The Eye Lids

Eyelids are crucial to the health of the underlying

eye.
They provide coverage of the cornea and aid in
the distribution and elimination of tears.
An exposed cornea will develop epithelial
defects, scarring, vascularization or infection.
Resulting symptoms include ocular irritation,
pain and loss of vision.

Eyelid closure distributes tears over the

surface of the eye and pumps them
through the lacrimal puncta into the tear
duct.
Thus, tearing or epiphora may result from
various eyelid disorders.

Anat.

Normal Anatomy
Both the upper & lower eyelids have
similar structure
They consist of an anterior lamella (skin &
orbicularis muscle) and a posterior lamella
(tarsal plate & conjunctiva)

The orbital septum extends from the

orbital rim and separates the preseptal
orbicularis muscle from the
preaponeurotic fat pad.
The lid retractors lie between the
preaponeurotic fat pad and the globe.

Lid Retractors
The upper lid retractors consist of levator
palpebra superior muscle and its
aponeurosis and the superior tarsal
muscle (Mullers muscle)
The lower lid retractors arise from the
sheat of the inferior rectus muscle and are
similarly composed of aponeurosis and
the inferior tarsal muscle

The structure eye lid margin

The gray line divide s
eye lid margin into
anterior and posterior
parts
Eye lashes, moll &
zeis glands orifices
takes place at the
front part
Meibomian gland
orifices are placed
behind the gray line.

Eyelid problems range from benign, selfresolving processes to malignant, possibly

metastatic, tumors.
Inflammation, infection, benign and
malignant tumors, and structural problems
such as ectropion, entropion and
blepharoptosis may occur.
Fortunately, most eyelid disorders are not
vision-threatening or life-threatening;
however, many cause irritative symptoms
such as burning, foreign-body sensation or
pain.

Blepharitis, or eyelid inflammation, one of the most

common problems, is characterized by
erythematous eyelids with accumulation of debris
along the eyelid margin.
Malignant eyelid tumors may be associated with lash
loss and erosion of normal eyelid structures.
Recognition and diagnosis of these problems are
crucial to their proper management.
Warm compresses and antibiotics suffice for many
conditions, while excision, cryotherapy or laser
treatment are required for some.

Disorders of the eye lashes

Trichiasis:Posterior
misdirection of eye
lashes from their
normal sites of
origin.
Metaplastic lashes:
which originate
from the
meibomian gland
orifices

. Epilation or removal of the misdirected

eyelashes ameliorates the symptoms. If
the offending eyelashes regrow aberrantly,
they may be reepilated or treated
permanently with electrolysis or
cryotherapy.

Distichiasis in which
partial or complete
second row of
lashes arises from
or behind the
meibomian gland
orifices

Madorosis is decrease in number or

complete loss of lashes

Poliosis Premature whitening of lashes

sometimes may involve eye brows

Madarosis
Decrease in number or complete loss of lashes
Local causes

Chronic anterior
lid margin disease

Infiltrating tumours

Burns, radiotherapy
or cryotherapy

Systemic causes

Generalized alopecia

Myxoedema

SLE

Syphilis
Leprosy

Following removal

Poliosis
Premature localized whitening of hair
Ocular associations

Chronic anterior blepharitis

Sympathetic ophthalmitis

Systemic associations

Vogt-Koyanagi-Harada
syndrome

Waardenburg syndrome

Blepharitis
Common bilateral symmetrical condition
Anterior form is usually because of
stayphlococcal infection in sebborrhoeic
patients
Posterior form is associated with
meibomian gland dysfunction
(ocular rosasea)

Patients typically experience itching,

burning, mild foreign-body sensation,
tearing and crusting around the eyes on
awakening.
On examination, the eyelid margins are
erythematous, and thickened with crusts
and debris within the lashes

Treatment of blepharitis consists initially of warm

compresses, eyelid scrubs and application of
antibiotic ointment.
Warm compresses should be applied for 15
minutes twice a day. This step loosens irritating
crusts in the eyelashes and melts the oil
produced by the meibomian glands, which can
occlude the gland orifices.
The eyelids should be scrubbed after the warm
compress is removed.

