Eyelid and Lacrimal System

The eyelids are small delicate structures that provide protection and work together with the lacrimal system to maintain the health of the eye. The tear film on the surface of the eye is a critical component of maintaining vision. Tears nourish and lubricate the surface of the eye as well as wash away debris. A smooth, balanced tear film, consisting of water, oil, and mucus, also allows light to enter the eye in an optimal fashion. If there is a disturbance of the tear film, patients will often experience tearing, burning, irritation, and most importantly, blurred vision. Patients who experience tearing either have a problem with tear production, tear drainage, or the eyelids.

Dry eye and increased tearing – The eye has two sets of structures that produce tears. Smaller tear glands help maintain a baseline level of moisture on the surface of the eye. As tear production diminishes, the surface of the eye starts to dry out. Further, inflammation of the oil glands along the edge of the eyelid also causes early breakdown and evaporation of the tear film. The brain senses the eye is both dry and irritated and in turn, signals the main tear gland to flush the eye. As a result, the dry eye ironically tears and becomes watery. Patients with dry eyes note intermittent tearing of the eyes during activities like reading, driving, watching TV, using a computer, or going outside on a windy day. These all cause the eye to dry out because the eye blinks less during these activities. The treatment for dry eyes includes replacing tears with artificial lubricants which can be bought over the counter, medications like Restasis that decrease inflammation in tear glands and encourages natural tear production to resume and plugging of the tear drain. Other causes of increased tear production include allergies, infections, and eyelashes poking the eye.

Blocked tear duct – An obstruction of the tear ducts may occur due to numerous reasons such as aging, trauma, inflammatory conditions, medications, and tumors and cause numerous signs and symptoms ranging from wateriness or tearing to discharge, swelling, pain, and infection. These signs and symptoms may result from the tear drainage system becoming obstructed at any point from the punctum to the nasal cavity. Depending on symptoms and their severity, doctors will suggest an appropriate course. In mild cases, treatment of warm compresses and antibiotics may be recommended. In more severe cases, surgical intervention to bypass the tear duct obstruction may be recommended.

Blepharitis – it is a common condition that causes inflammation of the eyelids. Anterior blepharitis affects the outside of the eyelid where the eyelashes are attached. It is commonly caused by bacteria and dandruff. Posterior dandruff affects the inner eyelid and is caused by problems with the meibomian (oil) glands. It is commonly caused by acne, rosacea, and dandruff.

Symptoms include:

  • A foreign body situation
  • Burning
  • Excessive tearing
  • Light sensitivity
  • Red and swollen eyelids
  • Dry eye
  • Crusting on the eyelashes

It is treated by using warm compresses to loosen crusting and dead skin cells, followed by lids scrubs. Packaged over-the-counter lids scrubs can be purchased or you can dilute baby shampoo with water and apply it to a washcloth. Because the eyelids can be tender, it is often tempting to be gentle with the lid scrub but if they are not scrubbed properly the treatment will not be effective. Because blepharitis rarely goes away completely, most patients must maintain lid hygiene for life. If there are episodes that become severe, antibiotic or steroid eye medications can be prescribed. Massaging the edges of the eyelids along the eyelashes can help express any oil that is trapped in the meibomian glands that, if left unaddressed, can lead to styes.

Chalazion – A chalazion is caused by a blocked duct in one of the meibomian glands. These glands are located in the eyelid directly behind the eyelashes and produce a thin, oily fluid that lubricates the eye. If it becomes infected it is referred to as a stye or a hordeolum. The eyelid usually becomes tender, red, swollen, and warm. A chalazion will often disappear without treatment in a month or so. The first treatment is to place warm compresses over the eyelid for 10-15 minutes at least four times a day. Use water that is no hotter than you can leave your hand in comfortably. This may soften the hardened oils blocking the duct, and promote drainage and healing. Massaging the eyelid can help express oil from the gland once it has been warmed from the compress. If the chalazion continues to get bigger, it may need to be removed with a minor procedure. This is most often done from the inside of the eyelid to avoid a scar on the skin.

Ectropion – Ectropion means that the lower eyelid is rolled out away from the eye, or is sagging away from the eye. The sagging lower eyelid leaves the eye exposed and dry. If it is not treated, the condition can lead to chronic tearing, eye irritation, redness, pain, sandy feeling, crusting of the eyelid, mucous discharge, and breakdown of the cornea due to exposure. The condition is usually the result of tissue relaxation associated with aging, although it may also occur as a result of facial nerve paralysis due to Bell’s palsy, stroke or other neurologic conditions, trauma, scarring, previous surgeries, or skin cancer. Normally, the upper and lower eyelids close tightly, protecting the eye from damage and preventing tear evaporation. If the edge of one eyelid turns outward, the wet, inner, conjunctival surface is exposed and visible because the two eyelids cannot meet properly and tears are not spread evenly over the eye. Ectropion can be surgically repaired and most patients experience immediate resolution with little, if any, post-op discomfort.

Entropion – Entropion is a condition in which the eyelid is rolled inward toward the eye. It can occur as a result of advancing age and weakening of certain eyelid muscles. Entropion may also occur as a result of trauma, scarring, or previous surgeries. A turned in eyelid rubs against the eye, making it red, irritated, painful, and sensitive to light and wind. If it is not treated, the condition can lead to excessive tearing, mucous discharge, and scratching or scarring of the cornea. A chronically turned in the eyelid can result in acute sensitivity to light and may lead to eye infections, corneal abrasions, or corneal ulcers. If entropion exists, it is important to have a doctor repair the condition before permanent damage to the eye occurs.

Dermatochalasis – As we age, the tone and shape of our eyelids can loosen and sag. Heredity and sun exposure also contribute to this process. If the sagging upper eyelid skin obstructs peripheral vision, it is not a cosmetic issue but is a medical condition. A surgical procedure called blepharoplasty can remove the excess skin and fat to eliminate the obstruction and expand the visual field.