Diseases Of The Eyelids | Operating Microscopes

Diseases Of The Eyelids
By B. L. MILLIKIN, M. D.,
OF CLEVELAND, OHIO.

Congenital Anomalies. Partial or complete absence of the eyelids (ablepharia) is occasionally met with as a congenital defect. It may occur in one or both eyes.

Lagophthalmos is a defect in which the eyelids are wanting and the orbit is divested of any covering for the globe. An abnormal shortness of the lids, which prevents their fully covering the eyeball, has been similarly, and perhaps more correctly, so designated by many authors.

Cryptophthalmos is a condition in which the eyeball is completely concealed by the skin, which is stretched over the orbital cavity. Sometimes the eyeball is absent. Under the latter circumstances, however, the name is not an accurate one.

Cleft eyelid (coloboma palpebre) is a congenital defect in which there is a fissure of the lid, usually triangular, with the base toward the ciliary margin. The fissure may exist in either the upper or lower lid, the former being the usual seat. It has also been reported in the upper and lower lids on each side. The cleft involves the entire thickness of the eyelid and is rounded off at its margins. It occurs oftener with cases of hare lip than with anomalies of the eyeball itself.

Symblepharon is a condition of union, either partial or complete, between the eyeball and the lids.

,Another unusual congenital anomaly is a union between the margins of the lid borders (ankyloblepharon). This attachment may be thread like or involve a considerable intermarginal surface. The external angles of the lids may be adherent, producing the defect known as blepharophimosis, resulting in a shortening of the palpebral opening.

Ectropion is an eversion of the edges of the eyelids, frequently accompa by enlargement of the eyeball.

Entropion is an inversion of the edges of the lids, and is usually associated with the incurving of the lashes a condition known as distichiasis.

Epicanthus is an unusual congenital anomaly caused by a fold of skin which stretches across the inner palpebral space connecting the eyebrow with the bridge of the nose, the fold thus covering all the structures located at the inner canthus. It is generally bilateral, and gives rise to, or is associated with, a flattening of the bridge of the nose. Slight degrees of it may exist in children at birth, and with the development of the nasal bones this deformity gradually passes away.

Associated with epicanthus may be microphthalmos (sometimes only apparent on account of the diminished palpebral opening), strabismus, droopin of the upper lid, and anomalies of the lachrymal passages.

Epicanthus may be remedied by an operation in which the redundant 16 241 It 242

DISEASES OF THE EYELIDS.

skin is removed from the bridge of the nose and the edges of the wound brought together with sutures.

Congenital ptosis is a drooping of the upper lid over the eyeball. It may be on one side or bilateral, and never amounts to complete closure of the lids. In this condition there is inability to raise the eyelid except by wrinkling the forehead through the action of the occipito frontalis muscle. The anomaly is not infrequently associated with other malformations, as epicanthus, paralysis of the eye muscles, etc. It may be corrected by operative procedures, described on page\557.

Erythema of the li s is a form of hyperemia of the skin, usually due to external irritation, such as burns, traumatism, and poisoning, or it may be indicative of some systemic disturbance. It is often well marked in inflammatory conditions of the eye.

Treatment will depend largely upon the cause, the erythema often disappearing with the cure of the primary lesion. Locally, soothing lotions, lead water or extract of hamamelis, will be all that is required.

Erysipelas is rarely, if ever, a primary affection of the lids. It usually develops from a similar lesion of the face. The danger in this disease is that it may involve the deeper tissues of the orbit, affecting the retina or the optic nerve, and thus eventuate in blindness. In severe cases it may produce slou hing of the eyelids,. with consequent deformity. The disease is cha9 , racterized. by great swelling, increased tension of the lids, smooth and brawny skin, deep redness, and the formation of vesicles or abscesses.

The treatment, both local and general, must be such as is usually adopted for erysipelas in other portions of the body.

Abscess of the lid (phlegmon) is characterized by an acute swelling of the eyelid, somewhat localized, indurated in the central portion, accompanied by much redness of the skin, heat, throbbing pain, malaise, and fever. The swelling is frequently very marked, the skin toward the height of the inflammatory stage in the severer cases often presenting a brawny appearance. Abscesses result from external injuries, from disease of the orbital walls, or they may arise from infectious causes or occur during illness e. g. influenza. The tendency for the abscess to "point" is quite characteristic. Abscesses occasionally lead to extensive sloughing of the lid tissues, and when they are not early opened they may result in lagophthalmos, ectropion, etc.

Treatment. In the early stage ice packs may sometimes abort the development of the abscess. Should the inflammation continue to increase, recourse should be had to hot packs and poultices to hasten the 11 pointing." As soon as there is evidence of pus a free opening should be made into the center of the induration and deep enough to give vent to the pus. In making the incision care should be exercised that the fibers of the orbicularis are not cut across. The abscess cavity may be washed out with peroxid of hydrogen or bichorid solution, I to 2000, until recovery takes place.

Furuncles and carbuncles are rare. With them develops a "core" or central slough. Otherwise they present the same symptoms as an abscess and require similar treatment.

Anthrax pustule (malignant pustule) is a specific, infectious disease, due to inoculation by the poison of anthrax (bacillus anthracis), and is generally transferred to man from animals affected with the disease. Usually it occurs in persons working among animals, as hostlers, tanners, farriers, butchers, shepherds, etc. The disease is characterized by marked edema, redness, heat, pain, localized hardness or induration, the last indicating the point of infectiom In malignant pustule, as in erysipelas, there may be very exten0',

HORDEOLUM.

243 sive sloughing of the eyelid, producing at times a condition of lagophthalmos. After sloughing of the lids the ciliary margins alone may remain intact on account of the rich vascular supply. There is usually marked general depression, with fever. By absorption of the anthrax poison into the deeper tissues orbital cellulitis, or even meningitis, may ensue with fatal results.

Treatment. This must be governed by general surgical principles. As soon as there is any evidence of pus the swelling should be freely opened, with one or more deep incisions, in order to prevent infiltration and possible involvement of the deeper structures of the orbit. The incision, followed by hot poultices or by compresses of absorbent cotton or gauze, wrung out of hot bichlorid of mercury solution, I to 2000 or I to 5000, will be very efficient. The administration of iron and quinin, tonics, stimulants, and good diet is of decided value.

