COMMON CONDITIONS OF THE EYE
The information outlined below on common eye conditions is provided as a guide only and it is not intended to be comprehensive.
Discussion with Raji is important to answer any questions that you may have. For information about any additional conditions not featured within the site, please contact us for more information.
Blepharitis is a very common condition which affects the eyelids. Blepharitis is often related to your skin type and results in inflammation of the eyelid margin. This can affect the roots of the eyelashes (anterior blepharitis) or the oil glands within the eyelids (posterior blepharitis).
Anterior blepharitis is associated with a bacterial infection of the eyelids. This cannot be caught from someone else who has it. The bacteria produce certain enzymes that result in irritation of eyelid and eye.
Posterior blepharitis is more often associated with skin conditions such as rosacea or seborrhoeic dermatitis which can affect the glands within the eyelid known as meibomian glands. Meibomian glands normally produce the oils which form part of your tear film.
Blepharitis can often give rise to irritation of the eyelids with secondary gritty, stinging or itchy sensation in the eye. Both the eyes and eyelids may appear red and inflamed. One can often see debris and crusting around the base of the eyelashes.
In some cases the surface of the eye will be affected. This can result in dryness and in some cases ulceration. This can particularly occur in the posterior type of blepharitis as the tear film is disrupted.
There are several things that can be done at home to help manage blepharitis. Firstly, the eyelashes can be cleaned to remove the debris. This can be achieved by filling a cup with warm water and a couple of drops of baby shampoo. This creates a weak detergent that can be used to clean the eyelid using a cotton-tipped ear bud. You should aim to clean the lashes twice a day.
The meibomian glands can be encouraged to secrete their important oils by applying warm compresses twice daily with simultaneous eyelid massage. You can simply apply a warm face cloth to the closed eyes when in the bath or shower for a period of two minutes. Other options include re-usable packs that can be applied to the eyelids such as those made by the Eyebag Company (www.eyebagcompany.com).
Flaxseed oil can be tried as second-line option. Flaxseed oil is rich in omega-3 oil which is though to improve the quality of the tear film and potentially reduce inflammation of the eyelid.
Medical treatments
Ocular lubricants can be used to improve the surface of the eye. Raji will discuss with you the best lubricants to use.
In some cases a steroid or antibiotic may be need to be applied to the eyelid (in the form of either a drop or an ointment) to reduce the inflammation. You shouldn’t use steroid ointments or drops without advice from an Ophthalmologist.
Oral antibiotics may also be required in severe cases for up to 2-3 months.
A chalazion is a cyst that occurs on either the upper or lower eyelid. It is caused by a blockage to one or more meibomian glands that are found in the eyelids.
Who gets chalazia and what are meibomian glands?
Meibomian glands are found within the eyelids and produce the oily component of your tear film. There are over 20 glands on each eyelid.
Chalazia are often found in patients with blepharitis. Debris from the skin accumulates around the base of the eyelashes (similiar to dandruff) and blocks the meibomian glands preventing the oils from reaching the surface of the eye. This can result in cyst formation.
What are the common symptoms?
Common symptoms include:
- A raised, red lesion on the eyelid that may sponatenously discharge.
- The lesion may be tender and cause the eyelid to swell.
What are the treatments for a chalazion?
The medical treatment is the same as for blepharitis with warm eyelid compresses and eyelid hygeine (see blepharitis page). Occasionally we may use an steroid eye ointment and a course of oral antibiotics such as Lymecycline .
Surgical management includes incision and currettage of the cyst. This is usually performed on the back of the eyelid and so usually leaves no scar on the front surface of the eyelid. The surgery is performed in clinic and you are usually able to go home shortly afterwards. You may have a patch on after your procedure and we do not recommend that you drive.
The incision and currettage can result in bruising and blood stained tears for a few hours. Occasionally despite the incision and currettage there may be a residual lump seen on the eyelid.
