Download The Eyelids

The Eye Lids
Prof. Dr. Rengin Yıldırım
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 (Muller’s 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.
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
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
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)
Anterior Blepharitis
Posterior Blepharitis
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)
Ptosis:
Abnormally low position (drooping) of the
upper lid.
Neurogenic
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Third nerve palsy
Horner syndrome
Marcus Gun jaw-winking syndrome
Third nerve misdirection
Ptosis
Myogenic
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Myastenia gravis
Myotonic dystophy
Ocular myopathy
Simple congenital
Blepharophimosis syndrome
Ptosis
Mechanical
Aponuretic
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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.
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
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. Plaque like
2. Nodular
3. Ulcerating