In cases of extensive sloughing of the skin of the lids marked lagophthalmos and corrosion can be prevented by fastening the remaining marginal portion of the lid to its fellow by two or three stitches The granular surface may then be treated with repeated skin grafts applied according to the Thiersch method. If this method cannot be followed, then the proper plastic operative procedures for these deformities must be undertaker, as indicated on page 555.

Ulcers of the lids may be due to contusions, burns, and various injuries, as well as to lupus, scrofula, syphilis, and herpes. The symptoms will vary with the cause; likewise the treatment.

Hordeolum (Stye). According to the location, hordeolum, may be hordeolum. externum. or hordeolum internum. Hordeolum externum is an acute inflammation of one or more of the glands of the hair follicles. Hordeolum internum is an acute inflammation of the Meibomian glands. In other words, hordeolum. or stye is a circumscribed inflammatory process, and is due to infection of the sebaceous glands or connective tissues of the lid, usually associated with the staphylococcus pyogenes aureus or albus.

Symptoms. These are rapid edema of the lids, redness and tenderness coming on after a short time a day or two often quite 'severe pain, and sometimes fever and general disturbance. A hard lump or point of induration is felt at the seat of inflammation. Within a few days the color of the tissue over the stye changes from a red to a yellow hue, and the abscess "Points." If allowed to take its course, the abscess sac ruptures, the pus escapes, and the symptoms rapidly abate.

In hordeolum. internum "pointing" of the abscess takes place on the inside of the lid through the palpebral conjunctiva; in hordeolum externum, near the margin of the lid through the skin. The latter variety is much the more common.

Styes usually occur in persons subject to blepharitis, the chronic inflammation of the latter affection affording good soil for acute infectious inflammation of the solitary glands. The infectious character is well indicated by the fact that persons are very liable to successive attacks of styes, which occur, in many cases, at frequent intervals over a period of months. Young persons are generally the subjects of this disease, especially if they are scrofulous, anemic, or poorly nourished.

These two varieties of hordeolum present essentially the same clinical picture. With both there is inflammation of the sebaceous glands, and they am analogous to acne in the skin. The marked swelling of the former, as distinguished from the latter, is due to the anatomical character of the tissues in which the inflammation takes place.

244 III DISEASES OF THE EYELIDS.

Treatment. In the early stage an attempt may be made to abort the development of a stye by the application of cold or very hot packs, or by touching the mouth of the gland involved with the sharpened point of a stick of nitrate of silver. If unsuccessful in this, " pointing" of the abscess should be encouraged by warm fomentations or properly applied poultices. Early opening of the stye is important. As soon as there is an indication of softening in the center of the induration a free incision should be made into the tumor in order to evacuate the contents and to prevent the extension of the necrotic process. Care should be taken that the incision is made parallel to the fibers of the orbicularis muscle, so that Do deformity may remain. Subsidence of the symptoms is rapid after evacuation of the contents of the abscess. Between the attacks treatment should be directed toward improving the general health and alleviating the inflammation of the lid margins; refractive errors, which may cause styes, should be corrected. Sulphid of calcium has some repute.

Exanthematous Eruptions of the Lids. Ulcer of the lids, due to variola or small pox, is of not infrequent occurrence. The parts attacked are the hair follicles and sudorific follicles and glands. The results of severe attacks are pitting, cicatricial contraction of the lids, with ectropion and loss of the eyelashes, which, when permanent, produces the condition called madarosis.

Treatment is directed toward limiting as much as possible the ulcerative process. Protecting the pustules by dusting with a dry powder, such as starch and zinc oxid, in equal parts, or touching the ulcerated portion with a sharpened stick of nitrate of silver, has been advantageously employed.

Vaccine Blepharitis (Vaccine Ophthalmia, Vaccinia of the Eyelids). This occasionally occurs from infection from a vaccination ulcer. it usually affects the borders of the lids, and is characterized by the rapid formation of an ulcer of the lid margin, accompanied by much redness, swelling of the lids and of the preauricular and submaxillary glands, together with general fever, malaise, etc. In the early stage the vesicles appear with pitted center, but later the pustules are quite characteristic. In the last stages of the ulceration they resemble syphilitic ulcers, and must be differentiated from these by the history and progress of the case. Associated with the disease of the lid, marked conjunctivitis occurs, often simulating a diphtheritic membrane.

Treatment is directed toward allaying the early inflammatory symptoms, and later touching the ulcers With a 2 or 3 per cent. solution of silver nitrate. Aseptic washes to keel) the eve clean should also be used.

Eczema appears either 'on the eyelids alone or is associated With general eczema of the face. It occurs also from the irritative secretions in chronic conjunctivitis, or in children as the result of rubbing the secretions from the eye upon the lids. It is most frequent in scrofulous or badly nourished children. Eczema is caused in adults by epiphora, ectropion, etc., the tears running over the checks excoriating the surface. In these cases the lesions are usually found on the lower lid.

Treatment must be directed primarily to the cause. Locally, zinc ointment or Habra's diachylon ointment, spread on lint or muslin and applied constantly, is satisfactory. Painting the skin with a 2 to 10 per cent. solution of nitrate of silver has been found to be very serviceable; only the latter in strong solution blackens the skin on exposure to light. Its action, however, in moist or ulcerative eczema is very effective.

Herpes zoster ophthalmicus is the term applied to that variety of

BLEPHA RITIS.

245 herpes zoster which attacks the skin of the eyelids and other areas supplied by the first division of the trigeminus nerve. The disease is characterized by the formation of vesicles over the terminal portion of the nerve. The attack is preceded by severe neuralgic pain over this area, succeeded by the formation of vesicles over the forehead, the eyelids, the Dose, cheek, and the upper lip, the disposition of the vesicles depending upon whether the first or second division of the trigeminus is affected. The third division is rarely affected. The vesicles first contain a clear, limpid fluid, but rapidly become cloudy and purulent, and finally dry into crusts. On removal of the latter, deep ulcers are found. After healing, permanent scars remain, which, by their peculiar grouping, indicate the nature of the attack. Not infrequently the cornea is affected, which greatly complicates the case. These ulcers of the cornea may result in permanent opacities. Iritis and cyclitis are not uncommon, especially if the nasal branch is affected ; indeed, there may be a destructive inflammation of the whole eye (ophthalmitis). Palsy of the ocular muscles and atrophy of the optic nerve may follow herpes.

