Ординатура / Офтальмология / Английские материалы / Oculoplasty and Reconstructive Surgery Made Easy_Garg,Touky, Nasralla_2009
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Diseases of the Lids 99
•This condition is more common in young females and is generally associated with dandruff of the scalp.
•Lid margin is thickened, edematous and may have dilated vessels. Gray or yellowish white scales are often observed along the lid margin, scraping of it may lead to tiny ulcers of fine points of bleeding.
•In chronic conditions cilia fall of (Madrosis) with fibrosis at the site. New misdirected cilia may grow (trichiasis).
•Infection can lead to recurrent stye and angular blepharitis
– conjunctivitis.
•In some cases secondary changes are seen in the conjunctiva and cornea due to hypersensitivity to staphylococcal exotoxins. They may develop into chronic papillary conjunctivitis, punctuate epithelial erosions in the lower part of the cornea. Marginal corneal ulcers or Phlycten.
•In some cases cystic nodules are seen at the openings of meibomian gland ducts and a foamy discharge is floating over the tear miniscus.
•Tear film is disturbed causing dryness of the conjunctiva and cornea (sicca).
•This peculiar condition is known as triple ‘S’ Syndrome, a combination of Staphylococcal infection, seborrhea and sicca.
Investigations
•Subjective ocular examination is adequate to make the diagnosis.
•In cases of seborrheic blepharitis careful slit-lamp examination reveals minute oil globules at the orifices of the meibomian glands.
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Treatment
Conservative long-term treatment is indicated as total eradication may not be possible.
Hot compresses are prescribed in melting solidified white deposits.
Hygeine of the lid margin with antiseptic soap with warm water atleast twice a day is important mechanical expression of excessive secretion from meibomian glands is advised.
•Local and systemic antibiotics are indicated to control the infection. Scales are softened by wetting with Boric acid and then mechanically removed by gentle scraping.
•Once the primary infection is under control, local steroids can be prescribed to treat secondary effects in the conjunctiva and cornea.
•Treatment with antibiotics and astringents should be continued for at least 2-3 weeks after visible cure.
•Simultaneous treatment of seborrheic dermatitis and dandruff with medicated shampoo is necessary.
•Improvement of general health with vitamins and antioxidants is essential to prevent relapses.
•In parasitic infection, mechanical removes of the organisms is most sufficient.
Prognosis
Generally prognosis is good however sustained medical treatment and compliance is required from the patient.
DERMATITIS
Introduction
•Skin of the eyelid is a very common site for inflammation even with very mild irritants as it is thinnest and most extensible in the body.
Diseases of the Lids 101
Figure 12: Drug induced |
Figure 13: Drug induced dermatitis— |
dermatitis—Front profile |
Right profile |
Figure 14: Drug induced |
Figure 15: Drug induced |
dermatitis—Left profile |
dermatitis—Zoomed in |
Clinical Signs and Symptoms (Figures 12 to 15)
•Acute dermatitis is characterized by erythema, vesiculation and crusting with burning sensation and itching.
•Chronic dermatitis is shown by thickening of the skin and itching with minimal erythema. Local drugs (Drops and Ointments) and cosmetics are the common irritants.
•In atopic dermatitis patient is sensitive to allergants to much greater degree than normal. They may have a past history of hay fever or asthma. chronic keratoconjunctivitis, keratoconus and lenticular opacities may be associated with atopy.
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•Contact dermatitis involving the eyelids are common. It is caused by transmission of irritating substances to the lids by fingers. Failure to rinse the hands adequately following transfer of irritating chemicals in soaps or detergants is the most common cause.
Investigations
•Subjective ocular examination is required to make the diagnosis.
Treatment
•Conservations management involves patch testing in order to identify the irritant and then its removal from the patients surrounding.
•Acute dermatitis is best treated with cold compresses and non-fluorinated short-term corticosteroids like hydrocortisone are helpful. Long-term use of corticosteroids is contraindicated as it may aggravate the dermatitis.
Prognosis
Prognosis is good.
WARTS (VERRUCA VULGARIS)
Introduction
•Warts are small elevated lesions with a papillomatous surface.
•It is a virus infection caused by wart virus belonging to PAPOVA group.
