Conditions of the eyelids

3 Instruct the patient to keep the eyelids clean by, twice a day, using warm water to wash off any crusts and discharge.

4 Instruct the patient to return if the swelling does not subside, as the simple operation of incision and curettage can be per- formed once the infection has cleared up, to remove any remaining material.

CONDITION GUIDELINE

Oedema of the lids

Oedema of the lids is a common condition and, because of the looseness of the tissue, the swelling can be so great as to close the eye.

Causes

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Insect bites/stings;

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Dermatitis;

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Stye;

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Chalazion.

Oedema of the lids is associated with:

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Orbital cellulitis;

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Conjunctivitis;

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Dacryocystitis;

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Drug allergy.

Patient’s needs

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Reduction of swelling;

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Treatment of cause;

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Analgesia as required.

Nursing action

Explain to the patient the methods that should be used to reduce the swelling:

1 Cold compress;

2 Bathing eyelid with sodium bicarbonate solution.

Explain to the patient the treatment of the cause of the condition.

Antihistamine ointment and/or tablets may be used to treat insect bites/stings.

CONDITION GUIDELINE

Blepharitis

Blepharitis can be an acute or a chronic inflammatory condition of the lid margins and is usually bilateral (Figure 6.8). It can be classified as anterior blepharitis or posterior blepharitis (that is anterior or posterior to the grey line). Blepharitis, and particularly posterior blepharitis, is often undetected, even when the eyes have been examined for other reasons.

Figure 6.8 Staphylococcal blepharitis. From Leitman (2007), Manual for Eye Examination and Diagnosis, 7e, Blackwell Publishing, reproduced with permission.

Causes

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Staphylococcal – chronic infection;

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Seborrhoeic – excessive secretion of lipid from meibomian glands;

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Possible association with dandruff, poor hygiene, eczema or allergy to make-up, or drugs;

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Acne rosacea.

Signs

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Red, swollen lid margins;

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Scales on lashes;

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Eyelid irritation;

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Burning sensation;

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Itching;

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Loss of eye lashes.

Patient’s needs

The patient requires relief of the following symptoms:

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Itchiness around eye;

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Discharge if an infective cause;

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Burning sensation.

Nursing action

Instruct the patient on the treatment:

1 Cleaning the eyelids:

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Clean lid margin and lashes with diluted baby shampoo (as this does not cause stinging) or diluted sodium bicarbonate (half a teaspoon to half a cup of cooled, boiled water) twice a day. Use good quality cotton buds or wrap a clean face cloth round your first finger to scrub the lid margins.

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Some patients prefer to scrub their eyelids whilst having a shower, in which case they should use the baby shampoo on a clean face cloth.

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Apply antibiotic ointment along the lid margin two or three times a day, if severe.

2 Dandruff – treat dandruff with antidandruff shampoo.

3 Make-up – stop using make-up or change the brand used: at the end of the day, remove all traces of make-up. It is advisable to dispose of eye make-up including mascara every 3 months.

4 Eczema – eczema may be treated with steroid ointment.

5 Drugs – stop using the offending drug;

6 Poor hygiene – instruct the patient on improving general hygiene, especially to hair, face and hands.

7 For the relief of soreness and itching, moisten clean face cloth under hot (as hot as you can stand) running water. Wring it out and place over closed eyelids. Repeat as the heat goes out of the face cloth.

8 Patients who are dependent on carers for their other hygiene needs should also be shown the technique of lid hygiene and general facial cleanliness.

Inform the patient that the treatment will need to continue for several weeks, if not for life, as it is a chronic condition, although the frequency of treatment can be reduced. Encourage him not to give up the treat- ment, even if it does not appear to be working in the initial stages.

Complications

Complications can occur following blepharitis caused by infective or- ganisms that result in ulceration of the lid margin:

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Conjunctivitis;

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Trichiasis and its sequelae due to chronic ulceration, which, when healed, contract the skin in that area, causing the lash(es) to turn inwards;

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Entropion or ectropion of the lower lid in particularly severe cases;

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Corneal ulcer.

CONDITION GUIDELINE

Stye or external hordeolum

A stye or external hordeolum is an inflammation of a gland of Zeis that opens into the lash follicle. An abscess forms, which usually points near an eyelash.

