Ординатура / Офтальмология / Английские материалы / The Eye Book A Complete Guide to Eye Disorders and Health_Cassel, Billig, Randall_2001

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Dermatochalasis (Drooping Eyelid Skin)

Over the years eyelid tissue loses its elasticity. Dermatochalasis (pronounced der-ma-to- -a-sis) is an agerelated drooping or sagging of the skin in the eyelid. (In the upper eyelid, this is commonly called hooding. In the lower eyelid, many people use the accurate but unflattering term bags.)

Dermatochalasis in the upper eyelid ranges from a mild loss of the normal eyelid fold—mainly a cosmetic issue—to extensive sagging, in which eyelid tissue completely covers the eyelashes and eyes and may even interfere with vision. (The severity of dermatochalasis often becomes an important concern with insurance companies, which tend not to pay for consultations and surgery related to cosmetic problems. Many insurance companies require a thorough eye examination with a summary letter from the eye doctor, photographs, and visual field testing to demonstrate the degree to which the droopy eyelids are impairing vision before they’ll agree to pay for surgery to correct the problem.)

Treatment: Surgery to correct dermatochalasis (called blepharoplasty) of either the upper or lower eyelids is usually performed by an eye doctor or a plastic surgeon. It is generally a safe procedure with few complications. (Note: Before having any form of surgery, discuss all your concerns with your doctor, and make sure you understand the risks and potential side effects involved.) Both eyes are usually done at the same time, so that the eyes will look “even.”

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During surgery of the upper eyelid, the excessive skin is removed. A crescent of skin between the brow and lash edge is removed along with some underlying fat, and then the edges of the skin are sewn together. (The operation to remove bags under the eyes is more involved but equally successful.) The stitches are removed within the first week to ten days. Discomfort is minimal, although you’ll probably have some black and blue marks around the eyes for a week or so; these fade, as bruises often do, to interesting shades of green and yellow before disappearing. Ice packs can help decrease the swelling. Within a couple of weeks all signs of the surgery will disappear, and vision and appearance will improve.

Ptosis (Drooping Eyelid)

Much less common and more complicated than dermatochalasis is drooping of the entire eyelid, not just the skin. This condition, called ptosis of the eyelid, usually occurs when the nerve that works the levator muscle (which raises the eyelid) is damaged. The muscle can be weakened by a stroke or a condition such as myasthenia, and even by normal aging.

Treatment: Surgical repair may be recommended when ptosis interferes with vision, or when it dramatically affects someone’s appearance. Note: Find a surgeon who specializes in this type of surgery! This operation, which may involve shortening the levator muscle and removing some of the overlying skin or some of the conjunctiva, is far more complicated than dermatochalasis

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surgery. Good surgical repair of ptosis alleviates the problem. Botched or overdone surgery may mean that your eyelids won’t close all the way—so your eyes will get dry and irritated from being exposed to the air. Although lubricating eye drops or ointments can help, this situation can be worse than the original ptosis.

Entropion and Ectropion (The Edge of the Eyelid Turning In or Out)

Sometimes the lower eyelashes turn inward and brush against the eye; this is called entropion. Sometimes they turn outward, so that the eyelid doesn’t close properly; this is called ectropion. Either way, the problem is irritating. Entropion causes the lashes to rub against the conjunctiva and the cornea, irritating the eye. Ectropion exposes the conjunctiva and cornea to the air, causing dryness.

Entropion sometimes begins when the eye is already irritated by something else. You blink hard, trying to get rid of whatever’s irritating your eye, and it just gets worse. Fortunately, this is usually a temporary condition that goes away when the initial problem—say, itchy eyes from hay fever—resolves itself. Chronic entropion, on the other hand, often develops as tissue deep in the eyelid ages and loses its strength, causing the edge of the lid to flip inward.

Ectropion too is a result of aging tissues. Many people who have it are bothered as much by the way it affects their appearance as by the way it makes their eyes feel;

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when the lid turns out so much that the lid’s reddish inner lining shows, it can be very noticeable.

Treatment: Treatment for entropion may be as simple and low-tech as a piece of adhesive tape: placed securely on the skin of the lower eyelid, the tape sometimes pulls the edge of the lid down and keeps it from turning in. Happily, this treatment sometimes reverses the condition, which settles down almost as if the lid had been “retrained” not to turn in. But this doesn’t always work; also, the skin on the eyelid can be irritated by the tape. When the tape treatment doesn’t work, then surgical repair usually solves the problem.

With ectropion, surgical repair as an outpatient is almost always necessary to relieve the chronic irritation caused by this condition.

Surgery can greatly improve either condition.

Myokymia (Twitching Eyelid)

Have you ever felt your eyelid jump, or seen it twitch in the mirror? This rapid twitching, called myokymia, though usually temporary, can become a nuisance if it persists. (You can stop it by pressing your finger over the twitching area, but it will probably start up again when you take your finger away.) Myokymia is most often caused by stress or fatigue and is not a sign of disease.

Treatment: The main treatment for myokymia is simply to wait it out and try not to let it drive you crazy. Eventually, when you get more sleep and feel more relaxed, it will probably go away; it usually resolves within

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three to four weeks. Note: If it doesn’t go away after three or four weeks, or if it seems particularly severe, then consult your eye care specialist for a thorough eye examination. Persistent myokymia may be the result of other conditions. Regardless of what’s causing it, if the myokymia is persistent and bothersome, administration of botulinum toxin to the muscles around the eyes might be considered as a treatment.

