Clinical Diagnosis in Ophthalmology

588 Pages·2006·97.83 MB·English

by  Jack J. Kanski

ACKNOWLEDGEMENTS
I am extremely grateful to medical colleagues for supplying me
with the new images for this book. I am also particularly indebted to
several medical photographers who frequently do not receive their
deserved recognition for contributions to medical texts. Although the
source of the images is indicated in the text, I would especially like to
acknowledge the following for making a major contribution to Clinical
Diagnosis in Ophthalmology.
Irina Gout MD, MScOphth, PhD
Prince Charles Eye Unit, Windsor, UK
Chris Barry CRA
Lions Eye Institute, Perth, Australia
Kulwant Sehmi FRPS, ABIPP, AIMI
Moorfields Eye Hospital, London, UK
Patrick Saine CRA
Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire, USA
Rhonda Curtis CRA, COT, FOPS
Washington University Medical School, St Louis, Missouri, USA
Stanislaw Milewski MD, MA, FACS
University of Connecticut, USA
Lawrence Merin RBP, FIMI
Vanderbilt University Medical Center, Nashville,Tennessee, USA
Pablo Gili MD
Area de Cirugia Unidad de Oftalmologia, Madrid, Spain
Usha Kaul Raina MD, FRCS (Edin), FRCOphth
Maulanta Medical College, New Delhi, India
Anne Bolton BA, BIPP, DATEC
Oxford Eye Hospital, Oxford, UK
Leslie MacKeen BSc, OA, CRA
Hospital for Sick Children, and Massie Labs, Toronto, Canada
Andrew Pearson MRCP, FRCOphth
Prince Charles Eye Unit, Windsor, UK
Ronald Marsh MD, FRCS, FRCOphth
Western Eye Hospital, London, UK
Sue Ford ARPS, AIMI, RMIP
Western Eye Hospital, London, UK
Andre Curi MD
Federal University of Minas Gerais, Brazil
CHAPTER 1
EYELIDS
DISORDERS OF LASHES
Trichiasis
Trichiasis is a very common acquired condition characterised by inturning of lashes arising from normal sites of origin.
It may be idiopathic or secondary to chronic lid margin disease. It should not be confused with pseudotrichiasis
associated with entropion.
■Fig. 1.1 Idiopathic trichiasis. ■Fig. 1.2 Severe long-standing trichiasis causing inferior corneal
scarring.
■Fig. 1.3 Trichiasis and misdirection of lashes due to severe ■Fig. 1.4 Trichiasis of the upper lid and corneal scarring due to
chronic anterior blepharitis. herpes zoster ophthalmicus.
2 Chapter 1 EYELIDS
Congenital distichiasis
Congenital distichiasis is a rare condition that may be sporadic or dominantly inherited. A minority of patients
also manifest chronic lymphoedema, spinal arachnoid cysts and congenital heart defects (lymphoedema–
trichiasis syndrome).
■Fig. 1.5 A partial or complete second row of lashes emerging at or
slightly behind the meibomian gland orifices. The aberrant lashes tend
to be thinner, shorter and less pigmented than normal cilia and are
often directed posteriorly. (Courtesy of D. M. Albert and F. A. Jakobiec.)
Acquired distichiasis (metaplastic lashes)
Acquired distichiasis is caused by metaplasia and dedifferentiation of the meibomian glands to become hair follicles in
patients with cicatrising conjunctivitis.
■Fig. 1.6 A variable number of lashes that originate from meibomian
gland orifices.
Disorders of lashes 3
Lash ptosis
Lash ptosis may be idiopathic or associated with the floppy eyelid syndrome, dermatochalasis or long-standing facial
palsy.
■Fig. 1.7 Downward displacement of normal lashes.
Ectopic lash
■Fig. 1.8 Subcutaneous lash. ■Fig. 1.9 Subconjunctival lash.
4 Chapter 1 EYELIDS
