Eyelid

Blepharitis
Def: chronic inflammation of the lid margin
Predisposing factors: old age – diabetes – malnutrition – avitaminosis
Types: squamous – ulcerative – parasitic – angular blephro conjunctivitis
Type squamous Ulcerative parasitic Angular
causes -metabolic -Predisposing factors Phthirus pubis Morax axenfeld
-infection -staph infection diplobacillus
Clinical picture - Small, white Symptoms - Nits Symptoms
scales -burning sensation - Alkaline cement -itching
-discharge
-Lacrimation
- hyperemic lid -Falling of lashes Signs
margin -Discharge -inner and outer
Canthi show
Signs maceration
- Yellow crusts
-conjunctival
- Minute ulcers
redness and
discharge
Complications ptylosis Ptylosis - eczema -Corneal ulcer
Styes - ectropion -ankyloblephritis

treatments -ttt of seborrhea -General health -dilute acetic acid - zinc sulphate
- remove scales by -Control diabetes 2% drops
3% sodium -Correction error of -terramycin
bicarbonate refraction -yellow oxide of ointment drops
mercury
-Antibiotic ointment -remove of crusts -gentian violet 1%
-steroid eye -antibiotic ointment -cutting the paint
ointment lashes
Chalazion (tarsal cyst)
Def: chronic non-specific inflammatory granuloma of a Meibomian gland
Causes: unknown
c/p: painless swelling – red conjunctiva over the nodule
Treatment
- very small chalazion: vit. A – local antibiotics and steroid
- marginal: scraping from lid margin followed by diathermy
- moderate or large: vertical incision

1
 Inflammation Hordeolum externum (stye) Hordeolum internum

Site At the lid margin related to a lash In tarsus deep to the orbicularis
muscle
Inflammatory signs Mild Marked
Swelling Related to lash Yellowish spot pus is seen shining
through the palpebral conjunctiva
Contraction of Not affected Diminished
orbicularis
Treatment -Antibiotic -antibiotic
-Horizontal incision to evacuate the pus -vertical conjunctival incision or a
horizontal skin incision & evacuate
the pus

Ectropion
Def: rolling outwards of the eyelid from the globe (usually affects the lower lid)
Type Fibrotic Paralytic senile Congenital mechanical
Causes Scarring and Paralysis of Senile weakness Increased
contractures of orbicularis of the weight of
the skin of the muscle orbicularis lower lid
lower lid by muscle and
burns-trauma- relaxation of the
or tumor palpebral lig.
Management -small scar: V 1-protection -instruct the -treat the
to Y plasty or Z the cornea by a patient to wipe cause
plasty drops during his lower lid
e.g multiple
the day and upwards
-large scar: skin ointment chalazia
graft during sleep - cautery
puncture to the
2-Medically palpebral
- cortisone conjunctiva
- antirheumatic
medication and - Snellen’s
massage inverting suture

3- lateral - lateral canthal

tarsorrhaphy sling (for sever
cases)
4- fascia lata
sling and
silicone sling
operation

2
 Entropion
Types: fibrotic – spastic – senile – congenital
c/p and complication: see trichiasis
Treatments
fibrotic:
- in the upper lid: Snellen’s operation – Webster’s operation – ant. lamellar reposition
- in the lower lid: Webster’s operation – wise procedure
spastic: treatment of any cause of irritation
- mild cases: T-shaped plaster – lateral canthotomy
- recurrent cases: lateral canthoplasty – skin and muscle operation
Involutional (senile): everting sutures – jones procedure – lateral canthal sling

Trichiasis
Etiology
- Congenital trichiasis: in all 4 lids
- Acquired trichiasis: trachoma - Ulcerative blepharitis – Burns
Clinical picture
Symptoms
-foreign body sensation -photophobia -lacrimation -blepharospasm
Complications
- Conjunctiva: Chronic conjunctivitis - Conjunctival ulcer - Epithelial plaque
- Corneal: Recurrent ulceration - Superficial vascularization - Epithelial plaque
Treatments
- Rubbing lashes: Destroy the hair follicles by: Thermal coagulation by
diathermy - Chemical coagulation by electrolysis – Epilation – cryo coagulation
- Trichiasis: Van Millengen’s operation (upper lid) – Webster’s operation(lower)
3
 Ptosis
Def: dropping of upper eyelid
Types and causes
- Myogenic: Congenital ptosis - Acquired ptosis
- Neurogenic: 3rd nerve palsy - Horner's syndrome
- Aponeurotic ptosis: Senile - Postoperative ptosis
- Mechanical ptosis: Excess weight - Conjunctival scarring
C/P
Symptoms: drooping of upper lid
Signs: arching of eyebrow - Chin elevation – corrugation of the forehead
Complications
- Amblyopia (unilateral congenital)
- Nystagmous and mental retardation (bilateral congenital)
- Torticollis and contracture of sternomastoid – lumbar lordosis
Treatment
1- Congenital ptosis: Squint surgery - Correct hypotropia (if present)
- Unilateral severe ptosis > do ptosis surgery as early as possible
- Jaw winking phenomenon > do frontalis sling
Surgeries
- Levator tucking > for mild ptosis
- Levator resection
2- Acquired ptosis
- Mechanical > remove the cause
- Hysterical > psychotherapy
- Myasthenia gravis > prostigmine
- Paralytic ptosis > wait for 6 months + vit. B complex therapy then evaluate
ptosis and surgery if needed
4
 Lacrimal
Epiphora
Causes
1- Diseases of the upper lacrimal passage
- Lids: Ectropion - Irregular posterior border - Orbicularis paralysis
- Punctum: stenosis or obstruction
- Canaliculus: Stenosis or obstruction either
* congenital
* Post inflammatory and post traumatic occlusion
* Foreign body: lashes
* Fungal canaliculus : caused by actinomyces
2- Diseases of the lower lacrimal passage
- Lacrimal sac:
* Congenital absence
* Adhesion from repeated inflammation
* Tumors of lacrimal sac
* Fracture of lacrimal bones
- Naso lacrimal duct
* Congenital: imperforate hasner's valve
* Acquired: venous congestion - adhesion - tumors of bony canals
- Nose: Polyp or tumors - Deviated septum

