I (Allah) Swear by the (passing)time.(1) Indeed mankind is in loss (because of this loss of time)(2) Except those, who are believers, and have done righteous deeds, and advise each other to truth and patience.(3)

Inflammations and Infections of the Eyelids Dr. Faizur Rahman Professor of Ophthalmology Peshawar Medical College

Congenital anomalies Coloboma Epicanthus Distichiasis Blephrophimosis syndrome Anchyloblephron Congenital ectropion Telecanthus

Coloboma of the Eyelid

EPICANTHIC FOLDS BILATERAL VERTICAL FOLDS OF SKIN THAT EXTEND FROM UPPER OR LOWER LID TOWARDS MEDIAL CANTHUS. MAY GIVE RISE TO PSEUDO-ESOTROPIA

Congenital Dystichiasis

Blephrophimosis Syndrome

Ankyloblephron

Congenital Ectropion Aetiology Clinical features Treatment

TELECANTHUS UNCOMMON INCREASED DISTANCE BETWEEN THE MEDIAL CANTHI AS A RESULT OF ABNORMALLY LONG MEDIAL CANTHAL TENDONS TREATMENT SHORTENING AND REFIXATION OF MEDIAL CANTHAL TENDONS

EPIBLEPHARON COMMON IN ORIENTALS EXTRA HORIZONTAL FOLD OF SKIN STRETCHES ACROSS ANT. LID MARGIN & LASHES ARE DIRECTED VERTICALLY TREATMENT RECOVER SPONTANEOUSLY PERSISTENT CASES REQUIRE HOTZ PROCEDURE

Categories. Congenital Anomalies Inflammations Disorders of position. Trauma Tumours

INFLAMMATIONS OF EYE LID ALLERGIC DISORDERS Acute allergic oedema Contact dermatitis Atopic dermatitis INFECTIONS Herepes zoster ophthalmicus Impetigo Erysipelas Stye Internal hordeolum CHRONIC MARGINAL BLEPHARITIS Anterior blepharitis Posterior blepharitis MISCELLANEOUS

ACUTE ALLERGIC OEDEMA INSECT BITES, ANGIOEDEMA, URTICARIA, DRUGS SUDDEN ONSET OF PAINLESS, PITTING PERIORBITAL AND LID OEDEMA TREATMENT SYS. ANTI-HISTAMINES

CONTACT DERMATITIS ANY SENSITIVITY TO TOPICAL MEDICATION LID OEDEMA ERYTHEMA TEARING ITCHING TREATMENT REMOVAL OF CAUSE TOPICAL STEROIDS

Patient with a nail polish allergy, otherwise known as eczematoid allergy.

Atopic dermatitis Common idiopathic skin condition Associated with asthma and hay fever Presentation: Chronic irritation and itching Associated with more generalized skin lesions

Close-up of a patient with atopic dermatitis of the face demonstrating darkening of the lids

Signs: Treatment: Bilateral thickening , crusting and fissuring Emollients such as oily cream Mild topical steroid such as hydrocortisone 1% Secondary infection require antibiotic therapy.

Erysipelas Acute subcutaneous spreading cellulitis caused by strep pyogens causes eyelid necrotization and secondary eyelid contracture Signs: Red well defined indurated expanding subcutaneous plaque Treatment: Oral phenoxymethylpencillin

Herpes simplex Unilateral condition effects children Sign: crops of small vesicles associated with mild lid oedema associated with ipsilateral follicular conj and keratitis Treatment: Acyclovir or penciclovir cream

HERPES ZOSTER OPHTHALMICUS VARICELLA-ZOSTER VIRUS ELDERLY AND IMMUNOCOMPRISED PRESENTS WITH PAIN IN THE DISTRIBUTION OF 5 NERVE MACULOPAPULAR RASH OVER FOREHEAD PROGRESSION THROUGH VESICLES, PUSTULES TO CRUSTING & ULCERATION

