3. I (Allah) Swear by the (passing)time.(1)
Indeed mankind is in loss (because of this loss of time)(2)
Except those, who are believers, and have done righteous deeds, and advise each other to truth and patience.(3)

4. Inflammations and Infections of the Eyelids
Dr. Faizur Rahman Professor of Ophthalmology Peshawar Medical College

5. Congenital anomalies Coloboma Epicanthus Distichiasis
Blephrophimosis syndrome
Anchyloblephron
Congenital ectropion
Telecanthus

6. Coloboma of the Eyelid

7. EPICANTHIC FOLDS
BILATERAL VERTICAL FOLDS OF SKIN THAT EXTEND FROM UPPER OR LOWER LID TOWARDS MEDIAL CANTHUS.
MAY GIVE RISE TO PSEUDO-ESOTROPIA

8. Congenital Dystichiasis

9. Blephrophimosis Syndrome

10. Ankyloblephron

11. Congenital Ectropion
Aetiology
Clinical features
Treatment

12. TELECANTHUS
UNCOMMON
INCREASED DISTANCE BETWEEN THE MEDIAL CANTHI AS A RESULT OF ABNORMALLY LONG MEDIAL CANTHAL TENDONS
TREATMENT
SHORTENING AND REFIXATION OF MEDIAL CANTHAL TENDONS

13. EPIBLEPHARON COMMON IN ORIENTALS
EXTRA HORIZONTAL FOLD OF SKIN STRETCHES ACROSS ANT. LID MARGIN & LASHES ARE DIRECTED VERTICALLY
TREATMENT
RECOVER SPONTANEOUSLY
PERSISTENT CASES REQUIRE HOTZ PROCEDURE

14. Categories. Congenital Anomalies Inflammations Disorders of position.
Trauma
Tumours

15. INFLAMMATIONS OF EYE LID
ALLERGIC DISORDERS
Acute allergic oedema
Contact dermatitis
Atopic dermatitis
INFECTIONS
Herepes zoster ophthalmicus
Impetigo
Erysipelas
Stye
Internal hordeolum
CHRONIC MARGINAL BLEPHARITIS
Anterior blepharitis
Posterior blepharitis
MISCELLANEOUS

16. ACUTE ALLERGIC OEDEMA INSECT BITES, ANGIOEDEMA, URTICARIA, DRUGS
SUDDEN ONSET OF PAINLESS, PITTING PERIORBITAL AND LID OEDEMA
TREATMENT
SYS. ANTI-HISTAMINES

17. CONTACT DERMATITIS ANY SENSITIVITY TO TOPICAL MEDICATION LID OEDEMA
ERYTHEMA
TEARING
ITCHING
TREATMENT
REMOVAL OF CAUSE
TOPICAL STEROIDS

18. Patient with a nail polish allergy, otherwise known as eczematoid allergy.

19. Atopic dermatitis Common idiopathic skin condition
Associated with asthma and hay fever
Presentation:
Chronic irritation and itching
Associated with more generalized skin lesions

20. Close-up of a patient with atopic dermatitis of the face demonstrating darkening of the lids

21. Signs: Treatment: Bilateral thickening , crusting and fissuring
Emollients such as oily cream
Mild topical steroid such as hydrocortisone 1%
Secondary infection require antibiotic therapy.

22. Erysipelas
Acute subcutaneous spreading cellulitis caused by strep pyogens causes eyelid necrotization and secondary eyelid contracture
Signs: Red well defined indurated expanding subcutaneous plaque
Treatment:
Oral phenoxymethylpencillin

24. Herpes simplex Unilateral condition effects children
Sign: crops of small vesicles associated with mild lid oedema associated with ipsilateral follicular conj and keratitis
Treatment:
Acyclovir or penciclovir cream

26. HERPES ZOSTER OPHTHALMICUS
VARICELLA-ZOSTER VIRUS
ELDERLY AND IMMUNOCOMPRISED
PRESENTS WITH PAIN IN THE DISTRIBUTION OF 5 NERVE
MACULOPAPULAR RASH OVER FOREHEAD
PROGRESSION THROUGH VESICLES, PUSTULES TO CRUSTING & ULCERATION

