1. External eye disorders
Dr P Deol

2. Eye lids

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

4. 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.

6. 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

7. 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

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

9. Eye lid lumps

10. 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

12. 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.

14. 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.

15. 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

17. 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.

18. 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.

19. 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.

20. ‘ Gritty Eyes ’

21. 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.

22. 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

23. 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

24. 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.

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

26. 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