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THE EYELIDS
Anatomy:
The lid contain:
1- Smooth muscles (Müller's muscles).
2- Striated muscles (Orbicularis oculi and Levator palpebrae superioris "LPS").
3- Dense fibrous plates (Tarsal plates).
4- Glands.
5- Nerves and blood vessels.
The contents of the lid are: (from anterior surface to posterior) Skin, the subcutaneous
tissue, muscular layer, the submuscular (areolar tissue) layer, the orbital septum which end as
a tarsal plate (that forms the architecture of lid) and finally the conjunctiva (palpebral) which
is situated most posterior.
The free margin of the eyelids contains:
1- The lashes (Cilia).
2- Grey line.
3- Orifices of Meibomian glands.
4- Mucocutaneous junction
5- Superior and inferior puncti of Naso-Lacrimal System (NLS).
Muscles of the eyelids:
1- Orbicularis oculi muscle: It is a thin oval sheet of concentric striated fibrous
surrounding the palpebral fissure. It can be divided into:
a- Peripheral (orbital) part: This is involved in forceful closure of lids.
b- Central (palpebral) part: This is involved in involuntary blinking and participates in
forceful closure with the orbital part.
c- Muscle of Rioland's: this part is represented by the gray line of lid margin.
d- lacrimalis muscle: that attached to the fundus of lacrimal sac. This part is involved in
pumping lacrimal drainage system.
Nerve supply:
Sensory: Ophthalmic branch of trigeminal nerve . Motor: Facial nerve.
2- Levator palpebrae superioris muscle: It is originates from the periosteum covering the
lesser wing of sphenoid bone at the apex of the orbit. The aponeurosis inserts into:
a- Skin of the upper eyelid, so it forms skin creases on the eyelid.
b- Upper edge and anterior surface of the tarsal plate.
c- Medial and lateral palpebral ligaments.
Function: To keep the palpebral fissure open against gravity.
Nerve supply: Sensory: Ophthalmic branch of trigeminal nerve. Motor: Oculomotor nerve.
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3- Superior palpebral muscle (Müller's muscle or superior tarsal muscle): It is a small
sheet of smooth muscle originated from the under surface of the LPS muscle and inserted to
the upper edge of the upper tarsal plate.
Nerve supply: Sympathetic nerves.
Function: Like LPS, is to keep the palpebral fissure open against gravity.
Glands in the eyelids:
1- Meibomian glands (Tarsal glands): Modified sebaceous gland located in the tarsal plate.
The upper tarsus contains 30-40 glands, while the lower tarsus contains 20-30 glands.
Function: It secret the lipid forms the outer layer of the tear film.
2- Zeis glands: Modified sebaceous gland opened with lash follicles.
3- Glands of Moll: They are modified sweat gland whose ducts also open into lash follicle
or directly in the anterior lid margin between the lashes.
Congenital anomalies of eyelids:
1- Ablepharon: Absence of the eyelids.
Treatment: Reconstructive plastic surgery.
2- Ankyloblepharon: Imperfect separation of the eyelids.
Treatment: Open the adhesion in between.
3- Coloboma of the eyelids: Common congenital anomaly in which there is failure of a
portion of the lid to develop leading to notch in the lid margin.
Treatment: Plastic surgery.
4- Blepharophimosis: Narrowing of the palpebral fissure.
Treatment: Plastic surgery at pre-school age.
5- Epicanthus: Common anomaly. There is a vertical skin fold in the medial canthal region,
which conceals the medial angle and caruncle giving a picture simulates convergent squint
(pseudosquint).
Abnormalities in shape and position:
1- Entropion:
It is an inward rolling of the lid margin causing continuous rubbing of the cornea and foreign
body sensation, which leads to conjunctival congestion, painful watery eye (tears production
due to stimulation of cornea) and sometimes epithelial defect and even corneal ulceration that
may be complicated by secondary bacterial infection of the cornea. So, it is a vision
threatening disease.
Causes (Types) of entropion:
a- Congenital: which is very rare.
b- Spastic entropion: secondary to any condition that causing severe & persistant spasm of
orbicularis oculi, e.g. ocular irritation (irritation leads to overriding of orbicularis oculi muscle
fibers), conjunctivitis, keratitis and ocular surgery or in hemi facial spasm.