Facial palsy is caused by a problem with the nerve that supplies the muscles of the face. It usually occurs on one side but can rarely cause problems on both sides of the face. There are many different causes of a facial palsy and these will be discussed with you in clinic.
Facial palsy can affect the muscles that normally close the eye. This in turn can cause problems to the eye itself. Tears are normally wiped across the eye when you blink. In facial palsy the ability to close your eye or blink is reduced. This can result in the eye becoming very dry and exposed. When the muscle around the eye is weak, the lower eyelid will often become loose which further affects the protective tear film of the eye. (see information sheet on ectropion)
In cases of long term facial palsy the human body will sometimes try and regenerate the nerve. Sometimes when this occurs there can be some “mis-wiring” which we call “aberrant nerve regeneration”. For example the nerve that normally stimulates the muscles in the cheek may unfortunately also cause the eye to simultaneously close or to water. This can be quite problematic for patients and sometimes we treat this with Botulinum toxin commonly known as “Botox®”.
What is the treatment?
There are various different teams involved in patients with facial palsy which often include the Ear, Nose and Throat team, the Plastic surgery team and the Eye team. In some cases the palsy will improve with very little treatment required. However in some cases we need to offer treatment. Below are listed some of the treatments for your eyes and eyelids.
Medical treatments
There are a variety of treatments that can be used to protect your eye.
Firstly you should put in lubricants in the eye to protect the surface, this is particularly important at night before you sleep as the eye will often remain open during the night.
Surgical treatments
Often we can put a small weight in the eyelid to help you close your eye. This is made of either gold or platinum and is hidden underneath the skin and muscle in the eyelid.
In some urgent situations if the eye is severely affected we may actually surgically close the eyelids over the eye for protection.
If the lower eyelid is very loose then we can perform an ectropion correction (see separate sheet).
Botulinum Toxin (Botox®/Dysport®) treatments
As mentioned occasionally the facial nerve in patients with facial plasy can regenerate and give rise to “aberrant nerve regeneration”. The treatment for this are injections of Botulinum toxin which is sometimes known as Botox®. This helps stop the wrong muscle being triggered and can help stop the eye watering when you eat.
Who gets Thyroid Eye Disease (TED)?
Thyroid eye disease is the most common condition affecting the eye socket (orbit) in the UK. It is more common in females than males and is seen mostly between the ages of 20 and 60.
For the most part TED is seen in patients with dysfunction of the thyroid gland. This is usually secondary to the immune system (antibodies) acting against the thyroid gland resulting in an increase in thyroid hormones circulating in the bloodstream.
For reasons we do not fully understand the same antibodies that affect the thyroid gland also affect the tissues in the eye socket.
What happens in thyroid eye disease?
The immune reaction in the eye socket results in inflammation and expansion of the structures within the orbit including the conjunctiva lining the eye, the orbital fat and the muscles around the eye.
The inflammation is seen as injection and redness of the eye itself and the eyelids. The enlargement of the fat and muscles can give rise to classic appearance of thyroid eye disease whereby the eyes are pushed forwards giving. This can result in an angry or startled appearance. In some cases this gives rise to exposure and discomfort of the eye. If the muscles around the eye are particularly affected one can experience a squint with secondary double vision. The muscles of the eyelids can be overstimulated which further adds to the appearance of eyelid retraction.
In severe cases the vision can be affected. This is usually due to exposure of the surface of the eye (the cornea) or due to pressure on the nerve behind the eye (the optic nerve). This is seen in cases when the fat or muscles within the eye socket expand significantly.
Hence TED can affect the eyes in the following way:
- Puffiness and redness of the eyelids (lid swelling)
- Eyelid retraction giving the staring appearance.
- Dry eye symptoms due to exposure of the surface of the eye.
- Movement of the eyes forward (exophthalmos) due to expansion of fat and muscle (further adding to the staring appearance).