Baby shampoo mixed with water produces a

soapy solution. With the eyelids closed, the
eyelid margin region should be gently scrubbed
with this solution, using a cotton-tipped
applicator, wash cloth or finger.
Erythromycin or another antibiotic ointment
should then be applied to the lid margin.
The ointment should be applied only at bedtime,
because it may temporarily blur vision. If an
obvious infection is present, antibiotic eye-drops
may also be used.

Anterior Blepharitis

Posterior Blepharitis

CHALAZION
Chalazia appear most commonly as
chronic subcutaneous nodules within the
eyelid.
Initially, a chalazion may be tender and
erythematous before evolving into a nontender lump.
Blepharitis is frequently associated with
chalazia.

A chalazion results from the obstruction of

the meibomian gland.
The blockage of the gland's duct at the
eyelid margin results in release of the
contents of the gland into the surrounding
eyelid soft tissue.
A lipogranulomatous reaction ensues.
Occasionally, chalazia become
secondarily infected.

Management includes warm compresses

applied for 15 minutes four times a day.
Blepharitis, if present, should be treated.
A topical antibiotic may be used if signs of
infection are present. If the lesion persists after
four weeks of medical therapy, it may be incised
and drained.
Rarely, the chalazion is injected with steroids;
however, this may result in hypopigmentation of
the overlying skin.

HORDEOLUM
A hordeolum, also known as a stye, is an acutely
presenting, erythematous, tender lump within the
eyelid .
An internal hordeolum involves infection of the
meibomian gland and may evolve into a
chalazion.
An external hordeolum occurs with infection of
the more anteriorly located glands of Zeiss or
Moll, present just anterior to the lash line.

Hordeola usually drain spontaneously

after one week of treatment with warm
compresses four times a day and topical
antibiotic ointment twice daily.
Incision and drainage are required for
nonresolving lesions.

Xanthelasma
-common, Bilateral
-middle age & elderly ppl
-high level of cholesterol & LDL

Multiple yellowish plaques

Usually on the medial aspect

Ttt:
Indicated for cosmotic causes:
- Excision
- Destruction by CO2 or argon

Cyst of Moll

Cyst of moll : small,round ,non tender, translucent, fluid filled

lesion on the anterior lid margin

ese cysts of the sweat glands (Molls gland)contain clear fluid which lights up
when transilluminated with a fiber-optic probe

Cyst of Zeis

This lesion contains oily secretions so its less

translucent than cyst of moll

Hydrocystoma

Hydrocystoma is similar in appearance to cyst of moll but not confined to lid

margin
)origin: eccrine sweat glands(

Squamous cell papilloma

-most common benign tumor
-either:
*flesh colored pedunculated lesion
*sessile with raspberry surface
-ttt : excision

Pedunculated squamous cell papilloma

keratoacanthoma
-rapidly growing lesion with central crater filled with keratin
-sun exposed areas, fair skinned ppl
-stages:
*rapidly growing hyperkeratotic lesion
( usu. In lower lid )
*static (3-4 months)
*involution( up to 1 yr ) , may leave
ugly scar
Ttt: * excision
*radiotherpy
*cryotherapy
* intralesional 5-FU-

Rapidly growing lesion with keratin filled crater

Capillary haemangioma
Common tumor in infancy
Not present at birth but few wks after
Increase in size in the 1st yr then regress over 4-5
yrs
F:M 3:1
Upper lid>lower lid
may have intraorbital extension
If affects visual axis : amblyobia
Ttt :intralesional steroid which renders vascular bed
more sensitive to chatecholamines

Unilateral raised bright lesion , blanches with pressure &

increases with crying

Capillary Hemangioma of Lid:

This is a benign vascular congenital lesion characterized strawberry colored flat or
elevated lesion that enlarges with valsalva. When large it can obstruct vision and cause
.amblyopia

)Capillary Hemangioma of the Lid (Strawberry Nevus)

Increases for several months then decreases spontaneously in most cases. Unilateral,
has dimpled surface, often extends into orbit

Port wine stain

rare congenital subcutaneous haemangioma
Usually unilaterally occurs in the face .
Associations:
ipsilateral glaucoma in lesions involving 1st an
2nd division of trigemnal N. in 30% .
diffuse ipsilateral choroidial haemangioma +
sturge weber synd. In 5% of cases
ttt:
erbium laser , esp. if done in early life

sharply demarcated ,
soft , pink patch
which not blanch
.with pressure

With age the lesion

does not grow but
darkens to red or
.purple

Overlyning skin
become hypertrophid ,
nodular and friable
may bleed or become
infected lesion

