1: Disorders of the eyelids

anterior blepharitis

chronic inflammation of the eyelash and follicle and its associaated gland

can be due to infection, infestation or inflammation such as staphylococcal bacteria, demodex mites or seborrheic

very common in population and most age groups

symptoms are typically worse in the morning

what is blepharitis often caused by

meibomian gland dysfunction. blovkage of gland pores can result in inflammation, sometimes complicated by bacterial infection

risk factors of anterior blepharitis

skin conditions such as rosacea, oily skin, dandruff, or sebhorric dermatitis

posterior blepharitis ( mixed blepharitis )

atopia/allergenic

eyelid mites and lice

make upuse and CLs use

environment being cold or dry, use of air con or open fires

some meds eg cancer drugs or topical drugs

systemic disease eg diabetes

clinical presentation of anterior blepharitis

might include crusting at the lash base and erythematosus of the lid margin. it can become a chronic condition that required periodic treatments with hot packs, lid scrubs and antibiotic ointment.

symtopms of anterior blepharitis

variable and unreliable: poor correlation between signs and symtoms

tend to get flares of remission and exacerbation eg comes and goes in waves

discomfort and eye rubbing

worse on awakening, crusty feeling in eyelashes and around the eyelids

associated with dry eye and wet eyes

burning and grittiness

mild photphobia

signs of anterior blepharitis

bacterial:

hard scales and crusting and collarettes

mild papillary conjunctivitis

lash loss, notching of margin, trichiasis

seborrheic:

hyperaemic and greasy crusting of lashes

posterior blepharitis involvement

demodex:

mites seen and cylindrical dandruff and collarettes

papillary conjunctivitis and red eye

treatments of anterior blepharitis

depends on the type as to what treatment is given

not alays effective but contols symptoms effectively

warm compress and eye bag

lid cleaning

tea tree oil lid wipes

antibiotics- topical ointments and oral doxycycline

novel treatments such as ciclosporin, light therapies

posterior blepharitis/ meibomian gland dysfunction

posterior lid inflammation, and typically due to meibomian gland dysfunction

glands either do not produce good enough meibum/oil or stop producing oil. This is typically down to th increase in melting point of these oils, meaning they can cause blockage and increased risk of infection and inflammation

increases tear film evaporation, and symptoms of dry eye like irritation, reflex tearing

is chronic and requires regular management

symptoms of posterior blepharitis

tend to get flares of remission and exacerbation eg comes and goes in waves

discomfort and eye rubbing

associated dry eye and watery eyes

burning and grittiness

mild photophobia

signs of posterior blepharitis

capping on glands seen, oils appear more firm and yelow

glands may also e recessed or plugged; notching

hyperamia and telangiectasia around posterior lid margin

pressure onto the lids causes secretion to be thick like toothpaste

tear flm very oily or foamy and unstable

tear break up time is very short

treatments of posterior blepharitis

warm compress and eye back ; 2x a day for 5 mins

omega 3 and 6 supplements

eyelid massage and lid treatments such as BlephEx

lifestyle changes ; blinking exercises , optimising VDU and use of heaing

eye drops / lubricants foir when needed and gels for the evening

if sevre, antii inflammatory meds

ectropion

associated with aging due to horizontal eyelid laxity

everson of eyelid

common cause of which loss of muscle tone

as lid margin falls away from its position agaainst the globe. the lacrimal punctum is no longer in position to drain tears from lacrimal lake.

epiphora

overflow of teas onto the cheel , may occur, cauing maceration of delicate skin in this area

ectropion symptoms

exacerbation of any ocular surface discomfort or diease

poor cosmesis

tarsal plate becomes inflamed, thickened and keratinised

corneal scarring and epithelial defects

epiphora

management of ectropion

initial magament may be topical lubricants and lid hygeince, but in time most reqire srgert for treatment, where the ld can be excised and pulled together to tighten. routine referral is indicated

entropion

inversion of the lid margin, usually bottom lid

may result from spasm of the orbicularis oculi muscle causing the lid margin to turn inwards. this inward turning puts the eyelashed in contact with the globe and can cause corneal abrasion.

scarring of the lif after trauma can also cause entropion

also polapse of orbital fat into lower lid can cause

synptoms of entropion

stinging. itchy , severe pain and potophobia

signs in ectropion

trichiasis, deep and perfuse corneal staining, red eye, epiphoria, inflamed lids

requires more urgent treat,ent and referral 2/52 due to severity

can try bandage CLs, chemodenervation

end result is surgery and should be prioritised

lash disorders

• trichiasis: eyelashes growing in abnormal directoion , usually into the eye, toward the palebral fissue

• distichiasis : additional rw of eyelashes

eyelashes loss and drop out

contact with the cornea can cause irritaation and painful abrasions and can lead to ulceration

chalazion

localised, non infectious and sometimes painless swelling of a meibomian gland, often caused by an obstructed duct. the gland may extrude its secretion into surrounding tissue, setting up a grabulomatous inflammation.