- Double vision (diplopia) or squint secondary to the eye muscle involvement
- The eye socket may ache, particularly on eye movement.
How long will TED last?
TED often lasts between 18 months and two years. The inflammation will often accelerate (the active phase) over the first few months and then gradually improve over the following 12-18 months. The severity of the condition (i.e the degree of double vision, change in appearance or reduction in vision) may also worsen over the first few months and then gradually improve. The aim of treatment is to try and reduce the degree of inflammation and severity and the time it takes for improvement. Disease progression is very variable each patient can be affected in different ways; both in terms of symptoms experienced and duration of the condition.
What is the treatment?
Active phase
During the active inflammatory phase we use drugs to suppress the immune system and reduce the secondary symptoms. The medications used involve both steroids and non-steroidal treatments. In most cases if steroids are required they will be given intravenously. Commonly used non-steroidal treatments include Methotrexate, Ciclosporin, Azathioprine and in severe cases biological agents such as Rituximab. These medications all have side effects and require regular monitoring of blood tests. These will be discussed with you fully in the clinic and your general practitioner will also be involved in monitoring your treatments.
In severe cases of TED the medical treatment may not prevent a reduction in vision. In such cases surgery may be required to expand the eye socket to either (i) reduce the pressure on the optic nerve or (ii) improve the surface of the eye.
If you have double vision during this phase you may require occlusion or prisms attached to your glasses.
Inactive phase
Once the inflammatory phase has settled (which may require the treatments as above) management is directed at the sequelae of TED which may involve surgery.
Such treatments include
- Orbital decompression surgery to help the eyes sit further back in the eye socket
- Squint surgery (to reduce double vision)
- Eyelid surgery to improve the eyelid position and reduce the soft tissue enlargement of the upper or lower eyelids.
What can I do to help my condition?
Often you may need to use lubricants to improve some of the discomfort associated with TED. You can also aim to sleep with more than one pillow and use cold compresses each day to try and reduce swelling around the eyes.
If you develop double vision you will need to inform the Driver and Vehicle Licensing Authority (DVLA) who will investigate your ability to drive safely.
Smoking is associated with worse outcomes in TED and it is imperative that if you smoke you either cut down or stop altogether.
Blepharospasm involves involuntary contraction of the eyelids and is also referred to as benign essential blepharospasm (BEB). The spectrum of symptoms in BEB is widely variable and the mildest form may involve a slight increase in blink rate or intermittent twitching. In the most severe forms BEB can result in more disabling symptoms such as the inability to open the eyes, ache around the eyes and a reduction in vision.
Who gets blepharospasm?
BEB is found in approximately 5 per 100,000 population and is more commonly found in females. Most patients are over the age of 60 years.
What causes blepharospasm?
The cause of BEB is poorly understood and is felt to be secondary to a dysfunction in the ‘circuit regulation’ of nerves providing ocular sensation and movement of the eyelid.
BEB is associated with dry eye and symptoms can be increased in certain situations including wind, pollution and stress.
What are the common symptoms?
Common symptoms include:
- Ocular discomfort in bright lights (photophobia)
- Increased blink rates
- Twitching or involuntary movements of the eyelids. This may start on one side of the face and spread to both sides with time.
- Dry eye symptoms (grittiness and redness of the eyes)
- Spasm of the eyebrow
What can improve blepharospasm?
Certain actions can improve BEB which can aid in the diagnosis. These include sleep, reduction in stress, occlusion of vision of the affected eye, ocular lubricants, talking and humming.
What are the treatments for BEB?
No cure currently exists for BEB and treatments are mainly aimed at alleviating symptoms.
Conservative measures include:
- Ocular lubrication
- Tinted lenses on spectacles (FL-41 tints)
- Eyelid hygiene
Medical treatments
The mainstay of treatment is the application of Botulinum A toxin. This is otherwise known as Botox® or Dysport®. Botulinum A Toxin provides temporary reduction in the eyelid spasm and has good success rates. The toxin is produced by a bacteria (Clostridium botulinum) and causes paralysis of muscle by blocking the neural input to muscle.
