Presentation Eyelid

7/28/2019 Presentation Eyelid

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Eyelids and Disorders

Dr. Prima Maya Sari,SpM


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Eyelid Anatomy.


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The Eyelids

Protect the eye from injury and excessive

light by their closure

Assist in the distribution of tears over the

anterior surface of the eye ball


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Cross section of the eyelid.


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The medial palpebral ligament attaches the medial ends of the tarsi to the

lacrimal crest and the frontal process of the maxilla.

The lateral palpebral ligament attaches the lateral ends of the tarsi to themarginal tubercle on the orbital margin formed by the zygomatic bone. It is a

poorly developed ligament.

The orbital septum, is prfeorated by the nerves and blood vessels that exit

from the orbital cavity to reach the face and scalp, and by the aponeurotic

fibers of the levator palpebrae superioris and the palpebral part of the lacrimal

gland.

The tarsal gland(meibomian glands) are embedded with in the substance of

the tarsal plates. They are arranged in a single row (30 to 40 in the upper lid,

and 20-30 in the lower) and the ducts discharge their secretion onto the

eyelid margin.

The tarsal gland secretion is oily in consistency and prevents the overflow oftears.

The oily material forms the external layer of the precorneal tear film and

hinders rapid evaporation of tears


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Smooth Muscle The smooth muscle forms the

superior and inferior tarsal muscles. The superior

tarsal muscle is continuous above with the levator

palpebrae superioris and below it is attached to the

upper edge of the tarsal plate of the upper lid. The

function of the superior tarsal muscle is to raise theupper lid and assist the striated muscle of the levator

palpebrae superioris.

Conjunctiva The conjunctiva is a thin mucousmembrane that lines the eyelids and is reflected at

the superior and inferior fornices onto the anterior

surface of the eyeball


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Diseases of the eyelids

Infections & inflammation of the eyelid glands :e.g. Blepharitis =infection of the eyelid & eyelidmargin

Positional abnormalities e.g. ptosis=drooping of

the eyelid Shape abnormalities e.g. entropion=inward

deviation of the eyelid, ectropion=outwarddeviation of the eyelid

Miscellaneous e.g. eyelid wart & nevus. Tumors of the eyelid ,squamous cell & basal cell

carcinoma

Trauma & eyelid laceration & primary repair.


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Classification of Blepharitis

Anterior Lid Margin

Seborrheic blepharitis

Staphylococcal blepharitis

Mixed seborrheic and staphylococcal blepharitis

Posterior Lid Margin

Meibomian gland dysfunction.

Localized lid margin disease

External hordeolum=Infection of Zeis gland=stye

Internal hordeolum=Infection of meibomian gland

Chalazion=Lipogranulomatous reaction in meibomian gland


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EYELID MARGIN INFLAMMATIONS

SEBORRHOIC BLEPHERITIS

Eyelid margin inflammation (blepharitis) is one of the mostcommon problems in ophthalmology.

Lid inflammation affects patients of all ages with either anacute or prolonged inflammatory reaction. Despite itsfrequency,.

Treatment is time-consuming and frequently, not completelyeffective.

There are recognized distinctive forms of blepharitis whichwill be described.

Clinically, these diseases have been divided into those which

involve mainly the base of the eyelashes (seborrheicblepharitis, staphylococcal blepharitis) and those whichinvolve the meibomian glands (meibomian glanddysfunction).


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SEBORRHEIC BLEPHARITIS

Patients with seborrheic blepharitis complain ofcontinuous burning, itching, light sensitivity, andheaviness of the lids.

Although it can occur at any age, it is frequently found inthe elderly.

It is often associated with seborrhea of the scalp, brow,and facial area or of the ears or sternal skin. Significant findings include eyelid inflammation and dry

flakes (dandruff) on the lids (dry seborrheic blepharitis). A variant of this consists of oily secretions and greasy

deposits on the eye lashes (wet seborrheic blepharitis)which may dry to form crusts (scurf). This greasy formmay be associated with meibomian gland dysfunction.


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CHRONIC BLEPHERITIS(EYELID INFECTION)

With chronicity, some patients developcorneal involvement with a punctatekeratopathy in the interpalpebral space.

