DISORDERS OF EYE – Chalazion, Entropion, Ectropion, Trichiasis and Ptosis
DISORDERS OF EYE – Chalazion, Entropion, Ectropion, Trichiasis and Ptosis
CHALAZION
A chalazion is a cyst in the eyelid that is caused by inflammation of a blocked meibomian gland. Chalazion is a chronic non-infective lipo-granulomatous inflammation of the meibomian gland; can appear as a single granuloma or multiple granulomas in the upper or lower eyelids. Bacteria, usually staphylococcus, and seborrhea are the causes of the chalazion. Chalazions differ from styes (hordeolums) in that they are more painful than styes, as well as bigger in size. A chalazion is not an infection but is an inflammation of the meibomian gland (sebaceous glands).
CLINICAL MANIFESTATIONS
- Swelling of the upper or lower eyelid
- Appears as a localized hard lump
- Lump is small, hard, and non tender
- Pain and redness of eye
- Foreign body sensation
MANAGEMENT
Treatment usually consists of application of warm compresses for 10 to 15 minutes, four times a day to reduce swelling and promote drainage of the gland. Administer antibiotic eye drops or ointments (chloromycetin) if a bacterial infection is suspected to be present. Administer injection of a steroid medicine in the area of the lump to help decrease the inflammation. In some cases, incision and drainage in the orifice with local anesthetics may be necessary. Teach the patient how to clean eyelid margins and not to squeeze the sty.
ENTROPION
Entropion is a condition in which the eyelid margin rolls inwards. Either the lower or the upper eyelid may be affected.
TYPES OF ENTROPION
1. Congenital Entropion: It is a rare condition seen since birth and usually associated with microphthalmos and anophthalmos (absence of the eyeball)
Cicatricial Entropion: The entropion occurs due to contraction of the conjunctival scar as in trachoma, membranous conjunctivitis, chemical burns and pemphigus. The upper lid is usually affected.
2. Senile Entropion: it is the most common variety of the entropion and usually affects the lower eyelid in elderly. Senile entropion occurs due to disappearance of orbital fat and also due to atrophic and inelastic condition of the skin in senility.
3. Spastic Entropion: This type of entropion is occurs following spasm of orbicularis due to chronic ocular irritation or after prolonged bandaging of the eye. Spastic entropion is more common in elderly and frequently involves lower eyelid
4. Mechanical Entropion: It occurs due to lack of support of the eyelids, as due to phthisis bulbi, enophthalmos, after enucleation or lack of orbital fat. The lower lid is usually affected.
CLINICAL MANIFESTATION
- Foreign body sensation in the eye
- Lacrimation
- Pain in the eye
- Blepharospasm
- Ciliary congestion
- Superficial opacities
- Corneal ulcer
MANAGEMENT
The spastic entropion is cured when the cause of blepharospasm is treated. The senile entropion can be treated by keeping the lower eyelid pulled downwards by application of strip of adhesive plaster. If the bandaging is the cause, it should be discontinued. In both senile and spastic entropion of gross degree involving the lower lid, a skin-muscle operation (Wheeler’s operation) may be advocated; other operations recommended are removal of excessive lid tissue next to the lateral canthus and tucking of the inferior lid retractors. Correction of cicatricial entropion involves eyelash eyelash transplantation and straightening of the deformed tarsus.
ECTROPION
Ectropion is a condition in which the eyelid margin rolls outwards that is becomes inverted. It may occur in various degrees.
CAUSES OF ECTROPION
- Spastic Ectropion: It occurs due to powerful contraction of the orbicularis muscle, when the skin is elastic and the eyeball is prominent or slightly proptosed. Both the eyelids may be affected.
- Senile Ectropion: The lower eyelid is affected in old age due to laxity of the lid tissues, loss of tone of the orbicularis muscle and weakness of medial and lateral canthal tendons
- Paralytic Ectropion: It occurs as a result of weakness of the orbicularis muscle due to paralysis of the facial nerve
- Cicatricial Ectropion: It occurs due to skin scarring as in the thermal burns, chemical burns, lacerating injuries and skin ulcers. Both the eyelid may be affected.
