THE PARAOPTOMETRIC: A LESSON IN COMMON DISORDERS OF THE LIDS AND ORBITS

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Chalazions are caused by a blockage and swelling of an oil gland. This eye has both a chalazion and blepharitis infection.
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Most styes, like the one pictured here, cause swelling for approximately three days before breaking open and draining.
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Artificial tears like Allergan’s Refresh can be used to keep the eye moist for cases with ectropion.

Tips for optometric assistants and technicians on how to improve their instrumentation skills.

Our lids and orbits play an important part in keeping the eye healthy. The eyelid is a protective fold of skin that covers and protects the eye, just as the eyelashes on our upper and lower lids act as a barrier protecting the eye from dust and debris.

BACKGROUND
The act of blinking allows the tears secreted in the eye to be evenly distributed over the eye’s surface which aids in removing foreign debris in tear film. The orbits or eye sockets are the bony cavities in the skull that house the eyeball and its associated blood vessels and muscles. It is surrounded by soft, fatty tissues which protect and cushion the eye. Disorders of the orbits usually arise from pathology that affects other tissues and organs and can present as either tumors or inflammation. A brief explanation follows.

DISORDERS OF THE ORBITS

  • Orbital Infections: These infections are also known as orbital cellulitis and can sometimes be sight and sometimes life threatening. Usually orbital infections are related to sinus infections. Thyroid eye disease, including Graves’ disease, is the most common. This is an autoimmune condition that results from thyroid gland dysfunction, and can cause the eye to protrude from the socket, lid retraction, and punctate keratitis of the cornea (secondary to cornea exposure from lid retraction). Treatments include: artificial tear supplements, medication to reduce orbital inflammation, and if necessary eyelid surgery.
  • Orbital Tumor: Tumors located in the orbits can either present as benign or malignant.  They may develop in the brain, nasal cavity or sinuses, and invade the orbit. They are a result of developmental abnormalities. Common treatment includes radiation therapy.

DISORDERS OF THE LIDS

  • Ptosis: Ptosis (pronounced “toe-sis”) presents as a drooping of the upper eyelid. It can present at birth (congenital) or later in life (acquired). Ptosis occurs due to the gradual atrophy of the muscle that lifts the upper eyelid, the levator muscle. The drooping of the lid can partially obstruct the pupil and reduce the visual field. The condition can be congenital secondary to developmental delay, or acquired, developing after trauma, and cataract- or laser vision-correction surgery. Surgical intervention is required to alleviate the lid droop. The surgeon will tighten the levator muscle in order to lift the lid.
  • Entropion: This is a condition in which the eyelid turns inward, causing the eyelashes to rub against the eye surface, resulting in irritation, tearing, sensitivity to light, and discomfort. The friction of the lashes against the cornea produces irritation, redness, and mucous discharge. Entropion occurs most often in older adults due to the stretching of the tendons and muscles that hold the eyelid tight against the eye. It may also form secondary to trauma, infection, or birth defect, and usually affects the lower lid. Surgery is often needed to correct the inward turn.
  • Ectropion: This condition occurs when the lower eyelid rolls out away from the eye, exposing the inner lid. The sagging lower eyelid exposes the inner lid and causes dryness, irritation, and redness. Artificial tears like Allergan’s’ Refresh’ can be used to keep the eye moist. Ectropion can form as a result of age and the relaxation of the muscle that holds the lid tight against the eye. It may also take place due to facial paralysis such as Bell’s palsy, trauma, or scarring. If left untreated, it can lead to chronic tearing, eye irritation, redness, pain, a crusting of the eyelid, mucous discharge, and exposure keratitis of the cornea. Surgery is recommended to resolve the outward droop, and often produces good results and relief.
  • Chalazion: A chalazion is a slow-growing firm lump on the eyelid caused by a blockage and swelling of an oil gland. It is sometimes confused with a stye. The eyelids have small glands called meibomian glands which are located near the eyelashes. This gland produces oils that mix with the tear film and lubricates the eye. When these glands become blocked and are unable to release their oil, a chalazion is formed. Chalazia are comprised of pus and lipids, and will usually resolve on its own or with warm compresses and medication.
  • Stye: A stye (hordeolum) forms as a result of a bacterial infection affecting the hair follicles or sweat gland of the lids. The bacteria grow in the root of the eyelash and produce a red, tender lump on the edge of the eyelid. Most styes cause swelling for approximately three days before breaking open and draining. Complete healing usually takes about a week. Treatment includes warm compresses, and over-the-counter antibiotics and creams. If the stye does not resolve within a week, then the physician may lance it to allow it to drain.
  • Trichiasis: This condition causes eye irritation, tearing, and pain because the eyelashes are misdirected and grow inward toward the eye. The rubbing of the lashes irritate the eye and produce, punctate keratitis, corneal abrasion, corneal ulcer, and scars. Periodic epilation of the ingrowing lashes with forceps will relieve the problem temporarily. But if there is continued re-growth, electrolysis or cryotherapy can be used to permanently destroy the hair follicle. Trichiasis is seen more common in adults and can be caused by eye infection, inflammation of the eyelid, and trauma.
  • Seborrheic Blepharitis: This is a chronic non-contagious inflammation of the eyelids stemming from inflammation of the oil glands at the base of the eyelashes which leads to irritated, itchy eyes and dandruff-like scales on the eyelashes. Malfunctioning oil glands, allergy, rosacea, and certain medications have also all been shown to contribute to the development of blepharitis. Blepharitis is a chronic condition and can be controlled by good eyelid hygiene and medication.

BASAL CELL CARCINOMA
The most common type of eyelid cancer is basal cell carcinoma; it usually appears on the lower eyelid near the nose and causes eyelash loss around the tumor. The eyelash loss can indicate that the tumor is malignant. Most basal cell carcinomas are usually treated and removed with surgery. If left untreated, these tumors can grow around the eye and into the orbit, sinuses, and brain.

  • Molluscum Contagiosum: These are small, waxy nodules that form in clusters and are caused by viral infection in immunocompromised patients. They present as raised, round, small bumps that have a small indentation or dot. Molluscum contagiosum is caused by a non-inflammatory contagious infection DNA virus. It usually affects children and teenagers. The condition is highly contagious and can be spread if scratched, passed by skin-to-skin contact, contact with contaminated objects, or sexually. The bumps associated with molluscum contagiosum usually disappear within a year without treatment but doctor-assisted removals with a curette or freezing are also options.

Janet Hunter is president of Eye Source LLC, and specializes in ophthalmic technician training.

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