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TEXT BOOK OF DISEASES OF THE EYE

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					  TEXT BOOK OF DISEASES OF THE EYE
The eye lid is made up of 4 layers. They are from without in-
wards:
1) Skin – it is thin and characterized by absence of fat.
2) Muscle layer.
    a) Orbicular is oculi consists of horizontal concentric fibers it is supplied by
             the zygomatic branch of the facial nerve. When the orbicularis oculi
             contracts the lids are firmly closed.
    b) Levator palpebrae superiors. The muscle fibres are arranged vertically; they
             end in an aponeurosis which is inserted .
                  i) To the skin of the upper lid.
                  ii) Upper border of the tarsus.
                  iii) Conjunctiva at the fornix.
It is supplied by the upper division of the 3rd cranial nerve.
It raises the upper lid.

    c) Muller's muscle: supplied by the sympathetic nerve.

3) Tarsus : Consists of dense fibrous tissue. Embedded in it are enormously
developed sebaceous glands-the meibomian (tarsal) glands.
4) Mucous layer : formed by the palpebra conjunctiva.              ‫خروج‬
        Glands of the eye lids:
Meibomian (tarsal) glands : They are embedded in the
tarsus and are modified sebaceous glands. They secrete an oily
secretion. They open through vertically arranged ducts into the
lid margin.
Glands of Zeis : they are sebaceous glands developed as
outgrowth of the hair follicles of the eye lashes. They are
situated at the lid margin.
Glands of Moll : these are modified sweat glands. The lid
margin – is covered with stratified epithelium which forms a
transition between the skin and the conjunctiva. It consists of:
   1. Eye lashes – arranged in 2 – 3 rows anteriorly.
   2. Opening of the ducts of the meibomian gland posteriorly.
   3. Glands of Zeis and Moll.
                                                    ‫خروج‬
   DISEASES OF THE LIDS:
   Oedema of lids – this is common and owing to looseness
   of the tissue may be so great as to close the eye.
   ANATOMY AND DISEASES OF THE LIDS
Causes:
  A. Inflammatory oedema.
     1.   Inflammation of the lids – allergic dermatitis due to atropine ointment
          and cosmetics, stye, insect bite.
     2.   Acute conjunctivitis.
     3.   Acute dacryocystitis.
     4.   Acute iridocyclitis.
     5.   Panophthalmitis.
     6.   Orbital cellulitis.

  B. Passive oederma due to circulatory obstruction.
     1.   Nephritic syndrome.
     2.   Cardiac failure.
                                                                ‫خروج‬
     3.   Cavernous sinus thrombosis.
 INFLAMMATION OF THE LIDS:-
Blepharitis: It is a chronic inflammation of the margin of
   the lid. The lid margin becomes thickened and red.

 VARIETIES AND ETIOLOGY:
   1) Squamous blepharitis : there is encrustration of lid margin
       by white scales. It is of 2 types.
a) Oleosa – Or seborrheic : Often essentially metabolic
   associated frequently with seborrheic dermatitis of
   scalp (dandruff). Exacerbation and remission of the
   ocular lesions parallel those of lesions of the scalp.
b) Siccaa : Chemical irritants and cosmetics such as
    "surma", acne rosacea, uncorrected refractive error
    particularly astigmatism.                ‫خروج‬
2) Ulcerative blepharitis : There is encrustation of the lid
    margin by yellow scales with underlying ulceration.
    The ulcers bleed on removing the scales. This
    distinguishes the condition from matting together of
    the lashes by conjunctival discharge in conjunctivitis;
    removal of the crusts in conjunctivitis reveals normal
    lid margin. Ulcerative blepharitis is an infective
    condition caused by staphylococci.
3) Mixed blepharitis: Staphylococci infection super
    imposed on Squamous blepharitis .
4) Margin is associated: with angular conjunctivitis –
    foamy discharge and excoriation of the skin of the
    lateral and medial canthi. It is caused by Morax –
    Axenfeld bacillius.
                                                ‫خروج‬
  TEXT BOOK OF DISEASES OF THE EYE
  The patients are usually children debilitated from :
1) Living under poor hygienic conditions –
  exposure to dust, smoke.
2) DISEASES – exanthematous disease, upper
  respiratory infections, tuberculosis, diabetes.
3) Dietary deficiency – malnutrition. Occasionally
  parasite causes blepharitis, blepharitis acarica.