HERPES ZOSTER OPHTHALMICUS TREATMENT SYSTEMIC VALACYCLOVIR OR FAMCYCLOVIR FOR 7 DAYS TOPICAL, ACYCLOVIR STEROID-ANTIBIOTIC COMBINATION TALC & CALAMINE TO BE AVOIDED

IMPETIGO UNCOMMON SUPERFICIAL SKIN INF. CAUSED BY Staph. aureus OR Strep. Pyogenes MACULES THAT RAPIDLY DEVELOP INTO VESICLES & BULLAE TO PRODUCE YELLOWISH CRUSTS TREATMENT TOPICAL ANTIBIOTICS ORAL CLOXACILLIN / ERYTHROMYCIN

STYE EXTERNAL HORDEOLUM AN ACUTE STAPH. INFECTION OF LASH FOLLICLE AND ITS GLAND OF ZEIS OR MOLL TREATMENT HOT COMPRESSES EPILATION OF LASH

INTERNAL HORDEOLUM AN ABSCESS CAUSED BY AC. STAPH INFECTION OF MEIBOMIAN GLAND TREATMENT IS INCISION AND CURETTAGE

CHALAZION MEIBOMIAN CYST CH. STERILE LIPO- GRANULOMATOUS INFLAMMATORY LESION BLOCKADE OF GLAND ORIFICES AND STAGNATION OF SECRETIONS NON TENDER, ROUND, FIRM LESION EVERSION OF LID MAY SHOW AN ASSOCIATED CONJ. GRANULOMA

CHALAZION TREATMENT SURGERY STEROID INJECTION SYSTEMIC TETRACYCLINE

BLEPHARITIS

BLEPHARITIS Inflammation or infection of the eyelid margins One the most common ophthalmological complications as well as one of the most difficult conditions to treat.

CLASSIFICATION TRADITIONAL STAPHYLOCOCCAL SEBORRHEIC MIXED

CLASSIFICATION McCulley’s STAPHYLOCOCCAL SEBORRHEIC SEBORRHEIC WITH STAPH. SUPER-INFECTION SEBORRHEIC WITH MEIBOMIAN SEBORRHEA SEBORRHEIC WITH SECONDARY SPOTTY MEIBOMIANITIS PRIMARY MEIBOMIANITIS

CLASSIFICATION STAPHYLOCOCCAL SEBORRHEIC MEIBOMITIS ACNE ROSACEA LOCALIZED GENERALIZED ACNE ROSACEA

HISTORY Duration of ocular symptoms Unilateral or bilateral presentation Association with potential exacerbating conditions Smoke Allergens Wind contact lenses low humidity Recent exposure to an infected individual (e.g., pediculosis)

HISTORY Ocular history Systemic history previous ophthalmic surgery Trauma (including radiation and chemical trauma) Systemic history dermatological diseases, such as acne, rosacea, eczema, allergies) Use of ocular medications or retinoids.

EXAMINATION Visual acuity Careful external examination of facial skin, eyelids, and eyelashes. Slit lamp biomicroscopy Tear film Anterior eyelid margin, eyelashes, posterior eyelid margin, tarsal conjunctiva, bulbar conjunctiva, and cornea. Tests Lissamine green Rose bengal Tear break-up time Schirmer testing Cochet-Bonnet esthesiometry to check corneal sensation for a unilateral case

STAPHYLOCCAL BLEPHARITIS ALSO CALLED INFECTIVE BLEPHARITIS Staphylococcus Aureus And Epidermidis 80% ARE YOUNG WOMEN USE OF COSMETICS USUALLY UNILATERAL IN CHRONIC CASES MAY BE BILATERAL SYMPTOMS BURNING, ITCHING, STINGING EYESTRAIN PHOTOPHOBIA FOREIGN BODY SENSATION WORSE IN THE MORNING

Patient with chronic staphylococcus blepharitis. SIGNS BRITTLE, HARD SCALES WITH COLLARETTES AROUND CILIA STERILE CORNEAL INFILTERATES 1mm FROM THE LIMBUS SMALL ULCERATIONS PANNUS MADAROSIS POLIOSIS TRICHIASIS Patient with chronic staphylococcus blepharitis.

