Lecture 2 DISEASES of EYELIDS, LACRYMAL SYSTEM & ORBIT Lecture is delivered by Ph. D., associated professor Tabalyuk Tetyana

EYELID ANATOMY The eyelids layers: skin muscle tarsus conjunctiva

BLEPHARITIS very common chronic inflammation of the eyelid margins Classification: divided into anterior & posterior forms: the former may be staphylococcal or seborrhoeic; a mixed picture is typical, however. Causative factors: staphylococcal: chronic infection of the bases of the lashes – common in patients with eczema seborrhoeic: usually associated with seborrhoeix dermatitis – involves excess lipid production by eyelid glands, converted to fatty acids by bacteria posterior: dysfunction of the meibomian glands of the posterior lid margins – common in patients with acne rosacea

Clinical features: usually worse in the morning, include grittiness, burning and redness, stickiness and crusting of the lids. SIGNS: staphylococcal: dandruff-like scaling, mainly around the eyelash bases; seborrhoeic: greasy debris around the lashes causing them to adhere to one another; posterior: frothy tear film and pluggung of the meibomian gland orifices All types usually manifest hyperaemia of the lid margins and conjunctiva, and tear film instability

Complications: corneal epitheliopathy scarring marginal keratitis reccurent bacterial conjunctivitis chalazia styes loss of lashes (madarosis) misdirection (trichiasis)

Management: lid margin hygiene using a weak solution or baby shampoo tear substitutes (e.g. hypromellose, carbomers) antibiotic ointment (e.g. fusidic acid, chloramphenocol) rubbed into the lid margins systemic tetracycline

Meibomian cyst (chalazion) a lesion consisting of lipogranulomatous inflammation centred on a dysfuctional meibomian gland Clinical features: Extremely common, particularly in patients with posterior blepharitis. A chronic, usually solitary, painless, firm swelling in the tarsal plate; Can follow an acute meibomian gland infection. May be assosiated with a secondary conjunctival granuloma Management: spontaneous resolution may occur, although usually only if the lesion is small. Surgical incision and curettage is often required

INTERNAL HORDEOLUM (acute chalazion) an acute bacterial meibomian gland infection Clinical features: An inflamed swelling within the tarsal plate which may be associated with (mild) preseptal cellulitis Management: Topical antibiotic ointment and systemic antibiotic (e.g. flucloxacillin) for preseptal cellulitis. Hot bathing may promote discharge. Incision and curettage Incision and curettage may be required for a large abscess, or for secondary chronic lesion.

EXTERNAL HORDEOLUM (stye) a small abscess of an eyelash follicle Clinical features: An acute painful inflamed swelling on the anterior lid margin, usually pointing through the skin Management: Removal of the associated lash, and hot bathing. Topical antibiotic ointment. Large lesions may require incision

Cysts of Zeis and Moll Management: Clinical features: A cysts of Zeis is a small, whitish, chronic, painless opaque nodule on the lid margin A cysts of Moll is similar but translucent Management: simple excision

MOLLUSCUM CONTAGIOSUM Clinical features: single or multiple, small, pale, waxy umbilicated nodules, which may cause a secondary chronic ipsilateral follicular conjunctivitis. These virally transmitted lesions are common and more severe, in AIDS patients. Management: expression or cautery.

Benign tumours of the eyelids Squamous cell papilloma (viral wart) Basal cell papilloma (seborrhoeic keratosis) Keratoacanthoma Melanocytic naevus Capillary haemangioma (strawberry naevus) Plexiform neurofibroma

Squamous cell papilloma (viral wart) Management: Simple excision, cautery or laser ablation Clinical features: The most common benign tumour of the eyelid which may be broad-based (sessile) or pedunculated

Basal cell papilloma (seborrhoeic keratosis) Management: Simple excision or curettage Clinical features: This common tumour usually found in the elderly, is a slowly-enlarging brownish papillary lesion with a greasy friable surface

Remains static for several months before involution Keratoacanthoma Remains static for several months before involution Clinical features: An uncommon, fast-growing, firm, pinkish nodule that develops a keratin-filled crater and may be mistaken for a malignancy

Melanocytic naevus Itradermal Intradermal naevus – an elevated lesion with variable pigmentation. When located on the lid margin may be associated with protruding lashes. No malignant potential. Junctional naevus – a flat well circumscribed lesion with a uniform brown colour, so-called because the naevus cells are located at the junction of the dermis and epidermis. Low malignant potential. Compound naevus – usually elevated, with a homogeneous tan to brown colour. Consists of both intradermal and junctional components, the latter conferming a low malignant potential.