Investigations
- Ocular examination: examine lid margin
- Diagnostic tests: Regurge test - Fluorescein test - Diagnostic syringing
Jones dye test – Dacrocystography - X ray on the nose & sinuses

5
 Acute dacrocystitis
Def: it is acute suppurative inflammation of the sac
Etiology: usually staph - may be pneumococci - or streptococci
C/p
Symptoms
- General: fever & headache
- Local: painful swelling at the site of the sac& Epiphora
Signs: Swelling - Regurge: - ve
Complications
Lacrimal fistula - Orbital cellulitis - Cavernous sinus thrombosis - Become chronic
Treatments
- General: antibiotics
- Local: hot fomentation
- Pus: drain
- Fistula: fistulectomy + dacryocystorhinostomy

Chronic dacryocystitis
C/p
Symptoms: fullness + watery eye
Signs: swelling - Regure test: +ve
Treatments
- Medical treatment: antibiotics - vasoconstrictor nasal drops
- Surgical treatment: Treatment of NLD obstruction

6
 Conjunctiva
Ophthalmia neonatorum
Def: conjunctivitis before or in the first month of life
D.D:
- congenital dacryocystitis - birth trauma - corneal FB
- abrasion - buphthalomos -MPC
Treatments
- Gonococcal: penicillin
- Other bacteria & chlamydia: broad spectrum antibiotics
- Viral: antiviral
- Chemical: stop E. D

Pterygium
Def: it is triangular encroachment of conjunctiva over cornea
C/p
Symptoms: disfigurement - diminution of vision - diplopia
Signs: a triangular fold commonly nasal and bilateral
D. D
True pterygium: degenerative condition unknown ae
Pseudo pterygium: a fold of conj. attached to base of healed ulcer
Treatment
- Follow up: if pterygium is small
- Operative treatment: excision with bare sclera operation - excision with grafting
- Postoperative treatment: beta irradiation - mitomycin c

7
 Trachoma
Def: chronic contagious inflammation of conjunctiva due to infection by
chlamydia trachomatis
Characterized by (Clinical stages)
- Formation of follicles & papillae
- Pannus formation
- Sub epithelial cellular infiltration
- Healing by fibrosis
Complications
- Eyelids: cicatricial entropion - trichiasis - ptosis
- Conjunctiva: xerosis – symblepharon – pigmentation
- Lacrimal: dacryocystitis – punctual occlusion
- Cornea: pannus formation – corneal ulcer - xerosis
Treatment
Acute treatment
- Systemic: sulphadiazine tab
- Local: sulphacetamide E. D & terramycin E. oint.
- Atropine
Surgical treatment
- Follicles: expression
- Papillae : scraping
- PTDS, PTCS: picking

8
 Pannus formation
Def: infiltration of the periphery of the cornea by chronic inflammatory cells &
vascularization
C/p
- Progressive pannus - Regressive pannus - Healed - dry - pannus siccus
Clinical Types of pannus
Trachomatous – leprotic – phylctenular – degenerative - vernal

D.D of conjunctival discharge

1- watery: viral – acute allergic drug
2- mucoid: chronic allergic – ropy in spring catarrh
3- mucopurulent: bacterial – chlamydial
4- purulent: gonococci

Dry eye
treatment
- protective glasses and contact lens
- artificial tears eye drops
- occlusion of the puncti to reduce tear drainage
- systemic steroids

9
 Spring catarrh
Def: bilateral, recurrent, seasonal allergic conjunctivitis
Causes: allergy to an exogenous allergen such as dust and U. V. rays
C/p
Symptoms: irritation - red eye - thready discharge
Signs
1- Conjunctiva
- Palpebral type: large - flat topped - fornix free - cobble stone arrangement
- Bulbar type: gelatinous masses - tranta's spots - hypertrophied Epithelium
with c.t core and hyaline degeneration
2- cornea
- S. P epitheliopathy - Superficial c. u. - Annular (360) pannus

