Anatomy.- The eyelids form the external covering of the eyeballs and serve to protect the eye from injury both from excessive light and foreign substances; they also serve at the same time to distribute to the eyes the moisture secreted by the various glands.
The eyelids or palpebrae, are two thin movable folds, the upper being the larger and more movable of the two; their movement is both voluntary and involuntary, the latter action being due to the orbicularis muscle. The opening of the lids is chiefly by the action of the levator palpebrae superiors lifting the upper lid; when opened an elliptical space is left between the margins of the lids; this opening varies greatly, being larger in prominent eyes than in sunken ones and greater when looking upward. The angles of junction of the upper and lower lids are called canthi the outer canthus is more acute than the inner; near the extremity of the inner canthus is found on both the upper and lower lids a slight elevation, the apex of which is pierced by a small orifice, the punctum lachrymale, the commencement of the small channel or canaliculus leading to the tear sac.
The eyelids are composed of four layers, arranged from without inward in the following order, the integument, a layer of muscular fibres, the tarsus or as often erroneously called the tarsal cartilage, and the conjunctiva. The integument, which is extremely thin but similar in every other respect to the integument elsewhere, becomes at the margin of the lids, conjunctiva. The integument which is extremely thin but similar in every other respect to the integument elsewhere becomes, at the margin of the lids, continuous with the conjunctiva. Beneath the skin the connective tissue is loose and contains no fat.
The muscular fibres consist of the orbicularis palpebrarum a large flat, voluntary muscle extending over the orbital margins above and below and terminating by tendinous attachments at the angles of the lids, the tendons, together with some fibres of the muscle, being inserted in the adjacent bony wall. The fibres of the orbicularis which lie upon the tarsi are paler than the others, and certain bundles of these give to the lid its involuntary action are known as the ciliary muscles of Riolani. The orbicularis is somewhat adherent to the skin, but glides loosely over the tarsus. It receives its nerve supply from the facial. Its fibres being more or less circular in arrangement, and acting as a sphincter serve to close the eyes.
The levator palpebrae superioris arises at the apex of the orbit, and passing along its upper wall becomes intermingled in front of the tarsus with the orbicularis; other fibres become attached to the upper edge of the tarsus, and still others go to the conjunctiva. This muscle is supplied by a branch from the third nerve and its action, is as its name implies, to raise the upper lid. The lower lid is supplied with a prolongation from the inferior rectus, whose insertion and action is analogous to that of the levator palpebrae.
The tarsi are two thin, elongated plates composed of condensed fibrous tissue, and serve to form the framework of the lids; they are united to each other and to the adjacent bone through the medium of the internal and external lateral ligaments.
The conjunctiva is a delicate mucous membrane which commences at the free border of the lid where it is continuous with the skin; it lines the inner surface of the lids and is then reflected upon the globe, over which it passes and becomes continuous with the cornea. The palpebral portion is thicker and more vascular than that covering the globe and is firmly attached to the tarsus. Where it passes from the lids to the globe it is thin and loose, and forms what are called the fornix conjunctiva. The plica semilunaris is a vertical fold of conjunctiva at the inner canthus, and the reddish elevation at the inner angles is called the caruncula lachrymalis.
The cilia are short, thick, curved hairs, arranged in double or triple rows at the margins of the lids; their follicles are surrounded by sebaceous glands and the glands of Moll. Within the tarsus are embedded the Meibomian glands, which in structure resemble the sebaceous glands. These various glands by their secretions serve to lubricate the eye, and discharge their secretion through excretory ducts opening by minute orifices upon the free border of the lids between the rows of cilia.
Blepharitis._ (Blepharitis Simplex, Blepharo-Adenitis, Blepharitis Ciliaris, Blepharitis Marginalis, Seborrhoea; Blepharitis Ulcerosa, Blepharitis Hypertrophica or Squamosa) Under this general heading inflammation of the lids, we shall group the various clinical sub-divisions. The numerous names (of which the above are but few) that have been given to an inflammation involving the border of the eyelids may be all grouped under two headings-non-ulcerative and ulcerative blepharitis.