Botulinum A toxin is applied using injections around the eyelids in clinic. Depending on the manufacturer the treatment will take between 2-7 days to take effect and may provide symptomatic relief last for 2-3 months at which point repeat injections are applied. In some cases the effects may last for more or less time.
Surgical treatments
In cases of BEB associated with dry eye, surgery may be aimed at improving the ocular surface. Minor procedures including occlusion of the tear duct may help to reduce dry eye and BEB.
In severe cases whereby BEB is not responsive to medical treatment more radical surgery may be indicated. This includes surgery to excise the muscle that causes the eyelid to close (orbiculectomy).
Why does my eye water?
Watery eye is very common and there are a variety of different causes. Broadly speaking we divide watery into problems relating to:
- The plumbing system (the tear duct)
- Over production of tears (the tear gland)
- The pump system (the eyelids)
When we review you in clinic it is important to try an establish the cause for your watering before a management plan can be put in place.
What can be wrong with the plumbing?
The tears are produced by the lacrimal gland and roll across the eye and down through the punctum into the tear system and into the nose.
Any block or narrowing along the course the exit system may give rise to a watery eye. This can include narrowing of the plug hole (punctal stenosis) or within the drain system (nasolacrimal duct block or stenosis). Treatments for this include punctoplasty surgery or dacryocystorhinostomy (DCR) surgery depending on the problem.
Why might my eye overproduce tears?
In some cases of watery eye the problem does not relate to a plumbing problem but to the eye over watering. This can be due to the eye being uncomfortable or dry and is known as reflex watering.
Think of your eye like a plant on your kitchen windowsill. If the soil becomes dry and cracked your reaction is often to over water the plant.
Your tear gland does the same thing when the eye is registered by the brain as being dry or sore (1). It over compensates (2) and produces too many tears (3) which gives you a watery eye.
This can often be when you are performing concentration activities such as watching television, computer work or reading. It may also occur when you are in very dry environments such as air conditioning.
The treatment for this type of watery eye is use lubricants to alleviate the symptoms and reduce your tear production by making the eye more comfortable.
How can my eyelids make my eye watery?
When you open and close the eyes you pump the tears down into the tear system. Hence anything which affects the eyelid position may increase watery. This includes ectropion and entropion. Your eyelid position may also contribute to the eye feeling uncomfortable which can give rise to reflex watering.
Dry eye is a very common condition. It occurs as a result of a reduction in the quantity or quality of your tear film. This leads to the eyes feeling irritable and sore. In some cases the eyes will also appear red or injected.
What is the cause of dry eye?
The tear film is made of several layers and is a complex structure. We think of the tear film as three layers.
1. A mucus layer which allows the tear to adhere to the surface of the eye. Any condition which disrupts the conjuctival surface of the eye can prevent the tears adhereing to the surface of the eye.
2. A middle watery (aqueous) layer which is formed by the tear (lacrimal) gland which sits beneath the outer aspect of the upper eyelid. In some cases the lacrimal gland may not produce enough aqueous resulting in dry eye.
3. An oily layer which is produced by the oil or ‘meibomian’ glands. There are a large number of these glands found in both the upper and lower eyelid. Conditions such as blepharitis can result in disruption to oil production. This causes the tears produced by the lacrimal gland to evaporate giving rise to dry eye.
What are the treatments for dry eye?
There are several things that can be done at home to help manage dry eye. In cases of blepharitis, the eyelashes can be cleaned to remove the debris. This can be achieved by filling a cup with warm water and a couple of drops of baby shampoo. This creates a weak detergent that can be used to clean the eyelid using a cotton-tipped ear bud. You should aim to clean the lashes twice a day.
