Download The eyelid

The eyelid
‫الدكتور محمد عبد هللا‬
‫منصور البغدادي‬
‫طب وجراحة العيون‬
Anatomy: The eyelid is a thin movable curtain composed of
skin on its anterior surface and mucus membrane
on its posterior surface.
Containing smooth and striated muscles and with
the tarsus plate forming the skeleton of the lid, that
serve to protect the delicate structures of the eye.
Structures of the
1. Skin layer: - it is thin, loose, and elastic and possesses few hair follicles and no
subcutaneous fat.
2. Orbicularis oculi muscle: - the function of this muscle is to close the lids.
Its muscle fibers surround the palpebral fissure in concentric fashion and spread
for a short distance around the orbital margin. Three portion
a. Pretarsal part: - the portion of the muscle that is in the lid.
b. Preseptal part: -the portion over the orbital septum.
c. Orbital part: -the portion outside the lid.
3. Areolar tissue: - the submuscular areolar tissue that lies deep to the orbicularis
oculi communicates with the subaponeurotic layer of the scalp.
4. Tarsal plate: - the main supporting structure of the lid it’s a dense fibrous tissue
layer that is called tarsal plate. The lateral and medial angles and extensions of
the tarsal plates are attached to the orbital margin by the lateral and medial
palpebral ligaments. The upper and lower tarsal plates are also attached by a
condensed, thin fascia to the upper and lower orbital margins. This thin fascia
forms the orbital septum.
5. Conjunctiva: - it’s a layer of mucus membrane, which adheres to the tarsal
plates.
EYELID MARGIN
The free margin is 25-30mm long and about 2mm wide. It is divided by the gray
line (mucocutaneous junction) into anterior and posterior margins.
A. Anterior margin:1. Eyelashes- project from the margins of the eyelids and are arranged
irregularly. The upper lashes are longer and more numerous than the lower
lashes and turned upward; the lower lashes turn downward.
2. Glands of zeis- these are small modified sebaceous glands that open into
the hair follicles at the base of the eyelashes.
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3. Glands of moll- these are modified sweat glands that open in a row near
the base of the eyelashes.
B. Posterior margin: - is in close contact with the globe, and along this margin are
the small orifices of modified sebaceous glands (meibomian, or tarsal glands)
C. Lacrimal punctum: - at the medial end of the posterior margin of the lid, a small
elevation with a central small opening can be seen on the upper and lower lids.
The puncta serve to carry the tears down through the corresponding canaliculus
to the lacrimal sac.
Palpebral fissure
It is the elliptic space between the two open lids. The fissure terminates at the
medial and lateral canthi. The lateral canthus forms an acute angle. The medial
canthus is more elliptic and surrounds the lacrimal lake.
Eyelid function

The primary function of the eyelid is to protect the eye and to preserve vision.

Glands within the eyelids produce the complex tear film that provides
nutrition, lubrication, and protection for the ocular surface.

The eyelids also contribute to the lacrimal pump and their blinking action
helps eliminate tears from the lacrimal lake.

The eyelids play an essential role in protecting the ocular surface from
trauma (physical and chemical trauma).

Limits the amount of light entering the eye.
Congenital abnormalities of the eyelid:1. Coloboma: Means absence of tissue, during embryonic development there is failure of a
particular tissue at specific site to develop it can occur in any part of the eye ex.
Cornea, iris, and retina. .etc. Coloboma of the lid means absence of part of the
eyelid, leading to a notch like defect at the lid margin (usually the upper eyelid).
This will lead to exposure keratopathy.
Treatment: - by reconstructive surgery. The time of operation depends on the size
of defect, if the defect is large the surgery done as soon as possible.
2. Epicanthus: Vertical fold of skin over the medial canthi, between the upper and lower lids.
The skin fold is often large enough to cover part of the nasal sclera and cause
"pseudoesotropia". It is typical of Asians and is preset to some degree in most
children of all races.
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The cause of epicanthus is lack of vertical skin between the canthus and the
nose. This may also be acquired after surgery or trauma of the medial eyelid
and nose.
Treatment: - in normal children diminished gradually and seldom apparent by
puberty. Surgical correction is directed at vertical lengthening and horizontal
shortening.