Shingles (Nerve Pain and Blistering,

Crusty Eyelids)

Remember when you had the chicken pox? Well, that virus is still around, somewhere, in your body. And it may have other cards to play: it’s the same virus that causes herpes zoster, or shingles, in adults. Anyone who has ever had chicken pox may develop shingles years afterward.

Remember how bad those chicken pox were? Shingles is worse. It can cause pain, often severe pain, plus blistering and crusting of the skin. These blisters follow the route of a sensory nerve, so you develop pain and then blisters down a path on the skin. If the sensory nerve on your upper face is affected, the pain and blistering will blanket your forehead and even the eyelids. Mercifully, although the pain is miserable, the eyes themselves are usually spared. However, in a few people, especially if the nerve to the end of the nose is involved, this sometimes affects the eye—usually after the skin lesions begin to get better. If you have shingles on your face, you need to see your

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eye doctor. Without treatment, if your eyes are affected, you’re at risk for developing uveitis, glaucoma, and other conditions that could cause permanent harm.

Treatment: Systemic antiviral medications don’t seem to affect the incidence or severity of “post-herpetic neuralgia” (the nerve pain that persists after the skin lesions have healed), but they do make the cutaneous lesions clear up faster and reduce the incidence of herpetic keratopathy and uveitis.

Hordeola and Chalazia (Sties or Lumps on the Eyelid)

A sty, also called a hordeolum, is an infection on your eyelid: a red, swollen area that hurts when you touch it. Sties can crop up on the outside of the eyelid at the base of a hair follicle (an external hordeolum, due to an infected sebaceous gland) or on the eyelid’s inner surface (an internal hordeolum, due to an infected Meibomian gland).

Sties can go away by themselves or with treatment. However, sometimes an internal sty evolves into a chalazion (pronounced sha- -zeon), a usually painless lump that results from the body’s inflammatory reaction to oily secretions in the clogged Meibomian gland. Chalazia typically don’t affect vision, won’t turn into cancer, and are essentially benign—more of a cosmetic nuisance than anything else. (However, if one of these lumps is located higher, in the middle of the upper eyelid, it can flatten the central cornea and distort vision.)

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Treatment: The best treatment for sties is heat: a warm, wet cloth held over the sore spot for twenty minutes at a time, three to four times a day. Antibiotics are seldom needed. Steroid injections may be beneficial.

Most chalazia go away by themselves; we tell our patients that if it’s small and not too bothersome, it’s probably better left alone. However, if a chalazion gets big enough to be annoying, or if it affects your vision, you may need to have it removed surgically. The procedure is minor, involving local anesthesia, and simpler than having a cavity filled at the dentist’s office. Within twenty-four hours your eyelid will be back to normal, except for some minor swelling and perhaps a black eye. Note: Although chalazia are usually minor, one-time occurrences, “repeat offenders” may indicate a more serious problem. Recurrent chalazia may actually be cancerous growths masquerading as benign eyelid lumps and may require a biopsy (a test in which a small sample of tissue is removed and analyzed).

Eyelid Tumors: Dangerous Masqueraders

Most of the eyelid’s problems are annoying but benign. A few, however, are more serious. And unfortunately, some of these—particularly, malignant tumors of the eyelid—are sneaky, disguising themselves as blepharitis, chalazia, or sties. Therefore, if you have any chronic eyelid problem that has not responded promptly to treatment, you should consult your eye doctor.

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Basal cell carcinoma, the most common eyelid malignancy, usually develops on the lower lid. It has many different patterns of growth: it can look like a bump, an ulcer, or a cyst, or it can even appear flat. As it grows, it may cause other eyelid problems, including entropion or ectropion, chalazion, or chronic blepharitis.

Squamous cell carcinoma is another common skin cancer of the eyelid. Squamous cell carcinoma too can mimic several benign eyelid problems.

Also like basal cell carcinoma, squamous cell carcinoma is thought to be caused by too much sunlight exposure; it often appears on sun-damaged skin, usually on the upper eyelid. For this reason it is imperative that people who have had a basal or squamous cell carcinoma wear a wide-brimmed hat, sunglasses, and sunscreen when outdoors. (Really, this is good advice for everyone, infants through adults.)

Sebaceous cell carcinoma is not as common but is even more serious—in fact, if not detected in time, it can be fatal. It too often resembles such common eyelid conditions as chalazion and blepharitis. So again, if you have recurrent or chronic chalazia or other eyelid problems, see your eye doctor, who may decide to order a biopsy.

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The Cornea

The cornea is truly the eye’s window. As described in chapter 1, it’s the transparent, domed “watch glass” that sits over the sclera (the “white” of the eye). Through this clear porthole the iris and pupil are easily visible; looking further still beyond them, we can see all the way to the back of the eye—the vitreous, retina, and optic nerve (see figure 1.1, panels A and B).

Before we discuss some things that can go wrong with the cornea, let’s take a moment to review its anatomy. The wafer-thin cornea—amazingly, only about 1 millimeter thick—is like a cake with five layers, each with its own special function. On top are epithelial (outer lining) cells (the “icing” on this cake, or the skin); this vital layer (also called the epithelium) protects the rest of the cornea and provides a smooth surface for tears. Next comes the cellophane-thin Bowman’s membrane; then the tough, transparent stroma, the bulk of the cornea (the cake itself); then another layer of cellophane, called