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Eyelid Disorders

Eyelid Disorders

Definition

An eyelid disorder is any abnormal condition that affects the eyelids.

Description

Eyelids consist of thin folds of skin, muscle, and connective tissue. The eyelids protect the eyes and spread tears over the front of the eyes. The inside of the eyelids are lined with the conjunctiva of the eyelid (the palpebral conjunctiva), and the outside of the lids are covered with the body's thinnest skin. Some common lid problems include the following: stye, blepharitis, chalazion, entropion, ectropion, eyelid edema, and eyelid tumors.

Stye

A stye is an infection of one of the three types of eyelid glands near the lid margins, at the base of the lashes.

Chalazion

A chalazion is an enlargement of a meibomian gland (an oil-producing gland in the eyelid), usually not associated with an infectious agent. More likely, the gland opening is clogged. Initially, a chalazion may resemble a stye, but it usually grows larger. A chalazion may also be located in the middle of the lid and be internal.

Blepharitis

Blepharitis is the inflammation of the eyelid margins, often with scales and crust. It can lead to eyelash loss, chalazia, styes, ectropion, corneal damage, excessive tearing, and chronic conjunctivitis.

Entropion

Entropion is a condition where the eyelid margin (usually the lower one) is turned inward; the eyelashes touch the eye and irritate the cornea.

Ectropion

Ectropion is a condition where one or both eyelid margins turn outward, exposing both the conjunctiva that covers the eye and the conjunctiva that lines the eyelid.

Eyelid edema

Eyelid edema is a condition where the eyelids contain excessive fluid.

Eyelid tumors

Eyelids are susceptible to the same skin tumors as the skin over the rest of the body, including noncancerous tumors and cancerous tumors (basal cell carcinoma, squamous cell carcinoma, malignant melanoma, and sebaceous gland carcinoma). Eyelid muscles are susceptible to sarcoma.

Causes and symptoms

Stye

Styes are usually caused by bacterial staphylococcal infections. The symptoms are pain and inflammation in one or more localized regions near the eyelid margin.

Chalazion

A chalazion is caused by a blockage in the outflow duct of a meibomian gland. Symptoms are inflammation and swelling in the form of a round lump in the lid that may be painful.

Blepharitis

Some cases of blepharitis are caused by bacterial infection and some by head lice, but in some cases, the cause is unclear. It may also be caused by an over-production of oil by the meibomian glands. Blepharitis can be a chronic condition that begins in early childhood and can last throughout life. Symptoms can include itching, burning, a feeling that something is in the eye, inflammation, and scales or matted, hard crusts surrounding the eyelashes.

Entropion

Entropion usually results from aging, but sometimes can be due to a congenital defect, a spastic eyelid muscle, or a scar on the inside of the lid from surgery, injury, or disease. It is accompanied by excessive tearing, redness, and discomfort.

Ectropion

Similar to entropion, the usual cause of ectropion is aging. It also can be due to a spastic eyelid muscle or a scar, as in entropion. It also can be the result of allergies. Symptoms are excessive tearing and hardening of the eyelid conjunctiva.

Eyelid edema

Eyelid edema is most often caused by allergic reactions, for example, allergies to eye makeup, eyedrops or other drugs, or plant allergens such as pollen. Trichinosis, a disease caused by eating undercooked meat, also causes eyelid edema. However, swelling can also be caused by more serious causes, such as infection, and can lead to orbital cellulitis which can threaten vision. Symptoms can include swelling, itching, redness, or pain.

Eyelid tumors

Tumors found on the eyelids are caused by the same conditions that cause these tumors elsewhere on the body. They are usually painless and may or may not be pigmented. Some possible causes include AIDS (Kaposi's sarcoma) or increased exposure to ultraviolet (UV) rays which may lead to skin cancer.

Diagnosis

An instrument called a slit lamp is generally used to magnify the structures of the eyes. The doctor may press on the lid margin to see if oil can be expressed from the meibomian glands. The doctor may invert the lid to see the inside of the lid. Biopsy is used to diagnose cancerous tumors.

Treatment

Stye

Styes are treated with warm compresses for 10-15 minutes, three to four times a day. Chloramphenicol ointment may be used as well. Sometimes topical antibiotics may be prescribed if the infection is spreading.

Chalazion

About 25% of chalazia will disappear spontaneously, but warm compresses may speed the process. Chloramphenicol ointment may be used as well. Because chalazia are inside the lid, topical medications are generally of no benefit. Medication may need to be injected by the doctor into the chalazion or if that doesn't help the chalazion may need to be excised. If what appears to be a chalazion recurs on the same site as any previous one, the possibility of sebaceous gland carcinoma should be investigated by biopsy.