The cause of herpes zoster is obscure, but it is an inflammatory affection of the trigeminus. Persistent neuralgia may remain after an attack of herpes.

Treatment. This is symptomatic. The vesicles should not be opened, but these should be dusted over with a drying powder (rice starch) and the ulcers allowed to heal beneath the crusts. Removal of the latter is productive of much pain. Internally morphin, quinin, and iron, according to indications, must be given. Keratitis and iritis require the usual measures elsewhere described.

Blepharitis (Blepharitis marginalis, Blepharitis ciliaris, Blepharo adenitis, Blepharitis ulcerosa, Psorophthalmia, Lippitudo ulcerosa, Tinea tarsi, Sycosis tarsi). On account of the peculiar anatomical structure of the margin of the eyelid this region is subject to a variety of diseases, with somewhat characteristic symptoms, forming a group by themselves. Rich in vascular and glandular structures,, the edges of the lids are the seat of marked inflammatory disturbances, the more especially as they are greatly exposed to external irritation. Therefore disorders of the margins of the lids are among the most common of all diseases of the eye. In intensity of inflammation there are all degrees, ranging from a mere red fringe of the lids to a disorganization of their borders.

Two principal varieties of marginal blepharitis have been described, according to the symptoms (1) squamous or simple blepharitis, and (2) ulcerated blepharitis.

(1) Simple Blepharitis (Blepharitis squamosa). In this variety the margins of the lids are bordered with a red fringe, fine bran like scales appearing at the roots of the cilia and between them, which drop off if the eyes are rubbed. There is also a tendency for the cilia to fall out if disturbed ; they grow again perfectly. When the scales are removed the skin beneath is found to be hyperemic, but not moist or ulcerated.

In another variety instead of the scales there is a wax like secretion which adheres to the lashes, gluing them together, but on its removal there is no evidence of ulceration beneath, the tissues appearing simply red and hy.

(2) Ulcerated Blepharitis. In this variety there are hyperemia, red shedding of lashes, and crusts. When the crusts are removed by washin(, an ulcerative process is evident beneath them. Many yellowish white g points appear, from the center of' each of which protrude a cilium.

I 246 DISEASES OF THE EYELIDS

pulling out the lash there is often found adhering to the root a small rounded drop of pus. Still deeper is found a small ulcerated base extending into the hair follicle. The cilia are readily removed on the slightest traction.

As the disease progresses the hair follicles are successively involved in the ulcerative process, until, not infrequently, the entire series of cilia is destroyed, leaving cicatrices with their attendant and consequent deformity. When the cilium has fallen out a new one takes its place, of a different color, more or less stunted in its growth, and in a malposition the result of cicatricial contraction of the ulcerated hair follicles. The lashes thus become more and more stunted and misplaced or entirely destroyed.

By the cicatricial contraction the lashes may be turned backward so as to touch the eyeball, giving rise to a condition of trichiasis, or the entire line of lashes may be destroyed, leaving the lid bald madarosis. Another result of the ulcerative process may be the gradual eversion of the lower eyelid, due to the cicatricial contraction, which pulls the conjunctiva forward upon the lid border, the lid itself falling away from the eyeball and permitting the tears to run over, in turn increasing the irritation (lippitudo, or 11 bleareye"). The final result is an ectropion. Hypertrophy of the body of the lid not infrequently ensues, due to the long continued inflammation, and produces drooping of the upper lid (hypertrophic blepharitis). It may be seen, therefore, that blepharitis ulcerosa, is a much more serious condition than blepharitis squamosa.

The patient suffers little inconvenience as the result of the disease in the milder forms, and consults a physician more on account of the disfigurement than from any great annoyance. In the more pronounced forms the sensitiveness to light, the irritation, the sticking of the lids in the morning, etc. are real discomforts. Patients are unable to use the eyes for close work with comfort, and when the lashes are greatly displaced, with the resulting corneal irritation, they become almost helpless.

Etiology. The causes of blepharitis are twofold viz. local and general. The local causes are external irritations due to vitiated air, smoke, injuries, and chronic conjunctivitis, especially if associated with excessive lachrymation, inflammation of the lachrymo nasal passages, and disease of the rhinopharynx. Abnormal shortness of the lids may excite the affection (Fuchs). Among the general causes are the exanthemata, scrofula, anemia, tuberculosis, syphilis, or malnutrition from any cause.

Stubborn varieties may depend upon eczema, eczema seborrhoicum, and seborrhea, and acne of the surrounding facial areas. Staphylococci are found in the pustules, and occasionally the tricophyton fungus (b. tricophytica). The demodex folliculorum has also been seen in the lid margin. Refractive errors unquestionably play an important role in the causation of marginal blepharitis, as well as in other irritative and inflammatory liddiseases ; but they have not yet been accorded their due weight as causative factors in these affections. Correction of these errors by proper glasses will alone very often relieve a patient from troublesome blepharitis, which other methods seem powerless to effect.

Pathology. In blepharitis the inflammatory process involves chiefly the cilia and glands. In squamous blepharitis scales are produced on the lid margins and the cilia fall out. These grow thinner and shorter and less pigmented, and, as the epidermis is cast off, they entirely fail to grow.

In blepharitis ulcerosa the epithelium and often the papilla are destro, y ed at the seat of ulceration, and if the ulcerative process extends deeply into the SYPHILIS OF PHE EYELIDS.

lb 247 tissues of the hair follicles, the cilia are permanently destroyed and cicatricial contractions take place.

Prognosis. Blepharitis is essentially a chronic disease. It may last for years and not infrequently for a lifetime. In young persons it may disappear spontaneously as they grow older, while in other cases it persists in spite of all treatment. It is essential that treatment should be vigorous to prevent permanent lesions.

