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Ophthalmology
Eyelids
Anatomy
• The eyelid is the protective cover or the curtain o f the
eye-ball
Composed of five layer :
1- Skin
2- Muscles; Orbicularis oculi, and Levator palpebral muscle
3- Sub-muscular layer
4- Tarsal plate forms the fibrous backbone of the lid
5- Conjunctiva; mucous membrane forms the inner lining layer
The margin of the lid
• is 2mm muco-cutaneous junction,contains :
1.
2.
3.
4.
5.
The lashes (Cilia).
Grey line
Orifices of Meibomian glands.
Mucocutaneous junction.
Superior and inferior puncti of Naso- lacrimal
system.
Muscles of the eyelids:
1- Orbicularis oculi muscle:
It is a thin oval sheet of concentric striated muscle fibers
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.
Nerve supply: 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 eyelids, 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: Oculomotor nerve.
3- Superior palpebral muscle (Müller's 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:
• Accessory lacrimal glands which contribute in the secretion of
aqueous tear
• Goblet glands, are unicellular glands which secret inner
mucous layer of the tear film.
• Meibomian glands are modified sebaceous glands embedded
in the tarsal plates, about 20-30 in each lid. Meibomian glands
secret the outer oily layer of the tear film.
Functions of the lids
• Protection to the eye globe by blinking reflex.
• Prevent dryness of the eye from continuous exposure.
• Contributes in tear secretion; secrets oily layer of the tear film
• Drainage of tear through the upper and lower puncti and
canaliculi.
• Spread tears over the anterior surface of the eye
Abnormalities in shape and position:
1. Trichiasis
• Misdirection of the eyelashes which may cause irritation and
ulceration of the cornea.
• Causes : scarring to the lid margin e.g. trachoma, trauma,
chronic blepharitis.
• Treatment: For isolated misdirection cilia
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.
2. Entropion
Inward inversion of the lid . Eyelashes cause rubbing and
ulceration of the cornea.
 Causes
• Congenital
• Cicatricial conjunctivitis secondary to scarring of palpebral
conjunctiva e.g. trachoma, chemical burn.
• Senile; Due to weakness of Orbicularis oculi muscle .
 Treatment : all of the above condition is treated surgically .
• Spastic : secondary to any condition causing severe ocular
irritation (irritation leads to overriding of Orbicularis oculi
muscle fibers), e.g.: conjunctivitis, keratitis and ocular
surgery. Treatment: of underlying cause and taping of lid
(turned outward).
3. Ectropion
• Outward eversion of the lid.
 Misdirection of the lacrimal puncti cause
o Tearing (epiphora)
o Exposure conjunctivitis and keratitis
 Causes
• Congenital
• Cicatricial; secondary to scarring of skin e.g. post-traumatic
• Paralytic; facial nerve palsy. Treatment: we should wait for 6
months for spontaneous recovery e.g. (Bell's palsy) then
lateral tarsorrhaphy is indicated.
• Senile; Due to laxity of lower lid tendons. Treatment: surgical
correction.
4. Ptosis
• It is an abnormal low position or dropping of the upper eyelid.
It could be unilateral or bilateral, and both of them could be
partial or complete. Usually the upper lid covers only 2 mm
from cornea. If more, is called blepharoptosis.
• Causes:
1-Congenital, present at birth, may be unilateral or
bilateral.Treatment : surgery .
2-Neurogenic :
 Oculomotor nerve palsy
 Causes complete ptosis, with impairment of eye movement
 Sympathetic palsy (Horner syndrome)
 Causes mild ptosis about 2-3mm dropping of the upper lid
3-Muscular :
 Myasthenia gravis, impairment of transmission at the
neuromuscular junction .Treatment :Medical.
 Myotonic dystrophy
4- Aponeurotic blepharoptosis:
• Weakness of the Levator palpebral aponeurosis (tendon)
i- Involutional (senile).
ii- Post operative.
5- Mechanical blepharoptosis:
Is the result of impaired mobility of the upper lid .
• Dermatochalasis
• Large tumour
• Severe oedema
• Heavy scar tissue
5. Lid retraction
Over-exposure of the eye, the sclera is exposed at the upper and
lower limbus.It occurs most commonly in Dysthyroid
Ophthalmopathy
6.Blepharospasm:
• Involuntary sustained closure of the eyelids which occurs
1. spontaneously (essential)
2. sensory stimuli (reflex).
Inflammation of the lid
1.Stye (External hordeolum) :
•
Acute Staphylococcus infection of a eyelash hair follicle or
one of the associated glands.
• Clinical features; small tender swelling in the lid margin
• Treatment;
a- Hot compresses
b- Topical antibiotics eye ointment
c- Epilation (removal of eyelashes by a forceps) to enhance drainage
of pus.
d- Systemic antibiotics if there is severe preseptal cellulitis.
2. Internal hordeolum;
 Acute Staphylococcus infection of a meibomian gland
 Clinical features; tender hyperemic, swelling within the lid .
 Treatment;
 Topical antibiotics
 Surgical drainage for the residual nodule after the acute
infection has resolved.
3. Chalazion
Chronic lipogranulomatous inflammation of a meibomian
secondary to retention of sebum and there is NO infection.
• It is more frequent and multiple in patients with acne rosacea
or seborrhoeic dermatitis
• Clinical features; painless swelling within the lid .
• Treatment
1. Surgical : The most common method
2. Steroid injection: Good alternative to surgery, 0.1-0.2 ml
triamcinolone infiltrated around the lesion, the success
rate is 80%. In unresponsive cases, another injection is
given two weeks later. Chalazion should be small in size to
be treated with steroid injection.
3. Systemic tetracyclines: As prophylaxis, particularly in acne
rosacea and seborrhoeic dermatitis where chalazion is
recurrent.
Blepharitis
• Inflammation of the eyelid margin
• Types of chronic blepharitis:
1- Anterior: a- Staphylococcal infection.b- Seborrheic dysfunction.
2- Posterior : meibomian gland dysfunction
Symptoms of chronic marginal blepharitis: (anterior and posterior)
• 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.Seborrhoic
• Clinical features; Redness of the lid margin, and presence of
white dandruff like scales
b.Staphylococcal (Ulcerative)
• Staphylococcus infection with purulent discharge, associated
with chronic conjunctivitis and recurrent styes
 Treatment:
• Lid hygiene, with removing crusts and toxic products by
washing the lids with weak solution of baby shampoo.
• Short coarse of weak topical steroids
• Topical antibiotics ointments in Staphylococcus infection
• Tear substitutes
• Oral azithromycin 500 mg daily for three days
Lid Tumors
Benign
• Xanthelasma; yellowish slightly elevated plaque of lipid
deposits
located medial aspects of both lids
Malignant
• Basal cell carcinoma; elderly people, starts as well
defined nodule, then the center becomes ulcerated and
crusted