Management of Internal Hordeolum, Essays (university) of Medicine

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INTERNAL HORDEOLUM

A. Palpebra Anatomy The superior and inferior lids are modified skin folds that can cover and protect the anterior part of the eyeball. Palpebra consists of five main networks. From the superficial to the inside there is a layer of skin, a layer of skeletal muscle (orbicularis oculi), areolar tissue, fibrous tissue (tarsus), and a layer of mucous membrane (pelpebral conjunctiva).

1. Skin The skin on the lids differs from skin on other parts of the body in that it is thin, loose, and elastic, with few hair follicles, and no subcutaneous fat.
2. The orbicularis oculi muscle The function of this muscle is to close the lids. Its muscle fibers surround the palpebral fissure concentrically and extend slightly beyond the orbital rim. Some of the fibers run down the cheeks and forehead. The portion of the muscle contained within the lids is known as the pretarsal portion; The portion above the orbital septum is the preseptal portion. The outer segment of the lids is called the orbital portion. The orbicularis oculi is innervated by the facial nerve.
3. areolar tissue Located beneath the orbicularis oculi muscle, connected to the subaponeurotic layer of the scalp.
4. Tarsus The main supporting structures of the lids are layers of dense fibrous tissue called the superior and inferior tarsus. The tarsus consists of the supporting

approximately 0.5 cm from the lateral margin of the orbit and forms an acute angle The orbital septum is the fascia behind the orbicularis muscularis that lies between the orbital rim and the tarsus and serves as a barrier between the orbital lids. The superior orbital septum is fused with the tendons of the levator lid superior and tarsus superior; The inferior orbital septum merges with the inferior tarsus The palpebral retractor opens the lids. In the upper lid, the skeletal muscle portion is the levator palpebra superioris, which originates at the orbital apex and runs forward and bifurcates into an aponeurosis and a deeper portion containing smooth muscle fibers of the Muller muscle (tarsalis superior). In the lower lid, the main retractor is the inferior rectus muscle, which projects fibrous tissue to envelop the inferior oblique muscle and insert into the lower border of the inferior tarsus and the orbicularis oculi. The smooth muscle of the lid retractors is innervated by sympathetic nerves. The levator and inferior rectus muscles are supplied by the oculomotor nerve. The blood vessels that supply the lids are the palpebral arteries. The sensory innervation of the upper eyelid is obtained from the frontal ramus of nerve V, while the lower eyelid is supplied by the second branch of nerve V. B. Definition Hordeolum is an infection of one or more glands in the eyelids. When the meibomian glands are affected,large swelling occursHence it is known as internal hordeolum. Hordelum externa or commonly called "stye"smaller and more superficialan infection of the glands of Zeis or Moll.7,

C. Epidemiology Hordeolum is a condition that often occurs and often patients do not go to health services to check themselves. There is no direct correlation between race, sex, or gender with regard to the prevalence of hordeolum. Adults may be more susceptible due to increased sebum viscosity. Patients with conditions such as blepharitis, seborrheic dermatitis, rosacea, diabetes, and hypercholesterolemia are also at increased risk of developing hordeolum. D. Classification a. External hordeolum Hordeolum externum is an infection of the glands of Zeiss or Moll with a protrusion, especially in the area of the lid skin. In hordeolum externum, pus can come out of the base of the hair. The protrusion towards the skin, accompanied by the movement of the skin and experience suppuration, breaks itself towards the skin b. Internal hordeolum Hordeolum internum is an infection of the Meibomian glands which are located in the tarsus with a protrusion especially in the area of the tarsal conjunctiva. The internal hordeolum is usually larger than the external hordeolum. In the internal hordeolum, the lump protrudes towards the conjunctiva and does not move with the movement of the skin, and rarely experiences suppuration and does not break down on its own.

