.
  2. Lubricants.
  3. Antibiotic ointment.
  4. Weak topical steroid.
  5. Systemic tetracycline.

Clogged Meibomian Glands

• Clogged Meibomian Glands

External Hordeolum (Stye)

• Acute staph. infection of hair follicles and associated glands.
• Signs and symptoms
  • Mild pre-septal cellulitis.
• Treatment: Hot compresses, epilation, topical antibiotics.
  • Also control any blepharitis.

Internal Hordeolum

• Acute staph. infection of meibomian gland.
• Signs: tender inflamed swelling within the tarsal plate. It may discharge anteriorly through the skin or posteriorly through the conjunctiva.
• Treatment: Control of infection with hot compresses and topical abs.

Chalazion

(Meibomian cyst)

• Chronic lipogranulomatous inflammation caused by obstruction of the gland orifice.
• Most common lid mass.
• Symptoms
• Signs
• Treatment: control posterior blepharitis
  • Hot compresses for 4 weeks
  1. Surgery (incision and curettage)
  2. Steroid injection

Chlamydial Conjunctivitis

• Adult Inclusion Conjunctivitis:
  • Sexually transmitted disease (50% associated with genital infection) caused by serotypes D to K.
  • Subacute onset, unilateral or bilateral mucopurulent discharge.
  • Follicular conj. Reaction
  • Non-tender lymphadenopathy.
  • Treatment: Topical tetracycline plus systemic tetracycline, doxycycline, or recently azithromycin.

Trachoma

• Infection caused by Chlamydia trachomatis (serotypes A, B, Ba & C).

• Obligate intracellular bacteria.

• The common fly is a major vector in the transmission of the disease.

• It is the leading cause of preventable blindness all over the world.

• Symptoms: During childhood with redness, and mucopurulent discharge.

• Signs: of active Trachoma

  • follicular conjunctivitis.
  • Limbal follicles.
  • Keratitis.

• Complications:

  • Progressive conjunctival scaring (Arlt’s line, and entropion).
  • Herbert pits.
  • Corneal pannus.

Entropion

• Inversion of the lid margin
• Types:
  • Congenital
  • Acute-spastic
  • Involutional
  • Cicatricial

Ectropion

• Eversion (Outward turning) of lid margin
• Types:
  • Congenital
  • Involutional
  • Paralytic
  • Cicatricial
  • Mechanical

Lid Tumors

• Benign:
  • Naevus, Capillary haemangioma, Port-wine stain …etc
• Malignant:
  • BCC, SCC, SGC, and Melanoma.

Port-wine Stain Hemangioma = Naevus Flammeus = Cavernous Hemangioma

Basal Cell

• 90-95% of bold/italics malignant eyelid tumors
• Lower lid and medial canthal areas
• Medial canthal lesions can be problematic
• Mortality is less than 1%

Ptosis

• Drooping of the upper lid.
• Pseudoptosis
• Classification:
  • Congenital.
  • Acquired:
    • Neurogenic
    • Myogenic
    • Aponeurotic
    • Mechanical

Clinical Evaluation

• History:
  • Age of onset, Trauma, Previous surgery, and Diurnal variations.
• Exclusion of Pseudoptosis.
• Associated signs.
  • EOM movements, pupil status, fatigability, and jaw-winking.

Management

• Risk of amblyopia in severe unilateral congenital ptosis.

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