1. Lecture 1 DISEASES of EYELIDS, LACRYMAL SYSTEM & ORBIT
Lecture 1 DISEASES of EYELIDS, LACRYMAL SYSTEM & ORBIT. “RED EYE” DISEASES
Lecture is delivered by
Ph. D., associated professor Tetyana Tabalyuk

2. Visual organ consists from:
1) peripheral part – eyeball with ocular adnexa;
2) guiding pathway – optic nerve, chiasm, optic tract;
3) undercortex centers – lateral geniculare nucleus and optic radiation;
4) higher visual centers in the occipital cortex.

3. Structure of Visual Analisator
1 - retina,
2 - optic nerve (non-crossed fibers),
3 -  optic nerve (crossed fibers),
4 - optic tract,
5 -  lateral geniculare nucleus,
6 - radiatio optici,
7 - lobus opticus

4. OPTICAL SYSTEM of the EYE:
EYEBALL
I. External (structural) layer – cornea & sclera;
II. Middle (vascular) layer – iris, ciliary body & choroid;
III. Internal layer – retina.
Internal nucleus of the eye includes: lens, vitreous & aqueous humor, which fill in eye chambers.
The eyes lie within two bony cavities, or orbits.
OCULAR ADNEXA :
Lacrimal gland & excretory system
Oculomotor apparatus
Eyelids
Conjunctiva
OPTICAL SYSTEM of the EYE:
Cornea
Aqueous humor
Lens
Vitreous

6. VISUAL FUNCTIONS: Light sensitivity Field of vision Visual acuity
Peripheral vision (rods are response) includes:
Light sensitivity
Field of vision
Central vision (cones are response) includes:
Visual acuity
Colour vision

7. Visual acuity transcription
20 feet equivalent
(USA)
6 meter equivalent
(Great Britain)
5 meter equivalent
(Ukraine)
20/20
6/6
1,0
20/25
6/7.5
0,8
20/40
6/12
0,5
20/60
6/18
0,3
20/200
6/60
0,1

8. EYELID ANATOMY
The eyelids layers: skin muscle tarsus conjunctiva

9. BLEPHARITIS very common chronic inflammation of the eyelid margins
Classification: divided into anterior & posterior forms: the former may be staphylococcal or seborrhoeic; a mixed picture is typical, however.
Causative factors:
staphylococcal: chronic infection of the bases of the lashes – common in patients with eczema
seborrhoeic: usually associated with seborrhoeix dermatitis – involves excess lipid production by eyelid glands, converted to fatty acids by bacteria
posterior: dysfunction of the meibomian glands of the posterior lid margins – common in patients with acne rosacea

10. Clinical features: usually worse in the morning, include grittiness, burning and redness, stickiness and crusting of the lids.
SIGNS:
staphylococcal: dandruff-like scaling, mainly around the eyelash bases;
seborrhoeic: greasy debris around the lashes causing them to adhere to one another;
posterior: frothy tear film and pluggung of the meibomian gland orifices
All types usually manifest hyperaemia of the lid margins and conjunctiva, and tear film instability

11. Complications: corneal epitheliopathy scarring marginal keratitis reccurent bacterial conjunctivitis chalazia styes loss of lashes (madarosis) misdirection (trichiasis)

12. Management: lid margin hygiene using a weak solution or baby shampoo
tear substitutes (e.g. hypromellose, carbomers)
antibiotic ointment (e.g. fusidic acid, chloramphenocol) rubbed into the lid margins
systemic tetracycline

13. Meibomian cyst (chalazion) a lesion consisting of lipogranulomatous inflammation centred on a dysfuctional meibomian gland
Clinical features:
Extremely common, particularly in patients with posterior blepharitis.
A chronic, usually solitary, painless, firm swelling in the tarsal plate;
Can follow an acute meibomian gland infection.
May be assosiated with a secondary conjunctival granuloma
Management: spontaneous resolution may occur, although usually only if the lesion is small. Surgical incision and curettage is often required

14. INTERNAL HORDEOLUM (acute chalazion) an acute bacterial meibomian gland infection
Clinical features:
An inflamed swelling within the tarsal plate which may be associated with (mild) preseptal cellulitis
Management:
Topical antibiotic ointment and systemic antibiotic (e.g. flucloxacillin) for preseptal cellulitis.
Hot bathing may promote discharge.
Incision and curettage Incision and curettage may be required for a large abscess, or for secondary chronic lesion.