Blepharitis

Blepharitis is treated with hot compresses, with antibiotic ointment, and by cleaning the eyelids with a moist washcloth and then with baby shampoo. Good hygiene is essential. Patients can try to keep rooms dry, such as by placing a bowl of water on top of a radiator. Tear film supplements such as hypromellose can help moisten the eyes when dry. If itching, soreness, or redness occurs from the tear film drops, they should be stopped. Topical or systemic antibiotics also may be prescribed. If the blepharitis doesn't clear up with treatment or if it seems to be a chronic problem, the patient may have acne rosacea. These patients may need to see a dermatologist as well.

Entropion and ectropion

Both entropion and ectropion can be surgically corrected. Prior to surgery, the lower lid of entropion can be taped down to keep the lashes off the eye, and both can be treated with lubricating drops to keep the cornea moist.

Eyelid edema

Patients with swollen eyelids should contact their eye doctor. A severely swollen lid can press on the eye and possibly increase the intraocular pressure. An infection needs to be ruled out. Or, something as simple as an allergy to nail polish and then touching the eyes can cause swelling. The best treatment for allergic eyelid edema is to find and remove the substance causing the allergy. When that is not possible, as in the case of plant allergens, cold compresses and immunosuppresesive drugs such as corticosteroid creams are helpful. However, steroids can cause cataracts and increase intraocular pressure and patients must be very careful not to get the cream in their eyes. This should not be done unless under a doctor's care. For edema caused by trichinosis, the trichinosis must be treated.

Eyelid tumors

Cancerous tumors should be removed upon discovery, and noncancerous tumors should be removed before they become big enough to interfere with vision or eyelid function. Eyelid tumors require special consideration because of their sensitive location. It is important that treatment not compromise vision, eye movement, or eyelid movement. Accordingly, eyelid reconstruction will sometimes accompany tumor excision.

Prognosis

The prognosis for styes and chalazia is good to excellent. With treatment, blepharitis, ectropion, and entropion usually have good outcomes. The prognosis for nonmalignant tumors, basal cell carcinoma, and squamous cell carcinoma is good once they are properly removed. Survival rate for malignant melanoma depends upon how early it was discovered and if it was completely removed. Sebaceous carcinomas are difficult to detect, so poor outcomes are more frequent.

All of these eyelid disorders, if not treated, can lead to other, possibly serious vision problemsdry eye, astigmatism, or even vision loss, for example. An ophthalmologist or optometrist should be consulted.

Prevention

Good lid hygiene is very important. Regular eyelid washing with baby shampoo helps prevent styes, chalazia, blepharitis, and eyelid edema. To avoid these problems, it's also important to refrain from touching and rubbing the eyes and eyelids, especially with hands that have not just been washed.

Blepharitis is associated with dandruff, which is caused by a kind of bacteria that is one of the causes of blepharitis. Controlling dandruff by washing the hair, scalp, and eyebrows with shampoo containing selenium sulfide to kill the bacteria helps control the blepharitis. When using anything near the eyes, it is important to read the label or consult with a doctor first.

Avoiding allergens helps prevent allergic eyelid edema. Staying inside as much as possible when pollen counts are high and eliminating the use of, or at least removing eye makeup thoroughly, or using hypoallergenic makeup may help if the person is sensitive to those substances.

Sunscreen, UV-blocking sunglasses, and wide brimmed hats can help prevent eyelid tumors.

Entropian and ectropian seem to be unpreventable.

KEY TERMS

Allergen A substance capable of inducing an allergic response.

Allergic reaction An immune system reaction to a substance in the environment; symptoms include rash, inflammation, sneezing, itchy watery eyes, and runny nose.

Conjunctiva The mucous membrane that covers the white part of the eyes and lines the eyelids.

Edema A condition where tissues contain excessive fluid.

Meibomian gland Oil-producing glands in the eyelids that open near the eyelid margins.

Resources

PERIODICALS

"At a Glance: Chalazion Versus Stye." GP May 3, 2004: 52.

"Practical Ophthalmology for GPs: The Treatment of Blepharitis." Pulse (May 10, 2004): 60.

ORGANIZATIONS

American Academy of Ophthalmology. 655 Beach Street, PO Box 7424, San Francisco, CA 94120-7424. http://www.eyenet.org.

American Optometric Association. 243 North Lindbergh Blvd., St. Louis, MO 63141. (314) 991-4100. http://www.aoanet.org.