3. Telecanthus: It is mean a wide distance between the medial canthus of each eye - wide
intercanthal distance -. This may be the result of traumatic disinsertion or
congenital craniofacial dysgenesis.
Treatment: Minor degree can be corrected with skin and soft tissue surgery.
Major craniofacial reconstruction is required when the orbit are widely
separated.
Abnormalities of the shape and position: 1. Entropion: It’s a condition in which the eyelid margin turn inward and the lashes are
misdirected, rubbing against the cornea causing irritation and corneal epithelial
defect causing aberration and ulcer and infection.
Types:a. Senile type (involutional): - occur as a result of aging, it is always affect
the lower lid and is a result of a combination of laxity of the lower lid
retractors, upward migration of the preseptal orbicularis muscle and
buckling of the upper tarsal border. Treatment: -by surgery is the definite
treatment, because if we leave it patient might lose his vision.
b. Spastic entropion: - due to contraction of the orbicularis muscle, or muscle
spasm that occurs after surgeries (cataract and others) - inflammation and
spasm - especially in elderly or the cause is a secondary infection of the
conjunctiva. Treatment: - usually resolution of the underlying cause leading
to relaxation of the muscle, but during that , plastering of the lid until
resolution complete and then removal of the plaster.
c. Cicatricial (fibrotic) entropion: - may affect both upper and lower lids
(simultaneously or separately) after fibrosis of the palpebral conjunctiva or
the tarsal plate. The causes: -may be chemical injury. Infection (trachoma)
or radiation or traumatic (surgery). The characteristic feature of trachoma is
usually affecting the upper eyelid. Treatment: - the surgery is the definite
treatment, because if we leave it patient might lose his vision.
d. Congenital type: -
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2. Ectropion: A condition in which lid margin is turned outward, so the bulbar and palpebral
conjunctiva are exposed (the patient cannot close his eye completely). Usually
bilateral and is a frequent finding in elderly. The symptoms are tearing
(epiphora), red eye, irritation, and even sever dermatitis of skin. Exposure
keratitis may occur.
Types: a. Involutional ectropion: - caused by relaxation of the orbicularis muscle
due to aging process. Treatment: - surgically by shortening of the lid.
b. Paralytic ectropion: - caused by facial nerve palsy. Usually resolve
spontaneously and required no treatment. (Recovery of facial nerve palsy).
c. Cicatricial ectropion: - its occur secondary to burns, laceration, infection
of lid injuries affecting lower lid. Treatment: - surgical revision of the scar
and often skin graft.
d. Spastic type: - usually temporary
3. Blepharoptosis: It is abnormally low position of one or both upper lids. The normal position of the
upper lid is mid way between the superior limbus and the upper pubillary margin
(2mm). It may be categorized by the onset: congenital or acquired. It may be
classified by the cause: myogenic, aponeurotic, neurogenic, mechanical, or
traumatic. The most common type of congenital ptosis result from a poorly
developed levator muscle (myogenic); the most common of acquired ptosis is
caused by stretching or even disinsertion of the levator aponeurosis
(aponeurotic cause). It is an important cause of visual loss. Although the
superior VF is primarily involved, central vision can also be affected.
Blepharoptosis has also been shown to decrease the overall amount of light
reaching the macula and therefore can reduce visual acuity as well, especially at
night.
Classification: A more specific and accurate classification system is based on a defined
underlying abnormality and includes the myogenic, aponeurotic, neurogenic,
mechanical, and traumatic ptosis.
A. Myogenic ptosis:  Congenital myogenic ptosis results from dysgenesis of the levator
muscle. Instead of normal muscle fibers, fibrous or adipose tissue is
presenting the muscle belly, diminishing the ability of the levator to
contract and relax. Characteristic feature of this type decrease levator
function, eyelid lag.
 Acquired myogenic ptosis, is uncommon and result from localized or
diffuse muscular disease such as muscle dystrophy, myasthenia gravis,
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and chronic progressive external ophthalmoplegia, or oculopharyngeal
dystrophy, myotonia dystrophica.
B. Aponeurotic type: - the levator aponeurosis transmits levator force to the eyelid.
Thus any disruption in its anatomy or function can lead to ptosis.