15. EXTERNAL HORDEOLUM (stye) a small abscess of an eyelash follicle
Clinical features:
An acute painful inflamed swelling on the anterior lid margin, usually pointing through the skin
Management:
Removal of the associated lash, and hot bathing.
Topical antibiotic ointment.
Large lesions may require incision

16. Cysts of Zeis and Moll Management:
Clinical features:
A cysts of Zeis is a small, whitish, chronic, painless opaque nodule on the lid margin
A cysts of Moll is similar but translucent
Management:
simple excision

17. MOLLUSCUM CONTAGIOSUM
Clinical features: single or multiple, small, pale, waxy umbilicated nodules, which may cause a secondary chronic ipsilateral follicular conjunctivitis. These virally transmitted lesions are common and more severe, in AIDS patients.
Management: expression or cautery.

18. Benign tumours of the eyelids
Squamous cell papilloma (viral wart)
Basal cell papilloma (seborrhoeic keratosis)
Keratoacanthoma
Melanocytic naevus
Capillary haemangioma (strawberry naevus)
Plexiform neurofibroma

19. Squamous cell papilloma (viral wart)
Management:
Simple excision, cautery or laser ablation
Clinical features:
The most common benign tumour of the eyelid which may be broad-based (sessile) or pedunculated

20. Basal cell papilloma (seborrhoeic keratosis)
Management:
Simple excision or curettage
Clinical features:
This common tumour usually found in the elderly, is a slowly-enlarging brownish papillary lesion with a greasy friable surface

21. Remains static for several months before involution
Keratoacanthoma
Remains static for several months before involution
Clinical features:
An uncommon, fast-growing, firm, pinkish nodule that develops a keratin-filled crater and may be mistaken for a malignancy

22. Melanocytic naevus Itradermal
Intradermal naevus – an elevated lesion with variable pigmentation. When located on the lid margin may be associated with protruding lashes. No malignant potential.
Junctional naevus – a flat well circumscribed lesion with a uniform brown colour, so-called because the naevus cells are located at the junction of the dermis and epidermis. Low malignant potential.
Compound naevus – usually elevated, with a homogeneous tan to brown colour. Consists of both intradermal and junctional components, the latter conferming a low malignant potential.

23. Capillary haemangioma (strawberry naevus)
Clinical features: an irregular red lesion in an infant which may cause a mechanical ptosis and amblyopia.
Management: local steroids if necessary, but frequently undergoes gradual spontaneous involution.

24. Plexiform neurofibroma
Typically occurs in neurofibromatosis-1, characteristically giving rise to an S-shaped lid margin and ptosis

25. Premalignant and malignant tumours of the eyelids
Actinic (solar) keratosis
Basal cell carcinoma
Squamous cell carcinoma
Sebaceous gland carcinoma
Management:
Surgical excision with a wide clearance margin is the treatment of choice for most lid malignancies
Radiotherapy in selected cases

26. Actinic (solar) keratosis
Clinical features: although rare, this is most common premalignant lid condition and is strongly associated with excessive sun exposure in light-skinned individuals. It is usually presents as a persistent scaly plaque, which must be biopsied.

27. Basal cell carcinoma
Clinical features: most common eyelid malignancy, is locally invasive but does not metastasize. About 50 % involve the lower lid, 30 % the medial canthal area.
Nodule –ulcerative - a «rodent ulcer», with rolled hyperkeratotic edges and central granulation, gradually enlarging over 1-2 years. A purely nodular appearance is common.
Sclerosing - a flat indurated plaque with poorly demarcated margins, often with loss of overlying lashes that may simulate chronic blepharitis

28. Squamosus cell carcinoma
Clinical features: is much less common than basal cell carcinoma. It grows more quiclkly and may metastasize. It may arise de novo or from premalignant condition such as actinic keratosis.
Nodular – starts as a hyperkeratotic nodule or plaque which later develops crusting fissures
Ulcerative – resembles a rodent ulcer

29. Sebaceous gland carcinoma
Clinical features: this is rare but very aggressive tumour, which may originate in a meibomian or Zeus gland as a film nodule either on the lid margin or within the tarsal plate, when it may be mistaken for an chalazion.

30. Entropion an inward-turning of the eyelid
Classification:
Involutional – most common form, results from age-related changes in lower lid
Cicatrical – most frequently secondary to scarring of the upper conjunctiva, as on chronic trachoma
Spastic – lower lid, caused by spasm of the orbicularis muscle due to ocular irritation or essential
Congenital – very rare, only involves the lower lid. Caused the hypertrophy of skin and orbicularis
Management : surgical correction :

31. Ectropion an outward-turning of the eyelid
Classification:
Involutional – most common form, age-related tissue laxity
Cicatrical – scarring resulting from burns or surgery (e.g. tumour resection)
Mechanical – excess lid weight (e.g. large tumour)
Paralytic –facial nerve palsy, associated with incomplete blinking and lid closure
Congenital – may be part of blepharophimosis syndrome
Management : surgical correction :