Treatment
- Dark glasses - Cold compresses to induce v. c
- Antihistaminic E. D as nostamin - Vasoconstrictive E. D
- Mast cell stabilizers - Change around atmosphere

10
 Cornea
Corneal ulcer
C/p: Symptoms
- Pain - Blephro spasm - Lacrimation - Visual acuity - Red eye
Signs
- Lid edema - Conjunctiva show ciliary flush - Cornea: gray area
- loss of luster - (+ve) fluorescein test - Iris: signs of iritis (flare – hypopyon)
Complications
1- non - perforating c. u
- Secondary iridocyclitis - Secondary glaucoma - Descematocele
2- perforating c. u
- Peripheral perforation: iris prolapse - ectasia of the leucoma adherent
- Central perforation: infection - anterior polar cataract – hypotony
- Other: complicated cataract - endophthalmitis – hypotony
Treatments
1- Topical: Antibiotic eye drops and eye ointment
- Cyclopegic E. D - Eye patching - Bandage soft c. L.
2- Systemic treatment
- Systemic antibiotic - NSAIDS
3- Surgical treatment
- Cauterization: to kill organism
- Paracentesis: aspiration of aqueous using insulin syringe
- Conjunctival flap: to prevent perforation
- Contact lens: to prevent perforation
- Tissue adhesive: cyanoacrylate
- Tarsorraphy: suturing lid margins together
- Therapeutic keratoplasty

11
 Dendritic Corneal ulcer
(herpes simplex keratitis)
C/p:
Symptoms: Pain - Redness - Defective vision
Signs: Ciliary injection - Ulcer
Treatment
- antiviral drugs: topical and systemic
- debridement: effective way

Corneal fistula
Def: it is epithelized corneal perforation
Complications
1- infection > endophthalmitis
2- hypotony > macular edema
3- synechia formation
4- ant polar cataract
Management
- grading: high or low risk ulcer
- hospitalization: high risk ulcer – single red eye

12
 Lens
Congenital cataract
Types
- Anterior polar cataract - Posterior polar cataract
- Lamellar cataract - Total cataract
C/p
Symptoms: white pupil - defective vision
Signs:
one of types is seen - exclude retinal anomalies - preferential looking test(VEP)
Treatment
1- surgical treatment: 1- irrigation – aspiration 2-Lensectomy
2- correction of aphakia: to avoid amblyopia

Complicated cataract
Def: lens opacification resulting from local eye disease or general disease
Local causes
- Corneal causes as keratitis
- Anterior chamber causes as glaucoma
- Uveal tract causes as iridocyclitis
- Lens causes as subluxation and dislocation
- Retinal causes as retinal detachment and retinitis pigmentosa
- High myopia - Intra ocular tumors - Topical drugs as steroid and adrenalin
Systematic causes
- Diabetes mellitus - Hypoparathyroidism - Galactosemia - Infestation
- Systemic drugs as steroids and ergot - Toxic cataract - Irradiation as x ray
Treatment: depends on the cause

13
 Senile cataract
Def: it is bilateral, gradually progressive lens opacity affecting old people
Types: cortical - nuclear - cortico-nuclear
Stages of senile cortical cataract
- immature stage: the lens is not totally opaque
- mature stage: the lens is totally opaque
- hyper mature stage: the lens loses water & shrinks

Stages of senile cataract

type stage symptoms color Iris

shadow
Senile incipient - Halos – fixed Musca Grayish + ve
Cortical - Uniocular diplopia or white
cataract polyopia
- night blindness
- hypermetropic shift
- irregular astigmatism

Immature Gradual drop of vision Grayish + ve

white
Mature HM white - ve
Hyper HM white + ve
mature
Shrunken
Senile - Day blindness Grades: + ve
nuclear - index myopia - light yellow
cataract - dark yellow
- orange
- brown
- black

14
 Uveal tract
Acute iridocyclitis
C/p
Symptoms: Pain - blepharospasm - lacrimation - photophobia
Signs: lid edema - ciliary flush or injection - keratic precipitates - ac signs
Complications
- Synechia formation: fibrous adhesions
- Complicated cataract: due to diffusion of toxins into lens
- 2ry glaucoma - Hypotony - Cvclitic membrane - Endophthlmitis
- Cystoid macular edema: due to the effect of inflammatory mediators on the
retinal vessels
Treatment
Topical treatment:
- cycloplgic eye drops as atropine sulfate 1%ED
- Steroids ED & E. Oint as dexamethasone phosphate 0.1%
- Dark glasses: for photophobia
- Hot fermentation
Systemic treatment
- Systematic corticosteroids: hostacortin tab (5mg)
- NSAID: voltaren, cataflam
- Antibiotic: if the cause is infection
- Resistant cases to steroid: give immuno-suppressive therapy as (cyclosporine)
Iridectomy types
Peripheral - Sector - wide basal - bizarre – visual

By: Abdulrhman Gamal

15