Ocul Dis-Lids

• -Lash misdirection
• -v. common, esp elderly
• -idiopathic, chronic blepharitis, trachoma (Chlamydia leading to infection), basal cell carinoma

• Trichiasis
• -ocular irritation, worse with blinking
• –hyperemia and epiphora–unilateral or bilateral
• –inward turning lashes
• –corneal staining

–artificial tears–epilation of lashes•regrow in 1-2 months–lid hygiene•If blepharitis–broad spectrum prophylactic antibiotics (preventative)–bandage contact lens–surgical removal•electrolysis; laser ablation; cryotherapy

• Decrease in number or complete loss of lashes
• –Lid margin disease (e.g. chronic blepharitis)
• –Skin disorders (e.g. psoriasis)
• –Systemic disease (e.g. leprosy)

• –Chronic, bilateral inflammation of the lid margins (may affect tear film, cornea, conj)
• -V. common, esp. with increasing age

• Anterior Blepharitis (Seborrhoeic)
• (•Burning•Grittiness•Mild photophobia)
• •Greasy anterior lid margins•Lashes may stick together•Scales on lashes and skin of lid

• Staph. blepharitis
• •Scales and crusts at base of lashes•Hyperaemia and telangietasis of anterior lid margin (due to TOXINS of Staph)

• Lid Hygiene (warm compresses, lid scrubs, lubricants)
• Antibiotic ointment (erythromycin or bacitracin, polysporin)
• Topical steroids for conj and/or corneal involvement (fluoromethalone)

• Meibomian Gland Dysfunction or meibonianitis
• -Roscea (common skin disorder), idiopathic skin disease (facial)

• Posterior Blepharitis
• –Posterior lid margin hyperaemic–Telangiectasis of lid margin–Obstructed meibomian orifices (inspissated)

• Posterior blepharitis
• -see inspissated glands -> oil in tear film (Px will have blurry vision)

• -Tear film instability (discomfort, blurred vision)
• -Corneal and Conjunctival involvement
• -Chalazion formation (more about this later)
• -Systemic causes of the blepharitis

• -Lid Hygiene (Warm compresses•Meibomian gland expression•Lid Scrubs•Artificial Tears)
• -Antibiotics for Ocular Rosacea (Systemic tetracycline or doxycycline or erythromycin)

• -sterile, block meibomian gland
• -common, esp. for Px with posterior bleph, rosacea, seborrhoeic dermatitis
• -asymptomatic, may press on cornea -> blur vision, blepharitis, unslightly

• Chalazion
• -non-tender, palable lump in lid

• -Topical therapy ineffective!
• -wait, may clear w/o treatment (hot compresses, digital massage qid)
• -Steroid Injection (triamcinolone)
• -Systemic antibiotic (tetracycline) for recurrent chalazia or with rosacea
• -Surgery
• -CONSIDER sebaceous gland carcinoma if reoccurs!

• -Infection of lid glands (internal or external, commonly acute staph infection)
• -Common in those with chronic blepharitis

• Internal Hordeolum
• •Tender, painful swelling within tarsal plate
• •May discharge through skin of lid or through palpebral conjunctiva

• •Warm compresses*
• •Antibiotics (systemic) rarely needed
• •May leave a residual nodule after healing – this may require surgical removal

• •Acute staph infection of gland of Zeiss or Moll
• -common stye

• External hordeolum (stye)
• •Tender swelling in lid margin
• •Points anteriorly through skin
• •Mx: Warm compresses•Removing lash (epilation) may speed resolution (almost never necessary)•Antibiotics not indicated

• -Yellowish, subcutaneous plaques of cholesterol and lipid
• -common in elderly, may indicate hyperlipidemia in younger Px
• -get cholesterol checked! Surgery for cosmetic reasons

• -Fluid filled cyst on lid margin, blockage
• -common (moll more common than zeiss)
• -moll: clear fluid (apocrine), zeiss translucent (oily)
• -differntial: sebaceous cysts (yellow, waxy, spongy)

• -blockage of sebaceous glands (yellow, waxy, spongy)
• -uncommon
• -monitor growth for carcinoma!