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c- Senile entropion (involutional entropion): affecting elderly patients and usually involves
the lower lid as the balance between the orbicularis oculi muscle and the lower lid retractors
is impaired with age leading to entropion.
d- Cicatricial entropion: secondary to any condition causing scaring and shrinkage of
conjunctiva, e.g.:
i- Chlamydial conjunctivitis.
ii- Chemical conjunctivitis (whether it is acidic or alkaline).
iii- Autoimmune conjunctivitis. e.g. Cicatricial pemphigoid and Stevens-Johnson syndrome
iv- Irritation conjunctivitis.
Management:
Usually surgical in addition to the corneal protection from the lash rubbing by
frequent epilation and contact lenses. Conjunctival scarring might need graft to repair the
scarred area.
2- Ectropion:
It is an outward rolling of the lid margin causing exposure of the palpebral and bulbar
conjunctiva. This exposure leads to exposure conjunctivitis, exposure keratitis and watery eye.
Long-standing cases lead to:
i- Dry and thick conjunctiva and even keratinization.
ii- Corneal ulceration. So, it is vision threatening disease.
iii- Redness, crusting and dermatitis of skin.
Causes (types) of ectropion:
a- Congenital ectropion.
b- Paralytic ectropion (Atonic): seen in cases of facial nerve palsy.
c- Senile ectropion (involutional):
commonly seen in the lower lid of elderly patients due to
atrophy of orbicularis oculi muscle and tarsal plate.
d- Cicatricial ectropion: which is occur secondary to:
i- Chemical burns of skin. ii- Infection of skin. iii- Radiation of skin. iv- Improper suturing
of lid wound. v- Trauma to the lid.
e- mechanical : as in bulky eyelid tumour.
Management: Involutional ,permanent paralytic and cicatricial ectropion are managed
surgically. Mechanical one is treated by treating the cause. Paralytic ectropion, if recovery is
expected then the patient is given lubricants and the cornea might be thought of being
protected by performing tarsorraphy (temporary closure of the lids by suturing them
together).Sometimes botulinum toxin injection to induce a protective ptosis is chosen to
protect the cornea while waiting for recovery
3- Blepharoptosis:
It is an abnormal low position or dropping of the upper eyelid
that may interfere with vision
in severe forms. It could be unilateral or bilateral, and both of them could be partial or
complete
and could be asymmetrical. Usually the upper lid covers only 2 mm from cornea. If
more, is called blepharoptosis.
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Differential diagnosis:
Pseudoptosis: is to be excluded in any case suspected to have dropped upper lid.
1. lack of lid support as in cases of sunken eyes (enophthalmos) gives an asymmetrical
appearance like ptosis.
2. Contralateral lid retraction, proptosis or large fellow eye.
3. Ipsilateral hypotropia.
4. Brow ptosis in which there is excessive brow skin hanging down.
5. Dermatochalasis: excessive skin of the eyelid mimicking ptosis.
Causes (Classification)of blepharoptosis:
a- Congenital blepharoptosis: the LPS muscle is very poor and there is absence of skin
creases.
b- Neurogenic blepharoptosis:
i- Oculomotor nerve palsy: causing severe unilateral ptosis with defects in adduction
elevation and depression of the eyeball +/- pupillary dilatation.
ii- Horner's syndrome: oculosympathetic palsy in which there is mild ptosis and miosis.
Pupillary reaction is normal. It could be congenital in which we can see iris heterochromia.
iii- Marcus Gunn Jaw-winking syndrome: it is a congenital anomaly in which, nerve to LPS is
a branch from nerves to mastication muscle (i.e. from trigeminal nerve).
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nerve misdirection: either acquired or congenital.
c- Myogenic blepharoptosis:
i- Myasthenia gravis: there is a defect in the neuromuscular junction (damage to acetyl
choline receptors). Treatment : medical treatment.
ii- Myotonic dystrophy.
iii- Ocular myopathy (localized defect similar to myasthenia gravis).
iv- Simple congenital myogenic blepharoptosis.
v- Blepharophimosis syndromes: it is a rare congenital ptosis with dominant inheritance in
which, there are bilateral ptosis, bilateral palpebral fissure narrowing, bilateral ectropion, and
increase in the distance between the two medial canthi (telecanthus).
d- Aponeurotic blepharoptosis:
weakness of the levator aponeurosis
i- Involutional (senile). ii- Post operative.
e- Mechanical blepharoptosis: deformity and increases weight of the eyelid
as in large lid tumour, dermatochalasis, lid edema or anterior orbital lesion.