■Fig. 1.10 Lash in a punctum may cause irritation on blinking. ■Fig. 1.11 Lash introduced into the anterior chamber during
surgery. (Courtesy of L. Merin.)
Madarosis
Madarosis is a decrease in number or complete loss of lashes.
Local causes
■Fig. 1.12 Severe long-standing anterior blepharitis. ■Fig. 1.13 Destruction of lashes by infiltrating lid tumours.
■Fig. 1.14 Thermal burns. ■Fig. 1.15 Trichotillomania– habitual hair removal. (Courtesy of
L. Merin.)
Disorders of lashes 5
Associated systemic conditions
■Fig. 1.16 ■Fig. 1.17 Alopecia
Generalised alopecia. areata.
■Fig. 1.18 Atopic dermatitis, characterised by itchy erythema, ■Fig. 1.19 Myxoedema, which may also cause loss of eyebrows
scaling and lichenification. and puffiness of periorbital skin.
■Fig. 1.20 Systemic lupus erythematosus, which may be ■Fig. 1.21 Ichthyosis, characterised by itchy, dry and scaly skin.
associated with a characteristic ‘butterfly’ facial skin rash. (Courtesy of A. Pearson.)
6 Chapter 1 EYELIDS
Hypertrichosis
Hypertrichosis is an excess number of lashes (polytrichosis) and/or abnormally long and luxuriant lashes (trichomegaly).
■Fig. 1.22 Congenital hypertrichosis. (Courtesy of L. Merin.) ■Fig. 1.23 Acquired hypertrichosis (left) caused by topical
latanoprost, which has also rendened the lashes darker.
Poliosis
Poliosis is a premature localised whitening of hair, which may involve the lashes and eyebrows.
■Fig. 1.24 Poliosis and vitiligo (patchy whitening of skin) in ■Fig. 1.25 Mild poliosis and meeting of eyebrows in
Vogt–Koyanagi–Harada syndrome. (Courtesy of S. Ford and Waardenburg syndrome; note iris heterochromia. (Courtesy of
R. Marsh.) A. Shun-Shin.)
Chronic marginal blepharitis 7
CHRONIC MARGINAL BLEPHARITIS
Chronic blephritis is a very common cause of ocular discomfort, but there is poor correlation between symptoms and
clinical signs.
Staphylococcal blepharitis
■Fig.1.26 Hard scales mainly located around the bases of the ■Fig. 1.27 Hyperaemia and telangiectasia of the anterior lid
lashes (collarettes). margins, and collarettes.
■Fig. 1.28 Microabscesses of lash follicles and madarosis of the ■Fig. 1.29 Hypertrophy and scarring of the lid margin and
upper lid. (Courtesy of S. Ford and R. Marsh.) madarosis in severe long-standing blepharitis.
8 Chapter 1 EYELIDS
Seborrhoeic blepharitis
Seborrhoeic blepharitis may occur in isolation or in association with staphylococcal blepharitis (mixed anterior
blepharitis).
■Fig. 1.30 Hyperaemic and greasy anterior lid margins. ■Fig. 1.31 Soft scales located anywhere on the lid margin and
lashes. (Courtesy of J. A. Silbert.)
Association
■Fig. 1.32 Seborrhoeic dermatitis, characterised by a red scaly rash
thatclassically affects the scalp (dandruff), central face, nasolabial
folds, eyebrows and central chest.
Chronic marginal blepharitis 9
Posterior blepharitis
Posterior blepharitis is a manifestation of meibomian gland dysfunction. It may occur in isolation or in association with
anterior blepharitis (mixed anterior and posterior blepharitis).
■Fig. 1.33 The tear film is oily and in severe cases froth ■Fig. 1.34 The meibomian gland orifices are capped by small oil
accumulates on the lid margins or inner canthi. globules.
■Fig. 1.35 The posterior lid margin shows hyperaemia, ■Fig. 1.36 Extensive obstruction of meibomian gland orifices and
telangiectasia and patchy obstruction of meibomian gland orifices. lid margin telangiectasia.