The eyelids are located on the surface of the body and are susceptible to inflammatory reactions from microorganisms, wind, dust, and chemicals. The openings for the various glands of the eyelid are mostly located at the lid margin and at the roots of the eyelash follicles, which are susceptible to bacterial infection. The lid margin is the intersection of the skin and mucosa, and lesions of the eyelid skin and conjunctiva can often cause lesions of the lid margin. Because the eyelid skin is thin and the subcutaneous tissue is lax, the eyelid becomes congested and edematous in response to inflammation. I. Blepharitis Blepharitis (hordeolum) is an acute inflammatory condition caused by the invasion of purulent bacteria into the eyelid glands. In the case of infection of the eyelash follicles or their accessory sebaceous glands (Zeis glands) or metaplastic sweat glands (Moll glands), it is called exophthalmos, formerly known as mydriasis. If it is an infection of the lid gland, it is called endophthalmitis. Etiology】Most cases are caused by infection of the eyelid glands by staphylococci, especially Staphylococcus aureus. Clinical manifestations] The affected area shows the typical manifestations of acute inflammation such as redness, swelling, heat, and pain. Pain is usually proportional to the degree of edema. In external blepharitis, the inflammatory response is mainly located at the lid margin at the base of the eyelashes. The redness and swelling are diffuse at the beginning, and on palpation, hard nodules with significant pressure are found; the pain is intense; and the ipsilateral preauricular lymph nodes are enlarged with pressure pain. Pain is particularly pronounced if the external blepharitis is adjacent to the external canthus and may also cause reactive bulbar conjunctival edema. Internal blepharitis is confined to the lid gland and the swelling is more limited; pain is evident; the lesion is hard and painful to palpation; and the conjunctival surface of the lid is confined to congestion, swelling, and yellow pus spots may form 2 to 3 d after the onset of blepharitis. In external blepharitis, the skin develops in the direction of the skin, with localized pus spots and softening of the nodules, which may break down on their own. In internal blepharitis, yellow pus spots often form on the conjunctival surface of the lid and break down into the conjunctival sac, and in a few patients, they may break down into the skin. The inflammation decreases significantly after the blepharitis breaks down and gradually subsides in 1 to 2 days. Most heal within a week or so. It may also resolve on its own without puncture and drainage. In children, the elderly, or patients with chronic wasting diseases such as diabetes mellitus who are weak and have poor resistance, blepharitis can spread to the subcutaneous tissues of the eyelids and develop into eyelid cellulitis if the causative agent is highly virulent. In this case, the entire eyelid is red and swollen and may spread to the ipsilateral side. The eyelid cannot be opened and is hard to the touch, with significant pressure pain and intense reactive edema of the bulbar conjunctiva, which can be exposed beyond the lid fissure, and may be accompanied by systemic symptoms such as fever, chills, and headache. If left untreated, it may sometimes cause sepsis or cavernous sinus thrombosis and endanger life. Diagnosis] The diagnosis is easily made based on the patient’s symptoms and the changes in the eyelid. Bacterial cultures are rarely needed to identify the causative bacteria. Treatment】 ① Early blepharitis should be treated with local heat compresses for 10-15 min each time, 3-4 times daily, in order to promote blood circulation to the eyelids, relieve symptoms, and promote inflammation subsidence. Antibiotic eye drops should be administered 4 to 6 times daily. For recurrent episodes and those with systemic reactions, oral antibiotic drugs can be administered to control the infection. ② When an abscess has formed, an incision should be made to drain the pus. The incision for external blepharitis should be made on the skin surface, with the incision parallel to the lid margin so that it is in line with the eyelid skin pattern to minimize scarring. If the abscess is large, drainage strips should be placed. The incision for endophthalmitis is often on the conjunctival surface of the lid with the incision perpendicular to the lid margin to avoid excessive injury to the lid ducts. ③ When an abscess has not yet formed it should not be incised, much less squeezed to drain the pus, as this can spread the infection and lead to life-threatening eyelid cellulitis or even cavernous sinus septicemia or sepsis. Once this happens, a full dose of broad-spectrum antibiotics that inhibit mainly Staphylococcus