Disorder of Lids & Lashes Flashcards
What is Ectropion?
outward rotation of eyelid margin - usually lower eyelid
70% bilateral
outward like ECscape
Ectropion Causes
4 acquired + 1 more
INVOLUTIONAL: age related change in eyelid tissue, ↑ lid laxity & weakness of muscle (obicularis oculi muscle) and tendons
CICATRICIAL: due to scarring- tissue contracts and underlying tissue + contraction causes change in its shape. May be due to trauma to eye, burn or after eyelid surgery (e.g. skin tumour on eyelid)
PARALYTIC: nerve innervation problem to eyelid muscle- usually during facial palsy
MECHANICAL: something obstructing normal position of eyelid tissue- usually due to tumour in, on or near eyelid margin or swelling & inflammation due to infection or allergy
CONGENITAL: v rare - bilateral
Ectropion Predisposing Factors
age as lid laxity ↑ (involutional ectropion)
Ectropion Symptoms
- sore - pain/ discomfort/ grittiness/ FB sensation
- red- due to inflammation & irritation- tears don’t coat surface as they should so eye may be dry
- watery- excessive, conjunctival sac exposed. Worse going indoor to outdoor (ask px “when is it worse?”)
- variable depending on severity
Ectropion Signs
-lower lid not opposed (in contact) to globe
-punctum in abnormal postition - visible w/o touching it
-exposure keratopathy - tears don’t coat ocular surface- exposed cornea -> will stain w/ NaFl as epithelium has probs broken down
-conj. hyperaemia
-epiphora - watering of eye down cheeks, tears can’t be contained in conj sac
Name two tests used to determine if patient has ectropion?
Distraction test: lower lid pulled from globe, if can pull >6mm= lax.
Snap-back test: use finger, pull lower lid down towards inferior orbital margin & then release it, observe - lid should snap- back to position. If delayed, shows poor tone of obicularis oculi muscle & poor recovery
Ectropion Management
-depends on sign/symptoms and how they impact px quality of life
Mild cases: -reassurance & advice
-lid rubbing may ↑ laxity so avoid
-ocular lubricants- during day -> eye drop, or ointment at night
Manage Exposure Keratitis: -tape lids closed w/ micropore tape at night to reduce exposure
-therapeutic CL protects exposure
-ocular lubricants
Moderate to severe cases: -where significant corneal involvement and risk of infective keratitis
-recurrent infections
-affecting px quality of life
-refer for consideration for surgery- depens on severity, location & cause
What is Floppy Eyelid Syndrome and what does it get confused with?
-can get mixed with ectropion
-uncommon
-worse in morning
-dry,gritty eye, affecting eye on side sleep on due to ↑ lid laxity -> “eyelid spontaneously flips over due to rubbing on pillow”
-middle aged obese men
-hx of sleep apnea
-can cause exposure keratitis, dry eye and chronic papillary conjunctivitis
-↑ lid laxity: measure using abnormal distraction & snap-back test
Entropion and Predisposing Factors
Inward rotation of tarsus (support structure in eyelid) & lid margin
Lashes touch ocular surface
Entropion = ENter
Age
Severe cicatrising disease affecting tarsal conj. - Steven Johnston Syndrome
Ocular irritation or previous surgery- spastic entropion
Entropion Causes
INVOLUTIONAL: age related degeneration, atrophy of tarsus, tendons& muscle
CICATRICAL: severe scarring & contraction in palpebral conj. - e.g. Steven Johnston syndrome
SPASTIC: abnormal, uncontrolled contraction of obicularis oculi muscle. Triggered by irritation to eye e.g. surgery. Resolves spontanteously
CONGENITAL: born w/, improper formation of attachment of retractor muscles at inferior border of tarsal plate
Entropion Symptoms
irritation especially on blinking
red
watery
FB sensation - grittiness
watery
blurred vision - due to scarring or watering
What are the signs of Entropion?
corneal/conj. disturbance (or both)
conj. hyperaemia
won’t see Meibomian Glands neatly in row, eyelashes turned in
lid laxity (involutional entropion)
absense of lower lid crease (congenital entropion)
use distraction test & snap back test to identify lid laxity
Entropion Management
depends on severity of symptoms
-temporary taping lid to skin of cheek: pull it away from globe, temporary relief
-epilation of lashes: significant grittiness/discomfort - take eyelash out - will grow back- temporary
- ocular lubricants: drops for use during day
unmedicated ointments for use at bedtime
-therapeutic CLs to proteect cornea from lashes
-referral for surgical intervention:
persisting symptoms despite above tx.
