Chalazia are cysts in the substance of the lid caused by a blockage in the meibomian gland. In the upper lid there are around 20 of these and in the lower there are around 24. They are corkscrew-shaped glands that exit on the lid margin and are filled with a cheesy, oily material, which is not particularly liquid at skin temperature. Obstruction to these glands unfortunately causes a backup and the material then ruptures out of the gland and into the tissue around into, producing an intense inflammation, which then gradually walls off, producing a pellet-sized cyst.
There are three strategies for dealing with chalazia.
The first is watch and wait and allow them to gradually go. This can take some months and if they are in an obvious position, it may not be reasonable to wait.
The second is to inject them with steroid, which, although does not get rid of the actual underlying lump, reduces the inflammation markedly and will often make the problem much less obvious.
The third option is to incise and curette the lump, to remove the cheesy sort of material and allow it to settle down. Even this does not get rid of some of the residual shell, which takes even a few weeks to resolve. This is the quickest way to resolution but does require a small procedure on the lid.
Often it is suggested that patients perform heat and compress when they get a cyst. Heat and compress is where the eyelid is heated up and the meibomian glands massaged towards the lid margin (down from above, and up from below). The value of this is to reduce the amount of trapped meibomian secretion within the glands, but it is not helpful once a cyst has formed.
Blepharitis is a catchall term to describe inflammation of the margin of the lid. It is an unusually common condition as the margin of the lid is a particularly delicate and sensitive area.
Blepharitis often produces stinging or burning eyes, and can reduce the vision a little bit as it reduces the integrity of the tear film and the surface of the eye.
Blepharitis can be associated with skin conditions, including rosacea and dermatitis, but it can exist on its own as well.
We recognise two basic types of blepharitis. One is an anterior blepharitis, which produces a scaly sort of material in and around the eyelashes. This is best treated with some form of detergent material to gently remove the scaling material, which can form on the tear film and make the eyes uncomfortable. We would recommend products such as Lid Care or SteriLid as over-the-counter products that work well for this.
Posterior blepharitis is related to obstruction to meibomian glands and is better treated with heat and compress, and sometimes some antibiotic ointment. Heat and compress is required to be correctly applied. Heat is usually in the form of a face washer or a heat pack, allowing the lid to become really quite warm. The reason or this is to make the meibomian glands more liquid and allow their discharge to the surface to be more effective. Massage needs to occur aimed at discharging these glands across the full length of the lid to the lid margin. Generally starting around the centre and moving towards the lid margin with the fingertip is a good way to improve the drainage of these glands.
A watery eye is due to an imbalance between the amount of tear production and the amount of tear outflow.
Tear production is by the lacrimal gland, which is up in the upper outer part of the area where the eye is, and underneath the upper lid. Tear outflow occurs on the nose side and down into the nose.
We make more tears at certain times, such as when the eye is irritated or wind is blowing or emotional crying, and if we make enough tears it will overflow even a normal drainage system. However it is much easier to overflow a drainage system that is partially or completely blocked. At rest most tears are evaporated, so even a completely obstructed tear outflow system may not water and it may be only under stress that it does so.
A key differentiation though is to establish whether or not the problem is mostly irritation and increased tear production, or obstruction and decreased tear outflow.
Outflow can be tested and sometimes improved with nasolacrimal duct lavage, or so-called sac “washout”. This is a procedure done in the office and can help tears traverse down the outflow a little bit better, or at least identify where and if there is an obstruction.
Conjunctivitis literally means inflammation of the conjunctiva, which is the lining underneath the lid and around the edge of the eye. Conjunctivitis can be infective or non-infective, and out of the infective ones, it can be viral or bacterial.
Conjunctivitis produces a red eye and a change in the tear film often to make it sticky or thick, and usually affects the quality of the vision and makes the eye uncomfortable.
Bad conjunctivitis can be very disabling and mild conjunctivitis just annoying.
Children get conjunctivitis in the epidemic proportions, but most of the causes there are viral and are often not viruses that cause conjunctivitis in adults.
There are forms of conjunctivitis that are particularly nasty and affect the front surface of the eye, called keratoconjunctivitis, and these are quite infective.
A relatively common cause of conjunctivitis is Herpes virus (HSV 1 – like the cold sore) and can affect the conjunctiva and sometimes the lid margin, particularly in the first infection.
Conjunctivitis is often treated with Chlorsig drops, but Chlorsig drops are of limited value and often it is better for us to identify the underlying cause and apply other more effective antibiotic or more specific treatment to the underlying cause.
Sometimes conjunctivitis does not have a clear cause and we will apply supportive treatment and sometimes some anti-inflammatories.
Dry eye is a term that covers a multitude of problems on the surface of the eye. Many of these are better termed tear film instability rather than truly dry eye, but they all have symptoms in common, which are discomfort and loss of clarity of vision. Both the discomfort and loss of clarity are intermittent, and often related to tiredness and weather.
There are a number of lubricants available on the market and they have different thicknesses and components. In general there are thin, quite watery lubricants, which get gradually thicker and still water-based, until they become a gel. Finally we add oil-based lubricants if the problems is somewhat intractable. Oil-based ointments work better overnight and certainly work better if the lid is involved.
Some lubricants seem to suit some people and not others, and often a trial of a number of them is required to find the one that suits you the best.
As we age, the complex structures of the lids that allow them to sit gently opposed to the surface of the eye and blink easily without abrading the surface eye can become damaged or dysfunctional. As the lid loosens, the lid might turn out, an ectropion, or roll over and inwards, an entropion.
Loosening of the lower eyelid can contribute to watering of the eye – if the lid turns out then the puncta, the drain plug, may not be in contact with the tear film anymore.
Many of the lower lid problems are amenable to relatively surgical solutions, such as tightening of the lid, either at the nose end or at the temple side.
The upper lid most common problem suffered from is ptosis, or dropping of the lid, which most often is due to stretching of the muscle that holds the upper lid in place. Stretching may require the lid muscle to be tightened, a process which can either occur through the skin or through the under surface of the lid.
Flashes and Floaters
These commonly accompany each other. Floaters are things that appear in the vision and may range from small, dot-like things, to larger translucent objects, to quite dense cobwebs, and even to the point where the vision is quite obscured.
Floaters are opacities in the vitreous, in the jelly in the back part of the eye, and usually indicate that the vitreous has changed in character and structure, as it does so, sometimes with inflammation, but often just with age.
Flashes occur when the retina is distorted. The vitreous (the jelly in the back of the eye) attaches to the retina and as the vitreous changes with age it can pull on the retina, producing a flash of light. These are most often in the dark when the eye is moved. The flash is brief, but often quite bright, in the far periphery.
New onset of floaters and flashes of light do require review and this should occur on a semi-urgent basis.
Mostly infections around the eye are in the eyelid or in the tear sac to the nose side. Infections in the eyelid can be quite significant and can even involve the tissue around the eye, so called the orbit. Diffuse infections are called cellulitis and can be a significant risk. Anything that is a swelling in the upper or lower lid, which seems to be expanding rapidly, needs to be attended to as a matter or urgency.