SYMPTOMS.- The non-ulcerative form commences as a simple hyperaemia of the lid-border, which gives to the lids a red, swollen appearance. This is accompanied by a slight burning and smarting in the eyelids which is aggravated by cold winds, smoke, dust, exposure to bright light or use of the eyes at close work. There is agglutination of the eyelids in the morning, with dry scales or scabs adhering to the margins of the lids and more or less photophobia and lachrymation are present. This variety depends upon an abnormal secretion of the sebaceous glands.
The ulcerative variety may be considered as an extension of the preceding form. If we remove with the forceps the yellow crusts surrounding and embedding the cilia which have formed through neglect in the previous stage we find a red, bleeding ulcerative surface. This surface to secrete pus that forms other crusts, and by extension of the ulceration the entire edge of the lid may become involved. At this stage the disease is know as blepharitis ulcerosa, and as it advances the edge of the lid not only becomes red and covered with scales, but considerably thickened, and it is then termed blepharitis hypertrophica. It the disease still continues unchecked it involves the hair follicles and causes the lashes to become stunted and misplaced (trichiasis), or to fall out, and when entirely wanting we have the condition known as (medarosis). The final stage of the disease is when the lid itself becomes rounded, red, thickened, everted and deprived of lashes (lippitudo).
COURSE.- The course of the disease is usually very chronic and yet should be cured by thorough and prolonged treatment.
CAUSES: The disease is especially the result of refractive errors in young, delicate persons of a strumous diathesis. As the causes are so closely associated with the treatment, they will be considered further under that heading.
TREATMENT.- First, we should examine the refraction and if any error is found, correct the same with the proper glass as in many cases this alone will cure the entire trouble.
In rare cases the presence of lice on the eyelashes may be the exciting cause (phthiriasis ciliarum), when we should be careful to remove them and apply either cosmoline or some mercurial ointment, which will destroy them and prevent their recurrence.
Fungous growths in the hair follicles are also said to cause this disease, in which case the hairs should be extirpated, and either external or internal medication employed.
Another cause is frequently found in affections of the lachrymal canal, particularly catarrh of the lachrymal sac and stricture of the duct; in these cases the tears, being hindered from flowing through their natural passage into the nose collect in the eye, flow over the lids and down the cheek; thus the retention of the tears will cause an inflammation of the margins and eventually of the whole structure of the lids. Any other affection which will have the same result (flowing of the tears over the lids) will of course, produce the same trouble and this is often found in slight degrees of eversion of the lower lids (ectropium), which displaces the puncta lachrymalis and thus prevents the tears from passing into the sac. In all such cases the first thing to be done is to open the canaliculus into the sac, and, if necessary, the nasal duct into the nose so as to give a free passage for the tears into that organs, after which the treatment is the same as in uncomplicated cases.
But the most common causes of ciliary blepharitis are exposure to wind, dust, smoke etc., especially when complicated with want of cleanliness; it is for this reason we see this trouble so frequently among the poorer classes. As it is upon this point-cleanliness -that the success of our treatment depends to a great extent, we should impress upon the patient is mind the necessity of it in terms as forcible as possible.
They should be directed to remove the scales or crusts from the margins of the lids as soon as formed, not allowing them to remain even a few minutes. This should not be done by rubbing, as the patient is inclined to do on account of the itching sensation, for by so doing excoriations are made, lymph is thrown out and new scabs form, which only aggravate the inflammation. But they should be directed to moisten the crusts in warm water and then carefully remove them with piece of fine linen or by drawing the cilia between the thumb and fingers; at the same time gentle traction may be made on the lashes, so as to remove all that are loose as they act only as foreign bodies. Sometimes the scabs are so thick and firm that moistening in warm water is not sufficient to remove them; in such cases, hot compresses or poultices should be applied for ten or twenty minutes at a time until they can be easily taken away.
Professor of Ophthalmology in the College of the New York Ophthalmic Hospital; Surgeon to the New York Ophthalmic Hospital. Visiting Oculist to the Laura Franklin Free Hospital for Children; Ex-President American Homoeopathic Ophthalmological, Otological and Laryngological Society. First Vice-President American Institute of Homoeopathy : President Homoeopathic Medical Society of the State of New York ; Editor Homoeopathic Eye. Ear and Throat Journal : Associate Editor. Department of Ophthalmology, North American Journal of Homoeopathy, etc.