Treatment. The treatment must have reference to both general and local conditions, as well as to the causes. Faulty states of the general health should be corrected by appropriate means. Excessive use of the eyes should be prohibited, refractive errors should be examined, and proper glasses prescribed. Chronic conjunctivitis, so generally present in these cases, should be relieved, and any obstruction to the free discharge of the tears through the proper channel should be removed.

For the milder forms of blepharitis the non irritating ointments give the most satisfactory results. After carefully removing the scales and crusts with warm water by gently washing them off, an ointment should be well rubbed into the roots of the lashes and along the margin of the lids, usually night and morning. For this purpose a I per cent. ointment of white precipitate, as being especially mild, has been much used. The yellow and red oxids of mercury are also favorite prescriptions in the proportion of one half to two grains to the dram of vaselin or simple cerate. A 5 per cent. solution of chloral hydrate, alternating with a salve of pyrogallol (1 : 8) and a 2 to 3 per cent. sulphur ointment, have been well recommended.

In the severer cases associated with deposits of hard and strongly adherent crusts, which glue the lashes together, the use of a solution of five grains of carbonate of sodium to the ounce of water is most effective in removing them. It is important not to irritate the bases of the ulcers too much by violent means of removing the crusts. A pledget of absorbent cotton, moistened with the above solution, enables the patient or surgeon to remove the crusts effectuallv and without force. After the margins of the lids and cilia have been cleared of crusts the various ointments can be applied thoroughly to the diseased structures. In case of ulceration touching the ulcers with a five to twenty grain solution of nitrate of silver, or with a sharpened point of a silver nitrate stick, acts most favorably. Where abscesses occur the cilia should be epilated with proper forceps, in order to give the remedies an opportunity of acting upon the diseased structures. No hesitation need be exercised about removing the cilia, for new hairs will replace those removed, even if they are repeatedly pulled out. When the disease has resulted in extensive cicatricial disturbances, as trichiasis, etc., proper operative measures alone are to be recommended. For the condition of madarosis no treatment avails.

Phthiriasis (blepharitis pediculosa) is an affection resembling blepharitis, and is associated with it. The ciliary margins present a dark appearance, which is due to the presence of the nits of the pediculus pubis. Close examination with a magnifying glass of the borders of the lid will reveal the bases of the cilia full of the black eggs of the lice, and generally many individual lice clinging to the lashes. Rubbing mercurial ointment into the margins of the destroys the lice and their eggs.

Syphilis of the eyelids is a somewhat rare affection. However, not is the primary ulcer met with in this situation, but also secondary and tertiary lesions. Both soft and indurated chancres occur on the skin of the The former is an ulcer with a ragged edge and with a tendency to.

,II I 248 DISEASES OF THE EYELIDS

spread. It appears without history of injury or other cause. The hard, indurated base of the ulcer in the other case is sufficiently indicative of its nature, and in due time secondary manifestations of the disease are likely to appear.

Not infrequently the lids, along with other portions of the skin, are the seat of secondary eruptions. During the third stage, occasionally, ulcers and gummata appear in the lids, the latter often presenting a striking similarity to chalazia. These sometimes develop rapidly and undergo extensive ulcerative changes, producing ectropion, lagophthalmos, etc.

Treatment must include the proper constitutional remedies, while the extension of the ulcerative process must be combated by the use of' the cau (nitrate of silver) and proper washes, or with compresses moistened with bichorid of mercury solution.

Tumors and Hypertrophies. Many benign growths occur in the eyelids, important on account of the disfigurement which they produce. Among these are papillomata, or warts, which grow on the lids and their borders. Occasionally, from irritation, these growths may assume an epitheliomatous type and prove serious. Their early removal, with cauterization of their bases, should be practised.

Angioma (nevus) occurs on the lids or their margins as a congenital growth. A nevus appears as a bright red spot, not elevated, and usually is located near the margin of the lid. Its tendency is to increase in area somewhat rapidly.

The cavernous variety is usually elevated, sometimes gives a pulsatile sensation, and consists of greatly enlarged vessels. It disappears under pressure and becomes much enlarged when the patient stoops over. Sometimes there may be a bruit present if the orbit as well as the lids is involved or if the dilatation of the vessels is extreme. The conjunctiva may also participate in the diseased process. A phlebolith in a varix of the conjunctival veins has been reported by Swan M. Burnett.

Small Devi may be excised or cauterized with nitric acid or with the electro cautery by means of the platinum point. Electrolysis may likewise be employed with advantage. In the larger varieties the growth may be cauterized at numerous points at a little distance from one another, as the cicatricial contraction of the scars will cut off the vascular supply between. As little sear as possible should be aimed at, and frequent sittings may be advisable.

Rare forms of benign growths are fibroma, adenoma, papilloma, enchondroma, neutered, and lipoma. The last named growth may produce a form of ptosis the so called ptosis lipomatosus. All of these growths should be removed if they produce any disturbing effects, and this is, as a rule, not difficult of accomplishment.

Cutaneous horns sometimes attain a considerable size. They arise from the skin of the lids, often near the margin, and sometimes involve a large proportion of the lid area. The excrescence is slow in its development and attains a horn like hardness, especially toward its extremity. The growth should be cut off and a plastic operation replace the lost cutaneous tissue.

Xanthelasina (xanthoma, vitiligoidea) occurs in the form of rounded spots of various sizes on the surface of the skin of the eyelids The patches are often situated on the eyelids near the inner angle, vary in size, and show a tendency to increase in numbers. They have a peculiar dark yellow color, which is their prominent feature. They give rise to no discomfort. They occur mostly in women of advanced years.

4 CHALAZION. 249

The yellow or brownish yellow patches may lie either on the surface of the skin (xanthelasma planum) or rise above it (xanthelasma tuberosum). These new growths of tissue are found to contain cells with granules or globules of oil. Brown or yellow molecules of pigment lie singly or in clusters in the cells and walls of the lymphatic vessels. Ablation may be practised on account of the disfigurement they produce.

Chalazion (Meibomian cyst, tarsal tumor, cystic tumor, tarsal cyst) occurs as a round tumor of variable size, giving the feeling of a shot beneath the finger. The skin over it is freely movable, but the growth has a firm attachment to the tarsus beneath.