This disease is chronic and incurable. Mildforms can respond to lid hygiene (hotcompresses and lid massage with removalof the lid flakes with mild soaps orcommercially prepared eye pads).


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STAPHYLOCOCCAL BLEPHARITIS

Patients with Staphylococcalblepharitis often complain ofburning, itching, and irritation,especially in the morning

They may report difficulty

opening their eyes in themorning with their lids mattedor stuck together.

Treatment ,eyelid hygine,antibiotics drops & ointments

as(chloramphenicol,gentamycin,framycetin,tetracycline..) mayneeded for long time as thecondition usually recurrent &chronic.


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MEIBOMIAN GLAND DYSFUNCTION Meibomian gland dysfunction is

characterized by bilateral,prolonged, posterior eyelidmargin inflammation.

Patients complain of rednessand burning, presumably fromthe free fatty acid irritation.Meibomian gland inspissationand occlusion with pouting ofthe orifices is typical.

A thick, yellowish oil can beexpressed from individualmeibomian glands unless thesecretions are inspissated in theorifice
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EXTERNAL HORDEOLUM(STYE)

Painful stye

External hordeolum=Infectionof Zeis gland=stye

Compared with seborrheicblepharitis patients, patientswith S. blepharitis are younger

and more frequently female.During acute S. blephararitis,perifolliculitis can lead toulceration and fibrinousexudates on the lid margin.

Typical changes of chronicblepharitis include crustingand hard brittle scales on thebase of the lashes.


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Chalazion

A chalazion is a chronic inflammatory granuloma of a

meibomian gland. It appears to be caused by alterationsin secretions with retention of secretory material due toobstruction of the ducts. The condition is associated withseborrhea, chronic blepharitis, and acne rosacea.

Chalazia originating in the Zeis sebaceous glands aretermed "external Chalazia"; those in the meibomianglands of the tarsus are termed "internal Chalazia."

Clinically, the lesion presents with soft tissue swelling,erythema, and a firm nodule. As the gland fills with oilysecretions, it increases in size over weeks.


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LONGSSTANDING CHALAZION WITH SPONTANEOUS RUPTURE &

GRANULOMATOUS CONJUNCTIVAL REACTION

Patients may develop an acuteinfection of an occluded meibomiangland (internal hordeolum) or

a prolonged obstruction withLipogranulomatous formation

(Chalazia). Chalazia typically eruptunder the conjunctival surface, butcan also erupt through the tarsus andinto the subcutaneous tissue. Theymay resolve on their own.

Occasionally, an incision and

drainage or intralesional steroidinjections are necessary. Withresolution, chalazion frequently resultin permanent stellate conjunctivalscarring and distortion of the eyelidmargin.


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SURGICAL DRAINAGE OF CHALAZION

Eyelid hygiene with eyelid massageand expression of meibomianglands should be taught.

Ointments should be avoided.

Topical corticosteroids are helpful

in some of the cornealcomplications but should generallybe avoided.

Oral tetracycline or doxycycline areeffective in reducing the symptoms

associated with meibomian glanddysfunction by an effect onaltering the oily products of themeibomian gland.


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ECTROPION (OUTWARD) DIRECTED

EYELID

Ectropion is a condition commonly encountered in clinicalpractice. The pathogenesis of ectropion varies. the evaluation and

treatment of the six elements of pathology that may be present in

an ectropic eyelid. These factors include: (1) horizontal lid laxity;(2) medial canthal tendon laxity; (3) punctal malposition; (4)

vertical tightness of the skin; (5) orbicularis paresis secondary to

seventh nerve palsy; and (6) lower eyelid retractor disinsertion.
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ENTROPION (INWARD) DIRECTED

EYELID Entropion is the inurning of the lid

margin toward the globe, resultingin corneal irritation from the skinand lashes.

Entropion can be classified intothree basic groups: congenital,

involutional, and cicatricial.

the involutional variety remains oneof the most common eyelidconditions encountered in practice.

The cicatricial variety, althoughuncommon, is by far the mostchallenging to treat.


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Trichiasis & Distichiasis

Trichiasis is defined as normal lashes that have a normal locationin the anterior lamella but are misdirected and rub against thecornea and conjunctiva.

Distichiasis also can be an acquired condition, occurring in cases

of Stevens-Johnson syndrome, toxic epidermal necrolysis,cicatricial pemphigoid, and chemical and physical injuries of theeyelids.