STAPHYLOCCAL EXOTOXINS STAPHYLOCCAL EXOTOXINS HAVE BEEN IMPLICATED AS A CAUSATIVE AGENT FOR BOTH MARGINAL INFILTRATES AND PHLYCTENULAR DISEASE ASSOCIATED WITH BLEPHARITIS

TREATMENT AGGRESSIVE EYELID HYGIENE TOPICAL ANTIBIOTIC WARM COMPRESSES EYELID SCRUBS TOPICAL ANTIBIOTIC ERYTHROMYCIN BACITRACIN TOPICAL CORTICOSTEROIDS IN MARGINAL INFILTRATES AND PHLYCTENULAR DISEASE

SEBORRHEIC BLEPHARITIS GENERALIZED SEBACEOUS GLAND ABNORMALITY EXTENDING ONTO EYELID MARGIN USUALLY BILATERAL SYMPTOMS ARE USUALLY OUT OF PROPORTION TO PHYSICAL FINDINGS

CLINICAL FINDINGS MAY REVEAL MILD INFLAMMATION OF ANTERIOR LID MARGIN ERYTHEMA EDEMA TELANGIECTASIA AT LID MARGIN SCALING & CRUSTING AT LID MARGIN OFTEN EXTENDING ONTO LASHES “SCURF”

TREATMENT EYELID HYGIENE LOCAL ANTIBIOTICS SELENIUM SHAMPOO WARM COMPRESSES EYELID SCRUBS LOCAL ANTIBIOTICS IF SUPERINFECTION IS SUSPECTED SELENIUM SHAMPOO FOR CONCURRENT SCALP SEBORRHEA

STAPHYLOCOCCAL SEBORRHEIC AGE mean 42 yrs mean 50 yrs FINDINGS Hard Adherent Scales, Crusts Pierced By Cilia, “collarettes” Greasy, less adherent scales “scurf” CORNEA Marginal infilterates, inferior SPEE, Phlyctenulosis inferior SPEE Tear Film Unstable, rapid break-up time Aqueous tear deficiency in 1/3 Treatment Topical antibiotics, Eyelid scrubs, warm compresses Eyelid scrubs, warm compresses, selenium shampoo

MEIBOMIANITIS MEIBOMIAN GLAND INFLAMMATION LOCALIZED MEIBOMITIS CHALAZION INTERNAL HORDEOLUM GENERALIZED MEIBOMITIS MEIBOMIAN SEBORRHEA MEIBOMIAN KERATOCONJUNCTIVITIS

CHALAZION MEIBOMITIS STYE

MEIBOMIAN SEBORRHOEA BUILD UP OF EXCESSIVE MEIBOMIAN SECRETIONS MILD INFLAMMATION OF ANTERIOR LID MARGIN TELANGIECTASIA

EXCESSIVE MEIBOMIAN SECRETIONS GROSSLY ABNORMAL MEIBUM EXPRESSED FROM GLAND ORIFICE

TREATMENT DAILY LID MASSAGE WARM COMPRESSES TO SOFTEN MEIBUM EXPRESSION OF EXCESS SECRETIONS

MEIBOMIAN KERATOCONJUNCTIVITIS MORE SEVERE FORM SEMI-SOLID, WHITE SECRETIONS VISIBLE AS “BRUSH MARKS” ENLARGED GLANDS THAT LATER ON DEVELOP ATROPHY RAPID TEAR BREAKUP DUE TO ABSCENT MEIBOMIAN SECRETIONS CORNEAL PUNCTATE EPITHELIAL EROSIONS PANNUS MARGINAL INFILTERATES CORNEAL THINNING

TOOTH PASTE LIKE SECRETIONS

TREATMENT AGGRESSIVE EYELID HYGIENE TOPICAL ANTIBIOTICS WARM COMPRESSES EYELID SCRUBS TOPICAL ANTIBIOTICS ORAL TETRACYCLINE REDUCES PRODUCTION OF FFA BY INHIBITING BACTERIAL ENZYMES AND CAUSE STABILIZATION OF TEAR FILM