Etiology. The cause of chalazion is not well understood. Generally it occurs in persons subject to inflammatory disturbances of the lid margins, frequently successive glands being attacked, one after another, until most of the Meibomian glands of one or more lids have been involved. Refractive errors seem to be an important element in many bad cases of chalazion, especially of the recurring type.

FIG. 172 Vertical section of chalazion (Meibomian cyst); X 10, glycerin: 1, stratified epithelium continued over the surface; 2, connective tissue outside tumor; 3, capsule of fibrous tissue from which septa pass inward, dividing the cyst into lobules; 4, epithelial cells inside capsule; 5, fatty material occupying center of lobules, the outer layers being more opaque (Pollock).

Pathology. Chalazion may be solitary or several chalazia may occur in the lid, and the lower and upper lids of both eyes may be the seat of the growths. They originate in the Meibomian glands, and develop from an obstructive inflammation of the duct of these glands, which prevents the excretion of the sebaceous material. This accumulation aids in the development of an inflammatory action involving the gland and its surrounding tissue. The result is a tumor of considerable size, the contents of which, undergoing a fatty de become soft, and fill the sac with a gelatinous mass of granulation tissue containing giant cells or with pus (Fig. 172). The process is very similar to the formation of an atheroma, except that the inflammatory changes tire more marked. There is no true cyst wall. If allowed to take its Course, the chalazion develops outward, toward the skin (external chalazion), or involves the conjunctiva (internal chalazion). It frequently perforates the latter. extensive granulations springing up on the under surface of the lid, often resembling a neoplasm. Usually a catarrhal conjunctivitis, which infects the Meibomian glands, precedes the chalazion.

Symptoms. These vary somewhat in the acute and chronic varieties. In the former the tumor may develop rapidly, with indications of much inflammation and with some pain and tenderness. It resembles a stye,250 41

DISEASES OF THE EYELIDS.

except that the tumor is more circumscribed and does not 11 point." The chronic variety grows slowly and causes no uneasiness to the patient, except the feeling of weight in the lid which it gives (Fig. 173). Should the growth perforate the conjunctiva, there may result some conjunctival and corneal irritation, due to the rubbing of the granulations upon these membranes. An acute chalazion is liable to be confounded with a stye, the diffuse appearance and 11 pointing " of the latter, however, serving to distinguish it. The chronic variety has been mistaken for small malignant growths and sebaceous cysts. The firm attachment of the chalazion to the torsos should serve to differentiate it from a cyst. Sarcomata, when small, are difficult to diagnose, and sometimes a microscopic examination becomes necessary to determine the true nature of the growth.

FIG. 173. Chalazion. (From a patient in the out patient department of the Western Reserve University, Medical Department.)

Treatment. The only satisfactory treatment for chalazion is surgical. Some relief, perhaps, may be afforded in the acute variety by frequent hot packs, followed by the use of the yellow oxid of mercury ointment. The proper surgical procedure for its removal is described on page 546.

Sarcoma, as a primary growth, develops in the connective tissue of the lids, and occurs usually in children. In the early stage of its growth the skin moves freely over the tumor, but this rapidly invades the overlying tissues, which break down and become ulcerated. Sarcoma of the eyelids, of the small spindle celled variety, may result from traumatism. It sometimes resembles a chalazion, but careful examination is likely to show a deeper coloring, with diffuse swelling. Microscopical examination alone will sometimes determine the true nature of the trouble.

Primary sarcoma of the eyelid may arise from any of the subepithelial

IIA, CA CINOMA OF THE LIDS.

tissues, and may be of the spindle , large or small round , or mixed Celled variety. Pigmentation of cells or cells and stroma is sometimes seen (melanosarcoma). W. H. Wilmer, who has described a melanotic giant celled sarcoma, has analyzed 35 cases, and finds that 40 per cent. were spindlecelled, 43 per cent. round celled, 17 per cent. mixed, and 11 per cent. presented myxomatous elements.

An early excision of the growth alone offers any hope of protection against a tal outcome of the trouble. Even after thorough removal return of the growth occurs in 40 per cent. of the cases (Wilmer).

Carcinoma. The most usual type of carcinoma of the lid is the epitheliomatous ulcer, commonly called " rodent or Jacob's ulcer." The border of the lid is the favorite starting point for the growth, which occurs in elderly persons. It usually be ns as a small pimple covered with a crust and its FIG. 174. Rodent uleer beginning in the left lower eyelid. (From a patient in Charity Hospital, Cleve growth is often exceedingly slow. As time goes on it gradually develops into a flat ulcer, with indurated, ragged, and elevated edges, attended with only a slight secretion. Eventually it may involve the lids, eyeball, and adjacent structures (Fig. 174). Rodent ulcer may be mistaken for a syphilitic ulcer, but generally the age of the patient, the slow growth of the tumor, and the therapeutic test with iodid of potassium, which rapidly relieves a syphilitic ulcer, suffices to differentiate the epitbelial growth from the latter affection. It is distinguished from lupus, because this disease occurs usually in young subjects, because of the greater inflammatory action of In us and because other portions of the body are at the same time similarly affected.

Pathology. Ordinary epitbelioma of the evelid presents no differences from epitbelioma of the skin elsewhere. From the greatly thickened epiderinis irregular outgrowths penetrate into the subepithelial structures Epithelial 252

DISEASES OF THE EYELIDS.

cell nests may also lie in this layer, together with " epithel ial pearls." The surrounding tissue is usually very vascular and infiltrated with round and from the epidermis or from the epithelial lining of the sebaceou; or sweat glands; rarely from Meibomian glands. At times it appears as a raised ulcer with infiltrated edges. The growth may be very slow, and cicatrization take place in the center as the ulceration progresses at the edges. If the ulcerative process is an elaborate one and extends into the deeper as well as surrounding tissues, a " rodent ulcer" results. The stroma of these epitheliomata is always more or less infiltrated with round cells and presents the appearance of granulation tissue.

Rare forms of cancer of the lid structures having their point of origin in the Meibomian or in Krause's glands may be denominated glandular carcinomata, in contradistinction to the ordinary epitheliomata and rodent ulcers.