• Tiny white superficial cysts
• -Derived from hair follicle or sebaceous glands
• -Very Common, not a big deal

• Viral Wart
• Pedunculated or broad based, pigmented or unpig., raspberry like surface
• -benign eyelid tumor, squamous papilloma
• -Very Common (>1/10), more frequent with age
• -Can be surgically removed

• Seborrhoeic Keratosis
• -Benign eyelid tumor
• -Overactivity of the sebaceous glands characterized by excessive secretion of sebum or an alteration in its quality, resulting in an oily coating, crusts, or scales on the skin.
• -Common in the elderly
• -Uncommon on lids (1/1000)

• Benign Eyelid Tumours
• -Most common pre-malignant skin lesion, rare on lids
• -refer to dermatologist

• -a rare disorder that is present at birth. A child with this condition will have a port-wine stain birthmark (usually on the face) and nervous system problems.
• -Naevus (subcutaneous cavernous hemangioma, red patch) involves trigeminal nerve distribution
• -uncommon (1/50,000)
• -may be angiomas in brain (tumor of lymph and bvs), high risk of ipsilateral glaucoma

• -Malignant Eyelid Tumours
• -most common skin cancer, common in elderly (rare for lids to be affected -likelihood: lower lid, medial canthus (risk for orbital involvment)
• -Related to sunlight exposure

• Basal Cell Carcinoma
• •Shiny, firm, pearly nodule•Fine vessels on surface•Initial growth is slow•Develops central ulceration, raised edges, with dilated vessels at edges

• Squamous cell carcinoma
• -less common than basal cell carcinoma, more aggressive though
• -metastasize (basal cell carcin does not metastasize)
• -may arise from actinic keratosis
• -more rapid growhth, no surface vascularization

• -uncommon
• -age (incrased horizontal lid laxity and atrophy of the orbital tissues -> globe moves posteriorly)
• -congential due to hypertrophy of musculature
• -scarring of tarsal conj (trauma, chemical burns, inflammatory conditions, trachoma)
• -spasm (surgical trauma, blepharospasm due to dry eye or Tourette's syndrome)

• –artificial tears
• –prophylactic antibiotic
• –epilation of lashes in minor cases
• –electrolysis (remove lashes)
• –lid taping
• –bandage contact lens
• –mucous membrane (cictricial/scarring cases)
• -surgery (tighten or shorten the skin)

• -an outward turning of the eyelid margin–almost exclusively the lower lid
• -Common
• –FB sensation–hyperemia–epiphora, corneal staining
• -age, scarring, mechanical, paralytic (CN7 causing lack of tone in orbicularis ie. Bell's Palsy)

• –artificial tears & ointment at night
• –lid taping at night
• –lid surgery if severe (tarsorrhaphy (lids stitched partially together) or inferior lid shortening)

• –Ptosis reduces on mouth opening–Abnormal levator innervation from N5 (trigeminal)
• –5% of congenital ptosis

Striated muscle dystrophy of the levator muscle–Often cause unknown–May be hereditary–Can also involve SR

• -most commonly a breakdown of tarsal plate (the tendon of levator)
• -often seen in senile (adipose tissue replaces levator) or postoperative (esp. CatS), blunt trauma, CL wear

• Horner's Sympathetic Palsy
• Acquired or congenital innervational defect–III N palsy, oculosympathetic palsy
• Signs: Neurogenic ptosis (weak Muller), miosis (unopposed sphincter), cycloplegia, exotropia (LR and SO function, no drepression in abduction), loss of sweating in acquired cases, lesion below superior cervical ganglion (external carotid artery plexus affected)

• -cerebral anuerysm compressing CN3
• -emergency, life-threatenging (MRI)

• –diabetes; hypertension
• -microangiopathy

• -stroke
• -tumor (lung carcinoma), thyroid (check neck), Pancoast tumor (arm pain), neuroblastoma (children), cluster migraine, Herpes Zoster, cavernous sinus (intracranial) tumor))

• Disorder of neuromuscular transmission characterized by weakness and fatigability of skeletal muscles (autoimmune reaction to decrease ACh receptors)
• -eye lid droop, transient double vision with fatigue, flutating muscle weakness
• -benign tumor of thymus (remove thymus, myasthenia gravis will go away)
• -elderly Px

• -genetic disease (Autosomal dominant)
• -Signs: –bilateral ptosis; orbicularis weakness; lid closure; extraocular muscle dysfunction; poor blinking; dry eyes, cataracts

• -severe cases may require surgery (esp congenital cases) shorten Muller, levator resection (most common), attach superior lid to frontalis muscle
• -watch for corneal exposure after surgery

contralateral lid retraction (pseudoptosis)

excessive skin on upper lids

• -shrunken globe (micophthalmos)
• -eye displaced backward (enophthalmos)
• -congenitally abesent (anophthalmos)

• Preseptal cellulitis
• -Spread of local infection to subcutaneous tissues anterior to orbital septum
• -uncommon to rare
• -complication of hordeolum, skin trauma

• Preseptal: normal vision, normal pupil, normal motility
• Orbital: Fever, Malaise & Pain, Reduced Vision(optic nerve involvement), Proptosis (protruding), Ophthalmoplegia (restricted mov't) POTENTIALLY LIFE-THREATENING

• preseptal: oral antibiotics (cephalexin, amoxicillan/clavulanic acid)
• orbital: hospitalization, antibiotics (IV, IM, Oral), blood tests, CT scan