Dr.
hassanain alrekabi
The eyelids
Benign nodules and cysts:
1- Chalazion (Meibomian cyst):
It is a chronic sterile lipogranulomatous inflammatory lesion caused by
blockage of meibomian gland orifices and leakage of sebaceous secretions .
It is more frequent and multiple in patients with sebaceous gland
dysfunctional diseases eg acne rosecia.
Presentation: Painless nodule and occasionally blurred vision
Signs:
a- Round, firm lesion in the tarsal plate.
b- Polypoid granuloma on eversion of lid .
c- Sometimes there is associated blepharitis.
Treatment:
a- Surgical:
The most common method, if the lesion is recurrent or multiple then biopsy
should be taken specially in old age patient (to exclude sebaceous gland
carcinoma which is extremely rare).
b- Steroid injection:
0.1-0.2 ml triamcinolone infiltrated around the lesion, the success rate is
80%. In unresponsive cases, another injection is given two weeks later.
Chalazion should be small in size to be treated with steroid injection.
c- Systemic tetracyclines:
As prophylaxis, particularly in acne rosacea and seborrhoeic dermatitis
where chalazion is recurrent.
2- Internal Hordeolum:
It is abscess caused by an acute staphylococcal infection of Meibomian
glands.
Signs: Tender, inflamed swelling within the tarsal plate.
Treatment:
a- topical antibiotics (ointments more important than drops).
b-Systemic antibiotics are needed if there is associating lid infection.
c- Incision and curettage for the residual nodule after the acute infection has
subsided.
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3- External hordeolum (Stye):
It is an acute staphylococcal abscess of a lash follicle and its associated
gland of Zeis.
Signs:
- Tender inflamed swelling in the lid margin, which points anteriorly through
the skin.
- More than one lesion may present.
- Occasionally minute abscess may involve the entire margin.
Treatment:
a- Hot compresses
b- Topical antibiotics (ointment is a must).
c- Epilation (removal of eyelashes by a forceps) to enhance drainage of pus.
Chronic Blepharitis
Chronic blepharitis is a very common condition which is usually bilateral
symmetrical.
Types of chronic blepharitis:
1- Anterior: a- Staphylococcal blepharitis.
b- Seborrheic blepharitis
2- Posterior: a- Meibomianitis.
b- Meibomian seborrhea.
Pathogenesis of chronic blepharitis:
1- Anterior chronic staphylococcal blepharitis: due to staphylococcal infection.
2- Anterior chronic seborrhoeic blepharitis: is usually associated with
seborrhoeic dermatitis e.g. scalp, naso labial folds, retro auricular area and
sternum.
Neutral lipids are converted by Bacterial lipase into irritating fatty acids
responsible for increase of symptoms.
3- Posterior chronic blepharitis: Associated with dysfunction of Meibomian
gland (ocular rosacea) which is in some patients associated with acne rosacea of
the face.
Symptoms of chronic marginal blepharitis: (anterior and posterior)
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They are: Burning, grittiness, mild photophobia, and crusting and redness of
the lid margin. The symptoms are characterized by remissions and
exacerbations. The symptoms are usually worse in the mornings.
Signs of anterior blepharitis:
a- The anterior lid margins show (by slit-lamp) hyperaemia and telangiectasia.
In longstanding cases the lid margin became scarred and hypertrophied (due to
recurrent infections), intrafollicular abscess may be present (staphylococcal
blepharitis).
b- Two types of scales: (important in differentiation)
i- Staphylococcal blepharitis: Are hard and brittle and are centered around
the lashses (collarettes).
ii- Seborrhoeic blepharitis: Are soft and greasy and located anywhere on lid
margin or on the lashes.
c- In longstanding cases, trichiasis, madarosis and occasionally poliosis
(whitening of the eyelashes) will occur.
Complications of anterior blepharitis:
a- External hordeolum (stye).
b- Tear film instability (due to the abnormal lipid secretion that affects the tear
film).
c- Hypersensitivity to staphylococcal exotoxins papillary conjunctival
reaction, punctuate epitheliopathy and marginal keratitis.
Treatment:
a- Lid hygiene: removing crusts and toxic products by scrubbing the lid
margins solution of baby shampoo.
b- Topical antibiotic ointment: fusidic acid or chloramphenicol.
c- Weak topical steroids: e.g. fluorometholone to control hypersensitivity to
exotoxins.
d- Tear substitutes.
Signs of posterior blepharitis (Meibomian seborrhea or meibomianitis):
a- Small oil globules capping the meibomian gland orifices.
b- Pressure on tarsal plate results in expression of copious amounts of
meibomian oil.
c- The posterior lid margin shows diffuse or localized inflammation centered
around meibomian gland orifices.
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d- Blockage of the main meibomian ducts gives rise to secondary cystic
dilatation and occasionally meibomian cysts.
Complications:
a- Tear film instability.
b- Papillary conjunctivitis plus punctuate epitheliopathy.
c- Internal hordeolum.
Treatment:
a- Systemic tetracyclines for 6-12 weeks: one of the followings,
i- Tetracycline: Four times daily for 1 week, then twice daily for 5-11 weeks.
ii- Doxycycline: Twice daily for 1 week, then once daily for 5-11 weeks.
b- Erythromycin when (a) is contraindicated.
c- Lid hygiene.
d- Topical steroids.
e- Tear substitutes.
f- Warm compresses to melt solidified sebum and mechanical expression (to
evacuate meibomian glands from their contents).