Treatment. Radical measures alone give any promise of permanent relief in carcinomata. An early operation for their removal should be performed and the exposed surface covered with suitable skin flaps. In the later stages palliative measures to aid in limiting the rapidity of the growth may be used. To further this end caustic, chloracetic acid, scraping with a curette, or the actual cautery may be employed. As milder measures aristol, chlorate of potassium, and injections of pyoktanin have been recommended. Not infrequently in the advanced cases it may be necessary to remove the eyeball, together with the orbital and periorbital tissues.

Lupus Vulgaris. Associated with lupus of the face or nose the eyelids may become the seat of this affection. The ulcers are formed by several points of infection coalescing and producing ragged, soft edges, which exude an offensive secretion. The disease frequently inflicts much damage to the lid tissue, eventuating in marked cicatricial contraction and deformity. The history of the case, together with the fact that the face and nose are involved in the same disease, will serve to distinguish lupus from the syphilitic ulcer, for which it is likely to be mistaken.

Treatment. Cauterization by means of caustic paste or the actual cautery gives the best results in the early stage of the disease. The ulcers may also be curetted. When the ulcers are large excision may be practised, with the proper plastic operation for covering the denuded surface of the eyelids.

Lepra. Leprosy of the eyelids is very frequent in countries where the general disease is prevalent. Tubercular growths form in the region of the brows and cilia, producing loss of the lashes and eyebrows. Anesthetic patches of a color slightly different from the surrounding skin, with entropion and ectropion, are frequently developed.

Elephantiasis Arabum is characterized by a chronic hypertrophy of the skin and subcutaneous tissue. The lids reach enormou's proportions, and from their mere weight prevent the patient from opening the eyes. The upper lids are the ones usually affected. Elephantiasis occurs congenitally or may result from an injury. According as the hypertropby affects the lymphatics or the blood vessels the names of elephantiasis lymphangiectodes and elephantiasis telanyiectodes have been assigned. Removal of the excessive growth of tissue sufficient to enable the patient to open the eyes offers the most hope of relief.

Tarsitis is usually a chronic inflammation of the torsos characterized by thickening of this body Acute tarsitis, with sloughing of the tissues, ha's been described. There is often found associated with conjuctivitis and blepharitis a thickening of the torsos, especially in scrofulous subjects. Syphilitic tarsitis is the most frequent variety of the disease, and in this epithelial cells. The growth may originate

BLEPHAROSPASM.

253 affection the thickening of the lids is often very marked, giving rise to much deformity. It usually occurs in the third stage of syphilis, and assumes the gummatous type of the disease; more rarely an acute form appears.

The symptoms of tarsitis are gradual thickening of the lid, without marked inflammatory disturbance, and the consequent inconvenience to the patient of the bulk of the eyelid, which may droop over the globe. If the lower lid is the seat of the disease, the weight of the lid sometimes pulls it away from the eyeball, producing an corrosion. In severe cases an atrophy of the tarsus may ensue after the subsidence of the inflammation (Fig. 175).

FIG. 175. Syphilitic tarsitis. (From a patient under the care of Dr. de Schweinitz in the Philadelphia Hospital.)

Treatment. The remedies appropriate to blepharitis should be used locally, and any constitutional disturbance corrected by proper means. In tarsitis syphilitica treatment suitable for the specific disease should be instituted. Recovery is slow, but generally perfect.

Blepharospasm is characterized by a cramp like contraction of some or of all of the fibers of the orbicularis muscle.

A frequent condition in many persons is the contraction of a few fibers of the orbicularis muscle in either the upper or lower lid, which is very annoy The twitching of the muscle may readily be seen by an observer. This condition is usually indicative of some local irritation of the eyes or the lids, and is of Do great import.

A more serious and uncomfortable phase of the difficulty is cramp of the entire muscle, when the eyelids close tightly and violently. There are two DISEASES OF THE EYELID & varieties of blepharospasm the clonic and the tonic spasms. In the former the spasm is of momentary duration, and consists of a series of forcible uncontrollable " blinkings ;" in the latter there is a violent closure of the lids, which remain tightly shut for some minutes or for days or months, and the patient is rendered practically blind by the inability to use the eyes. Blindness has occasionally resulted, manifest when the patient has become able to open the eyes, either with or without grave ophthalmoscopic changes.

Blepharospasm may be either a symptomatic condition or an essential disease. Children especially are prone to have slight more or less frequent " blinking " attacks or nictitation, especially when using their eyes in schoolwork. They are generally found to have slight conjunctivitis or an asthenopic condition due to refractive error. Not infrequently associated with this is a choreic or spasmodic affection of the facial muscles. Blepharospasm is essentially due to reflex irritation of the fibers of the trigeminus, and hence occurs in follicular conjunctivitis, with foreign bodies in the eye (when the spasms may be tonic), with blepharitis, refractive errors, and muscular insufficiencies. Depending upon the cause, the attacks are monocular or binocular, the latter form prevailing in all severe cases, the attacks being usually more severe on one side. In hysterical subjects the attacks come on without any known cause, the eyes close tightly, the spasm is persistent, and the patient is rendered helpless. In adults as well as in children the facial muscles may twitch as actively as the orbicularis. In elderly people the spasm is often associated with tic or with chronic conjunctivitis.

Treatment. The treatment of blepharospasm depends upon the cause. In case of local irritation removal of the foreign body, relief of conjunctivitis, blepharitis, or other local inflammation, correction of refractive errors, and gymnastic exercise for insufficiency of the eve muscles are the essential points to be considered. The general health should be looked into, and tonics, especially iron, quinin, and strychnin, should be exhibited, care being taken that the latter does not aggravate the trouble. Antispasmodics, as conium and gelsemium, pushed to their physiological tolerance, may be of benefit.

In many cases medication seems to have no beneficial effect. In some patients pressure on certain points seems to relieve temporarily the difficulty. The patient discovers these and learns to control, in a measure, the orbicularis spasm by pressing upon the point. This point may be situated on the forebead or in some other portion of the head. In such cases galvanism, or, in very bad cases, hypodermic injections of morphin in these regions, may be tried. Complete rest from work, with change of climate, sea bathing, or mountain climbing, have sometimes proved efficacious when other means have failed.

