CHAPTER II Tue Lips (Part 5)

eye of a child it sometimes happens that his lids evert; this is spastic ectropion, and is produced in a different way. The tense, elastic skin of the lid tends to draw the margin of the latter toward that of the orbit, and when a considerable swelling of the conjunctiva presses the margin outward from the eyeball a strong effort on the part of the orbicularis to keep the eye closed will evert the lid. The upper lid is the one generally affected, but THE LIDS 43 sometimes both, or the lower one alone, turn inside out in this man- ner. Once this has happened the peripheral fibers of the orbicularis contract spasmodically and keep the lid in this malposition, a venous engorgement ensues and the conjunctiva forms a thick red swelling; then it may be difficult to turn the lid back, or to keep it in its proper place, for sometimes the swelling is so great that the spasm of the orbicularis produces the eversion spontaneously. This condi- tion is seen most often in phlyctenular keratitis, but is met with occasionally in trachoma. An ectropion is produced in a similar manner when the tarsus is given an abnormal position by a tumor of itself or of the conjunctiva, by a protrusion from the anterior surface of the eyeball, or by exophthalmos. The causal lesion is evident in these cases. A notable example of this form can be seen sometimes in a patient who is suffering from exophthalmic goiter, when he is seized with a very painful spasm of the orbicularis which everts the lids, and perhaps dislocates the eyeball. Congenital ectro- pion is a rare malformation. ENTROPION When a patient complains that his lashes irritate his eyes he may have a few wild hairs, or some fine, white maldirected ones at the inner canthus, but the chances are that he has entropion. If the lashes are arranged normally along the outer edge of the margin of the lid, but are directed nearly parallel to the surface of the eyeball, they will touch the latter occasionally or in places, and we are deal- ing with a very mild degree, or an early stage of entropion, even though the inner edge of the margin of the lid may still be seen. If the lashes are distorted and disarranged the patient has trichiasis also, a combination which we meet with very commonly. When the lashes rub against the eyeball and the inner edge of the margin can no longer be seen the condition is further advanced, and when the lashes are hidden, but can be brought into view by traction on the skin of the lid so as to turn the margin out, it is extreme. Con- genital entropion is very rare. The two varieties of entropion ordinarily met with are the spastic and the cicatricial, the differentiation of which is very important, as they are not amenable to the same treatment. 44 DIAGNOSIS FROM OCULAR SYMPTOMS Spastic Entropion Spastic entropion is met with commonly in old age and therefore has been called senile, but it occurs at all ages. It is produced by the contraction of the orbicularis, but as the strongest contraction of this muscle cannot produce it in a normal lid, the main factor of its production must be sought for elsewhere. We find it in a re- laxed condition of the skin, which ordinarily exerts sufficient tension to keep the margins of the lids almost perpendicular to the surface of the eye. When for any reason, be it a cicatricial contraction on the part of the conjunctiva, or a loss of tone on the part of the skin, the outer edge of the margin overrides the inner in the act of wink- ing, so that the inner edge makes an acute angle with the surface of the eye, the traction of the peripheral fibers of the palpebral por- tion of the muscle tends to make the margin turn in. Lack of nor- mal support on the part of the eyeball produces the same effect, as may be seen after an enucleation, and the eyes of old people are apt to be sunken. Hence the predisposing factors to spastic entropion are a relaxation of the tension of the skin of the lid and a recession of the eyeball; the actuating factor is a contraction of the orbicu- laris. This form frequently is excited by the bandaging of an eye for a few days, as after the extraction of a cataract. Cicatricial Entropion The first thing we do in most cases in which we find the margin of the lid to turn in is to evert the lid and examine its conjunctival surface, for if the conjunctiva has been replaced by cicatricial tissue the contraction of this is ample to account for the condition. Cica- tricial entropion occurs most often after trachoma, but sometimes it follows burns, or pemphigus. As the cicatricial conjunctiva con- tracts the inner edge of the margin is drawn back and rounded off until the intermarginal space is obliterated. This brings the lashes to rub on the surface of the eye, even when they are intact, which rarely is the case. In the great majority of the patients the tarsus has been deformed and the bed of the cilia diseased by the primary affection, so that the entropion is complicated by trichiasis. The symptoms produced are the same as those of the spastic variety, but are much more intense:—pain, a feeling as though a foreign body were in the eye, lacrimation, photophobia, conjunctivitis, keratitis with the formation of ulcers, or of inflammatory opacities. THE LIDS 45 These two varieties often can be differentiated by making vertical traction on the skin of the lid; if this restores the lid to its normal position temporarily the entropion is spastic, otherwise it is cicatricial. THE EYELASHES The eyelashes are placed close together in a double or triple row along the outer edge of the margin of the lid, curve upward on the upper, downward