Entropion
Entropion or inversion of
the lid margin may be
congenital and acquired.
The acquired variety can
be the result of ageing
changes (involutional
entropion) or the
cicatricial changes
(cicatricial entropion)

Pathogenesis of Senile Entropion

1. Horizontal Lid Laxity as well as medial
and lateral tendon laxity
2. Overriding of preseptal orbicularis over
pretarsal orbicularis
3. Lower lid retractor weakness which is
recognized clinically by decreased
excursion of the lower lid in downgaze.

Cicatricial entropion can effect either the

upper and the lower lid.
Common causes include trachoma, acid
and alkali burns and chronic conjunctival
inflammations such as ocular pemphigoid.

Ectropion
Ectropion or the eversion of the lid margin
can be congenital and acquired.
The acquired forms are the result of either
ageing changes (involutional ectropion), or
mechanical reasons (caused by tumors)
or the scarring of the anterior lamella
(cicatricial ectropion) or weakness of the
orbicularis muscle (paralytic ectropion)

Facial palsy results in an inability to close

the upper lid and laxity of the lower lid.
A frank paralytic ectropion may occur as
well .
A thorough work-up for the etiology of the
facial palsy must be performed.

Treatment of the eyelid problems includes vigorous

lubrication of the eye with artificial tear drops and
lubricating ointment.
Plastic wrap, fixed to the skin with ointment, may be
placed over the orbital region during the night to create a
moisture chamber for the eye.
For temporary facial palsies such as Bell's palsy, small
external tantalum eyelid weights may be easily fixed to
the skin with double-sided tape . The weight passively
closes the upper lid, protecting the cornea.
Surgical procedures are performed in patients with
permanent palsies.

Ptosis:
Abnormally low position (drooping) of the
upper lid.
Neurogenic

Third nerve palsy

Horner syndrome
Marcus Gun jaw-winking syndrome
Third nerve misdirection

Ptosis
Myogenic

Myastenia gravis
Myotonic dystophy
Ocular myopathy
Simple congenital
Blepharophimosis syndrome

Ptosis
Mechanical
Aponuretic

Involutional
Postoperative

Blepharophimosis Syndrome:
Telecanthus, epicanthus inversus,bilateral
ptosis

Simple Congenital Ptosis

This is caused by a developmental dystrophy of
the levator muscle.
It can be bilateral or unilateral
In down gaze the ptotic eye lid is slightly higher
then the normal eye lid as a result of poor
relaxation
Frequently there is absence of the upper eye lid
crease
Usually levator function is poor
Sometimes weakness of the superior rectus
muscle may accompany

Simple Congenital Ptosis

Marcus Gunn Jaw-winking: A retraction of the ptotic lid in

conjunction with stimulation of the ipsilateral pterygoid muscle

Third nerve misdirection: Bizarre

movements of the upper lid which
accompany various eye movements

Evaluation of the patient with ptosis

Margin-reflex distance : This is the
distance between the upper lid margin and
the light reflex in pupil is normally 44.5mm. If this distance decrases then
there is ptosis.

Evaluation of the patient with ptosis

Vertical fissure height: This is the distance
between upper and lower eye lids
margins. Normally upper eye lid margin
rests 2 mm below the upper limbus, and
lower eye lid margin rests 1 mm above the
lower limbus. VFH is 9mm in males and
11mm in females.

Evaluation of the patient with ptosis

Levator Function can be assesed by the upper
the lid excursion. It is measured after eliminating
frontalis muscle function by pressing above the
eye brow and ask the patient to look down, and
up. The amount of excursion is measured with a
ruler.
Normal:15mm or more
Good: 12mm
Fair:5-11mm
Poor:4mm or less

Treatment of ptosis
Congenital ptosis in which levator
function is poor,
1. Levator resection is the most chosen
operation
2. Other procedures:
Frontalis Brow Suspension

Treatment of ptosis
Involutional and aponeurotic ptosis: In this
condition levator function is mostly good
and the pathology is the detachment of
the levator muscle from the upper border
of the tarsus so we just attach the levator
back to the upper tarsal border.