  Symptoms :
  Itching, soreness, lacrimation, photophobia.
                                              ‫خروج‬
Sequelae or complications:
 1. Chronic conjunctivitis.
 2. Marginal corneal ulcer.
 3. Styes.
 4. Permanent loss of a greater or losser number of
    lashes (madarosis ) due to destraction of root of
    the cilia.
 5. Tylosis – usuall affects upper lid. There is
    hypertrophy of lid border causin this part to
    become rounded and thick and to droop on
    account of its own weight.
 6. Trichiasis.
 7. Entropion.
 8. Ectropion.
                                         ‫خروج‬
Treatment :
1.   Improvement of general health and living condition.
2.   Treatment of seborrheic dermatitis o scalp with shampoo.
3.   Correction of refractive error.
4.   Removal of scales and crust with warm 3% soda bicarb
     solution.
5.   In cases of squamous blepharitis, dilute baby shampoo is
     applied on the lid margin with a swab stik. In more obstinate
     lesions, ointment of selenium oxide is used.
6.   allergy to chemical and cosmetic, 1% hydrocortisone
     ointment is applied to the lid margin thrice a day.
7.   In cases of ulcerative blepharitis antibiotics such as
     chloromycetin, erythoromycin or tetracycline are applied to
     the lid margin. In more severe cases the antibiotic which has
     proved to be effective is given systemically, in addition to
     local treatment.
8.   In cases of angular blepharitis oxteracycline ointment is
     applied.
                                                    ‫خروج‬
INFLAMMATION OF THE GLANDS OF
THE LIDS :
1) Eternal hordeolumor stye : is a circumscribed, acute
  inflammation at the edge of the lid, caused by staphylococcal
  infection of the glands of Zeis usually ending in suppuration.

Etiology :
Most common in children and young adults, often appear in
crops. Frequently associated with blepharitis or lowered state of
health – diabetes mellitus, and uncorrected refractive error.

Symptorns and Signs:
Red swelling appears in the lash line of the margin of the lid,
accompanied by pain, tenderness and often by considerable
oedema of the lids. Very soon a yellowish summit will be seen
orderlid indicating suppuration.
                                                    ‫خروج‬
Treatment :
1. Hot fomentation to hasten suppuration : as soon
   as a yellow spot is seen, the pus should be
   evacuated by a horizontal incision at the lid
   margin or epilation.
2. Antibiotics – choromycetin ointment.
3. Analgesics.
4. Prophylaxis.
5. Antibiotic ointment.
6. Treatment of diabetes, blepharitis, correction of
   refractive errors.
7. Avoidance of excess of sweets, oil in the diet.
                                        ‫خروج‬
2) Hordeolum internum : this is an acute suppurative inflammation
    of a meibomian gland due to staphylococcus. Sometimes it may
    be due to secondary infection of a chalazion.
- Symptoms and Signs:
    Symptoms are more violent than those of stye. Very soon pus
    points on the palpebral conjunctiva.
    ANATOMY AND DISEASES OF THE LIDS 33
                          Treatment :
   1.   It may be removed by operation – incision and curettage
        through the conjunctiva. A vertical incision is made through
        the palpebral conjunctiva and with a chalazion curette the
        contents are removed and the walls thoroughly scraped.
        Vertical incision is made to avoid cutting ducts of
        neighbouting meibomian glands and to prevent Entropion.
   2.   Injection of cortisone into the chalazion can be used as an
        alternate fromof treatment.
                                                      ‫خروج‬
    Blepharospasm :
    It is a condition in which there are involuntary and
    forcible eyelid closure (Refer Corneal ulcer for
    difference from photophobia).
1) Reflex sensory stimulation through branches of 5th
    cranial nerve – commonest.
      a) Phlyctenular keratoconjunctivitis.
      b) Foreign body on cornea.
      c) Membranous and pseudo membranous – conjunctivitis.
      d) Acte iridocyclitis.
2) Excessive stimulation of retina.
    a) Bright light on sensitive eye.
    b) Dilated pupil.
    c) Albinism.
3) Essential Blepharospasm without any cause.
4) Hysteria.                                ‫خروج‬
Trichiasis : - is an inversion of a varying number of eye lashes so
that they rub against the conjunctiva or cornea.
The margin of the lid may have a normal position, the
displacement affecting only the lashes or the margins may be
turned inward (Entropion ) as well as the lashes.

Etiology : same as Entropion.