aureus should be administered systemically as soon as possible, and bacterial cultures or drug sensitivity tests should be performed on the pus or blood to select more sensitive antibiotics. The condition should also be closely monitored for early detection of orbital and intracranial spread and signs of sepsis for appropriate management. II. Chalazion Cyst A chalazion is an idiopathic aseptic chronic granulomatous inflammation of the lid gland, previously known as a chalazion. It has a fibrous connective tissue envelope containing secretions from the lid gland and a chronic inflammatory cell infiltrate including giant cells. It resembles a tuberculous nodule in its pathologic pattern, but does not form caseous necrosis. Etiology] It may be caused by chronic conjunctivitis or blepharitis that leads to obstruction of the outlet of the lid gland and retention of glandular secretions in the lid, resulting in chronic irritation of the surrounding tissues. Clinical manifestations] It is most often seen in adolescents or middle-aged adults and may be related to the high secretion function of their lid glands. It usually occurs in the upper eyelid, but can also occur in the upper or lower eyelid or in both eyes, either singly or in multiple eyes, and is often recurrent. The course of the disease progresses slowly. They appear as round subcutaneous masses of varying sizes. Small cysts can be detected only by careful palpation. Larger ones may elevate the skin but are not adherent to it. Large masses may compress the eye, producing astigmatism and loss of vision. The conjunctival surface of the lid corresponding to the mass is a purplish or gray-red lesion. There is usually no pain and no significant pressure on the mass. Some patients may begin with mild inflammatory manifestations and tenderness without the acute inflammatory manifestations of blepharitis. Small cysts may resorb on their own. However, most remain unchanged for a long period of time or gradually grow in size and become softer in texture. They may also rupture on their own, discharging gelatinous contents and forming granulomas on the conjunctival surface of the lid or dark purplish-red granulation tissue under the skin. If there is a secondary infection, the lid cyst forms an acute purulent inflammation with the same clinical presentation as endophthalmitis. Diagnosis] The diagnosis is based on the absence of significant pain and hard lid nodules in the patient. In recurrent or elderly blepharocysts, the excised material should be examined pathologically to exclude blepharocarcinoma. When a blepharocyst is secondary to infection the clinical presentation is identical to that of endophthalmitis. The point of differentiation is that the presence of a painless mass before the onset of endophthalmitis is secondary to infection of the blepharocyst. In the case of a small, asymptomatic blepharocyst, no treatment is necessary and it is left to absorb on its own. Large cysts can be treated with heat or glucocorticoid injections into the cyst to promote absorption. (3) If it does not subside, it should be removed surgically under local anesthesia. The surgery is performed by using a lid gland cyst clamp to hold the turned eyelid so that the cyst lies within the ring of the clamp, cutting the cyst with a sharp knife with the incision perpendicular to the lid margin, scraping the cyst contents cleanly with a small sharp spoon, and cutting away the separated cyst wall to prevent recurrence. III. Blepharitis Blepharitis (blepharitis) is a subacute or chronic inflammation of the surface of the lid margin, the eyelash follicles, and their glandular tissue. There are three main types of blepharitis: squamous, ulcerative, and canthal: (a) Squamous blepharitis is a chronic inflammation caused by seborrhea from the lid margin. Etiology] The affected area is often found with pityrosporum ovale, which breaks down lipid material into irritating fatty acids. In addition, refractive error, visual fatigue, malnutrition, and long-term use of poor quality cosmetics may also be the cause. The lid margins are congested and flushed, with epithelial scales attached to the eyelashes and lid margins, and pitting sebum on the lid margins. Removal of the scales and scabs exposes a congested lid margin without ulcers or pus spots. The eyelashes fall off easily but can be regenerated. Patients experience itching, stinging and burning sensations in the eyes. If left untreated for a long time, the lid margin may become hypertrophied and the posterior lip bluntly rounded, so that the lid margin cannot come into close contact with the eye and the tear dots swell and turn out, resulting in tear overflow. The diagnosis is based on the typical clinical presentation and the absence of ulcers on the lid margin. Treatment】 ① Remove the causative factors and avoid irritants. If there is refractive error, it should be corrected. If there is a systemic chronic disease, it should be treated at the same time. In addition, attention should be paid to nutrition and physical exercise to enhance body resistance, keep bowel movements smooth, and reduce stimulation by smoking and alcohol. Clean the lid margin with saline or 3% boric acid solution, wipe off the scales and apply antibiotic eye ointment 2 to 3 times daily. This can be done once a day for at least 2 weeks after healing to prevent recurrence. (b) Ulcerative blepharitis is a chronic or subacute purulent inflammation of the eyelash follicles and their accessory glands. The majority of cases are caused by Staphylococcus aureus infection, but can also be transformed from scaly blepharitis to ulcerative blepharitis. Refractive error, visual fatigue, malnutrition, and poor hygiene may also be the causes. Clinical manifestations] Most commonly seen in children with malnutrition, anemia, or chronic systemic disease. As with scaly blepharitis, patients have itching, stinging, and burning sensations in the eyes, but they are more severe. There is more sebum on the lid margin, small pustules scattered at the roots of the eyelashes, and a scab covering the eyelashes, which are often cemented into bundles by the dried scabs. Removal of the scabs reveals the root of the eyelashes and small, shallow ulcers. The eyelash follicles are destroyed by the infection and the eyelashes tend to fall out with the scabs and cannot regenerate, resulting in bald eyelashes. After the ulcer heals, the scar tissue shrinks, causing the eyelashes to grow in a different direction, resulting in disorderly growth. If the disease is prolonged, it can cause chronic conjunctivitis and ciliary edge hypertrophy and deformation, ciliary edge ectropion, swelling or obstruction of the tear dots, resulting in tear overflow. The diagnosis is based on the typical clinical presentation and the presence of ulcers on the lid margin. Treatment] Ulcerative blepharitis is more stubborn and difficult to treat. It is best to perform bacterial culture and drug sensitivity tests, and sensitive drugs should be selected for active treatment. ① All causative factors should be removed and personal hygiene should be observed. ② Clean the lid margin daily with saline or 3% boric acid solution to remove pus crusts and eyelashes that have been loosened and remove pus from the follicles. Then massage the lid margin with a cotton swab coated with antibiotic eye ointment four times a day. (iii) After the inflammation has completely subsided, treatment should be continued for at least 2 to 3 weeks to prevent recurrence. (iii) Angular blepharitis [Etiology] Mostly caused by Morax-A (Morax-Axenfeld) bifidus infection. It may also be related to vitamin B2 deficiency. Clinical manifestations】 The disease is mostly bilateral and mainly occurs in the outer canthus. Patients experience itching, foreign body sensation, and burning sensation in the eyes. The lid margin and skin of the external canthus are congested, swollen, and infiltrated with vesicles. The adjacent conjunctiva is often chronically inflamed, showing congestion, hypertrophy, and mucous discharge. In severe cases, the inner canthus may also be involved. Diagnosis】 Based on the typical clinical manifestations, the diagnosis can be made. Treatment】 ① Use 0.25% to 0.5% zinc sulfate eye drops 3-4 times a day. This drug can inhibit the enzymes produced by Mo-Abis bacillus. ②Appropriate administration of vitamin B2 or vitamin B complex may be helpful. ③If chronic conjunctivitis is present, it should be treated at the same time. IV. Viral palpebral dermatitis Viral palpebral dermatitis is less common than bacterial infections of the eyelids and has the following two main types. (a) Herpes simplex virus blepharitis [etiology] Acute periocular skin disease caused by herpes simplex virus type I infection, often recurrent. The virus is usually present in the body and tends to become active when there is a cold, high fever, or low body resistance. It is also known as febrile herpes blepharitis because febrile illnesses can often cause the disease. Most herpes simplex viral blepharitis of the eyelids is recurrent and often recurs multiple times in the same area when induced by the above mentioned triggers. The lesions can occur on both the upper and lower lids, with the lower lid being the most common, consistent with the distribution of the infraorbital branch of the trigeminal nerve. Initially, papules appear on the skin of the lid, often in clusters, and soon form translucent blisters surrounded by a red halo. Eyelid edema. There is a tingling, burning sensation in the eye. The blisters break easily and ooze a