32. Lacrymal system anatomy:
Larcymal productive part &
Lacrymal excretory part

33. Investigation of lacrymal system
Functional ability of lacrymal excretory system – 1% Fluorecsein is dropped into conjunctival cavity
Positive canalicular test – disapearing of S. Fluorecsein from conjunctival cavity till 5 minutes, usually 1-2 minutes
Positive nose test – appering of S. Fluorecsein in 5 minutes
Shirmer test
Reveals hyposecretion of lacrymal gland – wetting of filter paper less then 15 mm

34. DACRYOADENITIS – inflammation of lacrymal gland
Clinical features: hyperemia, oedema and pain in upper-external part of orbit
Eyeball can be dislocated down and nasally
Prearicular lymph nodes are increased and painfull
Increased body temperature
Key sign – S-like form of rima ophthalmica
Management: systemically antibiotics, sulfanilamids, salicilates
In abscess – incision and

35. DACRYOCYSTITIS – inflammation of lacrymal sac
Ethiology: in infants – atresia of lower part of nasolacrymal duct; in adults – stenosis of nasolacrymal duct
Clinical features: exess tearing, pus discharge usually from one eye
Key sign – pus discharge from lower lacrymal point in palpation of area of lacrymal sac
Management: in infants – massage of lacrymal sac
Syringing of lacrymal excretory ways
Dreanage of lacrymal excretory ways
Chonic in adults – surgical - dacryocystorhinostomy

36. Orbital cellulitis Signs: eyelids oedema chemosis proptosis
limiting of eye movements
decreasing of visual acuity
general intoxication (headacke, increased temperature, brain signs).
Optic neuritis, papilloedema, central vein occlusion may occur with outcome in optic atrophy.
Management:
incision of orbit with drainage
antibiotics systemically
osmotherapy

37. Fissura orbitalis superior syndrome
Tumour, haematoma, foreign body in the area of fissura orbitalis superior usually causes:
Proptosis
Ptosis
Ophthalmoplegy
Mydriasis
Paralysis of accomodation
Decreasing of corneal sensitivity and skin sensitivity in the area of innervation of I branch n.trigeminus

38. TYPES of INJECTION of EYEBALL:
Superficial or conjunctival;
Deep or ciliary or pericorneal;
Mixt

39. + (superficial injection) + (deep or mixt injection) + -
DIFFERENTIAL DIAGNOSIS of INFLAMMATORY DISEASES OF EYE ANTERIOR SEGMENT
Sign
conjunctivitis
keratitis
iridocyclitis
red eye
+ (superficial injection)
+ (deep or mixt injection)
corneal syndrome +
pain -
(in daytime)
(at night, incresing in lighting & palpation)
decreased visual acuity
peculierities
discharge
corneal infiltrate
keratic precipitates, posterior synechiae, miosis, vitreous opacities

40. Bacterial conjnctivitis

41. KERATITIS

42. ANTERIOR UVEITIS

43. CLINICAL FEATURES of ENDOPHTHALMITIS:
red eye (mixt injection);
corneal syndrome;
reducing of visual acuity;
pain +
hypopion (pus in the anterior chamber);
abscess of vitreous (yellow fundus reflex)
CLINICAL FEATURES of PANOPHTHALMITIS:
pain;
hypopion;
abscess of vitreous
imbibition of cornea by pus
purulent choroidoretinitis (with visual field defects & fundus patches if seen)

44. LOCAL ANTIBACTERIAL TREATMENT:
drops - S.Sulfacili Na 30 %,
S.Dimexidi 10 %,
S.Gentamycini 0,3 %,
S.Laevomycetini 0,25 %,
S.Polymixini B 0,25 %,
S.Tobramycini 0,3 %,
S.Chlorhexidini 0,02 %,
S. Ciprophloxacini 0,3 %,
Сiloxani
Uniflox
Vigamox
Oftaquix etc.
ointments – Ung. Tetracyclini 1 %,
Ung. Tobramycini 0,3 %,
Ung. Erythromycini 1 %
“Floxal” etc.

45. LOCAL ANTIVIRAL TREATMENT:
drops -Interferoni,
Reaferoni,
Laferoni,
Viaferoni,
Interlok
IDU,
S. Florenali 0,1 %,
S. Oxolini 0,1 %,
S. tebrofeni 0,1 %
Virgan etc.
ointments – Ung. Florenali 0,5 %,
Ung. Oxolini 0,25 %,
Ung. Tebrofeni 0,5 %,
Ung. Acycloviri 5 % (or Zovirax or Verolex) etc.