ACNE ROSACEA COMMON CHRONIC INFLAMMATORY DISEASE WITH OCULAR &SKIN MANIFESTATIONS SEBACEOUS GLAND DYSFUNCTION 30-50 YEARS TYPE IV HYPERSENSITIVITY REACTION SYMPTOMS RANGE FROM IRRITATION TO BURNING TO FOREIGN BODY SENSATION

CLINICAL FEATURES CHRONIC BLEPHARITIS CONJUNCTIVAL HYPEREMIA RECURRENT CHALAZIA KERATITIS TEAR FILM INSTABILITY ROSACEA KERATITIS PERIPHERAL CORNEAL VASULARIZATION TELANGIECTASIA THINNING ULCERATION EVEN PERFORATION

TREATMENT ORAL TETRACYCLINES TOPICAL METRONIDAZOLE WARM COMPRESSES REDUCES FACIAL REDNESS WARM COMPRESSES EYELID SCRUBS TOPICAL STEROIDS ROSACEA KERATITIS

MEIBOMITIS ACNE ROSACEA AGE All Ages 30-50 yrs FINDINGS Irregular posterior margin, plugged gland orifices “brush marks” Marginal Telangiectasia, meibomitis, Recurrent chalazia CORNEA Inferior SPEE, Marginal infiltrates, Pannus, Corneal thinning Pannus, thinning, ulceration and perforation TEAR FILM Unstable, foamy Unstable TREATMENT Eyelid Scrubs, antibiotics, warm compresses, daily massage, oral tetracycline Tetracycline, topical metronidazole for facial redness

DIFFERENTIAL DIAGNOSIS INFECTIOUS STAPHYLOCCAL DEMODEX FOLLICULORUM CANDIDA PHTHIRUS INFLAMMATORY SEBORRHEIC MEIBOMITIS

DIFFERENTIAL DIAGNOSIS DERMATOLOGIC/ALLERGIC ACNE ROSACEA ATOPIC KERATOCONJUNCTIVITIS ATOPIC DERMATITIS PSORIASIS PITYRIASIS COSMETIC USE SYSTEMIC LUPUS ERYTHEMATOSUS ACQUIRED IMMUNODEFICIENCY SYNDROME CONGENITAL ERYTHROPOITIC PORPHYRIA

Picture demonstrating thinning of eyelids secondary to corticosteroid use. Note sleeves and scurf

Patient with Pthirus pubis with critters on eyelashes.

DOMEDEX FOLLICULORUM ADJACENT TO AN EYELASH

MEIBOMIAN GLAND DYSFUNCTION NUTRITIONAL TREATMENT OPTIONS OLEIC ACID OIL OF EVENING PRIMROSE OMEGA 6 F.A FLAVONOIDS RESVERATROL SILYMARIN BILBERRY EXTRACT HORMONAL TREATMENT OPTIONS ROLE OF ANDROGENs *Ophthalmol Clin N Am 16 (2003) 37-42

Infrared Warm Compression Device Wave length peak, 940 nm Treatment of non-inflamed obstructive meibomian gland dysfunction Improved tear stability Associated with release of meibum Effective and safe British Journal of Ophthalmology 2002;86:1403-1407

Fusidic Acid Gel For Recurrent Blepharitis And Rosacea Topical fusidic acid gel (Fucithalmic) Patients with blepharitis & concomitant Rosacea respond well to therapy. *Ann. Pharmacother., January 1, 2005; 39(1): 86 - 94.

Role of Ceramide Gel In Atopic blepharitis Ceramide comprises about 30% of stratum corneum lipids Role in both the water retention and barrier function of the skin Better patient compliance than ointments containing petrolatum useful supplementary therapy during periods of relatively light inflammation *British Journal of Ophthalmology 2003;87:362-363

Dark pink bougainvillea

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INFECTIVE DISORDERS HZO Signs: Common unilateral condition effects elderly pts Severe immunodeficiency states Presentation : Pain Signs: Maculopapular rash on the forehead , vesicles , pustules and crusting ulceration .