American Society of Ophthalmic Plastic and Reconstructive Surgery. 1133 West Morse Blvd, #201, Winter Park, FL 32789. (407) 647-8839. http://www.asoprs.org.

OTHER

"Eyelid Abnormalities." Eye Clinic of Fairbanks. http://www.eyeclinicfbks.com/ECFLID.htm.

RxMed. http://www.rxmed.com.

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Blepharospasm

Blepharospasm

Definition

Blepharospasm is an involuntary closure of the eyelids.

Description

"Blepharo" refers to the eyelids, and "spasm" to involuntary muscle contraction. In blepharospasm, the eyelids close involuntarily due to an unknown cause within the brain. Blepharospasm is a form of dystonia , a disorder characterized by sustained muscle contraction. The most common form of blepharospasm is called "benign essential blepharospasm," meaning it is not life threatening and is not due to some other identifiable disorder. A condition called hemifacial spasm causes similar symptoms, but affects only one side of the face, and is caused by an irritation of the facial nerve outside of the brain.

Demographics

Blepharospasm is estimated to affect approximately 15,000 people in the United States. Onset is most commonly between the ages of 40 and 60, but can begin in childhood or old age. Women are affected approximately twice as often as men.

Causes and symptoms

The cause of benign essential blepharospasm is unknown. Evidence suggests it may be genetic in some cases, although genes have not been identified. A person with blepharospasm often has dystonia in another region of the body such as the mouth or the hands (i.e., writer's cramp). Other forms of dystonia or tremor may affect other family members. Blepharospasm is not caused by a problem with the eyes themselves, but rather with the brain regions controlling the muscles of the eyelids.

Secondary blepharospasm occurs due to some identifiable cause. The most-common cause of secondary blepharospasm is a reaction to antipsychotic medications, and is called tardive dystonia. Damage to the brain, either through stroke , multiple sclerosis , or trauma, may also cause blepharospasm.

Blepharospasm often begins with increased frequency of blinking, which may be accompanied by a feeling of irritation in the eyes or "dry eye." It progresses to intermittent, and then sustained, forceful closure of the eyelids. Symptoms are usually worse when the patient is tired, under stress, or exposed to bright light. Symptoms may become severe enough to interfere with activities of daily living, and can render the patient functionally blind.

Diagnosis

Blepharospasm is diagnosed by a careful clinical exam. A detailed medical history is taken to determine exposure to drugs or other possible causative agents, and a family history is used to determine if other family members are affected by other forms of dystonia or tremor.

Treatment team

The treatment team consists of a neurologist and possibly a neurosurgeon.

Treatment

The most effective treatment for blepharospasm is injection of botulinum toxin (BTX) into the muscles controlling the eyelids. BTX temporarily prevents the muscles from contracting, allowing patient to keep their eyes open. BTX is a safe and effective treatment for this condition. Usually the effects are seen within several days of injection, have their maximum effect for 68 weeks, and last between 12 and 16 weeks, at which time reinjection is performed. Side effects of BTX injection include mild discomfort at the injection site(s), and occasional double vision or inability to lift the eyelids due to local spread of the toxin to other muscles. Dry eyes or excessive tearing may also occur. Development of resistance to BTX injections is possible if the patient's immune system creates antibodies against the toxin. While this has not been reported in blepharospasm as the injected dose is very low, it has occurred in other conditions in which the doses are higher.

Oral medications are rarely effective for blepharospasm. Among the most widely used are anti-cholinergics (trihexyphenidyl, benztropine), baclofen, and benzodiazepines (diazepam , clonazepam). Surgery is an option for patients who do not respond to BTX injections. The surgical procedures are performed to remove part of the overactive muscles, or to sever the nerve leading to them, or both. Unfortunately, surgery is rarely completely successful, and there is a high rate of recurrence of blepharospasm.

Clinical trials

There are no current clinical trials for blepharospasm since effective treatment is available.

Prognosis

Blepharospasm is a chronic condition, which tends to worsen over time. Many patients with blepharospasm develop other dystonias in other body regions.

Resources

WEBSITES

Benign Essential Blepharospasm Research Foundation. (April 19, 2004.) <http://www.blepharospasm.org/>.

WE MOVE. (April 19, 2004.) <http://www.wemove.org>.

Richard Robinson

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blepharospasm

blepharospasm (blef-er-oh-spazm) n. involuntary tight contraction of the eyelids, either in response to painful conditions of the eye or as a form of dystonia.

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