Signs

Signs of a stye or external hordeolum are swelling, often with pointing on the lid margin situated near a lash.

Patient’s needs

The patient requires relief of pain and swelling.

Nursing action

1 Explain the treatment, which is similar to that for a chalazion.

2 Incision and curettage is not necessary for a stye. Removal of the affected lash will cause the abscess to drain, but this action is mo- mentarily very painful.

3 If styes recur, the patient should be investigated for diabetes mellitus.

CONDITION GUIDELINE

Trichiasis

Trichiasis is a condition in which the lashes grow inwards and rub on the cornea. This may follow, for example, blepharitis, trauma or surgery to the lids. Often the cause is unknown.

Patient’s needs

The patient requires removal of the offending lash(es) which is(are) causing irritation to the eye.

Nursing action 1 Remove the lash by:

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Epilating it using epilation forceps: this will need to be repeated regularly;

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Assisting the doctor or specialist nurse to use electrolysis, when an electrode is introduced to each offending lash follicle to de- stroy it.

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Prepare local anaesthetic injection and drops.

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Instil antibiotic ointment to the eye following the procedure.

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Assisting the doctor to apply cryotherapy (liquid nitrogen) to the lash follicle to destroy it:

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Prepare local anaesthetic injection and drops.

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Instil antibiotic ointment following the procedure.

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Warn the patient that the eye will be uncomfortable for a few days following cryotherapy.

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Assisting the doctor to apply argon laser to the offending lash;

2 Check the cornea for abrasions from the ingrowing lash(es) by stain- ing lashes with G. fluorescein. If abrasions have occurred, instruct the patient to use the prescribed antibiotic ointment three times a day for three or four days.

3 Instruct the patient to return for further lash epilation as soon as he feels that the eye is becoming irritated, so that complications can be avoided by prompt treatment.

Complications

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Corneal abrasions;

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Corneal ulceration;

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Superficial corneal opacities;

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Vascularisation of the cornea;

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Unfortunately, treatment is rarely completely successful and usually needs to be repeated at regular intervals.

CONDITION GUIDELINE

Entropion

Entropion is the turning inwards of the eyelid, usually the lower lid (Figure 6.9).

Causes

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Spastic entropion occurring in old age when spasm of the orbicularis muscle occurs, causing the lid to turn inwards;

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Cicatricial contraction of the palpebral conjunctiva following trauma or disease to the lid or conjunctiva.

Patient’s needs

The patient requires relief of symptoms of irritation in the eye.

Nursing action

1 As a temporary measure, strap the lower lid to pull it outwards. Care must be taken not to leave the globe exposed as this could cause complications such as exposure keratitis.

2 Prepare the patient and equipment for surgery to evert the lid. Care must be taken when performing entropion surgery to avoid an ec- tropion resulting.

Figure 6.9 Spastic entropion. From Olver and Cassidy (2005), Ophthalmology at a Glance, Blackwell Publishing, reproduced with permission.

3 Entropion operations include:

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^Cautery;

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Transverse lid everting suture;

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Wies procedure – lid splitting and marginal rotation;

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Fox procedure – excision of triangle of conjunctiva and tarsal plate;

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Shortening of lower lid retractors.

Complications

The complications for entropion are the same as those for trichiasis.

CONDITION GUIDELINE

Ectropion

Ectropion is the turning outwards of the eyelid, usually the lower lid (Figure 6.10).

Causes

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Senile ectropion due to relaxation of the orbicularis muscle, turning the eyelid outwards;

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Cicatricial ectropion due to scarring following trauma or chronic disease of the lid or conjunctiva, pulling lid outwards;

Figure 6.10 Ectropion. From James, Chew and Bron (2007) Lecture Notes: Ophthalmology, Blackwell Publishing, reproduced with permission.

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Paralytic ectropion occurring with palsies of the seventh cranial nerve.

Because the punctum is not in apposition to the bulbar conjunctiva when an ectropion is present, the tears cannot flow through the punc- tum and into the lacrimal drainage system. They therefore spill over the lid margin and down the cheek.