•Sometimes it erupts as a crop of lesions which appear simultaneously.
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Figure 16: Verruca vulgaris lower lid
Clinical Signs and Symptoms (Figure 16)
It appears as elevated leision in the form of cyst either from upper and lower eyelid protruding anteriorly without any symptoms generally.
Investigation
Subjective ocular examination is generally recommended.
Treatment
Generally cryoapplication is recommended for the regression of wart.
Surgical excision is also indicated but it often leads to recurrence.
MOLLUSCUM CONTAGIOSUM
Introduction
• It is a caused by a viral infection and mostly affects children.
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•The typical lesionis multiple, skin colored dome shaped nodule measuring from 1-3 mm sometimes umblicated are seen.
•It is due to infection caused by viruses belonging to a group of poxviruses.
Clinical Signs and Symptoms (Figure 17)
•Lesions when present close to the lid margin can produce follicular conjunctivitis due to liberation of the virus into the conjunctival sac.
Figure 17: Molluscum contagiosum involving lids and face
Investigation
•Subjective ocular examination.
•Microscopically intracytoplasmic inclusion bodies can be seen which can displace and compress the nucleus to one side.
Treatment
Skin lesion treatment is recommended by expressionor cauterization.
Diseases of the Lids 105
Prognosis
•Generally it is good.
•Immunocompromised patients including those of AIDS are prone to develop this virus infection.
TRICHIASIS
Introduction
•Trichiasis is an inward misdirection of the lashes. In this condition few cilia are misdirected backward and they rub against the cornea.
•Trichiasis is caused by trachoma, ulcerative blepharitis, ocular burns, membranous conjunctivitis, injury or operation on the lid margin. It can also be seen in congenital distichiasis.
Clinical Signs and Symptoms (Figures 18 and 19)
•Patient complain of foreign body sensation, irritation, lacrimation, photophobia and pain. The misdirected lashes may rub against the cornea or cause corneal erosions and vascularisation and in severe long standing cases corneal pannus may develop.
Figure 18: Trichiasis lower eye lid
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Figure 19: Trichiasis upper eye lid
Investigation
•Subjective ocular examination and slit-lamp examination clinch the diagnosis.
Differential Diagnosis
• Pseudotrichiasis secondary to entropion.
Treatment
•Epilation (Mechanical removal of cilia with forceps) is effective but recurrence with in 4-8 weeks is common with this method.
•Hair follicles can be destroyed by electrolysis. This procedure is not simple and frequent multiple treatments are required to obtain desired results. In this procedure passage of an electric current (3-5 milli amperes) is passed through a fine needle inserted into the root of the eyelash. Then eyelash is removed with the help of forcep. It is a painful procedure.
•Hair follicles can also be destroyed by passage of a current of 30 milli ampere for 10 seconds through a diathermy needle.
Diseases of the Lids 107
•Cryotherapy is safe and effective method for destroying the misdirected lashes. The cryoprobe with –20oC temperature is applied on to the root of the eyelash, a freeze-thaw-freeze technique is used. It destroys the hair follicles but leaves a depigmented area after healing.
•Trichiasis can also be corrected with argon laser but it is less effective than cryotherapy.
•Surgical correction may be required in patient with severe trichiasis.
Prognosis
•Generally prognosis is good if proper and adequate treatment is given.
INTRODUCTION
Lid retraction is a disorder of eyelid malposition whether the upper lid, the lower lid, or both. The condition is characterized bytheappearanceofabandofwhitesclerabetweenthelimbus andtheeyelidmarginormargins,whentheeyeisintheprimary position. The most common cause of upper and lower eyelid retraction is thyroid ophthalmopathy.
ETIOLOGY AND PATHOPHYSIOLOGY OF EYELID CHANGES IN TED
Upper Eyelid Retraction
•Over action of levator muscle.
•Increased sympathetic tone to Muller’s muscle.
•Proptosis.
•Fibrosis and contracture of levator aponeurosis.
•Adhesions of the levator to orbital septum and skin.
•Over contraction of superior rectus muscle (SRM)
Lower Eyelid Retraction Causes
•Contraction of inferior rectus muscle (IRM)
•Proptosis
•Secondary to inferior rectus muscle recession.