Treatment of ptosis:
Exclude pseudoptosis,then the treatment of all types is surgical except in myasthenia gravis,
where the treatment is medical. Surgical procedures are:
a- Levator resection.
b- Frontalis brow suspension (Sling operation).
c- Tarso-conjunctival resection (Fasanella servete procedure).
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Choice of one of these three types depends on:
a- Aetiology of ptosis.
b- Severity of ptosis: Mild, moderate or severe.
c- Function of LPS: Good, fair or poor.
4- Trichiasis:
It is a posterior misdirection of the lashes arising from their normal sites of origin, most
annoying during blinking. It causes punctuate epithelial erosions of the corneal epithelium
followed by corneal ulceration and pannus formation in severe chronic cases.This is a common
acquired unilateral or bilateral condition which can occurs in isolation or may be associated
with scarring of the lid margin as in chronic blepharitis, herpes zoster ophthalmicus, chemical
burn and trachoma.
Treatment:
a- Epilation: Repeated every few weeks.
b- Electrolysis: Destruction to hair follicles by cauterization.
c- Cryosurgery: Destruction to hair follicles by freezing.
d- Laser ablation: Destruction to hair follicles by laser.
5- Blepharospasm:
Involuntary sustained closure of the eyelids which occurs spontaneously (essential) or by
sensory stimuli (reflex). Treatment: Is to treat the underline cause and in sever, and
resistance cases Botulinum toxin injection is indicated. It is temporary measure and can be
repeated frequently.
6- Madarosis:
It is a decrease in number or complete loss of lashes.
Causes:
Local Causes: chronic blepharitis, burns, radiation and infiltrating tumor.
Systemic causes: generalized alopecia, psoriasis, SLE, syphilis and leprosy.
7- Poliosis:
It is premature whitening of the hair which may include the lashes and eyebrows, common
ocular associations are chronic blepharitis and the commonest systemic association include
Vogt Koyanagi Harada syndrome.
Benign nodules and cysts:
1- Chalazion (Meibomian cyst):
It is a chronic lipogranulomatous inflammatory lesion caused by blockage of meibomian gland
orifices and stagnation of sebaceous secretions and there is NO infection. It is more
frequent and multiple in patients with acne rosacea or seborrhoeic dermatitis and other
sebaceous gland dysfunctional diseases.
Presentation: Painless nodule and occasionally blurred vision.
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Signs: a- Round, firm lesion in the tarsal plate. b- Polypoid granuloma on eversion of lid
(i.e. seen from the palpebral part of conjunctiva). c- Sometimes there is associated chronic
blepharitis.
Treatment:
Small lesions might disappear without treatment and persistent large cyst is
treated surgically by incision and curette through the tarsal conjunctiva. Intralesional
triamcinolone injection is an alternative way of treatment that may require repeated
injections. Systemic tetracyclines are given in cases of recurrent chalazia specially if the
patient have rosacea or seborrhoic dermatitis.Recurrent chalazion should raise the suspicion
of meibomian gland carcinoma or basal cell carcinoma.
2- Internal Hordeolum (meibomianitis):
It is a small abscess caused by an acute staphylococcal infection of Meibomian glands.
Signs: Tender, inflamed swelling within the tarsal plate.
Treatment:
a- which is done through using topical antibiotics. Systemic antibiotics are needed if there
is associating lid infection.
b- Incision and curettage for the residual nodule after the acute infection has subsided.
3- External hordeolum (Stye):
It is an acute small staphylococcal abscess of a lash follicle and its associated gland of Zeis.
Signs: i-Tender inflamed swelling in the lid margin, which points anteriorly through the
skin. ii- More than one lesion may present. iii- Occasionally minute abscess may involve the
entire margin.
Treatment:
a- Hot compresses to produce vasodilatation of blood vessels: is to increase the circulation
in the area and also for liquefaction of sebum to prevent stagnation in the duct of affected
gland.
b- Topical antibiotics to prevent infection of neighboring glands.
c- Epilation (removal of eyelashes by a forceps) to enhance drainage of pus.
d- Systemic antibiotics if there is severe preseptal cellulitis.
Benign tumors
1.Viral wart( sequamous cell papiloma)Is the commonest benign lid tumour seen in adults
as a pedunculated or sessile lesion with a characteristic raspberry like surface. Treatment is
by excision or laser ablation.