27. HERPES ZOSTER OPHTHALMICUS
TREATMENT
SYSTEMIC
VALACYCLOVIR OR FAMCYCLOVIR FOR 7 DAYS
TOPICAL,
ACYCLOVIR
STEROID-ANTIBIOTIC COMBINATION
TALC & CALAMINE TO BE AVOIDED

28. IMPETIGO
UNCOMMON
SUPERFICIAL SKIN INF. CAUSED BY Staph. aureus OR Strep. Pyogenes
MACULES THAT RAPIDLY DEVELOP INTO VESICLES & BULLAE TO PRODUCE YELLOWISH CRUSTS
TREATMENT
TOPICAL ANTIBIOTICS
ORAL CLOXACILLIN / ERYTHROMYCIN

29. STYE EXTERNAL HORDEOLUM
AN ACUTE STAPH. INFECTION OF LASH FOLLICLE AND ITS GLAND OF ZEIS OR MOLL
TREATMENT
HOT COMPRESSES
EPILATION OF LASH

30. INTERNAL HORDEOLUM
AN ABSCESS CAUSED BY AC. STAPH INFECTION OF MEIBOMIAN GLAND
TREATMENT IS INCISION AND CURETTAGE

31. CHALAZION MEIBOMIAN CYST
CH. STERILE LIPO- GRANULOMATOUS INFLAMMATORY LESION
BLOCKADE OF GLAND ORIFICES AND STAGNATION OF SECRETIONS
NON TENDER, ROUND, FIRM LESION
EVERSION OF LID MAY SHOW AN ASSOCIATED CONJ. GRANULOMA

32. CHALAZION
TREATMENT
SURGERY
STEROID INJECTION
SYSTEMIC TETRACYCLINE

33. BLEPHARITIS

34. BLEPHARITIS Inflammation or infection of the eyelid margins
One the most common ophthalmological complications as well as one of the most difficult conditions to treat.

35. CLASSIFICATION
TRADITIONAL
STAPHYLOCOCCAL
SEBORRHEIC
MIXED

36. CLASSIFICATION McCulley’s STAPHYLOCOCCAL SEBORRHEIC
SEBORRHEIC WITH STAPH. SUPER-INFECTION
SEBORRHEIC WITH MEIBOMIAN SEBORRHEA
SEBORRHEIC WITH SECONDARY SPOTTY MEIBOMIANITIS
PRIMARY MEIBOMIANITIS

37. CLASSIFICATION STAPHYLOCOCCAL SEBORRHEIC MEIBOMITIS ACNE ROSACEA
LOCALIZED
GENERALIZED
ACNE ROSACEA

38. HISTORY Duration of ocular symptoms
Unilateral or bilateral presentation
Association with potential exacerbating conditions
Smoke
Allergens
Wind
contact lenses
low humidity
Recent exposure to an infected individual (e.g., pediculosis)

39. HISTORY Ocular history Systemic history
previous ophthalmic surgery
Trauma (including radiation and chemical trauma)
Systemic history
dermatological diseases, such as acne, rosacea, eczema, allergies)
Use of ocular medications or retinoids.

41. EXAMINATION Visual acuity
Careful external examination of facial skin, eyelids, and eyelashes.
Slit lamp biomicroscopy
Tear film
Anterior eyelid margin, eyelashes, posterior eyelid margin, tarsal conjunctiva, bulbar conjunctiva, and cornea.
Tests
Lissamine green
Rose bengal
Tear break-up time
Schirmer testing
Cochet-Bonnet esthesiometry to check corneal sensation for a unilateral case

42. STAPHYLOCCAL BLEPHARITIS
ALSO CALLED INFECTIVE BLEPHARITIS
Staphylococcus Aureus And Epidermidis
80% ARE YOUNG WOMEN
USE OF COSMETICS
USUALLY UNILATERAL IN CHRONIC CASES MAY BE BILATERAL
SYMPTOMS
BURNING, ITCHING, STINGING
EYESTRAIN
PHOTOPHOBIA
FOREIGN BODY SENSATION
WORSE IN THE MORNING

43. Patient with chronic staphylococcus blepharitis.
SIGNS
BRITTLE, HARD SCALES WITH COLLARETTES AROUND CILIA
STERILE CORNEAL INFILTERATES 1mm FROM THE LIMBUS
SMALL ULCERATIONS
PANNUS
MADAROSIS
POLIOSIS
TRICHIASIS
Patient with chronic staphylococcus blepharitis.

