6.1.4 External eye pathology

Dry Eyes causes

• Aqueous layer deficiency

• Impaired lid function

• Epitheliopathy - irregular corneal epithelium = thin and unstable TF

• Medication e.g CNS acting drugs or BB

• RA - glands in eye don’t work properly

• Acne Rosacea

• Dermatitis

• Sjogren’s syndrome

• Environment - air conditioned and heated + windy, dry/dusty

Aqueous Layer deficiency

Adequate production and drainage of aqueous layer is necessary due to;

• Tear nutriants e.g Oxygen supply to cornea

• Anti-bacterial agents e.g lysozyme produced by lacrimal glands

• the mechanical flushing action of tear movement

Sx;

• soreness and burning

in dry eyes the osmolarity of aqueous increases = ocular damage

Impaired Lid function

Lid function is important for mucus distribution during blinking

• leads to tear deficiency and exposure keratitis - can lead to ulceration

Tear Substitues

• Carbomers (GelTears, Viscotears)

• Hypermellose

• Liquid Paraffin (hycosan night)

• Macrogels (systane)

• Sodium Hyaluronate (Hycosan)

• Diet (omega 3/6, fatty acids)

Carbomers

• Semi-solid formulations of high molecular weight

• Protective during sleep

• good retention time

• Can cause blurry due to viscosity

Liquid Paraffin

• Hycosan night

  • lubricates eye surface in case of recurrent corneal erosion

Sodium Hyaluronate

• Hycosan

  • viscoelastic high molecular weight polymer

  • increases goblet cell density and reduces inflammation of ocular surface

  • improves tear stability and wettability

Causes of Anterior Blepharitis

• due to bacteria (staphylococcal) - lives on the skin

• Seborrheic Dermatitis (disorder of ciliary sebaceous glands)

Bacterial Bleph

• Lid margin hyperaemia

• margin swelling

• crusting of margin (scales on base of lashes)

• misdirection of lashes

• Recurrent styes

• conjunctival hyperaemia

Seborrheic

• Lid margin hyperaemia

• Oily or greasy deposits on lid margins

• conjunctival hyperaemia

When would you refer Blepharitis?

• Routine: if pharmacological therapy doesn’t help

• Urgent; if unilateral as suspect MG carcinoma

Dacryocystitis

Inflammation or infection of lacrimal sac

• most often secondary to nasolacrimal duct obstruction

Sx;

• sudden onset

• pain

• tender swelling

• epiphora

• fever

Signs;

• Red, tender swelling centred over lacrimal sac and around the orbit

• Purulent discharge from the puncta

• frequent conjunctivitis and pre-septal cellulitis

Management of Dacryocystitis

Emergency if;

• Children

• Severe case if Px is unwell

• Cases which don’t respond to anti-biotics for 7 days

Urgent otherwise

• should respond to systemic antibiotics, manage to resolution

Entropion and its sx

• Inward rotation of the tarsus and lid margin, causing lashes to come into contact with the ocular surface

sx;

• Irritation (FB sensation)

• Epiphora

• Lid spasm

• Red eye

Causes of Entropion

• Age related laxity

• trachoma

• surgery

• congenital

Management of entropion

Initial management;

• Tape the lid to the skin of the cheek for temporary relief

• Therapeutic CL to protect the cornea

• Ocular lubricants

Refer routinely for surgery

Ectropion and its Sx

• Outward rotation of eyelid margin - usually bilateral

Sx;

• Sore, red, watery eye

Causes of Ectropion

• Age related lid laxity

• scarring and contraction of skin

• trauma

• congenital

• lid swelling due to inflammation

• skin tumours

Management of Ectropion

Mild cases = tape lid at night to avoid corneal exposure, ocular lubricants

Refer in severe cases for surgery

Trichiasis, sx & causes

Inward misdirection of lashes towards the cornea

• Ocular discomfort

• irritation

• FB sensation

• Epiphora

• red eye

Causes can be congenital and acquired - e.g repeated trachoma infections & scarring

Signs of Trichiasis

• Lashes in contact with ocular surface

• Conjunctival injection

• Corneal epithelial abrasion

• Staining of cornea and conjunctiva

If longstanding;

• Pannus

• Ulcer

• Infective keratitis

Management of Trichiasis;

• Epilation of lashes

• Therapeutic CL for temp relief

• Ocular lubricants

• lid hygiene for associated bleph

Routine referral if secondary to entropion for lid surgery

Basal Cell Carcinoma

Malignant tumour of the skin, rarely metastasizes, slow growing and locally invasive

• Slow developing

• non resolving lesion of eyelid skin

• not painful

Signs of BCC?

• Nodular - pearly appearance with abnormal vessels

• May bleed

• Ill defined borders

• Change in lid contour

• sclerosing - flat hardened plaque of thickened skin

Management of BCC

• Routine referral with details of location, size - likely surgery

• advise sun protection

Chalazion (Meibomian cyst) & its Sx

Blockage of the Meibomian gland duct with a chronic granulomatous inflammatory lesion - usually caused by non infection MG occlusion

• Painless lid lump, usually single, may be recurrent, may rupture

• occasionally blurred vision from induced astigmatism

Signs of Chalazion

• Well defined - 2-8mm nodule in tarsal plate

• Lid eversion may show external conjunctival granuloma

• Associated blepharitis

• Induced astigmatism

• If recurrent consider carcinoma

Management of Chalazion

• Self resolving (2 weeks - months)

• regular lid hygiene

Refer if persistent, large and recurrent or causing corneal distortion

Hordeolum & Sx

External (stye) - Acute bacterial infection of the lash follicle and its associated gland of Zeiss or moll

Internal (oil) - Acute bacterial infection of MG - usually staphylococcal, can develop into chalazion

Sx;

• Tender lump in eyelid

• Epiphora

• Local redness of eye and lid

Signs of Hordeolum

External - tender inflamed swelling on the lid margin, may point anterior through skin

Internal - tender inflamed swelling within the tarsal plate that’s more painful than stye. May point anteriorly through skin or posteriorly through conjunctiva

Management of Hordeolum

• Most resolve spontaneously, or discharge by resolution

• Remove lash from infected follicle

• Manage bleph

• return if it persists or worsens

• topical antibiotics

Refer - in cases which do not discharge (internal hordeolum)

Pre-septal Cellulitis & SX

• Bacterial infection of tissues lying anterior to the orbital septum

• Common in infants under age of 10

• Caused by Staphylococcal, Streptococcal

Sx;

• Acute onset of swelling, redness and tenderness of lids

• Fever

• Malaise - discomfort/illness

• Irritability

Signs of Pre-septal Cellulitis

• Erythema of skin - reddening, dilation of BV

• Lid oedema, warmth and tenderness

• Ptosis

• Pyrexia (fever > 38 degrees)

Orbital Cellulitis & Sx

Bacterial infection of tissues lying posterior to the orbital septum (within the orbit) - severe and life threatening

• Sudden onset of unilateral swelling of conjunctiva and lids

• Pain on ocular movement

• blurred vision

• dipl.

• fever

• severe malaise

Signs of Orbital cellulitis

• Proptosis

• Restriction of EOM

• Pain with eye movement

• Reduced VA + Cv

• RAPD

• Pyrexia

Management of Pre-septal & Orbital Cellulitis

Emergency referral