2.Simple naevus They become darker at puberty, might be pigmented or not, elevated or
flat depending on their location within the skin layers. At the lid margin they might have
lashes growing through them. Some have malignant potentials.
3.Strawbwrry naevus(capillary haemangioma)Is an uncommon tumour with a female
predilection. Appears just after birth as a pinkish swelling that blanches with pressure and
might increase in size upon crying. if it is on the upper lid it might cause mechanical ptosis
interfering with vision and leading to amblyopia. It might have orbital extension causing squint
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or proptosis. Usually it enlarges in size progressively then involute after the second year of
age so that by the age of 4 years about 40% disappears and at 7years 70% disappear.
Treatment is by steroid injection intralesionally and in selected cases surgical excision.
4.Port-wine stain (cavernous haemangioma) Is a rare congenital tumour of the skin,
lesions are to start with flat red swelling and doesn't blanch on pressure. They contain thin
walled vessels within the skin. As the patients grows the lesion darken and the skin becomes
hypertrophied and might become friable and easily bleed or infected. Treatment is by laser
early in life because it helps in flat lesions without much skin hypertrophy.
Eyelid malignancies
1- Basal cell carcinoma BCC is the commonest human malignant tumour affecting elderly. It
is locally invasive non metastasizing tuomur.90% of BCC affect the head and neck and 10% of
those affect the eyelids.
Clinical forms:
1.nodular BCC: slowly growing shiny indurated nodule with surface vascularization that may
destroy large portion of the lid.
2.ulcerative BCC( rodent ulcer): Chronic lid ulceration with raised rolled edge that may
bleed.
3.sclerosing BCC : indurated plague with loss of lashes resembling chronic blepharitis. It
spreads radially beneath the epidermis making it difficult to delineate the margin of the
lesion.
2-Sequamous cell carcinoma
This is less common but more aggressive than BCC with a predilection to the lower lid. May
arise de novo or from a preexisting actinic keratosis.
Clinical forms:
a.nodular: hard keratotic nodule the surface of which might show crustation and fissuring
but not vascularization.
b.ulcerative: red base with a sharply defined-punched out- indurated and elevated borders
3-Meibomian gland carcinoma
Very rare malignant eyelid tumour with 10% mortality rate. It has an upper lid predilection
with two main clinical forms:
1.nodular:just like chalazion
2.spreading:diffuse thickening of the lid margin and loss of lashes. Conjunctival spread
might occur giving a picture mimicking chronic conjunctivitis.
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Allergic disorders
1.Acute allergic lid oedema Caused by insect bites, angioedema, urticaria and rarely
caused by drugs e.g. ACEI specially enalapril.
Signs:Unilateral or bilateral, painless pitting periorbital and lid edema. Systemic
antihistamines may be helpful in treatment.
2.Contact dermatitis:It is a common unilateral or bilateral localized oedema and crusting
frequently caused by hypersensitivity to topical medication. Treatment is by identification and
removal of the cause and topical application of a mild steroid such as 1%hydrocortisone.
3.Atopic dermatitis: Eczema is a very common idiopathic skin condition frequently
associated with asthma and hay fever. Usual presentation is with irritation and itching, eyelid
involvement is usually uncommon but if it occurs it is always associated with a generalized skin
lesion.
Signs are bilateral thickening, crusting and fissuring of the upper eyelids.
Treatment: is by emollients like oily cream to hydrate the skin and mild steroids. Secondary
bacterial infection may require antibiotics.
ocular associations with generalized atopic dermatitis like: i. staphylococcal blepharitis.
ii.chronic keratoconjunctivitis in adults. iii. Keratoconus. iv. presenile posterior sub capsular
cataract
Infections:
1.Herpes Zoster ophthalmicus:
It is a common unilateral condition typically affects elderly patients or those with
immunodeficiency states. Usual presentation is with pain along the distribution of the
trigeminal nerve. Signs include forehead maculopapular rash ,vesicles, pustules, crusting and
ulceration. In severe cases secondary bacterial infection causes periorbital oedema that may
give an erroneous impression that it is bilateral.
Hutchinson sign is the involvement of the side of the nose which is associated with high
intraocular complications.
Treatment is by systemic and topical antiviral agents e.g. acyclovir, famciclovir, valaciclovir
plus a steroid-antibiotic combination cream topically.
2.Herpes simplex: Primary HS infection is an uncommon unilateral condition, typically
affects children. It might be so severe in patients with atopic dermatitis or immunodeficiency.