44. STAPHYLOCCAL EXOTOXINS
STAPHYLOCCAL EXOTOXINS HAVE BEEN IMPLICATED AS A CAUSATIVE AGENT FOR BOTH MARGINAL INFILTRATES AND PHLYCTENULAR DISEASE ASSOCIATED WITH BLEPHARITIS

45. TREATMENT AGGRESSIVE EYELID HYGIENE TOPICAL ANTIBIOTIC
WARM COMPRESSES
EYELID SCRUBS
TOPICAL ANTIBIOTIC
ERYTHROMYCIN
BACITRACIN
TOPICAL CORTICOSTEROIDS
IN MARGINAL INFILTRATES AND PHLYCTENULAR DISEASE

46. SEBORRHEIC BLEPHARITIS
GENERALIZED SEBACEOUS GLAND ABNORMALITY EXTENDING ONTO EYELID MARGIN
USUALLY BILATERAL
SYMPTOMS
ARE USUALLY OUT OF PROPORTION TO PHYSICAL FINDINGS

47. CLINICAL FINDINGS MAY REVEAL MILD INFLAMMATION OF ANTERIOR LID MARGIN
ERYTHEMA
EDEMA
TELANGIECTASIA AT LID MARGIN
SCALING & CRUSTING AT LID MARGIN OFTEN EXTENDING ONTO LASHES “SCURF”

48. TREATMENT EYELID HYGIENE LOCAL ANTIBIOTICS SELENIUM SHAMPOO
WARM COMPRESSES
EYELID SCRUBS
LOCAL ANTIBIOTICS
IF SUPERINFECTION IS SUSPECTED
SELENIUM SHAMPOO
FOR CONCURRENT SCALP SEBORRHEA

49. STAPHYLOCOCCAL
SEBORRHEIC
AGE
mean 42 yrs
mean 50 yrs
FINDINGS
Hard Adherent Scales, Crusts Pierced By Cilia, “collarettes”
Greasy, less adherent scales “scurf”
CORNEA
Marginal infilterates, inferior SPEE, Phlyctenulosis
inferior SPEE
Tear Film
Unstable, rapid break-up time
Aqueous tear deficiency in 1/3
Treatment
Topical antibiotics, Eyelid scrubs, warm compresses
Eyelid scrubs, warm compresses, selenium shampoo

50. MEIBOMIANITIS MEIBOMIAN GLAND INFLAMMATION LOCALIZED MEIBOMITIS
CHALAZION
INTERNAL HORDEOLUM
GENERALIZED MEIBOMITIS
MEIBOMIAN SEBORRHEA
MEIBOMIAN KERATOCONJUNCTIVITIS

51. CHALAZION
MEIBOMITIS
STYE

52. MEIBOMIAN SEBORRHOEA BUILD UP OF EXCESSIVE MEIBOMIAN SECRETIONS
MILD INFLAMMATION OF ANTERIOR LID MARGIN
TELANGIECTASIA

53. EXCESSIVE MEIBOMIAN SECRETIONS
GROSSLY ABNORMAL MEIBUM EXPRESSED FROM GLAND ORIFICE

54. TREATMENT DAILY LID MASSAGE WARM COMPRESSES TO SOFTEN MEIBUM
EXPRESSION OF EXCESS SECRETIONS

55. MEIBOMIAN KERATOCONJUNCTIVITIS
MORE SEVERE FORM
SEMI-SOLID, WHITE SECRETIONS VISIBLE AS “BRUSH MARKS”
ENLARGED GLANDS THAT LATER ON DEVELOP ATROPHY
RAPID TEAR BREAKUP DUE TO ABSCENT MEIBOMIAN SECRETIONS
CORNEAL PUNCTATE EPITHELIAL EROSIONS
PANNUS
MARGINAL INFILTERATES
CORNEAL THINNING

56. TOOTH PASTE LIKE SECRETIONS

57. TREATMENT AGGRESSIVE EYELID HYGIENE TOPICAL ANTIBIOTICS
WARM COMPRESSES
EYELID SCRUBS
TOPICAL ANTIBIOTICS
ORAL TETRACYCLINE
REDUCES PRODUCTION OF FFA BY INHIBITING BACTERIAL ENZYMES AND CAUSE STABILIZATION OF TEAR FILM