yellow, sticky fluid. After about 1 week, the congestion decreases, the swelling decreases, the blisters dry up, and the crusts fall off without scarring, but there may be mild hyperpigmentation. Recurrence is possible. If it occurs at the lid margin, there is a possibility of spreading to the cornea. The same damage can occur on the lips and nasal vestibule. Diagnosis】 Based on the medical history and typical ocular manifestations, the diagnosis can be made. Treatment】 ① Keep the eye clean to prevent secondary infection. Do not rub the eye. ②Inside the conjunctival sac, apply 0.1% acyclic guanosine drops to prevent spreading to the cornea. ③Apply 3% acyclic guanosine ophthalmic ointment or 0.5% herpes net ophthalmic ointment to the skin lesions. (B) Herpes zoster virus blepharitis [Etiology] caused by varicella-zoster virus infection of the trigeminal nerve hemimelia or the first branch of the trigeminal nerve. The clinical manifestations] Before the onset of the disease, there are often mild and severe prodromal symptoms, such as general malaise and fever. Then severe neuralgia appears in the lesion area. A few days later, the affected eyelids, forehead skin and scalp are flushed and swollen, and clusters of small transparent blisters appear. The distribution of the herpes does not cross the central boundary of the lid and nose (Figure 4-4). The base of the blisters has a red halo, and the skin between the blisters is normal. After a few days, the fluid within the herpes becomes cloudy and purulent, forming a deep ulcer. About 2 weeks later, the scabs fall off. Because the lesions reach deep into the dermis, permanent skin scars are left after debridement. After the inflammation subsides, it takes several months for the skin sensation to return. Herpes zoster keratitis or iritis of the ipsilateral eye can occur at the same time, and this is more likely when the nasociliary nerve is involved and herpes appears on the nose. Diagnosis】 Based on the medical history and typical ocular manifestations, the diagnosis can be made. Treatment】 ①Appropriate rest should be taken to improve body resistance. Give analgesics and sedatives if necessary. ②No local medication is needed when the herpes is unruptured. If the herpes breaks down without secondary infection, the affected area can be coated with 3% acyclic guanosine ophthalmic ointment or 0.5% herpes net ophthalmic ointment. If there is secondary infection, antibiotic ophthalmic solution can be added as a wet compress 2 to 3 times a day. Use 0.1% acyclic guanosine drops in the conjunctival sac to prevent corneal involvement. ③ Systemic application of acyclic guanosine, antibiotics and glucocorticoids is required for severe cases. Contact dermatitis of lids is an allergic reaction of the eyelid skin to an allergen, and can also be part of an allergic reaction to the skin of the head and face. Etiology] Drug dermatitis is the most typical. Common allergens are topically applied antibiotics, local anesthetics, atropine, trichothecene, iodine, mercury, and other preparations to the eye. Many chemicals that come into contact with the eyelids, such as cosmetics, hair dyes, medical tape, contact lens care solutions, and eyeglass frames, may also be allergens. Whole body exposure to certain allergenic substances or certain foods can also occur. Sometimes the disease develops only after a period of exposure to allergens, such as in patients with long-term use of atropine or trichothecene eye drops. Clinical manifestations】 Patients feel itching and burning sensation in the eyes. In acute cases, the eyelids become red and swollen, and papules, blisters or pustules appear on the skin, accompanied by yellowish mucous exudate. The skin soon becomes crusty and flaky. Sometimes the lid conjunctiva is hypertrophic and congested. In subacute cases, symptoms occur more slowly, but often persist. In chronic cases, the skin of the lid is thickened and rough, with a scaly surface and a mossy appearance, which can result from acute or subacute eczema. The diagnosis is based on the history of exposure to allergens and the clinical manifestations of eczema of the eyelid skin. However, the only accurate way to distinguish between allergic or irritant dermatitis is to perform a patch test. Treatment】 ① Stop exposure to the allergen immediately. If the patient applies multiple drugs at the same time and it is difficult to identify which drug is causing the allergy, suspend all drugs. Apply saline or 3% boric acid solution as a wet compress in the acute stage. Apply glucocorticoid eye drops in the conjunctival sac. After the oozing of the eyelid skin stops, glucocorticoid eye ointment can be applied, but should not be bandaged. Apply antihistamines systemically. Oral prednisone may be administered in severe reactions.