Eyelid Disorders

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Introduction

Eyelid disorders are a common presenting complaint in primary care. Although most eyelid conditions can be managed conservatively, some risk sight loss and require referral to ophthalmology.

Eyelids are composed of skin, muscle, connective tissue, glands and conjunctiva. They have an important role in preventing the eye from drying out and help protect the eye from foreign bodies and excessive light.

Meibomian glands are in the posterior aspect of the eyelid (Figure 1). They are modified sebaceous glands that make an oily substance to prevent tears evaporating. Medial to the meibomian glands is the lacrimal punctum which drains tears.

Eyelid anatomy relevant to eyelid disorders
Figure 1. Eyelid anatomy.1

Eyelashes are in the anterior aspect of the eyelid and help prevent foreign bodies from entering the eye. Each eyelash follicle is associated with sweat and sebaceous glands.


Blepharitis 

Blepharitis is inflammation of the eyelid. It is a common cause of ocular discomfort that accounts for 5% of ophthalmology related presentations in primary care.2

Although the exact aetiology of blepharitis is unclear, the underlying disease process involves congestion and inflammation of eyelash follicles and eyelid glands. Blepharitis often has multiple causative factors.

Causes of blepharitis include:

  • Staphylococcal infection
  • Seborrheic dermatitis
  • Acne rosacea
  • Dry eyes (e.g. from contact lens use)
  • Demodex infestation (mites)

Blepharitis commonly presents with bilateral sore, gritty eyelids that are red and swollen. There is sometimes crusting around the lashes (Figure 2).

Lid hygiene is important for treating and preventing blepharitis.

There are three steps to cleaning eyelids that should be performed at least once a day:

  • Warm compression of the eyelids with cotton wool dipped in hot water to loosen debris
  • Eyelid massage to empty glands of debris
  • Cleaning eyelids with cotton wool to remove debris

If symptoms do not resolve despite lid hygiene, antibiotics can be considered. Initially topical antibiotics (e.g. chloramphenicol) and then oral antibiotics (e.g. tetracyclines).


Hordeolum

An external hordeolum is caused by a staphylococcal infection of an eyelash follicle. External hordeolum tend to affect children and young adults and are also known as a stye.

An internal hordeolum is an infection of a meibomian gland and is far less common.

External hordeolum present as tender, red eyelash follicle swellings (Figure 4).

Figure 4. External hordeolum.5

Hordeolum often resolve spontaneously. Patients should be encouraged to perform warm compression of the eyelid multiple times a day to reduce swelling.

Other treatment options include:

  • Removal of the eyelash associated with external hordeolum
  • Incision of the hordeolum with a fine sterile needle
  • Topical antibiotics (e.g. chloramphenicol) or oral antibiotics (e.g. co-amoxiclav) if the hordeolum is recurrent or severe

Chalazion

A chalazion is a granulomatous inflammatory lesion that forms in an obstructed meibomian gland.

Unlike hordeolum, chalazion are non-infectious. Chalazion are often associated with blepharitis and acne rosacea.

Chalazion present as painless red eyelid cysts in the internal eyelid (Figure 5). If chalazion are infected they become internal hordeolum.

 

Chalazion and external hordeolum can be easily distinguished as chalazions are not painful. In contrast, external hordeolum are associated with pain (i.e. ‘styes sting’).

Chalazion often resolve spontaneously. Patients should be encouraged to perform warm compression of the eyelid (to loosen meibomian gland content) and eyelid massage (to express meibomian gland content) twice a day.

Persistent chalazion sometimes require referral to ophthalmology for consideration of incision and curettage.


Entropion

Entropion is inward turning of the eyelid. Inward turning eyelashes may irritate the cornea causing ulceration and risking sight loss.

The most common cause is age-related degenerative changes to the lower eyelid. Entropion can also be caused by eyelid irritation or scarring. Trachoma (a bacterial eye infection caused by Chlamydia trachomatis) is a common cause of entropion in places that have limited access to sanitation and water.

The management of entropion includes:

  • Examination for corneal abrasions. Corneal ulceration is sight-threatening and requires ophthalmology referral.
  • Entropion repair surgery may be considered.
  • Temporary relief can be provided by taping the lower eyelid to the cheek.

Ectropion

Ectropion is an outward turning of the eyelid. There is a risk of exposure keratopathy, which is damage to the cornea due to ocular dryness caused by inadequate lid closure.8 Exposure keratopathy can cause sight loss.

Ectropion is mostly caused by age-related degenerative changes to the lower lid. Another common cause is facial nerve palsy (e.g. Bell’s palsy).

Entropion presents with a sore red eye. The eye is often watery due to disrupted tear drainage.

The management of ectropion includes:

  • Ophthalmology referral if signs of exposure keratopathy such as a painful red eye are present
  • Ocular dryness can be prevented with lubricating eye drops and taping the eyes shut at night
  • Severe cases may require ectropion repair surgery

Trichiasis

Trichiasis is when eyelashes grow inwards due to damaged eyelash follicles. Inward growing eyelashes may irritate the cornea causing corneal ulceration and risking sight loss.

Most cases of trichiasis are caused by eyelid infection.

When assessing trichiasis, it is important to examine for evidence of corneal damage.

Trichiasis is treated by removing problem eyelashes (e.g. with epilation).


Key points

  • Eyelids are composed of skin, muscle (orbicularis oculi, levator palpebrae superioris and Müller’s muscle), connective tissue, glands and conjunctiva.
  • Blepharitis is inflammation of the eyelid and presents with bilateral sore, gritty eyelids.
  • An external hordeolum (style) is caused by a staphylococcal infection of an eyelash follicle.
  • A chalazion is a granulomatous inflammatory lesion of an obstructed meibomian gland.
  • Blepharitis, hordeolum and chalazion can often be treated conservatively with eyelid hygiene. 
  • Entropion and trichiasis can cause corneal ulceration, which can lead to sight loss.
  • Ectropion can cause exposure keratitis, which can result in sight loss.
  • Any indication of risk to cornea or risk of sight loss requires referral to ophthalmology.

Reviewer

General Practitioner


Editor

Dr Chris Jefferies


References

  1. Henry Vandyke Carter (modified by Jonathan Malcolm). Eyelid anatomy. License: [Public domain]. Available from: [LINK]
  2. NICE CKS. Blepharitis. Published in 2019. Available from [LINK]
  3. Clubtable (Wikipedia user). Blepharitis. License: [Public domain]. Available from: [LINK]
  4. Imran Kabir Hossain. Anterior blepharitis. License: [CC BY-SA]. Available from: [LINK]
  5. Andre Riemann. Hordeolum externum. License: [Public domain]. Available from: [LINK]
  6. Michal Klajban. Chalazion. License: [CC BY-SA]. Available from: [LINK]
  7. Poupig (Wikipeida user). Chalazion. Licence: [CC BY-SA]. Available from: [LINK]
  8. Wanjiku Mathenge. Emergency management: Exposure keratopathy. Published 2018. Available from: [LINK]
  9. Mary Lowth. Chalazion. Published in 2016. Available from: [LINK]
  10. Mary Lowth. Conditions Affecting the External Eye. Published in 2016. Available from: [LINK]
  11. Mary Harding. Blepharitis. Published in 2014. Available from: [LINK]
  12. Thomas Watchman. Eyelid Disorders. Published in 2019. Available from: [LINK]
  13. Mostafa Khalil, Omar Kouli. The Duke Elder Exam Of Ophthalmology: A Comprehensive Guide for Success. Book published in 2020.
  14. The College of Optometrists. Clinical Management Guidelines. Published in 2018-2020. Available from: [LINK]

 

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