58. ACNE ROSACEA
COMMON CHRONIC INFLAMMATORY DISEASE WITH OCULAR &SKIN MANIFESTATIONS
SEBACEOUS GLAND DYSFUNCTION
30-50 YEARS
TYPE IV HYPERSENSITIVITY REACTION
SYMPTOMS
RANGE FROM IRRITATION TO BURNING TO FOREIGN BODY SENSATION

59. CLINICAL FEATURES CHRONIC BLEPHARITIS CONJUNCTIVAL HYPEREMIA
RECURRENT CHALAZIA
KERATITIS
TEAR FILM INSTABILITY
ROSACEA KERATITIS
PERIPHERAL CORNEAL VASULARIZATION
TELANGIECTASIA
THINNING
ULCERATION
EVEN PERFORATION

60. TREATMENT ORAL TETRACYCLINES TOPICAL METRONIDAZOLE WARM COMPRESSES
REDUCES FACIAL REDNESS
WARM COMPRESSES
EYELID SCRUBS
TOPICAL STEROIDS
ROSACEA KERATITIS

61. MEIBOMITIS
ACNE ROSACEA
AGE
All Ages
30-50 yrs
FINDINGS
Irregular posterior margin, plugged gland orifices “brush marks”
Marginal Telangiectasia, meibomitis, Recurrent chalazia
CORNEA
Inferior SPEE, Marginal infiltrates, Pannus, Corneal thinning
Pannus, thinning, ulceration and perforation
TEAR FILM
Unstable, foamy
Unstable
TREATMENT
Eyelid Scrubs, antibiotics, warm compresses, daily massage, oral tetracycline
Tetracycline, topical metronidazole for facial redness

62. DIFFERENTIAL DIAGNOSIS
INFECTIOUS
STAPHYLOCCAL
DEMODEX FOLLICULORUM
CANDIDA
PHTHIRUS
INFLAMMATORY
SEBORRHEIC
MEIBOMITIS

63. DIFFERENTIAL DIAGNOSIS
DERMATOLOGIC/ALLERGIC
ACNE ROSACEA
ATOPIC KERATOCONJUNCTIVITIS
ATOPIC DERMATITIS
PSORIASIS
PITYRIASIS
COSMETIC USE
SYSTEMIC
LUPUS ERYTHEMATOSUS
ACQUIRED IMMUNODEFICIENCY SYNDROME
CONGENITAL ERYTHROPOITIC PORPHYRIA

64. Picture demonstrating thinning of eyelids secondary to corticosteroid use. Note sleeves and scurf

65. Patient with Pthirus pubis with critters on eyelashes.

66. DOMEDEX FOLLICULORUM ADJACENT TO AN EYELASH

67. MEIBOMIAN GLAND DYSFUNCTION
NUTRITIONAL TREATMENT OPTIONS
OLEIC ACID
OIL OF EVENING PRIMROSE
OMEGA 6 F.A
FLAVONOIDS
RESVERATROL
SILYMARIN
BILBERRY EXTRACT
HORMONAL TREATMENT OPTIONS
ROLE OF ANDROGENs
*Ophthalmol Clin N Am 16 (2003) 37-42

68. Infrared Warm Compression Device
Wave length peak, 940 nm
Treatment of non-inflamed obstructive meibomian gland dysfunction
Improved tear stability
Associated with release of meibum
Effective and safe
British Journal of Ophthalmology 2002;86:

69. Fusidic Acid Gel For Recurrent Blepharitis And Rosacea
Topical fusidic acid gel (Fucithalmic)
Patients with blepharitis & concomitant Rosacea respond well to therapy.
*Ann. Pharmacother., January 1, 2005; 39(1):

70. Role of Ceramide Gel In Atopic blepharitis
Ceramide comprises about 30% of stratum corneum lipids
Role in both the water retention and barrier function of the skin
Better patient compliance than ointments containing petrolatum
useful supplementary therapy during periods of relatively light inflammation
*British Journal of Ophthalmology 2003;87:

71. Dark pink bougainvillea

72. THANK YOU

74. INFECTIVE DISORDERS HZO Signs:
Common unilateral condition effects elderly pts
Severe immunodeficiency states
Presentation : Pain
Signs:
Maculopapular rash on the forehead , vesicles , pustules and crusting ulceration .