on the lower, so that they do not interlace when the eye is closed, and each lash tapers to a point. Those on the upper lid are longer and twice as numerous as those on the lower. Each lash lives four or five months and then is cast off to be re- placed by another. Sometimes rows of supplementary cilia are found growing from the posterior part of the intermarginal space in lids that otherwise are normal, and usually are described as very fine hairs that occupy the site of the Meibomian glands. I have had the opportunity to observe for a number of years a case in which a row of well formed lashes, of the same color as the others and curving with them, occupies this site in all four lids and has caused no trouble. This is distichiasis. It is congenital and unimportant, except for the fact that it may be mistaken for the condition of trichiasis in which the distorted lashes happen to form a second row. Westhoff is quoted by Ball as saying that sometimes it appears to be hereditary. Occasionally an irregular and confused growth of lashes appears in old people from rudimentary or pathologically altered hair germs. A very rare condition is a hereditary arrest of the growth of each lash at certain points so that each looks beaded and is brittle between the beads. If the lashes are normal in every way except that they are clubbed instead of ending in points, it is probable that they have been cut or singed. The lashes retain their color in age longer than the hairs of the scalp, but finally they become gray. White lashes may be congeni- tal, and sometimes this is true of only a part of them, but colored lashes have been known to turn white rather suddenly in sympa- thetic ophthalmia, in trigeminal neuralgia, after operations on the eye, and even when no cause could be assigned. Roemer says that this has occurred as the result of a fright, and imagines that the effect of the nervous and circulatory disturbance is to deprive the hair papilla of its power to form coloring matter, and to cut off the supply of pigment from the hair trunk. 46 DIAGNOSIS FROM OCULAR SYMPTOMS Some or all of the lashes may be absent. Congenital alopecia forms a part of a universal alopecia due to a fault of development. More often absence of the lashes is due to a cicatrix, or to one of the diseases included under blepharitis, and when it is permanent it shows that the papille have been destroyed. Sometimes the lashes fall out after an attack of an acute infectious disease, like typhoid or scarlet fever, in syphilis, in chronic arsenical poisoning, in exoph- thalmic goiter, and after removal of the thyroid. TRICHIASIS The subjective symptoms of trichiasis are the same as those of entropion, for they are caused in both by the scratching of the sur- face of the eye by the lashes. It is quite exceptional to meet with a case of pure trichiasis in which we find the margin of the lid in its proper position, but with a lot of deformed lashes scattered irregu- larly over the intermarginal space, their points extending in every direction, many of them toward the eyeball. With a magnifying glass and oblique illumination we are able to make out more that are small and colorless, but quite as capable of irritating the eye as the larger ones. The appearance of all these lashes under the mag- nifying glass is such that it has been compared to that of a tangled forest. 'The trichiasis may involve the whole, or only a part of the margin, may affect any one or all four of the lids, and questioning will almost certainly elicit a history of a long standing blepharitis. In the great majority of cases the trichiasis is associated with entro- pion, the lashes are pressed more firmly on the surface of the eyeball, and the irritation is more intense. The cornea may become ulcerated where its epithelium has been scraped off, or the epithelium may become indurated, thick, opaque, and finally be covered by dense vascular opacities. BLEPHARITIS MARGINALIS When the margins of the lids are red and swollen we say that the patient is suffering from blepharitis marginalis, a term which is inclusive of a number of local diseases. We may divide it clinically as well as pathologically into three varieties:—hyperemia, sebor- rhea, and ulcerative blepharitis. THE LIDS 47 Hyperzemia of the Margin of the Lid It is well known that the eyes are apt to “swim in tears,” the lids to be hot and heavy so as to impart a tired, sleepy aspect to the face, to itch and burn, causing the patient to rub them and dis- tracting his attention from his work, and their edges to be red, after a carouse with overindulgence in alcoholic liquor, but it is not so well known that the same symptoms may be produced in certain persons by such slight external irritations as smoke, wind, or a bright light, by eyestrain, by the emotions, and by severe bodily exertions. Yet this is true, and the unfortunate victims are apt to be misjudged harshly as habitually dissipated. Such a condition is not only an impediment to the enjoyment of innocent pleasures by persons who suffer in this way, but has proved a serious obstacle to success in business. A careful differentiation of the cause of a hyperemia of the margins of the lids is imperative. In a doubtful case we may get some help from a chemical analysis of the contents of the stomach, where this shows the presence or absence of alcoholic gastritis. During an attack of acute hyperemia we find the margins of the lids to be very red, with many minute, bright red vessels, and to be slightly swollen, but to present no sores or scabs, no localized foci of inflammation, and no scales, as a rule. The palpebral