Ptosis (blepharoplosis, blepharoplegia) is a term properly applied to a drooping of the eyelid due to paralysis of the levator palpebrarum muscle. In addition to true ptosis there is a more or less marked degree of drooping of the lid due to its increased weight or bulk, which prevents tile levator from sufficiently raising the lid to expose the eyeball. This often is the case in tarsitis, hypertrophic blepharitis,. granular corjunctivitis, and tumors of various sorts occurring in the substance of the lid. But ptosis proper is due either to paralysis of the oculo motor nerve or to a fault in the development of the levator muscle itself.

The affection may be a congenital or an acquired one. In the congenital cases the ptosis may be associated with other congenital malformations of the lids, eye, or orbit. In some cases of unilateral congenital ptosis. usually on LAGOPHTHALMOS.

255 the left side, while the eyelid cannot be raised voluntarily, it is raised when the jaw is moved during eating, or there is contraction of the levator in association with the external pterygoid. Not infrequently ptosis is the result of injury to the muscle fibers or to the supraorbital branch of the oculo motor (Fig. 176). Paralysis of the eye muscles is frequently associated with ptosis, and it may be found in certain cases of hemiplegia or from lesion of the cortical center. In bilateral ptosis the peculiar pose of the head, which is thrown back to enable the patient to look under the drooping lids, is strikingly characteristic.

Treatment. The cause must determine the proper procedure. Medicinal measures must be instituted if the palsies are of syphilitic, rheumatic, or of FIG. 176 Tranniltic ptosis with Cystic tumor Of orbit. (Western Reserve University, Medical Department.)

other origin which is amenable to medicinal agents. The surgical treatment is described elsewhere (see page 557).

Lagophthalmos manifests itself by an inability of the eyelids to close, the degree of this immobility varying as the cause is a paralytic or a nonparalytic one. The non paralytic causes are shortening of the eyelids, which may be congenital or due to loss of tissue of the lids from burns, ulceration, gangrene, etc. ; corrosion ; loss of reflex sensibility in the eyeball and protrusion of the globes, so that the lids are unable to cover them, as in exophthalmic goiter, orbital tumors, etc.

The most marked cases are caused by paralysis of the orbicularis muscle, usually associated with facial paralysis. The distressing symptoms of lagoph arise in connection with the cornea ' which is exposed to external irritations and suffers the loss of the lubricating and protecting action of the lids. The exposed portions of the cornea and conjunctiva become chronically inflamed, and ulceration and even blindness may be the result.

Treatment should have in view, primarily, the protection of the eyeball from external irritation. Patients are likely to suffer most while asleep from inability to close the lids by voluntary action. Hence in bad cases the lids I 256 DISEASES OF THE EYELIDS.

should be closed with adhesive plaster, a compress and bandage, or by other suitable means. Relief should be directed to the cause of the affection in the paralytic variety, and the operation of tarsorrhaphy (page 547) may be required.

Symblepharon is an abnormal adhesion of the eyelid to the eyeball. It may be congenital, but is usually the result of injuries, especially burns from acids, lime, or hot metal (Fig. 177). It occurs always when the conjunctival structure is destroyed in its sulcus and when the palpebral and bulbar conjunctivae are cauterized in approximate positions. It also results from purulent and granular conjunctivitis, pemphigus, etc. Not infrequently the lid margins become strongly adherent to the cornea by cicatricial bands or the entire body of the lid may be adherent (Fig. 178).

FIG. 177. Symblepharon due to burn hot metal. (From a patient in Western Reserve University, Medical Department.)

Ankyloblepharon has the same causes as symblepbaron, and likewise may be congenital or acquired. It consists of a union between the margins of the upper and lower lids, and may be partial or complete. In the acquired variety burns are the most common cause.

Biepharophimosis is an agglutination of the eyelids at the outer angle of. the eye, caused usually by chronic conjunctivitis or ulceration at the commissure. The adhesions cause shortening of the palpebral opening.

Treatment. These conditions, generally due to a similar cause, require like treatment. In ease of injury, burns, etc. care should be exercised to keep the lids well separated from each other as well as from the eyeball. In case of extensive burns of both the bulbar and palpebral conjunctive no method will prevent the lid and the eyeball from becoming adherent, with the formation of a more or less complete symblepharon. When the deformity has occurred suitable surgical measures should be employed for its correction (see page 548).

ENTROPION. 257

Trichiasis is a term used to describe that condition of the lids where the eyelashes are turned backward so as to rub against the eyeball. A single cilium or the entire row of lashes may be inverted.

II. The most frequent cause of trichiasis is trachoma. The entire conjunctival surface being, as a rule, involved in chronic trachoma, the resulting cicatricial contraction affects the entire border of the lid and occasionally develops more or less complete trichiasis. The more localized affection is likely to be due to burns, blepharitis, injuries, operations, etc. The result of the lashes turning in is marked irritation of the cornea, which often results in ulcers ; thickening of the epithelial covering, somewhat simulating pannus; constant lach ; and, in long continued cases, permanent impairment of vision.

Distichiasis is a term applied to that affection where there are double FIG. Incomplete symblepharon due to burn. (From a case in Western Reserve University, Medical Department.)rows of lashes, one row being directed properly, while the other is turned backward against the eyeball. Some authors consider distichiasis simply one step in the development of trichiasis and assign the term to the congenital affection alone. The causes of the two affections are the same.

Treatment. Should a single lash or a small number of lashes turn in, temporary relief is afforded by epilation of the cilia which are at fault. The lashes grow again, however, and this operation must be frequently repeated. Patients can often remove the lashes themselves with a pair of cilium forceps. For permanent relief electrolysis or some other operative procedure must be employed (see page 545).

Entropion is a turning inward against the eyeball of the external lidmargin. Not only the lashes but the skin of the palpebral margin is rolled back against the eye. Two varieties of this affection have been described, the spasmodic and the organic. The former results from the over action of the orbicularis muscle due to the reflex irritation of conjunctivitis, iterating, etc. In elderly people it not infrequently results from operations when the eve has been kept bandaged too long. The organic type results from chronic 17

I 258 DISEASES OF THE EYELIDS

trachoma, diphtheritic conjunctivitis, burns, injuries, etc., which lead to cicatricial contraction of the conjunctiva. The effect upon the cornea may be serious on account of the production of ulcers, opacities, etc.