Hutchison sign Periorbital oedema Treatment: Systemic : Valaciclovir 1 gm tds for 7 days or famciclovir 250 mg tds for 7 days

Topical : Acyclovir or famciclovir cream Steroid antibiotic combination such as fucidin H , Hydrocortisone and fusidic acid

Superficial skin infection caused by staph aureus or b.hemolytic sterp Occurs in children Associated with inf of the face Signs: Erythematous macules vesicle formation and bullae – yellow crust Treatment: Topical antibiotic Systemic flucloxacillin or erythromycin Impetigo

Necrotizing fasciitis Cutaneous gangrene which usually effects the trunk ,perineum and legs caused by strep pyogens and staph aureus Effects elderly and debilitated pts following trauma Signs: Bilateral lid oedema and erythema rapidly progress to gangrene Treatment: High doses of parental benzyl pencillin and surgical debridement of necrotic tissues. Necrotizing fasciitis

Internal hordeolum Acute staph infection of meibomian glands Signs: Tender inflamed swelling with in tarsal plate, discharge ant or post . Treatment: I&C

Stye Acute staph abscess of lash follicle and associated with gland of Zeis or Mole Signs: Tender inflamed swelling in the lid margin , more than one lesion may be present and minute abscess may involve the entire lid margin External hordeolum

In severe cases mild preseptal cellulitis . Treatment: Hot compresses Epilation Systemic antibiotic

Molluscum contagiosum Skin infection caused by pox virus Immunocompromised pts mainly effected Signs: Single or multiple pale ,waxy , umbilicated nodules Causes follicular conj , superficial keratitis . Treatment: Shave excision and cauterization , cryo, laser. Molluscum contagiosum

Chronic lipogranulomatous inflammatory lesion caused by blockage of gland orifices and stagnation of sebaceous secretions Presentation : Painless nodule , Astigmatism . Signs: Painless round firm lesion in the tarsal plate , polypoid granuloma , associated chr post blepharitis. Chalazion

Treatment: Surgery Steroid injection: 0.1 to 0.2 ml triamcinolone diacetate diluted with lignocaine to a conc. of 5mg per ml . Second inj after 2 wks Systemic tetracycline in pts with recurrent chalazion.

Blepharitis Blepharitis refers to a family of inflammatory disease of the eyelids (chronic inflammation) It is usually bilateral ,symmetrical and is more common in the older age group

Anterior Posterior Mixed. Types

Most common causes of Blepharitis are Staphylococcal infection and irritation from oily Mebomian gland secretion Pathophysiology involves bacterial colonization of eyelids resulting in direct mirobial invasion of tissues ,immune system mediated damage ,or damage caused by bacterial toxins ,waste product and enzymes Seborrhic Blepharitis may be associated with seborrhic dermatitis Pathogenesis

Association SYSTEMIC DISEASES Rosacae Seborrhic dermatitis Herpes simplex dermatitis Varicela Zoster dermatitis Staphylococcal dermatitis OCULAR DISEASES Dry eyes syndromes Chalazion Conjunctivitis , Keratitis Association

Symptoms Burning Watering Foreign body sensation Crusting and matting of eyelashes Photophobia Redness of lids and eyes Pain and defective vision Symptoms

Gross examination shows erythema and crusting of eyelashes and lid margins Slit lamp examination may show madarosis,poliosis,trichiasis crusting of lashes and Mebomian orifices, eyelid margin ulcers, Telengectiasis and tylosis Papillary conjunctival reaction Aqueous tear deficiency Posterior Blepharitis may be related to Mebomian gland dysfunction. Signs

Complications Chronic conjunctivitis Keratitis Phlyctenulosis External hordeolum Tear film instability trichiasis

Treatment Lid hygiene Topical antibiotics Topical steroids Tear substitutes Systemic antibiotics Treatment of complication