CLINICAL MANIFESTATIONS
- Epiphoria
- Chronic conjunctivitis due to exposure
- Conjunctive become dry and thickened
- Corneal ulcer
MANAGEMENT
In the case of spastic ectropion the cause of blepharospasm has to be treated. For other types of ectropion, plastic operation is needed. The most common operation is skin-muscle operation (Wheeler’s Operation), in which a 4mm broad orbicularis strip is exposed, divided in the middle and then overlapped for 4mm. In the paralytic type a lateral tarsorrhaphy is indicated.
TRICHIASIS
Trichiasis is a condition of an inward misdirection of eye lashes with normal position of the lid margin, so as to rub against the cornea.
CAUSES AND RISK FACTORS
Trachoma, ulcerative blephritis, spastic entropion, membranous conjunctivitis, external hordeolum, mechanical injury, burns and operative scar on the eyelid margin.
CLINICAL MANIFESTATIONS
- Foreign body sensation in the eye
- Lacrimation
- Pain in the eye
- Blepharospasm
- Ciliary congestion
- Superficial opacities
- Corneal ulcer
MANAGEMENT
- Isolated misdirected cilia may be removed by epilation forceps
- Electrolysis Epilation: A weak galvanic current from cathode is passed to the root of the eyelashes by a fine platinum needle and the root is destroyed due to the liberation of hydrogen gas. A current of 2mA is passed for 10 seconds into the lash root
- Cryoepilation: The cryoprobe with -20 degree celcius is applied for 20-25 seconds. It is the best method for segmental trichiasis. Its main disadvantage is depigmentation of the skin.
PTOSIS
Ptosis is also called “drooping eyelid”. This condition is sometimes called “lazy eye” but that term normally refers to amblyopia. It is caused by weakness of the muscle responsible for raising the eyelid, damage to the nerves that control those muscles, or looseness of the skin of the upper eyelids. If severe enough and left untreated, the drooping eyelid can cause other conditions, like amblyopia or astigmatism.
CAUSES AND RISK FACTORS
Ptosis occurs when the muscles that raise the eyelid (levator and Muller’s muscles) are not strong enough to do so properly. Drooping eyelid can be caused by the normal aging process, a congenital abnormality (present before birth), or the result of an injury or disease. Exposure to the toxins in some snake and insect venoms, such as that of the black mamba, may also cause ptosis.
Risk factors include aging, diabetes, stroke, horner syndrome, myasthenia gravis, and a brain tumor or other cancer, which can affect nerve or muscle reactions.
CLASSIFICATION
Depending upon the cause it can be classified into:
- Neurogenic ptosis which includes oculomotor nerve palsy, horner’s syndrome, marcus gunn jaw winking syndrome, IIIrd cranial nerve misdirection
- Myogenic ptosis which includes myasthenia gravis, myotonic dystrophy, ocular myopathy, simple congenital ptosis, blepharophimosis syndrome
- Aponeurotic ptosis which may be involutional or post-operative
- Mechanical ptosis which occurs due to edema or tumors of the upper lid
- Neurotoxic ptosis which is a classic symptom of envenomation by elapids such as cobras, or kraits. Bilateral ptosis is usually accompanied by diplopia, dysphagia and/or progressive muscular paralysis. Regardless, neurotoxic ptosis is a precursor to respiratory failure and eventual suffocation caused by complete paralysis of the thoracic diaphragm. It is therefore a medical emergency and immediate treatment if required.
- Pseudo ptosis due to i. Lack of of lid support: empty socket or atrophic globe. ii. Higher lid position on the other side: as in lid retraction
CLINICAL MANIFESTATIONS
- Drooping of one or both eyelids
- Increased tearing
- If ptosis is severe, interference with vision
MANAGEMENT
Treatment depends on the type of ptosis and is usually performed by an ophthalmolic plastic and reconstructive surgeon. Aponeurotic and congenital ptosis may require surgical correction if severe enough to interfere with vision. In children with ptosis, surgery may be necessary to prevent amblyopia. Surgical procedures include: Levator resection. Muller muscle resection and frontalis sling operation.
Ptosis that is caused by a disease will improve if the disease is treated successfully.
Non surgical modalities like the use of “crutch” glasses or special Scleral contact lenses to support the eyelid may also be used.