Signs are crops of small vesicles and lid oedema, vesicles may rupture then crust and heal
within few days. There might be associated ipsilateral follicular conjunctivitis and keratitis.
Treatment is by topical antiviral cream.
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3. Molloscum contagiosum This is an uncommon skin lesion caused by poxvirus. On the lid it
shows as a small umblicated waxy pale nodule which may be multiple and can be associated with
follicular conjunctivitis and keratitis. Treatment is by shave excision , destruction by laser
,cautery or cryotherapy.
Marginal Chronic Blepharitis
Chronic blepharitis is a very common condition which is usually bilateral symmetrical.
Types of chronic blepharitis:
1- Anterior: a- Staphylococcal infection. b- Seborrheic dysfunction. c- Mixed.
2- Posterior: a- Meibomianitis. b- Meibomian seborrhea.
3- Mixed (any one of the anterior type plus any one of the posterior).
Pathogenesis of chronic blepharitis:
1- Anterior chronic staphylococcal blepharitis: due to staphylococcal infection.
2- Anterior chronic seborrhoeic blepharitis: is usually associated with seborrhoeic
dermatitis e.g. scalp, naso labial folds, retro auricular area and sternum.
Neutral lipids are converted by Bacterial lipase into irritating fatty acids responsible for
increase of symptoms.
3- Posterior chronic blepharitis: Associated with dysfunction of Meibomian gland (ocular
rosacea) which is in some patients associated with acne rosacea of the face.
Symptoms of chronic marginal blepharitis: (anterior and posterior)
They are: Burning, grittiness, mild photophobia, and crusting and redness of the lid margin.
The symptoms are characterized by remissions and exacerbations. The symptoms are usually
worse in the mornings.
Signs of anterior blepharitis:
a- The anterior lid margins show (by slit-lamp) hyperaemia and telangiectasia. In
longstanding cases the lid margin became scarred and hypertrophied (due to recurrent
infections), intrafollicular abscess may be present (staphylococcal blepharitis).
b- Two types of scales: (important in differentiation)
i- Staphylococcal blepharitis: Are hard and brittle and are centered around the lashses
(collarettes).
ii- Seborrhoeic blepharitis: Are soft and greasy and located anywhere on lid margin or on
the lashes.
c- In longstanding cases, trichiasis, madarosis and occasionally poliosis (whitening of the
eyelashes) will occur.
Complications of anterior blepharitis:
a- External hordeolum (stye).
b- Tear film instability (due to the abnormal lipid secretion that affects the tear film).
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c- Hypersensitivity to staphylococcal exotoxins , papillary conjunctival reaction, punctuate
epitheliopathy and marginal keratitis.
Treatment:
a- Lid hygiene: removing crusts and toxic products by scrubbing the lid margins daily with
either commercially lid scrub or a cotton bud tipped in 25% solution of baby shampoo.
b- Topical antibiotic ointment: fusidic acid or chloramphenicol.
c- Weak topical steroids: e.g. fluorometholone to control hypersensitivity to exotoxins.
d- Tear substitutes.
Posterior blepharitis (Meibomian seborrhea or meibomianitis):
that may be alone or in association with anterior blepharitis, it may be secondary to meibomian
gland dysfunction or meibomianitis.
Meibomian glands are modified sebaceous glands within the tarsal plates of the lids and are
responsible for the tear lipid layer secretion which is responsible for prevention of rapid
evaporation of tear and help maintaining its smooth stable surface. in posterior blepharitis
with meibomian gland seborrhea or dysfunction the symptoms are severe but the signs are
minimum. Signs: There is oily secretion of the glands localized on the orifices of the glands
and on the lid margin and sometimes you can express the oily secretion by gentle pressure on
the lid margin. When there is meibomienitis, the margin looks inflamed around the meibomian
orifices, in long standing cases it is hypertrophied and notched. The oil secretion may be
turbid or toothpaste like and when the gland ducts are blocked no secretion can be expressed
and meibomian oil filled cysts might be formed at the lid margin.
The condition might be complicated by tear film instability, conjunctivitis and inferior
punctuate epitheliopathy.
Treatment:
a- Systemic tetracyclines (Corynebacterium acnes) for 6-12 weeks
b- Erythromycin when (a) is contraindicated.
c- Lid hygiene.
d- Topical steroids.
e- Tear substitutes.
f- Warm compresses to melt solidified sebum and mechanical expression (to evacuate
meibomian glands from their contents).
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