 Congenital aponeurotic ptosis: is caused by failure of the aponeurosis
to insert in its normal position on anterior surface of the tarsus. It is a
rare cause of congenital ptosis and may be associated with birth
trauma.
 Acquire type: -is the most common of all forms of ptosis. It is caused by
stretching, dehiscence, or disinsertion of the levator aponeurosis from
its normal position. Common causes are involutional attenuation or
repetitive traction on eyelid (frequent eye rubbing or wearing of rigid
contact lenses), may be exacerbated by intraocular surgery or eyelid
surgery. This type characterized by high or absent upper eyelid crease
secondary to upward displacement or loss of the insertion of levator
fibers into skin. It may be worsen in the reading position and therefore
interfere with the patient's ability to read as well as limiting the superior
VF.
C. Neurogenic ptosis:  Congenital neurogenic ptosis: It is caused by innervational defects that occur during embryonic
development. It is rare and is associated with the congenital cranial
nerve III palsy, congenital Horner syndrome, or the Marcus Gunn jawwinking syndrome.
 Acquired neurogenic ptosis: - it is a result from interruption of normally
developed innervation and is most often secondary to acquired cranial
nerve III palsy, to an acquired Horner syndrome. The majority of
acquired oculomotor nerve palsies is vasculopathic and associated with
diabetes, hypertension, or arteriosclerotic disease.
Other, unusual, causes of acquired neurogenic ptosis include myotonic
dystrophy, Guillain-Barre syndrome, and iatrogenic botulism (botulinum
toxin injection in the forehead or orbital region to ameliorate benign
essential blepharospasm).
D. Mechanical ptosis: - it is usually referred to the condition in which a neoplasm
weight or pulls down the upper eyelid, resulting of ptosis. It may be caused by a
congenital abnormality, such as plexiform neuroma or hemangioma, or by an
acquired neoplasm, such as a large chalazion or basal cell or squamous cell
carcinoma. Post surgical or post traumatic edema may result in temporary
mechanical ptosis.
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E. Traumatic ptosis: - blunt or sharp trauma to the levator aponeurosis or the
levator muscle may also cause ptosis. The underlying histologic defects may be
a combination of myogenic, aponeurotic, and Cicatricial elements. Orbital or
neurosurgical procedures may also lead to traumatic ptosis.
Pseudoptosis: - (apparent eyelid drooping)
It should be differentiated from true ptosis. An eyelid may appear to be abnormally
low in various conditions, including hypertropia, enophthalmos, anophthalmos,
phthisis bulbi, or a superior sulcus defect secondary to trauma or other causes.
Contralateral upper eyelid retraction may also simulate ptosis.
Pseudoptosis is sometime used to describe dermatochalasis, the condition in which
excess upper eyelid skin overhangs the eyelid margin, transects the pupil, and
gives the appearance of a true ptosis of the eyelid margin.
Clinical evaluation of the patient with ptosis
HISTORY
1. The Age at onset of ptosis.
2. Duration (congenital Vx. Acquired cases).
3. Old photographs may be helpful in establishing the age at onset.
4. Symptoms of possible underlying systemic disease, such as associated
diplopia, variability of ptosis during the day and excessive tiredness.
Physical examination: It is begins with four clinical measurements to determine the degree of severity
of ptosis that is of high importance in surgical management: 1. Vertical interpalpebral fissure height.
2. Margin- reflex distance.
3. Upper eyelid crease position.
4. Levator function (upper eyelid excurtion).
We record these data by means of a drawing of the cornea, pupil size, and the
position of the upper and lower eyelid in relation to these structures.
1. Vertical interpalpebral fissure height: - it is measured at the widest point
between lower and upper eyelid.
2. Margin- reflex distance (MRD): - is the distance from the upper eyelid
margin to the corneal light reflex in the primary position. It is probably the
single most effective measurement in describing the amount of ptosis. The
light reflex may be obstructed by the eyelid in severe cases of ptosis and
therefore has a zero or negative value.
