External eye disorders Dr P Deol

Eye lids

Entropium In-turning of the eye lids due to degenerative changes (common >40years) Ccx – eyelashes rub on cornea = irritation Rx – Refer for surgical correction.

Ectropium Eye lid is turned out. Often asymptomatic, but may cause watery eye (epiphoria), eye irritation and exposure keratitis. Most common in the elderly with facial nerve palsy. Routine ref for corrective lid surgery if significant symptoms.

Causes of Ptosis Age related – stretching and thinning of levator muscles or its aponeurosis. Horners syndrome Partial or complete CNIII palsy Myasthenia gravis Orbital tumours or inflammation Congenital Idiopathic

Approach to a patient with Ptosis Unilateral v Bilateral Bilateral – age related / MG Severity – Horners will only produce mild ptosis Double vision and limited eye movements? MG / partial CN III palsy Abnormal pupil size on side of ptosis? Small abnormal pupil = Horners Large abnormal pupil = Partial CN III palsy Fatiguability? = MG

Ptosis Refer all cases of ptosis to an opthalmologist to exclude serious underlying. Surgery if eyelid droop is obstructing vision or significant cosmetic defect.

Eye lid lumps

Eyelid lumps Red + inflamed ? Yes No Pigmented ? Yes No Inflamed chalazion Stye Lid abscess Inflamed tumour Naevus Melanoma Chronic chalazion Benign tumours Malignant tumours e.g. BCC, SCC

Chalazion Non infectious, granulomatous focal inflammatory lesion due to obstructed lid meibomian (lipid) sebacous glands. Often results from poor healing of an internal hordeolum(stye) Mildly red and tender when acute and inflamed. When chronic, painless firm lumps deep in the upper or lower lids. Almost always resolve spontaneously – no Rx usually required. Incision and curette under LA is curative.

Hordeolum (Stye) A hordeolum is an acute purulent eyelid inflammation. Hordeola have an acute onset and are painful, red, localized swellings with abscess formation Hordeola are usually self-limiting, resolving within 5-7 days when they drain External hordeola are due to blockage and infection of a lash follicle or the adjacent sebaceous glands of Moll (sweat) or Zeis (sebum). Abscess points outward. Internal hordeola are due to blockage and infection of the Meibomian sebaceous glands. Less common. Point inwards onto conjuctiva. Can persist as Chalazion or Meibomian cyst.

Hordeolum Warm compresses/soaks are the mainstay of treatment. Can treat with antibiotic eye drops. Treatment can be to remove the central offending lash – may allow discharge and resolution. If associated mild localised cellulitis treat with oral antibiotics. Fluctuant tender mass in the eyelid – can arise from a stye or other skin infection. Treatment requires urgent opthalmic referral (risk of progressing orbital cellulitis). Lid abscess

Orbital cellulitis Severe sight and life threatening infection of the orbit soft tissues, usually bacterial. Complications : Blindness c/o optic neuropathy, Death c/o meningitis or encephalitis. Requires urgent opthalmic referral for admission and treatment. High dose BS IV antibiotics and urgent orbital CT scan.

Orbital cellulitis Symptoms Pain, blurred vision, double vision, fever and malaise Signs Eyeball and eyelids are red. Proptosis ( eyeball pushed forward) Decreased VA Limitation or eye movement in 1+directions Relative afferent pupil defect High fever, unwell.

Pre septal cellulitis Infection of the subcutaneous tissue of the eyelids. No extension into orbit. Mild to moderate eyelid swelling maybe only symptom. Ensure none of the signs of orbital cellulitis are present. Management Children who are unwell with fever require urgent paediatric referral. Adults – BS PO antibiotics with frequent review until resolved.

‘ Gritty Eyes ’

Blepharitis Chronic irritation of the eyelid margin. Due to obstruction of the meibomian (lipid) glands +/or chronic colonisation of the lid margins( staphlococcal) Signs Thickened lid margins Lid teneangiectsaia Blocking of Meobomiam gland orifices Scales on the eye lashes . Loss of lashes if severe.

Blepharitis - Management BD lid hygiene Warm compress for 5 mins to closed eyelid Scrub lid margin gently with cotton bud dipped in diluted ‘baby shampoo’ or boiled water. Frequent artificial tears can help is coexisting dry eyes If consider staph colonisation (lid margin erythema / pin point lid margin ulceration) – Chloramphenical / Fusidic acid eye drops BD to lid margins for 3/52. Routine opthalmic referral

Keratoconjunctivitis Sicca Causes Abnormal wetting (mucin deficiency) Aqueous tear deficiency ( reduced lacrinal gland fn) Postmenopause AI disease (Sjogrens syndrome / SLE / RA) Drug indiuced ( Diuretics ( BB, Diuretics) HIV Lymphoma Abnormal spreading / Lagopthalmos Reduced blink frequency CNVII palsy, Parkinsonism

Keratoconjunctivitis Sicca - Management Schirmer test Mild – Preserved tear substitutes 3-4 daily (G hypromellose 0.3% or G polyvinyl alcohol Liquifilm Tears) Moderate – Unpreserved tear substitutes. Eye ointments containing paraffin before sleep Lacri-lube, Lubri-Tears. Use spectacles / contact lenses to reduce evaporation from surface, Severe – punctal occlusion (temporary collagen / silicone plugs or permanent surgical occlusion. Hourly unpreserved tear substitutes.

Pterygium Creamy coloured raised triangular plaque on the conjunctiva (either side of cornea) = pterygium If plaque grows over edge of cornea = pinguecula.

Pterygium No need to treat unless encroaching over the pupil – then refer to surgical excision. May respond to steroid eye drops ( Caution – must exclude corneal ulcer first). Recurrence possible