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Inflammations

 

Inflammations


II. INFLAMMATORY LID DISEASES



The inflammatory lid diseases are:-



1. Stye.

2. Chalazion.

3. Infected chalazion

4. Blepharitis.

5. Meibomianitis.

1. STYE (HORDIOLUM EXTERNUM)

Definition:-

Acute suppurative inflammation of the skin appendages at the lid margin (hair follicles, Zeis glands or Moll glands).

Etiology:-

A. The causative organism: Staph. aureus.

B. Source of infection: Usually external, but may be blood born from a nearby septic focus as bad tooth or sinusitis.

C. Predisposing factors:

- Errors of refraction especially in young age. In this case the patient squeezes his lids to improve vision (pinhole effect). This leads to congestion of the lid and increase susceptibility for infection.

- D.M. especially in adults.

- Blepharitis especially the ulcerative type.


Diagnosis:-

Symptoms:

- Diffuse stage: Dull pain and diffuse lid swelling.

- Localized stage: Localized swelling at the lid margin and throbbing pain (pus under tension).


Signs:


- Diffuse stage: Diffuse lid swelling, hyperemia and maximal tenderness at the site of infected gland.

- Localized stage: Pus points in relation to a lash (in front of the grey line), surrounded by hyperemia and localized tenderness.

Complications:-

- The most common is one lash trichiasis.

- The most serious is cavernous sinus thrombosis.

Differential diagnosis:-


1. Infected chalazion (see later).

2. Marginal chalazion: It is a chronic painless swelling behind the grey line, while stye is an acute painful swelling in front of the grey line.

 
Treatment:-

1. Systemic anti Gram positive antibiotics as penicillin 250 - 500 mg every 6 hours.

2. Hot fomentations.

3. If pus is formed it should be drained either by leaving the stye to open spontaneously, apilation of the infected lash or horizontal skin incision.

2. CHALAZION (MEIBOMIAN CYST)

Definition:-

Chronic lipogranulomatous inflammation of one of the Meibomian glands.


Etiology:-

Obstruction of its duct leading accumulation of its sebaceous secretion inducing a granulomatous reaction.

Duct obstruction is predisposed mainly by seborrhea and vitamin A deficiency. In these conditions the chalazion is usually multiple and recurrent.

Diagnosis:-

Symptoms:

Painless localized swelling of the lid of accidental onset and gradual increase in size.

Signs:

1. Tarsal chalazion:


- Single or multiple well localized non tender swellings can be easily palpated in the lid substance (it is easier to be felt than seen).

- It is not attached to skin & disappears by contraction of orbicularis oculi

- From the conjunctival side the chalazion appears as a pale area surrounded by hyperemia.
 

2. Marginal chalazion:

- It is a small swelling in the lid margin behind the grey line.

Complications:-

1. Infection leading to acute chalazion (painful).

2. Opening into the conjunctiva with incomplete evacuation will lead to the formation of chalazion granuloma. This will lead to chronic conjunctivitis.

3. Pressure on the cornea by a large chalazion causing astigmatism.


Differential diagnosis:-

- Adenoma or adenocarcinoma of Meibomian gland: There is recurrence in the same site. In such cases, histopathological diagnosis should be done.

- Sebaceous cyst: It is attached to skin and becomes more apparent by  contraction of orbicularis oculi.

- Marginal chalazion should be differentiated from stye (see before).


Treatment:-

1. Small chalazion: Local steroid ointment for 1 week (usually not effective).
 
2. Tarsal chalazion: It is removed as following:

- Local anaesthesia by topical novosine eye drops plus infiltration of novocain in submuscular layer.

- Hold the chalazion by the chalazion forceps. It is important for fixation of the chalazion, hemostasis, protection of the globe and lid evertion.

- Excise the conjunctival wall of chalazion to prevent recurrence.

- Curettage to ensure complete evacuation to prevent chalazion granuloma formation.

- Bandage for few hours and eye ointment that contains both steroids and antibiotics should be used for few days.
 

3. Multiple chalazions are removed in different sessions plus vitamin  A support.
 
4. Recurrent chalazion: - In the same site we do excision biopsy.

 

                        - In different sites we give vitamin A.
 

5. Marginal chalazion: Shaving by scalpel while the eye is protected by the lid spatula.

6. Infected chalazion: Antibiotics and drainage of pus.

3. INFECTED CHALAZION (HORDIOLUM INTERNUM)

It is acute suppurative inflammation of a Meibomian gland.

 Etiology:-

A. Causative organism: as stye.
 
B. Source of infection: as stye.

C. Predisposing factors: Chalazion.

Diagnosis:-

Symptoms:

- Diffuse stage: Dull aching pain and diffuse swelling of the lid.

- Localized stage: Throbbing pain (pus under tension) and a localized lid swelling.

Signs:

- Lid swelling that disappears by lid closure and not related to lashes.

- Maximal tenderness over the infected gland.

- The underlying chalazion can be felt.

- Pus points under the conjunctiva in the localized stage.

Complications:-

- Opens spontaneously into the conjunctiva leading to incomplete evacuation of its contents. So that chalazion granuloma develops.

- Cavernous sinus thrombosis.