most common on top lid due to number of meibomian glands

chalazion

when incerting the lid, the tarsal surface will not be smooth as expected but have a irregular nodule or cobblestone like appearance

risk factors include prior blepharitis, meibomian gland dysfunction, and those that have sebhorreic dermatitis or rosacea

can resolve spontaneously but can take a ew months

management of chalazion

reassure px and advise them to use an eye bag or some hot compress for at least 5 mins

sometimes lid massage lightly with findgers can help with the swelling

managment has 40% sucess rate

after 4 weeks, referral may be possible. HES will either use steriod injection to reduce inflammation or perform surgical excision.

hordeolum

stye

acute inflmmation of an eyelid gland, usually caused by staphylocci

an infected zeis or moll gland is called an external hordeolum or common stye

a localised infection of a meibomian gland usually drains from the inside surface of lid thus called an internal hordeolum

external hordeolums are of the glands of zeis. more prominent anteriorly and on naked eye observation

symptoms of hordeolum

because theyre infected, can be painful and filled with mucopurlent pus

anterior and posterior form a nodular mass and a large redder amount of inflammation than a chalazion

pain, tenderness, swelling and a burning sensation

more painful for an internal hordeolum

management of hordeolum

to soften the coagulated material and allow it to drain

most likely to resolve spontaneously in a fortnight so it may be bezt to monitor and refer it if it doesnt resolve in 3 weeks

if it doesnt resolve in 3 weeks, antibiotics may be prescribed as it may inctease the risk of cellulitis

xanthalasma

raised plaques that may look nodular and have a yellow like tinge

accumulation of lipid under the skin

not symptomatic although px can findit cosmetically unappealing

often idiopathic, although 1/3 of px with it tend to have an arcus and high blood lipids/cholesterol

typically medial and bilateral but asymmetric

more frequ in older px , rare in those under 50

management of xanthalasma

is to reassure px and to refer to GP non urgently for lipid evaluation blood test if not done recently

treatment is surgical and only cosmetic as it has a high rate of recurrence

mollescum contagiosm

type of virus that can infect skin, giving pink/flesh coloured bumps that can have a central crater

usually in clusters but can be in isolation. can be found around the body

rarely symptomatic but if any infection enters the eye it can cause viral conjunctivitis like symptoms with follicles on the tarsal conjunctiva

discharge if popped is watery

tends to get worse before bettem but relsoves spont over the course of a couple months

management mollescum contagiosm

reassure px

refer if doesnt get better after 1-2 years but no treatment usually necessary, just adivse on hygeine and reduction of transmission

treatment can unclude removal and cauterisation

squamous papilloma

commonly referred to as a skin tag and can occur around the body , including genit tongue eyelid and face 7more common around body in obese people but no real aetiology/ risk factor increase for those with eyelid ones

can be brownish or flesh coloured and has larger viewable size and can appear nodular and/or finger like with its projection

most common when people get older

minimal risk treatment is only cosmetic, and is surgical excision

tumours

benign or malignant

benign is abnormal but noncancerous collection of cells that may or may not be progressive in its size. dont use terms like tumor in front of px until certain

when investigating a lump or bump or anything unusual in the eye, we want to ensure we can rule of the risk of it being malignant.

if malignant: invade local tissue, spread and grow, progresses and invades adjacent tissue

most eyelid lesions are benign, which dont metastasis

malignant tumors

• malignant lesions tend to ulcerate ie cause a breakage or cratering of the skin

• malignant tend to not be painful to touch and dont feel tender to px

• malignant tend to be firm to the touch

• tend to not be different colour

• malignant tend to be irregular and asysmetric

• malignant invade and destroy tissues eg uvea, retina

• causes tellangiectasia : can see blood vessels on the face

• can have rolled translucent margins that are shiny and whitish in appearance known as pearly borders

• can sometimes have feeder vessels, ie cause blood supply to look aggravated

basal cell carninoma

most common form of skin cancer.

associated with sun exposure so more common in those liviing in sunny climates

associated also wit older people around 60s

very variable, clinical appearance but can have an ulcerated centre, pearly margins, raised edges

progression takes a long time eg 5 years and metastases are rare, worth asking px to look at their older photos and try to assess change

can be invasive and locally destructive so still requires referral

squamous cell carcinoma

second most common form of malignancy

difficult to diffrentiate betwween BCC and SCC , it depends on which layer of the skin it originates from,- this comes from a more internal layer making it more likely to spread and grow

appears more like hard scaly dead skin than BCC however it is not easy to diagnose

requires more urgent referral for confirmation 2/52, but as it is difficult to distinguish this is why we referral all suspect malignancy inclduding BCC urgently as to ensure that we do not delay potential care if scc is present