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3. Upper eyelid crease: - the distance from the upper eyelid crease to the
eyelid margin is measured. Because the insertion of fibers from the levator
muscle into the skin contributes to the formation of the upper eyelid crease,
high, duplicated, and asymmetric creases may indicate abnormal insertions
or disinsertion of the levator aponeurosis. The crease is usually elevated in
patient with involutional ptosis. It is shallow or absent in patients with
congenital ptosis. The upper eyelid crease is typically lower or obscured in
the Asian eyelid, with or without ptosis.
4. Levator function: - it is estimated by measuring the upper eyelid excursion
from downgaze to upgaze with frontalis muscle function negated. Accurate
analysis of the amount of levator function is crucial in determining the cause
and treatment plan.
5. other: - includes
a. Checking head position, chin elevation, brow position. These features
help to show the patient how ptosis affects function.
b. Evaluate the quantity and quality of the tear film and presence or
absence of lagophthalmos (incomplete closure of the eyelids). Because
poor tear film and lagophthalmos predispose to postoperative dryness
and exposure keratitis.
c. Absence or presence of a normal Bell's phenomenon.
d. Assess corneal sensation.
e. Assessment of the variation in the amount of ptosis with EOM or jaw
muscle movements. This may be seen in Marcus Gunn jaw-winking
ptosis, aberrant regeneration of the III CN or the facial N.
f. Assessment of visual function and refractive error to treat concomitant
amblyopia.
g. Assess the function of EOM because of associated maldevelopment of
them.
h. Assessment of pupillary function (affected in Horner syndrome, IIICN
palsy)
6. ancillary test: a. VF. examination
b. Pharmacologic exam. (4%-10% cocaine).
c. Ice bag test.
d. Tensilon test
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Treatment: GOALS of surgery: There are several important goals to achieve in ptosis surgery:
1. To create or enhance symmetry in the primary position,
2. To elevate the upper eyelid to an appropriate level,
3. to set the proper eyelid contour,
4. To establish and maintain a proper eyelid crease and fold, and
5. To preserve eye-protective mechanisms EPMs.
There are many operations that can be performed to achieve these goals.
The time of operation is important, especially in congenital type, and it depend on
the lid position. If it cover the pupil the surgery should done immediately even if it
small. If it is not cover the pupil the surgery can be wait until preschool age.
4. Trichiasis:The normal eyelashes directed anteriorly away from the globe.
Trichiasis is an acquired condition in which eyelashes are misdirected posteriorly
toward the conjunctiva or cornea.
Trichiasis is simply a misdirection of lashes toward the globe.
In distichiasis, lashes or hairs emanate from the meibomian orifices (it may be
congenital and acquired).
Distichiasis it is a hereditary condition in which an extra row of eyelashes is
present.
Symptoms: If contact is made with the conjunctiva, a foreign body sensation and localized
conjunctival vascular injection result.
Corneal involvement produces pain and photophobia.
Etiology of trichiasis
Following trauma or surgical interruption of the eyelid margin.
Chronic inflammatory conditions, ranging from blepharitis and chalazion to
conjunctival cicatricial disorders such as ocular pemphigoid or Stevens-Johnson
syndrome, also frequently result in trichiasis.
Management: 1. Mechanical Epilation: -for few isolated misdirected cilia. Recurrence in 3-4
weeks.
2. Electrolysis: - Recurrence rate is high.
3. Cryotherapy: - for segmental trichiasis, by use of nitrous oxide probe using
double freeze/thaw technique. The disadvantages are edema for several
days, loss of skin pigmentation, notching of the eyelid margin.
4. Argon laser: - less effective than Cryotherapy. Useful for a few scattered
eyelashes.
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5. Surgery: - when trichiasis is confined to a segment of the eyelid.
5. Madarosis:Decrease in numbers or complete loss of lashes either locally from the lid as
in chronic lid margin diseases or infiltrative tumor, burn, or radiotherapy. Or
the loss is of systemic causes as in myxoedema, SLE and leprosy or from
skin diseases as in generalized alopecia, or as in psoriasis.
Inflammations of the eyelid (glands): 1. Stye (external hordeolum): It is an acute suppurative inflammation of the lashes follicles or associated gland
of Zeis. The usual micro organism is Staphylococcus aureus.