recurrent infection
risk of microbial keratitis (sight-threatening)
->keep going with other txs whilst waiting to be seen
Trichiasis Causes and Predisposing Factors?
inward misdirection of lashes towards cornea
secondary to no. of conditions
Causes: CONGENITAL: failure of epithelial germ cells to differentiate completely to Meibomian glands (autosomal dominant)
ACQUIRED: result of another condition (entropion, abnormal growth in scar tissue following injury, Steven-Johnson, or chronic blepharoconjunctivitis)
Predisposing Factors:
-staphylococcal bleph
-cicatricial conditions- scarring
-HZO- Herpes Zoster Ophthalmicus
What are the symptoms of Trichiasis?
discomfort/ irritation
watery eye
FB sensation- feel something stuck in eye- need to rub eye
red eye
What are the signs of Trichiasis?
lash(es) in contact w/ ocular surface
conj hyperaemia- grade on grading scale
corneal epithelial abrasion- usually line abrasion
NaFl staining of cornea/conj.
What are Chronic/Severe Signs of Trichiasis? (many eyelashes)
Pannus- subepithelial irritation which results in fibrovascular tissue in growth from limbus to cornea due to repeated irritation & inflammation
Corneal ulcer - want to avoid pxs getting to this point
Infective keratitis - want to avoid pxs getting to this point
What is the management for Trichiasis?
Epilation:
-remove troublesome lash(es)
-forceps, sterile tweezers
-may require frequent visits 4-6week hairgrowth cycles
Manage underlying cause along with epilation:
-entropion
-bleph
Therapeutic CLs
Ocular Lubricants
Refer if severe (significant corneal involvement):
-electrolysis
-laser photocoagulation
-if referred avoid epilation
What are the causes of Chalazion?
inflammatory and sterile lump
blockage of secretory gland in lid: meibomian gland or glands of Zeiss and Moll
spontaneous
following acute infection- internal hordeolum
What are the risk factors for Chalazion?
chronic bleph- inflammation of eyelid tissue
rosacea
sebarrhoeic dermatitis
pregnancy
diabetes mellitus
Chalazion Symptoms
painless lump(s)
gradual ↑ in size (wks/mths)- chronic not acute
can be recurrent especially if underlying eyelid condition eg bleph
blurred vision- if larger can induce astigmatism
sometimes after infection
Chalazion Signs
well-defined solid module in tarsal plate
lid eversion- external conj granuloma
induced astigmatism/hyperopia- shifting power of cornea by pushing on cornea
may be associated bleph
Chalzion Management
frequent, repeated hot compresses, hot spoon, steaming
lid massage
manage any associated bleph
advice: -likely to take wks/mths to resolve
-if large/disrupting BA refer for incision & cutterage/steroid injection (NOT DONE OFTEN)
no need for antibiotic as not associated with infection
Hordeolum Causes and Predisposing Factors
acute staphylococcal infection of glands
usually tender and red
PF: chronic blepharitis
infection of meibomian glands (internal)
infection of glands of Zeiss and Moll (external) and lash follicle (aka Stye)
Hordeolum Symptoms
tender lump in eyelid
sometimes painful
epiphora/ sticky discharge
local redness of eye & lid
Hordeolum Signs
MAY BURST: be ready with gloves and cotton buds
tender inflammed swollen area on lid/ in tarsal plate
may involve entire lid in more severe cases (or just part of eyelid or both eyelids)
may point anteriorly through skin or posteriorly through conj.
Hordeolum Management
none- may resolve spontaneously
hot compresses, hot spoon, steaming
manage any associated bleph
remove associated lashes (external hordeolum)
Advice: -internal hordeolum may evolve into chalazion -> get px to come back
-may take wks/mths to resolve
If non resolving/significant discharge/multiple:
-antibiotic ointment (chloramphenicol 1% qds 5-7days)
-oral antibiotic flueloxacillin 500mg qds 7-14days ONLY IP/GP
Hordeolum vs Chalazion
Chalzion is painless and quiet whereas hordeolum is tender, painful and hot
May be distorted vision with chalazion
May be associated discharge with hordeolum - none with chalazion
Chalazion has likely slower onset (wks/mths) whereas hordeolum has an acute onset
With chalazion px may have previous hx of hordeolum in affected area
Px won’t wince if touch a chalazion but may if touch hordeolum