Patients with distichiasis and trichiasis present with similarsymptoms of a watery, red, and irritated eye.

The treatment of distichiasis and trichiasis are similar and basedon the extent of lid involvement. If the affected area is limited toa few lashes, simple periodic epilation or electrolysis may suffice.More extensive involvement limited to a localized area of the lidmay be treated by focal cryotherapy application.


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Blepharoptosis=ptosis= drooping of the

upper eyelid

A-Congenital ptosis.

B-Acquired:-

1-mechanical=heavy eyelid e.g. mass orinflammations

2-senile=Aponeurogenic Ptosis= disinsertional of

the aponeurosis insertion of levator muscle

3-myogenic=myasthenia gravis

4-neurogenic=third nerve palsy


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MECHANICAL PTOSIS

ALLERGY & INFLAMMATION OR TUMORS= HEAVY EYELIDS or

SECONDARY TO SCARRING

Mechanical ptosis maydevelop secondary to scarringfrom burn injuries or diseasesthat can cause severeconjunctival cicatricial changes

in the lids such as Stevens-Johnson syndrome or ocularpemphigoid.

Large orbital tumors and lidlesions may induce

mechanical ptosis. Classicexamples includeneurofibromas, orhemangiomas of the upper lid


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HEREDITARY BLEPHAROPHYMOSIS SYNDROME.

WHAT ARE THE APPARENT ABNORMALITIES???


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CONGENITAL PTOSIS

Blepharoptosis, defined as

drooping of the upper eyelid,

is a common ophthalmologic

condition. The normal upper

lid margin rests between 1 to

3 mm below the superior

limbus on primary gaze.

evaluation is whether the

problem is congenital or

acquired.


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Eyelid retraction

Thyroid disease is the Mostcommon cause of unilateral orbilateral lid retraction

Surgical treatment of eyelid

retraction is usually reservedfor patients whose endocrinestatus and eyelid height havebeen stable for at least 6months to 1 year, and in

whom retraction causessignificant exposurekeratopathy, lagophthalmos,chronic conjunctival injection,and cosmetic imperfection.


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CONGENITAL ABNORMALITIES OF THE EYELIDS.

COLOBOMA OF THE UPPER EYELID.

A lid coloboma is a full-

thickness developmental

defect that may involve

the upper eyelid, thelower eyelid, or both. The

edges of the defect may

be adherent to the bulbarconjunctiva and cornea.


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EYELID NAEVUS

Histologically, nevi areclassified as junctional,compound, or intradermaldepending on the location of

the nevus cells in the skin.

Most congenital nevi are ofcompound variety. The"kissing" nevus with mirror-

image configuration involvingapposed portions of theupper and lower lids is acompound nevus


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Basal cell carcinoma of the eyelid

Basal cell carcinoma is by far themost common malignant tumor

involving the ocular adnexa,

accounting for 90% of all eyelid

malignancies and 20% of all lid

tumors.

In the United States, basal cell

carcinoma develops in approximately

400,000 people annually!!

The tumor primarily involves the

lower lid (50% to 66%).

An incisional biopsy of anysuspicious eyelid lesion is required to

establish a definitive histologic

diagnosis before complete excision

and repair.

Squamous cell carcinoma of the eyelid


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Squamous cell carcinoma of the eyelid

Is a malignant neoplasm of keratinizing cells of the

epidermis

It constitutes approximately 9% ofall periocular cutaneous tumorsand is considered the second mostcommon eyelid malignancy.

Squamous cell carcinoma of the

eyelids is a potentially lethaltumor that can invade the orbit bydirect or perineural extension,spread to regional lymph nodes,as well as metastasize to distal

sites. Actinic keratoses considered as

apremalignant lesions, cutaneoussquamous cell carcinoma also mayarise from radiation dermatoses,burn scars, and inflammatorylesions


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Malignant melanoma

Malignant melanoma Malignant melanoma representsapproximately 5% of all cutaneouscancers.

Superficial spreading melanomais considered the most commonvariant of melanoma, accountingfor 70% of cutaneous melanomas.

Clinically, its location on thenonexposed skin surfaces and amore rapid rate of growth are thedistinguishing features of thistumor.

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