Signs and symptoms : (same for Entropion).
     The misdirected lashes cause mechanical irritation and injury
to cornea with ulceration – pain, lacrimation, photophobia,
Blepharospasm, vascularisation and opacities of cornea.
Treatment :
If only a few cilia involved – epilation or electrolysis to destroy
the hair follicles. If extensive – surgical treatment as for
cicatricial Entropion.
                                                      ‫خروج‬
  TEXT BOOK OF DISEASES OF THE EYE
- Treatment : - is the same as same as for stye except that the
  incision should be made exactly as for chalazion i.e. a vertical
  incision on the palpebral conjunctiva. This is to avoid cutting
  ducts of neighbouring meibomian glands and to prevent
  Entropion.
- chalazion : - This is a chronic granulomatous enlargement of one
  of the meibomain glands.

   Etiology & Pathology :
  It occurs most frequently in adults. The meibomian duct becomes
  obstructed through proliferation of its epithelium and
  consequently the gland enlarges. The fatty secretion escapes into
  the surrounding tissue and excites a foreign body reaction
  (lipogranuloma) which consists of lymphocytes, epitheloid cells
  and giant cells. The blood supply is cut off by the surrounding
  fibrous tissue leading to degeneration of contents – jelly like
  mass.
                                                        ‫خروج‬
  Symptoms : chalazion may cause:
1) Cosmetic disfigurement – lid swelling.
2) Conjunctiva irrition.

  Signs :
  The process develops slowly. After weeks or
  months it presents a circumscribed swelling
  which feels hard, not adherent to skin. On
  everting the lid, its situation is usually shown
  by a purple discolouration of the conjunctiva.
                                         ‫خروج‬
   Complications:
1. It may be secondarily infected forming an internal
   hordeolum.
2. In old people, recurrent chalazion may lead to the
   development of Meibomian gland carcinoma.
3. Mechanical ptosis in cases of large chalazion.
4. The chalazion may press on the cornea causing
   astigmatism.
5. The chalazion may burst either on the skin surface
   or on the conjunctival surface, with granulation
   tissue protruding.
6. The granuloma may protrude through a duct of the
   meibomian gland on the lid margin – marginal
   chalazion.
                                            ‫خروج‬
  Entropion : is a rolling of the margin of the lid
  and with it the lashes.

Etiology and Varieties :
I) Cicatricial entopion – due to cicatricial changes
   in the conjunctiva and distortion of the tarsal
   plate, most commonly affects the upper lid .
   a) Old case of trachoma .
  b) Blepharitis
  c) Burns and other injuies to the lids
  d) Operation upon the lids
  e) Diphtheritic conjunetivitis
                                           ‫خروج‬
II) Spastic entropion:
Due to spasm of the palpebral portion of the orbicularis
   muscle, most commonly affecting lower lid, strong
   contraction of the circularly arranged fibers tends not
   only to approximate the lid margins but also to turn them
   inwards of outwards according to the degree of
   mechanical support afforded by the globe and orbital
   contents. If the support is insufficient intropion is
   produced:
      i) Atrophy or absence of eye ball
      ii) Old persons ( senile entropion) owing to absence of orbital fat.
      iii) Tight bandaging after surgical operation of the eye.
      iv) Blepharospasm
Symptoms and signs – same as for trichiasis .
                                                                 ‫خروج‬
Treatment:
I) Cicatricial entrpion : The principles governing various operation are:
i) Altering the direction of eyelashes
    a) Snellen,s operation
    b) Jaesch Arlt operation
ii) Straightening of the distorted tarsus.
II) Spastic entropion
i) Pull the lower lid down and out and apply leucoplast which should extend below
      the mandible.
ii) Injection of alcohol is made close to the lateral 3rd of the lid margin .
iii) Plastic surgery of lower lid - modified wheeler's operation

Ectropion : It is a rolling out of the margin of the lid
Etiology and varieties :
Cicartical Ectropion : due to cicatricial changes in the skin of the lids-
     Blepharitis, burns, operations on the lids, leprosy.
Both upper and lower lids may be affected.