Capillary haemangioma (strawberry naevus) Clinical features: an irregular red lesion in an infant which may cause a mechanical ptosis and amblyopia. Management: local steroids if necessary, but frequently undergoes gradual spontaneous involution.

Plexiform neurofibroma Typically occurs in neurofibromatosis-1, characteristically giving rise to an S-shaped lid margin and ptosis

Premalignant and malignant tumours of the eyelids Actinic (solar) keratosis Basal cell carcinoma Squamous cell carcinoma Sebaceous gland carcinoma Management: Surgical excision with a wide clearance margin is the treatment of choice for most lid malignancies Radiotherapy in selected cases

Actinic (solar) keratosis Clinical features: although rare, this is most common premalignant lid condition and is strongly associated with excessive sun exposure in light-skinned individuals. It is usually presents as a persistent scaly plaque, which must be biopsied.

Basal cell carcinoma Clinical features: most common eyelid malignancy, is locally invasive but does not metastasize. About 50 % involve the lower lid, 30 % the medial canthal area. Nodule –ulcerative - a «rodent ulcer», with rolled hyperkeratotic edges and central granulation, gradually enlarging over 1-2 years. A purely nodular appearance is common. Sclerosing - a flat indurated plaque with poorly demarcated margins, often with loss of overlying lashes that may simulate chronic blepharitis

Squamosus cell carcinoma Clinical features: is much less common than basal cell carcinoma. It grows more quiclkly and may metastasize. It may arise de novo or from premalignant condition such as actinic keratosis. Nodular – starts as a hyperkeratotic nodule or plaque which later develops crusting fissures Ulcerative – resembles a rodent ulcer

Sebaceous gland carcinoma Clinical features: this is rare but very aggressive tumour, which may originate in a meibomian or Zeus gland as a film nodule either on the lid margin or within the tarsal plate, when it may be mistaken for an chalazion.

Entropion an inward-turning of the eyelid Classification: Involutional – most common form, results from age-related changes in lower lid Cicatrical – most frequently secondary to scarring of the upper conjunctiva, as on chronic trachoma Spastic – lower lid, caused by spasm of the orbicularis muscle due to ocular irritation or essential Congenital – very rare, only involves the lower lid. Caused the hypertrophy of skin and orbicularis Management : surgical correction :

Ectropion an outward-turning of the eyelid Classification: Involutional – most common form, age-related tissue laxity Cicatrical – scarring resulting from burns or surgery (e.g. tumour resection) Mechanical – excess lid weight (e.g. large tumour) Paralytic –facial nerve palsy, associated with incomplete blinking and lid closure Congenital – may be part of blepharophimosis syndrome Management : surgical correction :

Lacrymal system anatomy: Larcymal productive part & Lacrymal excretory part

Investigation of lacrymal system Functional ability of lacrymal excretory system – 1% Fluorecsein is dropped into conjunctival cavity Positive canalicular test – disapearing of S. Fluorecsein from conjunctival cavity till 5 minutes, usually 1-2 minutes Positive nose test – appering of S. Fluorecsein in 5 minutes Shirmer test Reveals hyposecretion of lacrymal gland – wetting of filter paper less then 15 mm

DACRYOADENITIS – inflammation of lacrymal gland Clinical features: hyperemia, oedema and pain in upper-external part of orbit Eyeball can be dislocated down and nasally Prearicular lymph nodes are increased and painfull Increased body temperature Key sign – S-like form of rima ophthalmica Management: systemically antibiotics, sulfanilamids, salicilates In abscess – incision and

DACRYOCYSTITIS – inflammation of lacrymal sac Ethiology: in infants – atresia of lower part of nasolacrymal duct; in adults – stenosis of nasolacrymal duct Clinical features: exess tearing, pus discharge usually from one eye Key sign – pus discharge from lower lacrymal point in palpation of area of lacrymal sac Management: in infants – massage of lacrymal sac Syringing of lacrymal excretory ways Dreanage of lacrymal excretory ways Chonic in adults – surgical - dacryocystorhinostomy

Orbital cellulitis Signs: eyelids oedema chemosis proptosis limiting of eye movements decreasing of visual acuity general intoxication (headacke, increased temperature, brain signs). Optic neuritis, papilloedema, central vein occlusion may occur with outcome in optic atrophy. Management: incision of orbit with drainage antibiotics systemically osmotherapy

Fissura orbitalis superior syndrome Tumour, haematoma, foreign body in the area of fissura orbitalis superior usually causes: Proptosis Ptosis Ophthalmoplegy Mydriasis Paralysis of accomodation Decreasing of corneal sensitivity and skin sensitivity in the area of innervation of I branch n.trigeminus