Treatment. Spasmodic entropion is generally relieved by the disappearance of the conjunctivitis, keratitis, or foreign substance which has caused it. Early removal of the bandage is necessary when the entropion occurs after cataract operations. Strips of adhesive plaster applied to the lid margin by one extremity and by the other to the check, or collodion painted over the lid, or strips of gauze fixed with collodion applied in the same manner as the adhesive strips, serve a most useful purpose in case of spasmodic ectropion. The serre fine has been used with advantage by fixing a fold of the skin, thus pulling the lid margin away from the eyeball. The chronic types of entropion require careful surgical treatment. The operations are described on page 548.

Ectropion is a rolling outward of the eyelids, so that the conjunctival portion is exposed to view. This eversion may be partial or complete. It may also be spasmodic or muscular and chronic or organic. In the former case it is due to the over action of the peripheral fibers of the orbicularis muscle. The lower lid sometimes shows a tendency to droop, particularly in elderly people and in persons affected with facial palsy. The tears thus run over the checks and occasion additional irritation.

The causes of organic ectropion are those which produce a cicatricial shortening in the length of the eyelids, as chronic blepharitis, lupus, necrosis of the orbit or malar bone, abscesses, burns, and injuries (Fig. 179). The eye being more or less exposed, the cornea suffers from external irritants.

Treatment. Not infrequently the excessive lachrymation which occurs in ectropion may be cured by slitting up the canaliculus and passing probes through the naso lachrymal duct. Associated inflammation of the cornea and conjunctiva should receive attention. The severer chronic forms of the affection require operative measures for their relief (see page 551).

Seborrhea is characterized by a secretion on the margin of the lids either of an oily fluid or of a sebaceous material, which dries, forming crusts or scales along the cilia. Generally, seborrhea of the face, scalp, or other portions of the body is an accompanying affection. It not infrequently occurs in voung persons about the age of puberty. Conjunctivitis and marginal blepharitis are frequent concomitants.

Treatment must be directed to the improvement of the general health. Removal of the crusts and the application of mercurial or sulphur ointments, together with measures suited to conjunctivitis and blepharitis, are required.

FiG. 179. Case of ectropion. (From a patient in the Charity Hospital.)

CHROMIDROSIS.259 Milium. Milia are accumulations of sebum in closed sebaceous glands. These growths are about the size of a milletseed, from which they take their name. They present a yellowish white appearance, and are slightly elevated above the surrounding skin, giving the feeling of a pinhead under the finger. They usually indicate improper care of the skin, and occur in persons with some disturbance of digestion, constipation, etc.

Treatment. Hot applications, frequently repeated, together with suitable remedies for indigestion or constipation, will prove beneficial. After removal of the milium with a knife point or needle, hot packs and mild ointments, well rubbed in, will afford relief.

Molluscum contagiosum (molluscum sebaceum) occurs in the lids in the form of small rounded tumors which originate from the sebaceous glands. They attain the size of a pea, have an umbilicated appearance due to the orifice of the gland on the summit of the growth, and have a wax like color. The material from the growths is contagious. The disease not infrequently occurs among children in asylums and schools in the nature of an epidemic. The contagious nature of the disease is supposed to be due to a parasite, and the affection is allied in character to cantagious epitheliomata. The parasite is believed by some authors to belong to the class Coccidia, and to inhabit the epithelial cells and cause the formation of these small prominent epithelial growths. The coccidia multiply in the cells of the epithelia] projections; these are then cast off and accumulate as a mass of epithelial detritus. According to H. Muetze, the molluscum corpuscles are the product of a degeneration of the epithelial cells caused by the contagium, the nature of which is uncertain ; but the corpuscles themselves are not parasites.

Treatment consists of opening each molluscum and scraping out its contents. Cauterizing the sac with nitrate of silver may also be employed.

Ephidrosis (hyperidrosis) is a rare affection of the lids characterized by profuse secretion from the sweat glands. It is associated with excessive sweating of other portions of the face or body, and has been noticed in cases of unilateral facial sweating. Its cause is Dot understood. It may produce excoriations, especially at the angles of the eyes and in the skin folds.

Treatment must be directed to the excoriations of the skin and to the cause if it can be discovered.

Chromidrosis (sometimes called seborrha nigricans') is the formation of various colored secretions on the eyelids, the oily like fluid giving a bluish or blackish color to the affected skin. It usually occurs on the lower lid. The discoloration can readily be removed by wiping. Some authors believe that it is always an evidence of malingering, as it most frequently occurs in hysterical patients, particularly young women. In rare instances it is genuine. It may be caused by a deposit of dust upon a cutaneous surface affected with seborrhea.

Treatment should be directed toward the relief of any general disturbance of the health. The discoloration may be removed with some oily substance ; lead water and glycerin have been recommended.

Sebaceous cysts are small rounded bodies of the size of a pea or of a hazelnut which occur in the thicker portions of the skin of the eyelids, especially in the superior or external orbital portion of the lid (Fig. 180). They develop from the sebaceous follicles of the skin, and contain a sebaceous, oily like material, and frequently fine hairs. They have well formed I For a full account of this affection see a paper by Dr. J. K. Mitchell in the Phila. Ned. journ., 1898, i. 117 119.

260 DISEASES OF THE EYELIDS cyst walls, which enables the surgeon to dissect them out without great difficulty, this being the proper method of treatment. FIG. 180. Sebaceous tumor of the eyelid. (From a patient in the Western Reserve University, Medical Department.) Dermoid cysts likewise occur in the same region and should be removed in like manner.

Cysticercus has been observed a few times under the skin of the eyelids, having the appearance of a sebaceous cyst, only the contents are fluid. On opening the tumor the remains of the parasite are discovered.

THE EYEBROWS.

The eyebrows may be the seat of eczema or of seborrhea, and are a favorite situation for the development of sebaceous and dermoid cysts. Occasionally these growths extend some distance into the orbit, where by pressure they may produce a depression in the underlying bone.

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