Differential diagnosis:-

Treatment:-
as stye, but drainage of pus is done by a vertical incision through the conjunctival side.

4. BLEPHARITIS

Blepharitis is chronic inflammation of the margins of the four eyelids.

there are 5 types:

- Scaly blepharitis.

- Ulcerative blepharitis.

- Mixed blepharitis.

- Angular blepharitis.

- Parasitic blepharitis.

A. SCALY (Seborrheic) BLEPHARITIS

It is the chronic inflammation of the 4 lid margins characterized by the formation of scales formed of dryed sebaceous secretion.

Etiology:-

Most commonly it is a manifestation of seborrhea (hereditary).

Clinical picture:-
Symptoms:
Itching, discomfort and scanty discharge.

Signs:

Small scales like dandruff are seen on and in-between the lashes. Removal of these scales leaves unulcerated hyperemic lid margin. Dandruff in the scalp and eyebrows confirm the diagnosis.

Complications:-

1. Secondary staph. infection leading “mixed blepharitis” blepharitis. Both types of blepharitis should be treated.

2. Madarosis (loss of lashes).

3. Itching may cause eczema, dermatitis, ectropion and epiphora.

Treatment:-

1. Lid hygiene: The lid margins is scrubbed with neutral pH shampoo or special preparations. Also seborrhea of scalp and brows should be treated.

2. Systemic tetracycline in small doses (250 mg twice / day) is used if the case is associated with dermatitis.

3. Local steroid rubbed with the lashes only in severe cases.

B. ULCERATIVE BLEPHARITIS

It is the chronic inflammation of the 4 lid margins characterized by ulceration of the lid margin.

Etiology:-

- Chronic Staph. aureus infection of the lash follicles.
- Predisposing factors: Bad hygiene and malnutrition.

Clinical picture:-

Symptoms:

Severe itching, burning sensation, lacrimation, photophobia and blepharospasm.

Signs:

- The lid margins are congested and edematous with crustations. The crusts may form collarettes surrounding the lashes.

- Removal of the crusts leaves bleeding ulcers.

- Lashes are glued together (Differential diagnosis from MPC).

Complications:-

I. As a source of infection:-

     - Marginal corneal ulcers (catarrhal ulcers).

     - Chronic conjunctivitis.

     - Endophthalmitis after intraocular operations.

II. Lid complications due to scarring:-

- Trichiasis.

- Madarosis (loss of eye lashes).

- Tylosis (rounded lid margin) ---> epiphora ---> eczema and dermatitis ---> cicatricial ectropion ---> more epiphora.

III. Recurrent styes.

Treatment:-

1. Remove the crusts by 3 % sodium bicarbonate lotion.

3. Antibiotic eye ointment is rubbed to the lashes 3 times / day to affect the hidden bacteria. It is given till 2 weeks after clinical cure of the condition. Antibiotics are given according to culture and sensitivity. Steroids are added to decrease fibrosis.

C. ANGULAR BLEPHARO-CONJUNCTIVITIS

It is chronic inflammation of lids and conjunctiva with special predilection to the angles of the eye.


Etiology:-

Infection by Morax axenfeld diplobacillus which is characterized by:-

- It secrets proteolytic enzymes causing marked itching and skin maceration.
- Killed by lysozyme, so that it affects the canthal areas where lysozyme is deficient.
- It secrets lysozymase enzyme to inhibit the lysozyme. This lysozymase is inhibited by zinc preparations.

Clinical picture:-

Symptoms:

- Marked itching.

- Scanty muco-purulent discharge and redness of angles of the eyes due to conjunctivitis.

Signs:

- The skin of the canthal areas is hyperemic, macerated and edematous.

- Congestion of the angular parts of conjunctiva.

Complications:-

As ulcerative blepharitis + hypopyon corneal ulcer.

Treatment:-

1. Sodium HCO3 3 % eye lotion tds..

2. Local tetracycline eye ointment.

3. Zinc sulphate eye drops 0.5%

D. PARASITIC BLEPHARITIS

It is chronic inflammation of the lid margins caused by parasitic infestation.

Etiology:-

There are 2 types: - tick type caused by Demodix folliculorum.


                   - lice type caused by Pthyrus pubis.

It is predisposed by the very bad hygiene.

Clinical picture:-

- Symptoms: Itching and lacrimation.

- Signs: - The parasite is seen on the lashes.

         - The black nests of eggs are also seen.

Treatment:-

1. Improve the hygienic condition.

2. To remove the parasite we cut the lashes by scissors, then wash by acetic acid lotion 3%.

3. Yellow oxide of mercury 1% is applied 3 times / day.

4. Other parasitic infestations in the body and other family members are treated (the lice type is caused by Pthyrus pubis louse which infect the pubic hairs).

5. Meibomianitis

It is a common chronic inflammation of Meibomian glands caused by excessive secretion. It may be associated with blepharitis. It is also called “hot eye syndrome”.

Symptoms:-

Intense burning in the morning that improves during the day. There is slight continuous discharge.

Signs:-

- There is conjunctival hyperemia.

- The lid margin is hyperemic with froth at the orifices of Meibomian glands. The oily Meibomian secretion can be expressed by massaging the eyelids.

Treatment:-

Lid hygiene and periodic expression of Meibomian glands