1. Staphylococcal
2. Seborrheic
3. Mixed
4. Meibomian Keratoconjunctivitis (MKC)
5. Meibomian seborrhea or meibomian gland dysfunction (MGD)

• Conjunctival stain,

• Corneal stain--SPK

• Lid stain

• Pouted or pointed glands

• Frothing

• Reduced TBUR

• Scurf/scale: Greasy (seborrheic), harder, crusty, collarettes (Staph)

• Poliosis (no melanin in lashes)

• Madarosis (no eyebrows/eyelashes)

• Pachyblepharon (thick lid margins.)

Itching, burning, dryness. foreign body sensation, mattered lids, redness, puffiness, scratchiness, lash loss, bumps on lids (sty or hordeolum)

• TBUT ( lower usually because glands sitting there not expressing, reduces oils in tear film amd increases evaporation)
• Bulbar conjunctival stain (use lissamine green, flourescein with yellow filter) Rose bengal staining occurs later and  indicates associated dry eyes
• Corneal stain (usually limbal SPK from overnight)
• Lissamine green as disease progresses makes palpebral easier to see.
• Forceful expressions: toothpaste/string like, no discharge due to stenosis/ swelling lid

Injection

Concretions

Yellow, corksrew appearance of glands,

deep plugging,

papillae (pimple),

Follicle (small sac),

Telangiectasia (tortuous vessels)

Less common, Treatable

Signs: inflammation, collarettes, madarosis (no eyebrow/eyelashes)

Follicular response,

younger px,

shorter history of Sx

95% associated seborrhea ( excessive sebum coating) or dermatitis

Sx: chronic mild inflammation, greasy crusts, bulbar injection,

papillary response (likesomeone w/allergy, redness)

• Chronic w/ overlying exacerbations,

• Mixed crusts,

• more common than staph alone

• Meibomian gland with assoc corneal changes.

Sx/symp:

• Inflammation around the meibomian glands,

• Glands difficult to express.

• Expression is thick, Posterior inflammation, unstable tearfilm with debris,

• associated papillary hypertrophy ( a lot of nipple-like projections),

• Associated keratitis: 10, 2, 4, 8oclock linked to free Fatty acids,

• Limbitis precedes slight localized injection, mild foreign body sensation, trace to 1+ localized SPK.

• Delayed type Hypersensitivity (DTH) with increased cell mediated immunity etiology,
• scarring and vascularization associated.

Tx: Steroid

• Anterior lid changes may also be present ( madarosis -no lashes/lids, pachyblepharon -thick lid margins, scalloped margins)

Associations: rosacea (facial redness and pimples), seborrhea

OVERproduction of sebeaceous material and rapid turnover of epithelial cells.

this overproduced sebum is why the lid margins stains so well.

o: all glands patent

Grade 1 = 1 or 2 partially obrstructed (clear fluid when mild pressed)

Grade 2: three or more partially obstructed (expelling opaque fluid when pressed) ,

Grade 3: one or two blocked glands with many partially obstructed (foam along lid margins)

Grade 4: three or more blocked with remainder partially obstructed.

Mite causes inflammation by over prolipheration

Telangiecstasia of the blood vessels of the face,

rapid turnover of epithelial cells,

pistules across the cheeks,

Rhinophyma ( Bulbous/ swollen nose pores gives nose enlarged appearance) becomes apparent,

• mimics ocular pemphigoid.

associated with small intestine bacterial overgrowth (SIBO):

Test with lactulose breath test.

Treatment: Rifaximin

Resolves for 6mos or longer.

dysfunction of sebaceous glands making too much SEBUM and RAPID CELLULAR TURNOVER,

diffused or localized

Signs:

• Dermatitis (red blotchy in caucasians, hypo or hyperpigmentation in black people),

• dandruff (check for dandruff on brows, scalp line ask if they use anti dandruff shampoo),

• flaky scaly skin and/or scalp,

• prone to eczema

1/3rd of seborrhea px will develop MKC.

may exist without other facial signs.

may apper before full rosacea.

teleangiectasia of lid margin, thickening of lid, MGD.

Include: Blepharitis, inflammation, tearing, chalazia (swelling of eyelid due to obstructed and retained secretion of meibomian glands),

Hordeola (furuncle of margin of eyelid starting from sebaceous gland of an eyelash),

corneal vascularization,

corneal &/ conjuntival scarring, corneal thinning, corneal perforation

Metrogel (applied to lids)

Doxycycline

• Ulceration (break in mucous membrane)

• Perforation

• Corneal pannus and thinning

• Cicatrization

• Conjunctivalization/keratination of the cornea

• Concretions (calcified sebaceous material)

• Contact lens intolerance

1. Nutritional management (seborrhea px should reduce fatty food) take antiocidants, omega 3 supplements or LNA- alpha-linolenic acid (flax seed oil).
2. Hygeine : warm compresses, massage (open glands), GENTLE lid scrubs tid.
3. Forceful expression (6 wk interval use topical anesthetic on cotton swab, lipflow instrument every 6months)
4. Topical therapeutic agents :antibiotic ointments (on lashes like bacitracin, erythromycin (Safe for pregnant or nursing woment), besivance, azasite), steroid ointments (tobradex, blephamide, on swab for lid disease)or solutions, anti-inflammatory treatments (azasite dailyx1mo and restasis) BID),  bland ointment (smothers the mite demodex)
5. Oral antibiotics: stop bacterial proliferation, stop lipase and decr. fatty acids, Px improve cos decrease in free fas, decreased substrate for bacteria to feed on, decreased exotoxin production and decreased hypersensitivity) e.g. tetracycline, docycycline: alodox, nutridox.
6. (caution: teracyclines retard bone and dentitial development no pregnant, nursing, children, peptic ulcer disease

Moraxella or staph. atopy

affects angles of the lid

S/S: red, flaky, ulcerative canthal regions irritation, tenderness.