                                                                  ‫خروج‬
2) Senile ectropion – the lower lid is affected in old age due to laxity
   of the tissue of the lid and due to loss of tone of the orbicularis
   muscle.
3) Paralytic ectropion – it occurs as a result of weakness of the
   orbicularis muscle due to facial nerve paralysis . The lower lid is
   affected.
Symptoms – Epiphora due to eversion of lacrimal punta.
Complications
1) Xerosis of conjunctiva
2) Chronic conjunctivitis and exposure keratitis particularly in
   Ectropion of upper lid.
Treatment :
1) In mild cases row of heat cautery applied to the palpebral
   conjunctiva below the lek margin . As a result of fibrosis of
   conjunctiva ectropion is corrected .
2) Lateral tarsorrhaphy
3) In severe case, platstic surgery – Kuhnt Szymanowski operation.
                                                          ‫خروج‬
SYMBLEPHARON:
   is a cicatricial attachment between the conjunctiva of the lid and
  the eye ball, it may affect both lids, but usually the lower,
  sometimes it includes part of the cornea.

Tyes:
1) Anterior- when extending bridge like from lid to globe, leaving a
   free portion of the conjunctiva corresponding to the fornix .
2) Posterior- When it involves only the fornix.
3) Total – When the lids are adherent to the globe throughout.

Etiology :
It is caused by the junction of 2 opposing granulating surfaces raw
    surfaces hence it occurs after.
   1) injuries especially burns from lime, acids, and molten metal.
   2) Operations.
   3) Trachoma, rarely diphtheritic conjunctigitis.              ‫خروج‬
Symptoms:
1) It often interferes with movement of eye ball producing diplopia.
2) Traction upon the adherent parts causes irrition
3) In extensive cases the cornea is involved and vision is affected.
4) If there is inability to close , lagoph thalmos.
5) Cosmetic disfigurement.

Treatment:
1) Prophylactic - use of contact shell in fresh cases of alkali burns,
   after operations on lids.
2) Curative.
a) If anterior and not extensive, the band is divided and the 2 raw
   surfaces kept from uniting by separating them daily with a glass
   rod smeared with antibiotic ointment .
b) In more sever cases of anterior symblepharon, in posterior and
   total symblepharon the separated raw surfaces must be cobered
   with conjunctiva or with grafts of mucous membrane from the lip
   to keep them from uniting .
                                                        ‫خروج‬
Lagophthalmos:
  This is the condition of incomplete closure of the palpebral aperture when an
  attempt is made to shut the eyes.

Causes:
   1)   Exophthalomos as in Graves' disease, proptosis due to orbital tumour.
   2)   Facial never paralysis .
   3)   Cicatricial ectropion of upper lid .
   4)   Symblepharon.
   5)   Laxity of the tissue and absence of reflex blinking in people who are
        extremely ill – coma, keratomalacia etc.

Complications:
   1) Parenchymatous xerosis of conjunctiva.
   2) Chronic conjunctivitis and exposure keratitis

Treatment:
   1) Of the cause whenever possible.
   2) Application of a bland or antibiotic ointment to protect cornea.
   3) Lateral or median tarsorrhaphy to protect the cornea.
                                                                 ‫خروج‬
1) Distichiasis: It is a condition in which there is an extra posterior
   row of eye lashes. The posterior row occupies the position of the
   opening of Meibomian glands, these lashes may irritate the
   cornea.
2) Coloboma of the lid: It is a triangular gap in the lid magin,
   generally affecting the upper lid. It may form part of Golden
   Har's syndrome- accessory auricles, dermolipoma at the limbus,
   hypoplasia of the maxilla and anomalies of the vertebral column.
3) ptosis or blepharoptosis : is a drooping of the upper lid usually
   due to defective development or paralysis of the levator
   palpebrae superioris (L.P.S.).

All degrees o ptosis occur- partial or complete. When
   severe it interferes with vision by covering the pupil.
1) Patients attempt to raise the lid by forced action of the occipito
   frontalis muscle, wrinkling the skin of the forehead and raising
   the brow.
2) When condition is severe and bilateral they favour exposure of
   the pupil by throwing the head backwards.
                                                        ‫خروج‬
Etiology & Classification:
1) Congenital ptosis:
    a) With normal superior rectus funtction.
    b) With superior rectus weakness- developmentally superior
       rectus is closely related to L.P.S.
    c) Marcus Gunn or jaw-winking ptosis.

