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Lids/Lacrimal

 Trichiasis (ingrowing lashes)

  • Management
    • Epilate (pluck)
  • When to refer
    • if regrow refer to Hospital Eye Service 

Please indicate number of lashes, < 5 refer direct minor ops for electrolysis, if >5 routine clinic as need cryo in theatre

 

Entropion (in turning lid)  

  • Management
    • Tape down away from globe pending surgery.
  • When to refer
    • Refer all as urgent  risk of corneal damage, will probably need corrective surgery
  • For information to see www.eyecaretrust.org.uk

 

Ectropion (out turning lid)

Not dangerous, may cause epiphora (watery eye)/soreness

  • Management: - 
    • Artificial eye drops eg Hypromellose/liquifilm/lacrilube at night if sore to avoid desiccation of conjunctiva

      

  • When to refer: - 
    • Refer as routine if patients wants corrective surgery

 

 Abnormal eyelid mass

 

Suspected skin malignancy

 

           If suspected BCC on lid/medial canthus, or if excision is likely to distort eye lid (with 3mm margin) then to refer urgently to             ophthalmology

 

            If fast growing or suspicious of SCC then refer via          DERMATOLOGY 2WW

 

 

Benign eyelid mass

 

            Only refer if visually disabling

        

            If large lesion then refer direct to oculoplastic specialist clinic

 

 

Small lid masses

  • Only refer if visually disabling or possibility of being malignant.

 

Blepharitis (inflamed lash margins)

  • Chronic lid inflammation managed with
    • Hot compresses
    • Lid hygiene with dilute sodium bicarbonate solution/lid care wipes
    • Artificial tears
    • No make up
    • Chloramphenicol/ fucithalmic ointment if infected
    • Oral tetracycline eg Doxycycline 100mg od for 1 week, then 50mg od for 8 weeks Indication for oral ab’s?
  • When to refer: - 
    • Refer as routine if above have not helped and symptoms severe enough to consider topical steroids.

If lids persistently swollen consider alternative diagnosis eg malignancy

For information and pictures see www.optometry.co.uk (click clinical and search blepharitis)

 

 

Meibomian cyst (nflammatory granuloma caused by obstruction of gland) 

Meibomian cysts (Chalazia) are benign, granulomatous lesions of the upper or lower eyelid that will normally resolve within 6 months with conservative management.

Conservative treatment consists of regular (four times a day) application of heat packs and massage.

Incision and curettage of meibomian cysts will be funded where the following criteria are met:

· The meibomian cyst has been present continuously for more than 6 months

· Where conservative treatment has failed (see above)

AND IS EITHER

· present on the upper eyelid and interfering with vision

OR

· The meibomian cyst is regularly infected (e.g 2 times within six month time frame) and in need of medical treatment for infection

Indications for direct referral

Recurring cysts

Meibomian cysts that keep recurring or have atypical features require biopsy to rule out malignancy.

Diagnostic uncertainty

Suspected eyelid malignancy should be referred for specialist opinion. (please refer to the provider directory of service for guidance as to which clinics these patients should be booked into)

Once it is established that a lesion is a simple meibomian cyst and that it is not malignant its removal will not normally be funded by the NHS though a clinician may request exceptional funding.

Clinicians referring on this basis : https://www.kernowccg.nhs.uk/get-info/individual-funding-requests/

 

Dermatochalasis (excess upper lid skin)

When to refer: - 

  • Only refer if superior visual field defect – see community optom first
  • Routine if eligible

Ptosis

When to refer:

  • Refer to eye casualty if sudden onset ptosis
  • Refer routinely if confirmed superior field defect and patient wants surgery
  • Children <8y if involves visual axis refer to orthoptics urgently  risk of amblyopia

 

Epiphora (watery eye)

If intermittent unlikely to be severe enough for surgery

  • Management & when to refer
    • Exclude lid disease e.g. Malposition, blepharitis
    • Refer to minor ops for syringing, if symptoms affecting sight. If puncti stenosed may need minor dilatation procedure. 
    • If Dacryocystitis
      • treat with systemic antibiotics
      • if severe with pre-septal orbital cellulitis  refer to eye casualty, if resolving refer for routine Mr Westlake clinic may need dacryocystorhinostomy (DCR)
      • For elderly with co-mobidity and mild symptoms, unlikely to benefit from. DCR due to risk of hypotensive GA. Elderly may benefit from sac washout/blepharitis treatment and/or correction of lid malposition, so refer for these as appropriate. P




        Epiphora neonates
  • Management
    • Nasolacrimal duct often perforates within first year
    • Advise lid cleaning and expressing mucus from lacrimal sac
    • Only give fucithalmic ointment if infected.
    • Remember Chlamydia and ophthalmia neonatorum
  • When to refer
    • Refer as routine if epiphora after one year old for syringe and probe.
    • Refer earlier if episode of dacryocystitis.

 

Dry eye

  • Management
    • Exclude lid disease
    • Use lubricant eg Hypromellose, polyvinyl alcohol, carbomer according to severity
    • Avoid air conditioning and smoking
  • When to refer: -
    • Refer to routine clinic only if severe symptoms despite regular lubricant, or staining of cornea.
    • Refer urgently if severe staining, photophobia, loss of vision

 

Thyroid Eye Disease (TED)

  • Management
    • If mild and minimal ophthalmic symptoms treat with topical NSAID or Selenium for 6 months.
  • When to refer
    • Routine clinic for all cases for baseline measurements unless very mild. If diplopia combine with thyroid orthoptic appointment.
    • Eye Casualty if acute onset diplopia, loss of vision, severe proptosis, chemosis (swollen/congested conjunctiva)