RED, Painful, Tender Nodule.

can be internal (meibomian gland, tx with lots of warm compresses), or external (follicle at base of shaft).

Infextions,

• drain by: remove lash, lance at peak, excision
• Leaves scar tissue when resolved

Chalazion, associated with Blepharitis

Granulomatous, can occur secondary to hordeolum

Compresses

Excision
May induce astigmatism if large.

• Extra row of lashes typically grow from meibomian gland orifices.
• Complications: trichiasis (lashes turn inward), corneal foreign body sensation and tracking.                                       

Pediculosis Palpebrum

/Phthiriasis palpebrum associated with blepharitis

Body Lice

Crab Lice (adults, assoc w/ sexual contact)
Sx: discharge, red lid margins.

Signs:

SLE see trnslucent lice, fecal material dark red/red brown granules.

palpable pre-auricular node

Treat infestation with Rid, kwell, nix for body.

smother the lice with vasoline, bland ointment.

physostigmine to kill

yellow mercuric oxide QD

remove with forceps and swabs.

repeat in 2 weeks to kill hatchlings.

Less common

shows collarettes

Entropion,

Disease of Lid Placement

Congenital Entropion,

Disease of Lid Placement

• Rare,

• confused with epiblepharon (horizontal infold of skin near lid margin)

• Occurs from improper aponeurosis insertion of the retractor

Involutional Entropion,

Disease of Lid Placement

MOST COMMON,

age related loss of horizontal lid tone and weakness of lid retractors,

atrophy orbital tissues.

Cicatricial Entropion,

Disease of Lid Placement

seconary to conjuctival scarring,

present in anthrax and stephen johnson

Spastic Entropion,

Disease of Lid Placement

Severe Irritations of anteriro segment leading to spasm.

seen occasionally with blepharospasm.

neurological

Ectropion,

Disease of Lid Placement

Involutional Ectropion,

Disease of Lid Placement

Cicatrical or mecahnical Ectropion,

Disease of Lid Placement

scarring-- burns, dermatoses, tumor, trauma

Treatment of Ectropion,

Disease of Lid Placement

ENtropion,

Disease of Lid Placement

surgery,

epilation,

glue

ENtropion,

Disease of Lid Placement

Paralytic

ECtropion,

Disease of Lid Placement

Bells Palsy- paralysis of orbicularis

Exposure secondary to lagophtlamos --> epiphora

Medication induced state with botox

Congenital Ectropion,

Disease of Lid Placement

Lagophthalmus

Disease of Lid Placement

Incomplete lid closure,

lubrication,

taping, tarsorrhaphy if severe.

Nocturnal

Lagophthalmus

Disease of Lid Placement

check by reclineing and close eyes, check for glow of NaFl  using burton lamp.

idiopathic

adults> children b/c tear decreases.

wose inferiorly in the morning

Orbital

Lagophthalmus

Disease of Lid Placement

Mechanical Lagophthalmus

Disease of Lid Placement

Parlytic Lagophthalmus

Disease of Lid Placement

• Bell's- unilateral CN VII   Facial N paralysis.

• Orbicularis affected-- cannot close lids properly

• frequently viral with self-limited inflammation, resolve in 3 months and 85% resolve in 3 wks

• Recur with residual damage,

• Vascular associations

• rule out stroke because in Bell's the forehead and face flaccid, stroke may be uneven.
• The flat side in bells is the problem

Treatment for paralytic Lagophthalmus

Disease of Lid Placement

Congenital Ptosis,

disease of lid placement

Autosomal Dominang, improper devlopment of levetor palpebral superirois.

ptotic lid is higher than normal in downward gaze,

Blepharophimosis Ptosis,

disease of lid placement

Ptosis, miosis, anhydrosis

[image]

dilates normal eye byt not horners,

tests oculosympathetic paresis

elevates affected side,

due to hypersensitivity of mueller's muscle.

important to rule out malignancy in central and pre-ganglionic

autosomal dominant, muscle wasting,, px has mournful expression.

difficulty relaxing muscle once contracted, associated with cardiac and pulmonary problems.

Ocular signs of Myotonic Dystrophy

disease of lid placement

• Ptosis cataract

• retinopathy

• near-light reflex dissociationlow IOP

Ptosis,

diplopia,

nystangmus,

gatigue as day goes on

Myasthenia Gravis,

disease of lid placement

AD, loss of receptors giving rise to muscle fatigue and weakness,

mostly females 20-50 yo

90% will have ocular

Tensilon test: Edrphonium, short durationa nticholinesterase will inprove the pstosis (10 min)

Px stand on toes or walk stairs and see that they may have ptosis.

Steroids, immunosupressive, anticholinesterases,

thymectomy if associated thymoma(tumor of epithelial cells of thymus)

Obese middle aged men with loose skin whose lids are easily everted causing exposure, drying of cornea and palpebral conjunctiva, redness and papillary response.

associated with sleep apnea.

Fat droops over upper lid,

elderly px, redudancy of skin, orbital fat protrusion through septum, indistinct creases of the lid.

notch on medial third of lid, cleft in the lid caused by incomplete closure of embryonic tissue,/

90% of time is upper lid.

Associations: dermoids (saclike growth), strabismus, corneal opacity.

Tx; surgical repair at age 3-6 months, supportice tx to reduce corneal exposure problems

Vertical shortening of the eyelids and too small to blink

Tx: surgery