BLEPHAROSPASM
Spasm of the eyelids may be unilateral or
bilateral. Unilateral lid spasm may occur in
conjunction with unilateral or hemifacial spasm.
Hemifacial spasm results most commonly from
irritation of the seventh nerve roots by a dilated
or tortuous vascular structure .
Because tumor is the etiology in up to 1 percent
of patients, all patients with hemifacial spasm
should receive a magnetic resonance imaging
scan of the brain.

Bilateral blepharospasm is most commonly the

result of dry eyes, corneal irritation or benign
essential blepharospasm.
Brain imaging is not required. Benign essential
blepharospasm may be caused by an
overexcitatory drive of the basal ganglia.
Initial treatment is artificial tear drops and
injections of botulinum toxin to weaken the
affected muscles.

Dermatochalasis
It is very common in
elderly,
The eye lids have
baggy appearance
with indistint lid
creases.
Treatment is
blepharoplasty

Lid Retraction
This condition is
suspected when the
upper lid margin is
above the superior
limbus.
It is most commonly
seen in thyroid eye
disease

Epicanthal folds
These are very
common,
Bilateral vertical skin
folds that overhangs
from the upper or
lower lid towards the
medial canthus.
They may give rise to
a pseudo-esotropia.

Telecanthus
This is an uncommon
condition.
There is increased
distance between the
medial canthi as a result
of abnormally long medial
tendons.
It should not be confused
with hypertelorism in
which there is wide
separation of the orbits.

Coloboma
This is uncommon
congenital partial or fullthickness eye lid defect.
The upper lid coloboma is
not associated with
systemic anomalies
The lower lid coloboma is
frequently associated with
systemic anomalies such
as Treacher Collins Syn.

Strawberry Naevus
(Capillary Haemangioma)
Unilateral, red, raised
lesion
Most common during
first year of life
Resolves
spontaneously by the
age 4-7
Steroid injections can
be given for vision
threatening cases

Pyogenic Granuloma
Fast growing
granulamatous
hemangioma
which is usually
after surgery or
trauma

Keratoacanthoma
Uncommon benign
but rapidly growing
tumour
Most common in
immunsuppressive
patients

Solar (Actinic ) Kertosis

Most common premalign skin lesion

Basal Cell Carcinoma

Most comman human
malignancy
90% cases occur in
head and neck, 10%
of these involve eye
lid.
Slow groving, locally
invasive but non
metastasizing

Treatment is complete surgical resection

with histologic control of margins.
Radiation and cryotherapy, which have
higher recurrence rates than surgical
resection, are used when surgery is not
appropriate or possible.

Squamoous cell carcinoma

It accounts for 5-10

% of eye lid
malignancies
Potentially more
aggressive tumour
than BCC
There are 3 main clinical types

1.
2.
3.

Plaque like
Nodular
Ulcerating

Treatment is similar to that for basal cell

carcinoma.

SEBACEOUS CARCINOMA
Sebaceous carcinoma occurs in middleaged to elderly patients and may mimic a
chalazion or chronic unilateral or bilateral
blepharitis.
It invades locally and spreads to regional
preauricular or submandibular lymph
nodes. Distant sites of metastasis include
lungs, liver and bone.

Sebaceous carcinoma of the right

upper lid, mimicking a chalazion.
Seborrheic keratoses are visible
above the left brow and on the right
cheek

Ttt of malignant tumors

-Surgical excision: ttt of choice
The entire tumor should be removed with
preservation of as much normal tissue as
possible
Small BCC can be cured by excision of the
tumor together with 4 mm margin of normal
skin
Large BCC & more aggressive tumors like SCC
& SGC more radical excision is needed
Frozen section can improve the success rate

Radiotherapy:
Indications:
*small BCC which doesnt involve
the medial canthal area in pts
not fit for or refuse surgery
*kaposi sarcoma: radiosensitive
Contraindications:
*medial canthal BCC
*upper eyelid tumors:subsequent
keratinization results in chronically
uncomfortable eyes
*aggressive tumors : sclerosing BCC, SCC, SGC

Complications:
Skin damage
Nasolacrimal duct stenosis
Dry eye ,keratopathy,cataract
Retinopathy, optic neuropathy

Recurrent chalazia should be

diffrentiated from Sebaceous
gland carcinoma
In doubtful cases biobsy should
be taken