Patient’s needs

The patient requires relief of symptoms:

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Watering eye;

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Irritable sensation;

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Discharge, which may be present;

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Sore skin area over maxilla from constantly wiping away tears.

Nursing action

Prepare the patient and equipment for surgery to invert the lid:

1 Lazy-T procedure – full thickness excision;

2 Retropunctal cautery;

3 Bick procedure – full thickness excision.

Care must be taken when performing ectropion surgery to avoid an entropion resulting.

CONDITION GUIDELINE

Ptosis

Ptosis is drooping of the upper lid (Figure 6.11). It may be unilateral, bilateral, constant or intermittent.

Causes

Congenital ptosis is caused by failure of development of the levator muscle. It is usually bilateral. The child with bilateral congenital ptosis has to tilt his head backwards to be able to see properly. This will prevent amblyopia developing. There is a danger that amblyopia will occur with unilateral ptosis.

(a)

(b)

Figure 6.11 Left ptosis. From Leitman (2007), Manual for Eye Examination and Diagnosis, 7e, Blackwell Publishing, reproduced with permission.

Acquired ptosis is caused by:

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Mechanical failure – abnormal weight on lid due to oedema, tumour, scarring;

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Muscle involvement – trauma to muscle. Disease involving muscles, e.g. muscular dystrophy, myasthenia gravis. If, following an injection

of neostigmine, an anticholinesterase drug, the ptosis is temporarily relieved, myasthenia can be diagnosed;

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Paralysis of nerves supplying the upper lid.

Patient’s needs

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Correction of lid, if it obscures sight;

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Treatment of underlying disease.

Nursing action

Explain and prepare the patient for any of the following treatments:

1 Lid surgery to resect the levator muscle or remove growths if present;

2 Wearing of special glasses or contact lenses with ‘ptosis edge’ to hold the lid up;

3 Treatment of causative or underlying disease, e.g. myasthenia gravis.

Bell’s palsy

Bell’s palsy is due to paralysis of the seventh nerve with resulting incomplete lids closure and corneal exposure. As a result of ineffective lid closure and corneal exposure, patients may present with a painful, red watery eye. The early management of Bell’s palsy is aimed at the painful red eye. Initially copious topical lubricant and taping of the eyelid at night is all that is required.

The patient will need constant reassurance and support at every stage. If corneal exposure is severe, a temporary lateral tarsorrhaphy may be needed.

Lateral tarsorrhaphy joins the upper and lower lids laterally in order to reduce the palpebral aperture and protect the cornea. The long-term management of poor lid closure may include the implantation of gold weights into the upper lid. This procedure allows a better lid closure and a more natural blink.

Possible complications may include extrusion or migration (Collin & Rose, 2001).

Blepharospasm

Blepharospasm is a condition that causes forceful, painful spasm eyelid clo- sure resulting in difficulty in opening the eye. Photophobia is present and the condition is exacerbated by bright lights, stress and excessive move- ment around the person. It can cause the individual concerned to become socially isolated and unable to work. There may be some accompanying con- traction of the lower facial muscles. Treatment is by injections of botulinum (Kanski 2006) into the orbicularis muscle. This is repeated every two to three months.

CONDITION GUIDELINE

Tumours

Growths on the eyelids can be either benign or malignant.

Benign

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Papilloma;

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^Warts;

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Granulomas;

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Xanthelasma.

Malignant

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Basal cell carcinoma (see Figures 6.12 and 6.13);

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Squamous cell carcinoma;

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Melanoma.

Figure 6.12 Rodent ulcer.

Figure 6.13 Basal cell carcinoma.

Patient’s needs

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Removal of tumour is required urgently, especially if it is thought to be malignant.

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Mohs’ micrographic surgery (where available) is used in the manage- ment of periocular basal cell carcinoma. Mohs’ micrographic surgery allows each cancerous layer to be visualised through the microscope.

Excision of the cancerous layer continues until cancer-free layers are obtained.

Nursing action

1 Prepare the patient and equipment for removal of the tumour. Skin grafting or flaps may be necessary depending on the size and posi- tion of the tumour.

2 Send specimen to the laboratory for histology.

Surgery to the lids must be performed with great care to avoid either an ectropion, entropion or trichiasis resulting.