C.F:- are those of acute inflammatory process (pain, redness, edema of the lid)
it can cause Preseptal orbital cellulites.
DDx:- infected chalazion.
Treatment: 1. Hot compresses
2. Topical AB.
3. Drainage by needle.
NB: - recurrent stye in middle age patient may indicate systemic diseases ex. DM.
so those may need investigations.
2. Chalazion (meibomian cyst):It is a chronic lipogranulomatous inflammation of the meibomian glands, due to
closure of the orifices and accumulation of its secretion causing gradual pain
with no acute inflammatory features, unless secondary infection by
staphylococcus aureus causing acute suppurative infection. We can
differentiate it from stye from involvement of lid margin in stye, while in chalazion
near the orifices of the glands. Also by the history the stye is acute and dramatic
condition.
C.F: - apart from secondary infection, it can cause blurring of vision or astigmatic
error if large.
Treatment: 1. It can be resolved spontaneously.
2. By hot compresses and fine message of the lid.
3. Intralesional steroid injection for the near punctum and canaliculi.
4. Surgically, by incision and curettage.
3. Internal hordeolum
It is secondary infection of the chalazion. The opening of the infected gland
directed to the conjunctiva.
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4. Zeis, Moll’s and sebaceous cysts:Benign condition characterized by very thin cyst with clear fluid close to the
eyelid margin. While the sebaceous cyst characterized by yellow gray fatty
material.
Treatment: - incision by needle prick, usually for cosmetic reason.
5. Chronic Marginal Blepharitis: Inflammation of the eyelid margins, is one of the most common causes of
external ocular irritation. It can be infectious or inflammatory etiology; the most
common causes of blepharitis are Staphylococcal infection and irritation from
oily meibomian gland secretions.
C.F: Symptoms: - burning, itching, foreign body sensation, and crusting, particularly
upon awakening.
Signs: - hard, brittle fibrinous scales and hard matted crusts surround individual
cilia on the anterior eyelid margin. Small ulcer when the hard crusts are
removed. Injections and telangiectasis of the anterior and posterior eyelid
margin may be seen in varying degrees.
Aqueous tear deficiency is found in some patients.
Treatment: 1. Lid hygiene by removing of the crusts and scales by cotton with normal saline
or Johnson baby shampoo also rub to remove debris.
2. Antibiotics as chlorenphenicol or fusidic acid at night on the lashes.
3. Topical steroids especially when there is reactive conjunctivitis.
4. Tear substitute in tear film abnormality.
5. Systemic tetracycline for 6-12 weeks. Avoid it in pregnancy, children, and
breast feeding women.
Lid tumors: The eyelids are composed of different tissues including skin, skin Adnexa, blood
vessels, lymphatics, nerves, fibrous connective tissue, muscles, and conjunctival
mucus membrane. These tissues can be involved in neoplastic processes.
A. Benign tumors: 1. Squamous cell papilloma.
2. seborrhic keratosis.
3. keratoacanthoma.
B. Malignant tumors: 1. Basal Cell Carcinoma.
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It is usually affect lower lid, elderly patient, single, slowly growing,
presented as longstanding ulcer with round edges. it can cause local
invasion without metastasis. It has better prognosis than scc.
Treatment: 1. Surgical excision.
2. Radiotherapy.
3. Cryotherapy.
The uses of these types of therapies depend on the site, size, and
the age of the patient.
2. Squamous Cell Carcinoma.
It is more serious, less common, and associated with the solar
keratosis. It can be metastasis to other part of the orbit and body. The
presentation is as hard nodule or crusted ulcer.
Dx: -by biopsy.
Treatment: 1. Surgical excision.
2. Radiotherapy.
3. Cryotherapy.
4. Chemotherapy if there is metastasis
3. Sebaceous Gland Carcinoma
It is relatively rare. It is important to recognize these malignancies
because up to one half of these potentially fatal neoplasms may
resemble benign inflammatory diseases, particularly chalazia and
chronic blepharoconjunctivitis. Proper treatment therefore is often
delayed, and the tumor spreads. Most of these tumors arise from the
numerous sebaceous glands in the eyelids (the meibomian glands and
the glands of Zeis).
Treatment: - complete surgical excision.
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