2) Acquired ptosis:
   a) Neurogenic – due to lesion of 3rd never nucleus, 3rd nerve
      trunk in its intracranial or orbital course as in cases of brain
      tumour, meningitis, aneurysm etc.
   - Horner's syndrome due to affection of sympathetic nerves.
   b) Myogenic – Myasthenia gravis.
   c) Mechanical ptosis - due to increased weight of lid as in
      trachomatous ptosis, tylosis , tumours of upper lid or lack of
      support of upper lid as phthisis bulbi etc.
   d) Traumatic ptosis.
                                                                 ‫خروج‬
Treatment:
1) Medical : in the acquired form cause is determined and treated –
   Syphilis – Inj. Penicillin I.M. – Myashthenia gravis _
   Physostigmine

2) Surgical – usually necessary for Congenital ptosis.
   a) If the levator palpebrae superioris is not completely paralysed
      this mucle may be shortened. Conjunctival approach –
      Blaskowicz operation. Skin approach – Everbusch's operation

   b) If the levator muscle is paralysed but the superior rectus is
      active, the latter muscle may be pressed into service to lift the
      lid—Motais' operation .

   C) If both levator and superior rectus are paralysed, the action of
      the frontalis muscle may be utilized in raising the lid: frontalis
      suspension – the frontalis muscle is sutured to the tarsal plate
      using strips of fascia lata or 4.O supramid suture . As a result
      contraction of frontalis muscle elevates the lid. ‫خروج‬
TUMOURS OF the eye lids :
1) Benign tumouts of the lids are
    a) Papilloma
    b) Molluscum contagiosum – is a small umbilicated , nodular
       swelling, generally multiple due to a large pox virus.
       Histologically large eosinophilic intra cytoplasmic inclusion
       bodies occur (Henderson – Paterson bodies). It produces
       follicular conjunctivitis and superficial punctuate keratitis.

Treatment:
Excision of these nodules
   c) Naevus
   d) Xanthelasma or Xanthoma – this is a raised yellow plague,
      most commonly found in the upper and lower lids near the
      inner canthus and often symmetrical in the 2lids on both sides.
      They are most common in :
   1) Elderly women
   2) Diabetes mellitus
   3) Excessive levels of blood cholesterol           ‫خروج‬
Treatment : They may be excised if causing cosmetic
  disfigurement .
e) Haemangioma – may occur in 2 forms.
               __ telangiectasis
               __ cavernous haemangioma
It is seen usually in children and often follows the distribution of the
    1st and 2nd division of 5th cranial nerve. In Sturge – Weber
    syndrome it is associated with haemangioma of the choroid ,
    buphthalmos and also with haemangioma of the leptomeninges,
    causing homonymous hemianopia or epilepsy. The intracranial
    causing lesion may be diagnosed on x-ray skull since there are
    often calcareous deposits underlying the cerebral cortex.
f) Neurofibromatosis – Von Reckinghausen's disease.
The hypertrophied nerves can be felt through the skin as hard cords.
   It may be associated with café au lait spots elsewhere in the body ,
   buphthalmos, proptosis in some cases and enophthalmos in others.
                                                         ‫خروج‬
2) Malignant tumours of the lids are:
  a) Rodent ulcer or basal cell carcinoma. It originates either from
     the basal layer of the epidermis or from the epithelium of the
     hair follicles and glands of the skin . It shows a predilection for
     the inner canthus. It starts as a small pimple which ulcerates
     and if the scab is removed it is found that the edges are raised
     and indurated. The ulcer spreads very slowly destroying the
     lids, orbital structures. It is locally malignant and the regional
     lymph nodes are not involved.
  b) Squamous cell carcinoma: It originates at the lid margin which
     is the transition zone of the epithelium. It starts as a small
     nodule which ulcerates. The regional lymph nodes preauricular
     or submandibular become enlarged. Histologically it shows
     epitheliai pearls'
  C) Meibomian gland carcinoma: it is an adenocarcinoma of the
     Meibormian gland. The upper lid is more commonly affected
     than the lower lid. In old people it may start as a recurrent
     chalazion. Therefore in this group of patients it is advisable to
     send the curettings of a chalazion for histopathological
     examination.
                                                        ‫خروج‬
       ‫دعوني االن اترككم مع‬


         ‫البوم الصور‬


‫خروج‬
angular blepharitis
chalazion
hordeolum internum
Trichiasis
Blepharitis
External hordeolum
Lid diseases
Ulcerative Blepharitis
blepharospas
eye lids
Squamous Blepharitis
angular blepharitis




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  chalazion




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       hordeolum internum
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   Trichiasis




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       Blepharitis




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       External hordeolum




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       Lid diseases




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       Ulcerative Blepharitis




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       blepharospas




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       eye lids



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Squamous Blepharitis




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