Lids, Lashes and Tears

Question 1

What is an ectropion?

Answer 1

The outward rotation of eyelid margin (usually lower), 70% bilateral, can be asymmetric

Question 2

Name the 5 main causes of Ectropion

Answer 2

Involutional
Cicatricial
Paralytic
Mechanical
Congenital

Question 3

What is involutional ectropion

Answer 3

Most common cause. Age related, can be caused by muscle weakness or increased lid laxity

Question 4

What is cicatricial ectropion

Answer 4

Ectropion caused by scarring, which has contracted changing the shape of skin. May be from trauma, burn or surgery.

Question 5

What is paralytic ectropion

Answer 5

Nerve issue usually after a facial palsy

Question 6

What is mechanical ectropion

Answer 6

Something obstructing normal position of tissue, due to tumour in or near lid margin. May be caused by inflammation from injury (but this is acute and normally ectropion is chronic)

Question 7

What is a pre-disposing factor of ectropion?

Answer 7

Age - as lid laxity increases

Question 8

What are symptoms of ectropion?

Answer 8

Can see Punta pointing abnormally, Sore (pain/ discomfort/ grittiness), red eye, watery, symptoms vary depending on severity

Question 9

What are the signs of ectropion?

Answer 9

Lower lid not opposed (in contact) with globe; punctual in abnormal position; Exposure keratopathy; Conjunctival hyperaemia; Epiphora

Question 10

How can you test for ectropion?

Answer 10

Distraction test (if you can move lower lid >6mm away from globe it is called lax, indicated increased lid laxity)
Snap-back test (pull lower lid down, release it, should “snap back”, poor recovery indicated muscle weakness)

Question 11

How to manage ectropion?

Answer 11

Depends on impact to px quality of life.
Mild cases = Offer reassurance about condition and advice, ocular lubricants, advise avoid rubbing eyes.
Manage exposure keratitis = tape lid closed when sleeping, ocular lubricants.
Moderate to severe cases: Consider for surgery if: recurrent infections, significant corneal involvement, still affects life after above measures.

Question 12

What is floppy eyelid syndrome?

Answer 12

Spontaneous flipping of lid on side they sleep on, uncommon, symptoms worse in morning (dry, gritty eyes)

Question 13

Who typically get floppy eyelid syndrome?

Answer 13

Middle aged men, obese, sometimes hx of sleep apnoea

Question 14

What is Entropion?

Answer 14

Inward rotation of eyelid and lid margin (lashes in contact with ocular surface, cases irritation)

Question 15

What are the causes of entropion (4)?

Answer 15

Involutional
Cicatricial
Spastic
Congenital

Question 16

What are the predisposing factors?

Answer 16

Age
Severe cicatrising disease (affecting tarsal conjunctiva)

Question 17

Entropion - Symptoms

Answer 17

Irritation (especially on blinking)
Foreign body sensation
Red
Watery
Blurred vision

Question 18

Entropion - Signs

Answer 18

Inward rolling of lid margin
Associated irritation signs
Corneal/conjunctival disturbance (could be both)
Conjunctival hyperaemia
Lid laity (involutional entropion)
Conjunctival scarring (cicatricial entropion)
Absence of lower lid crease (congenital)
Distraction test
Snap-back test

Question 19

Entropion - management

Answer 19

Taping lid to skin, epilation of lashes, ocular lubricants, therapeutic contact lens. Referral for surgery if persists after above

Question 20

What is Trichiasis?

Answer 20

Inward misdirection of lashes towards cornea

Question 21

What are the causes of trichiasis?

Answer 21

Congenital: Failure of epithelial germ cells to differentiate completely to Meibomian glands

Acquired: The result of another condition (entropion, abnormal growth following injury, Stevens-Johnson syndrome, or chronic blepharoconjunctivitis)

Question 22

What are the predisposing factors of trichiasis?

Answer 22

• Staphylococcal blepharitis
• Cicatricial conditions (scarring conditions)
• HZO

Question 23

What are the symptoms of trichiasis?

Answer 23

Discomfort, irritation

Foreign body sensation

Watery eye

Red eye

Won’t go away, tends to get worse as lashes grow

Question 24

What are the signs of trichiasis?

Answer 24

Lash(es) in contact with ocular surface

Conjunctival hyperaemia

Corneal epithelium abrasion

Fluorescein staining of cornea/conjunctiva

Chronic, severe signs:
- Pannus (occurs in chronic conditions where there is constant irritation)
- Corneal ulcer
- Infective keratitis

Question 25

Trichiasis - Management

Answer 25

Epilation of lashes; manage underlying cause; therapeutic contact lens; ocular lubricants; refer if significant corneal involvement

Question 26

What is a chalazion?

Answer 26

Inflammatory & sterile lump. (not infectious) blockage of a secretory gland causing a lump or lesion, usually painless

Question 27

What are the causes of a chalazion?

Answer 27

Spontaneous or Following acute infection - internal hordeolum

Question 28

What are the risk factors of a chalazion?

Answer 28

Chronic blapharitis

Rosacea

Seborrhoeic dermatitis

Pregnancy

Diabetes mellitus

Question 29

Chalazion - Symptoms

Answer 29

Painless lump(s)

Can be recurrent, may have had it before - especially if they have an underlying eyelid condition

Sometimes after infection - history may say had painful eye a few weeks ago

Gradual increase in size (over weeks/months)

Blurred vision (if larger can induce astigmatism)

Question 30

Chalazion - Signs

Answer 30

• Well-defined solid nodule in tarsal plate
• Lid eversion (difficult with this) - may see external conjunctival granuloma
• Induced astigmatism/hyperopia
• May be associated blepharitis

Question 31

What is a hordeolum?

Answer 31

Acute staphylococcal infection of the glands; usually tender and red

Question 32

What is an internal hordeolum?

Answer 32

Infection of meibomian gland

Question 33

What is an external hordeolum?

Answer 33

Infection of glands of Zeiss and moll

Question 34

What is the predisposing factor of a hordeolum?

Answer 34

Chronic blepharitis

Question 35

Hordeolum - Symptoms

Answer 35

Tender lump in eyelid

Sometimes painful

Epiphora/sticky discharge

Local redness of eye and lid

Question 36

Hordeolum - Signs

Answer 36

Tender inflamed swollen area on lid/in tarsal plate

May involve entire eyelid in more severe cases

May point anteriorly through skin or posteriorly through conjunctiva (seen on eversion of lid)