4. Diabetes mellitus is usually associated with recurrences.
5. Metabolic factors such as chronic disease, eating a diet high in carbohydrates and alcohol are also predisposing factors. F. Pathophysiology Three different glands within the eyelid are involved in the pathogenesis of hordeolum when they are infected. Infection occurs due to thickening or stasis of gland secretions of Zeis, Moll, or Meibom. The glands of Zeis and Moll are the ciliary glands of the eye. Zeis glands secrete sebum with antiseptic properties that can prevent bacterial growth. Moll glands produce immunoglobulin A, mucin 1, and lysosomes which are important in immune defense against bacteria in the eye. The meibomian glands are sebaceous glands found on the tarsal plates of the eyelids and produce a secretion that forms an oily film on the surface of the eye that helps maintain eye lubrication. When this gland is clogged it will cause the eye's defense to be disrupted. Staphylococcus aureus is the etiology of bacterial infection because Staphylococcus aureus is the most common pathogen. After a local inflammatory response occurs, infiltration by leukocytes develops into a purulent pocket or abscess. Infection of the glands of Zeis and Moll (ciliary glands) causes pain and swelling at the base of the eyelashes with localized abscess formation. The external hordeolum produces the characteristic stye appearance with localized pustules at the eyelid margin. When the meibomian glands are acutely infected they will produce an internal hordeolum. Because of its deeper position within the eyelids, the internal hordeolum has a less pronounced appearance than the external hordeolum.

G. Diagnosis In diagnosing hordeolum, the symptoms and signs that appear in the patient must be considered. Symptoms and signs seen from the history and physical examination. In diagnosing hordeolum no additional investigation is needed because the diagnosis is made clinically or based on clinical manifestations. Additional examinations and radiology are usually performed if complications occur and the infection has spread and caused periorbital or orbital cellulitis. For example, in internal hordeolum which can cause corneal irritation where fluorescence examination can be carried out Clinical manifestations of hordeolum are as follows:

1. External hordeolum9,
   • Symptoms: Acute pain is usually accompanied by swelling of the lids, mild lacrimation and photophobia. The external hordeolum usually looks like a lump protruding anteriorly through the skin with the eyelashes at the apex.
   • Sign : a. The cellulitis stage is characterized by a tender, hyperemic, hard swelling localized to the palpebral margin. b. The abscess formation stage is characterized by a tip of pus at the palpebral margin in contact with the infected cilia. In the external hordeolum multiple lesions may appear and occasionally an abscess may involve the entire lid margin.

or in combination with oral (systemic) antibiotic drugs. 6 The order of management of hordeolum is as follows:

1. Warm compresses 3 times a day for 10-15 minutes at a time to help with drainage. Do it with your eyes closed.
2. Antibiotics are indicated if there is no improvement with warm compresses for 24 hours, and if the inflammatory process spreads around the hordeolum area. Topical antibiotics. Bacitracin or tobramycin eye ointment every 4 hours for 7-10 days. Erythromycin eye ointment can also be given for cases of external hordeolum and mild internal hordeolum. Systemic antibiotics Given if there are signs of bacteremia or there are signs of enlarged lymph nodes in the preauricular. In cases of internal hordeolum with moderate to severe cases. Can be given cephalexin or dicloxacillin 500 mg orally 4 times a day for 7 days. If you are allergic to penicillins or cephalosporins, clindamycin 300 mg orally 4 times a day for 7 days or clarithromycin 500 mg 2 times a day for 7 days can be given.
3. If the treatment does not respond well, then a surgical procedure may be needed to make the hordeolum drain. At the hordeolum incision, topical anesthesia is given with pantocaine eye drops. Filtration anesthesia with procaine or lidocaine is performed in the hordeolum area and an incision is made if:

• The internal hordeolum is made an incision in the area of pus fluctuation, perpendicular to the palpebral margin.
• The external hordeolum is made an incision parallel to the palpebral margin and then an incision is made, excohleation or curettage of all the contents of the inflamed tissue in the pouch and then an antibiotic ointment is given. J. Prognosis

The prognosis is generally good, because the inflammatory process in the hordeolum can heal by itself, as long as the cleanliness of the eye area is maintained and warm compresses are applied to the sore eye and appropriate therapy.