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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.