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Lash Disorders Trichiasis: primary (metaplastic lashes and distichiasis) or secondary (entropion). Madarosis: local or systemic. Poliosis: Local (blepharitis) or systemic (vkh). Allergic Disorders


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Lids, Lacrimal apparatus and Orbit
Dr. Yasser Al-Fakey

M.D., M.Sc (Ophth.), FRCS



Lash Disorders


  • Trichiasis: primary (metaplastic lashes and distichiasis) or secondary (entropion).

  • Madarosis: local or systemic.

  • Poliosis: Local (blepharitis) or systemic (VKH).



Allergic Disorders


  • Acute allergic edema: insect bit, angioedema or urticaria.

Unilateral or bilateral painless and pitting edema.

  • Contact dermatitis: Sensitivity to topical medications.



Xanthelasma


  • Elderly people or those with hypercholesterolemia.

  • Cholesterol and lipid subcutaneous plaques.

  • Treatment: surgical excision or CO2 laser evaporation.



INFECTIONS


  • Blepharitis.

  • Hordeolum:

1) Externum (Stye)

2) Internum (Acute chalazion)



  • Viral infections.

  • Trachoma.


Blepharitis


  • Anterior, posterior or mixed.

  • Symptoms: burning, grittiness, mild photophobia, crusting and redness of lid margin.

  • Signs: lid margin (hyperemia, telangiectasia and tiny abscesses) scales and lashes (greasy and stuck together).

  • Complications: Stye, Tear film instability, Hypersensitivity to staph. toxins, trichiasis, madarosis and poliosis.

  • Treatment:

1) Lid hygiene

2) Antibiotic ointment

3) Systemic tetracycline

4) Lubricants

5) Weak topical steroid.

External Hordeolum (Stye)


  • Acute staph. infection of hair follicles and associated glands.

  • Signs

  • Mild preseptal cellulitis.

  • Treatment: Hot compresses, Epilation, Topical antibiotics and even systemic if associated with preseptal cellulitis.



Internal Hordeolum (Acute Chalazion)


  • Acute staph. infection of meibomian gland.

  • Signs: tender inflamed swelling within the tarsal plate. It may discharge anteriorly through the skin or posteriorly through the conjunctiva.

  • Treatment: Control of infection then curettage if residual mass.


Chalazion (Meibomian cyst)


  • Chronic lipogranulomatous inflammation caused by obstruction of the gland orifice.

  • Most common lid mass.

  • Symptoms

  • Signs

  • D.D. of recurrent chalazion

  • Treatment:

1) Surgery

2) Steroid injection



Viral infections


  • Herpes simplex:

Primary herpes simplex, usually affects children, crops of small vesicles with mild edema and may be associated with viral keratoconjunctivitis.

Treatment with acyclovir


Herpes Zoster Ophthalmicus

  • Unilateral condition, usually affect elderly people.

  • Vesicles, pustules and crusting ulceration.

  • Hutchinson sign

  • Treatment: systemic and topical acyclovir



Chlamydial Conjunctivitis


  • Adult Chlamydial Keratoconjunctivitis:

-Sexually transmitted disease (50% associated with genital infection) caused by serotypes D to K.

-Subacute onset, unilateral or bilateral mucopurulent discharge.

-Follicular conj. Reaction and corneal involvement is uncommon.

-Non-tender lymphadenopathy.

-Treatment: Topical tetracycline

Systemic tetracycline, deoxycycline or recently azithromycin.




Trachoma


  • Infection caused by Chlamydia trachomatis (serotypes A, B, Ba & C).

  • Obligate intracellular bacteria.

  • The common fly is a major vector in the transmission of the disease.

  • It is the leading cause of preventable blindness allover the world.

  • Symptoms: During childhood with redness, and mucopurulent discharge.

  • Signs:

  • follicular conjunctivitis.

  • Limbal follicles.

  • Keratitis.

  • Lab. Investigations:

1) Direct monoclonal fluorescent antibody microscopy

2) ELISA


3) Polymerase chain reaction (PCR)

4) Giemsa stain (inclusion bodies)



  • Complications:

  • Progressive conjunctival scaring (Arlt line, PTDs and entropion).

  • Herbert pits.

  • Corneal pannus.


WHO grading:

  • TF = trachomatous follicles.

  • TI = trachomatous inflammation.

  • TS = trachomatous scar.

  • TT = trachomatous trichiasis.

  • CO = corneal opacity.


ENTROPION


  • Types:

  1. Involutional

  2. Cicatricial

  3. Spastic

  4. Congenital

  • Complications

  • Treatment



ECTROPION


  • Types:

  1. Involutional

  2. Cicatricial

  3. Paralytic

  4. Mechanical

  • Complications

  • Treatment



LID TUMORS


  • Benign: Naevus, Capillary haemangioma, Port-wine stain …etc

  • Malignant: BCC, SCC, SGC and Melanoma.


PTOSIS


  • Drooping of the upper lid.

  • Pseudoptosis

  • Classification:

  1. Neurogenic

  2. Myogenic

  3. Aponeurotic

  4. Mechanical



Clinical Evaluation


  • History:

Age of onset, Trauma, Previous surgery and Diurnal variations.

  • Exclusion of Pseudoptosis.

  • Associated signs.

EOM movements, Bell’s phenomenon, Increased innervations, Fatigability and Jaw-winking.

  • Measurements:

PFH, MRD 1, MRD 2, Levator function and lid crease.

Management


  • Preferable age for surgical correction?

  • Type of surgery

  1. Levator Resection

  2. Frontalis Suspension

  3. Mullerectomy

  • Postop. Complications and patient expectation.

LACRIMAL APPARATUS


Excessive Watering


  • Lacrimation: reflex over-production of tears.

  • Epiphora: mechanical obstruction of tear drainage.

  • Lacrimal pump failure.



Examination of Lacrimal System


  • The eyelids.

  • The dynamics of eyelid closure.

  • The puncta.

  • The marginal tear strip.

  • The lacrimal sac.

  • Dye Disappearance Test.

  • Probing and irrigation.

  • Jones dye test

  • Radiography


Congenital Nasolacrimal Duct Obstruction


  • Symptoms

  • Signs

  • DDT

  • Complications

  • Management:

Massage

Probing


Probing + Stent

DCR
Infections of The Lacrimal Passages




  • Acute dacryocystitis:



  • Symptoms

  • Signs

  • Complications

  • Treatment:

Systemic antibiotics

Stab incision

DCR

Chronic Dacryocystitis:


  • Symptoms: epiphora + mucopurulent discharge

  • Signs: painless swelling

+ve regurgitation test

probing and irrigation



  • Treatment: DCR

Dry Eye


  • Symptoms

  • Signs: Tear meniscus, Tear BUT test, Schirmer test, SPK and Rose Bengal stain.

  • Treatment: Preservation of tear

Lubricants

Punctal plugs

Permanent occlusion


Orbital Diseases


DD preseptal cellulites (proptosis and limitation of EOM)

Treatment: admition, Iv antibiotics, CT-scan and fever chart.




  • Graves Ophthalmopathy

Most common cause of unilateral or bilateral proptosis

Symptoms (active and inactive)

Signs

Treatment




  • Orbital Blow-out fracture

Symptoms

Signs


Indications for treatment


  • Tumors

Metastatic tumor

Lymphoma


Rhabdomyosarcoma


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