conjunctiva is injected, the lacrimal secretion is increased. Repeated attacks are apt to result in a chronic condition in which the margins of the lids are constantly red, thick and heavy, with large, distended vessels ranging in color from red to violet. Such patients suffer a great deal from photophobia and exercise much care in protecting their eyes from the light. We have to ascertain the cause as best we can from the history and habits of the patient, as well as from an exam- ination of the eyes for eyestrain. Seborrhea Not infrequently when a patient complains of itching and burn- ing of the margins of the lids we may be able to see little or nothing abnormal at first, except perhaps some little whitish scales about the roots of the lashes. If we rub the lashes these scales become loosened, part fall off, and the rest cling like powder to the lashes and the margin of the lid. After removing these with a bit of wet 48 DIAGNOSIS FROM OCULAR SYMPTOMS cotton the skin is seen to be reddened, but not ulcerated. Once in a while crusts that glue the lashes together will be seen, but they do not cover ulcers and they must not be confounded with the crusts of dried mucus and pus that glue the lashes together in acute con- junctivitis. The scales and crusts of this seborrhea sicca consist of dry sebum with cast off epidermis, and cover colonies of fungi, which probably cause the disease, located on the surface and in the excretory ducts of the glands. The lashes are apt to be loose and some fall out when we rub them, but usually they grow in again un- changed; it is only when the condition has lasted a long time that they become distorted or permanently lost as the result of the ex- tension of the disease to the hair papilla. Sometimes the excessive secretion of sebum from the sebaceous glands is so great that it does not dry into scales, but gives the lashes an oily appearance, although the other symptoms remain about the same; then the disease is called seborrhea oleosa. Although this disease probably is parasitic in origin, its develop- ment and persistence are favored by refractive errors, especially hypermetropia and astigmatism, which increase the congestion of the margin of the lid, a fact that needs to be borne in mind in the treatment of nearly all marginal affections. The irritation may be caused also by crab lice. Lawson says that pediculi capitis have never been known to locate in either the brows or the cilia, even when they were swarming on the scalp. The scales formed at the roots of the lashes are dark from the nits contained in. them, and black nits are to be seen on the lashes themselves, so the condition is recog- nized easily with, the aid of a magnifying glass. We never ascribe such a. condition as this to the demodex folliculorum, which often is to be found on the roots ‘of the lashes, or in the sebaceous follicles, because this parasite very rarely if ever induces any symptoms in man. Blepharitis Ulcerosa When we find ulcers on the margin of the lid beneath the crusts we have to deal with a follicular or perifollicular inflammation of the hair follicles which is commonly referred to as blepharitis ulce- rosa. ‘The largest number of cases are eczematous in their nature and are met with in ill conditioned children; a smaller number ap- pears in adults, among whom sycosis is more common, though ec- zema sometimes occurs. THE LIDS 49 The first stage of an eczematous inflammation of the margin of the lid presents a hyperemia with many little red nodules about as large as pinheads, which quickly become vesicles, forming the second stage. The third stage follows rapidly in which the vesicles change to pustules, which soon rupture, leave erosions, and usher in the fourth stage. The first three stages are apt to escape observation because of the rapidity with which they develop, but the fourth lasts a long time and is the one commonly seen. The margins of the lids are swollen, thick, and covered with crusts that glue the lashes to- gether. Near the crusts we often see pustules, or deep crater-like ulcers with an eyelash protruding from each, as in sycosis, but the surrounding inflammation negatives the probability of the latter; in any case of doubt we should pull out one of these lashes and examine its root under the microscope in search of a tricophyton. As soon as the crusts are removed a depressed raw surface that bleeds easily is revealed. The course of an eczematous blepharitis is very slow, but its ill results may be extreme. The lashes fall out because of the injury done to their follicles, and when the disease is neglected they may not return at all, leaving alopecia, or they may return in faulty positions and present the disarranged and distorted appearance described under trichiasis. At the same time the margin of the lid sometimes becomes inverted or everted, producing entropion or ectropion. Per- haps the most familiar result in a neglected case is a smooth, thick, glazed, everted margin, bordered on the inner side by red, and more or less destitute of lashes, which is a hideous deformity that pro- duces epiphora through its interference with the normal conduction of the tears, with a consequent irritation of the skin. The result is even more horrible when the inner edge of the margin is eroded so as to produce entropion. When the inflammation subsides the formation of crusts lessens and epithelium forms over the erosions, but this is desquamated for some time in the form of whitish scales. This is the stage of healing. The differentiation of the various diseases that are classed together as blepharitis ulcerosa is not so very difficult.