75. Hutchison sign Periorbital oedema Treatment:
Systemic : Valaciclovir 1 gm tds for 7 days or famciclovir 250 mg tds for 7 days

76. Topical : Acyclovir or famciclovir cream
Steroid antibiotic combination such as fucidin H , Hydrocortisone and fusidic acid

77. Superficial skin infection caused by staph aureus or b.hemolytic sterp
Occurs in children
Associated with inf of the face
Signs: Erythematous macules vesicle formation and bullae – yellow crust
Treatment:
Topical antibiotic
Systemic flucloxacillin or erythromycin
Impetigo

79. Necrotizing fasciitis
Cutaneous gangrene which usually effects the trunk ,perineum and legs caused by strep pyogens and staph aureus
Effects elderly and debilitated pts following trauma
Signs: Bilateral lid oedema and erythema rapidly progress to gangrene
Treatment: High doses of parental benzyl pencillin and surgical debridement of necrotic tissues.
Necrotizing fasciitis

81. Internal hordeolum Acute staph infection of meibomian glands
Signs: Tender inflamed swelling with in tarsal plate, discharge ant or post .
Treatment: I&C

82. Stye
Acute staph abscess of lash follicle and associated with gland of Zeis or Mole
Signs:
Tender inflamed swelling in the lid margin , more than one lesion may be present and minute abscess may involve the entire lid margin
External hordeolum

83. In severe cases mild preseptal cellulitis .
Treatment:
Hot compresses
Epilation
Systemic antibiotic

84. Molluscum contagiosum
Skin infection caused by pox virus
Immunocompromised pts mainly effected
Signs: Single or multiple pale ,waxy , umbilicated nodules
Causes follicular conj , superficial keratitis .
Treatment: Shave excision and cauterization , cryo, laser.
Molluscum contagiosum

86. Chronic lipogranulomatous inflammatory lesion caused by blockage of gland orifices and stagnation of sebaceous secretions
Presentation : Painless nodule , Astigmatism .
Signs: Painless round firm lesion in the tarsal plate , polypoid granuloma , associated chr post blepharitis.
Chalazion

88. Treatment:
Surgery
Steroid injection: 0.1 to 0.2 ml triamcinolone diacetate diluted with lignocaine to a conc. of 5mg per ml .
Second inj after 2 wks
Systemic tetracycline in pts with recurrent chalazion.

89. Blepharitis
Blepharitis refers to a family of inflammatory disease of the eyelids (chronic inflammation)
It is usually bilateral ,symmetrical and is more common in the older age group

90. Anterior
Posterior
Mixed.
Types

91. Most common causes of Blepharitis are Staphylococcal infection and irritation from oily Mebomian gland secretion
Pathophysiology involves bacterial colonization of eyelids resulting in direct mirobial invasion of tissues ,immune system mediated damage ,or damage caused by bacterial toxins ,waste product and enzymes
Seborrhic Blepharitis may be associated with seborrhic dermatitis
Pathogenesis

92. Association SYSTEMIC DISEASES Rosacae Seborrhic dermatitis
Herpes simplex dermatitis
Varicela Zoster dermatitis
Staphylococcal dermatitis
OCULAR DISEASES
Dry eyes syndromes
Chalazion
Conjunctivitis , Keratitis
Association

93. Symptoms Burning Watering Foreign body sensation
Crusting and matting of eyelashes
Photophobia
Redness of lids and eyes
Pain and defective vision
Symptoms

94. Gross examination shows erythema and crusting of eyelashes and lid margins
Slit lamp examination may show madarosis,poliosis,trichiasis crusting of lashes and Mebomian orifices, eyelid margin ulcers, Telengectiasis and tylosis
Papillary conjunctival reaction
Aqueous tear deficiency
Posterior Blepharitis may be related to Mebomian gland dysfunction.
Signs

97. Complications Chronic conjunctivitis Keratitis Phlyctenulosis
External hordeolum
Tear film instability
trichiasis

98. Treatment Lid hygiene Topical antibiotics Topical steroids
Tear substitutes
Systemic antibiotics
Treatment of complication