The meibomian glands can be encouraged to secrete their important oils by applying warm compresses twice daily with simultaneous eyelid massage. You can simply apply a warm face cloth to the closed eyes when in the bath or shower for a period of two minutes. Other options include re-usable packs that can be applied to the eyelids such as those made by the Eyebag Company (www.eyebagcompany.com).
Flaxseed oil can be tried as second-line option. Flaxseed oil is rich in omega-3 oil which is though to improve the quality of the tear film and potentially reduce inflammation of the eyelid.
We usually encourage you to keep well hydrated; this maximises your tear production.
Medical treatments
Ocular lubricants can be used to improve the surface of the eye. There are a large number of lubricants available in on the market. Different lubricants will treat different problems. For example a lubricant used for aqueous deficiency (i.e. a reduction in tear production by the tear gland) is different to a lubricant that we might prescribe for oil deficiency (i.e a problem with the oil glands). Mr Norris will discuss with you the best lubricants to use when you are reviewed.
In some cases a steroid or antibiotic may be need to be applied to the eyelid (in the form of either a drop or an ointment) to reduce the inflammation. You shouldn’t use steroid ointments or drops without advice from an Ophthalmologist.
What are punctal plugs?
If you think of your eye as a bath, your dry eye occurs when the bath is empty. This can occur because the ‘tap’ or tear gland does not produce enough tears. One method of improving the surface of the eye (akin to filling the bath) is to put a plug in the tear duct. These are known as punctal plugs and can significantly improve dry eye in cases where lubricants alone are ineffective.
What are the surgical options for dry eye?
In some cases we may cauterise the tear duct or even excise part of the tear duct to stop the tears draining away. Please refer to punctal plug/ punctal cautery section in procedures to read more about this.
Basal cell carcinoma (BCC) is a type of skin cancer that is commonly seen on the face and other sun exposed areas of the body. BCCs are the most common type of skin cancer that exist accounting for over 80% of all skin cancers and can often occur on the eyelids. The prognosis for BCCs is excellent and in most cases can be treated. This type of skin cancer is not usually life threatening unless it is very advanced (which is extremely rare).
Who gets BCCs?
The risk factors for BCCs are as follows:
- People with pale skin and fair hair who burn easily in the sun.
- Previous significant sun exposure or sun-burn.
- Previous sun-bed usage.
- Previous BCCs – about a third of patients will develop a new BCC within 3 years of having a previous BCC treated.
- Long-term immunosuppression (such as chronic use of steroids).
- Radiation exposure
- Rare conditions such as Gorlin syndrome and Xeroderma Pigmentosa that result in multiple lesions.
- BCCs do not tend to run in families (unless associated with conditions such as Gorlin syndrome).
- BCCs tend to occur in more elderly individuals but can occur in people in their 20’s and 30’s.
What are the common symptoms?
Symptoms are variable and several different types of BCC exist. Common symptoms include:
- A raised lesion on the face that does not improve of its own accord and that occasionally may bleed or fail to heal.
- An area of red irritated or scaly skin that doesn’t improve of its own accord.
- Sometimes a BCC may have a ‘pearl’ or ‘shiny’ appearance.
- Occasionally a small ulcer may be present. Such BCCs have historically been called ‘rodent cell ulcers’ as these types of BCC gradually nibble away at the skin getting larger and larger over a period of time.
Can a BCC be treated?
There are many different treatments available for BCCs in depending on which part of the body they occur. These include surgical excision, cryotherapy, radiotherapy and certain types of skin creams. However, BCCs around the eyes are often treated surgically. In Southampton we are able to provide a Mohs Surgery service in conjunction with a dermatologist. This is a very bespoke way of excising BCCs and preserves as much tissue as possible to allow for reconstruction with Raji. Mohs surgery has a good success rate with under 2% of patients having a recurrence of the BCC within the first 5 years.
Discussion with Raji is important to answer any questions that you may have. For information about any additional symptoms you may be suffering from that are not featured within the site, please contact us for more information.
