Disease of eyelid ,Anatomy and physiology of eyelid

This presentation provides a comprehensive overview of various diseases affecting of eyelid . It covers the anatomy of the eyelid, common condition, their causes, symptoms, diagnostic method and treatment options. This is an essential resource for medical students, ophthalmologist, and healthcare professional to better understand and manage eyelid disorder

1. Diseases Of Eyelids Abhinandan Biniwale B. Optometry (3 rd year)

2. Gross Anatomy The eyelids are mobile tissue curtains placed in front of the eyeballs. These act as shutters protecting the eyes from injuries & excessive light. These also perform an important function of spreading the year film over the cornea and conjunctiva & also help in drainage of tears by lacrimal pump system.

3. Congenital Anomalies Congenital Ptosis - It is a common congenital anomaly.It is usually,but not invariably, bilateral,and is due in most cases of defective development of the muscles. There may be a defect in the upward movement of the eyes,due to absence of the posterior insertion of the levator into the fornix. And sometimes to coincident maldevelopment or defective innervation of the superior rectus.

4. Congenital Coloboma - It is a rare condition characterized by a full thickness triangular gap in the tissues of the lids. The anomaly usually occurs near the nasalside and involves the upper lid more frequently than the lower lid . Treatment consists of plastic repair of the defect.

5. Epicanthus- It is a semicircular fold of skin which covers the medial canthus . It is a bilateral condition and may disappear with the development of nose. It is the most common congenital anomaly of the lids Treatment consists of plastic repair of the deformity.

6. Cryptophthalmos - It is a very rare anomaly in which lids fail to develop and the skin passes continuously from the eyebrow to the cheek hinding the eyeball

7. Microblebharon – In this condition, eyelids are abnormally small. It is usually associated with microphthalmos or anophthalmos . Occasionally, the lids may be very small or virtually absent and the condition is called Ablepharon .

8. Epiblebharon – It refers to a congenital anomaly in which a horizontal fold of tissue rides above the lower eyelid margin. It usually disappears with the growth of face and needs no surgical correction.

9. Euryblepharon – It refers to unilateral of bilateral horizontal widening of palpebral fissure. It is usually associated with lateral canthal malposition and lateral ectropion . Congenital euryblepharon usually involves the lateral portion of lower eyelids.

10. Congenital Ankyloblepharon – . It is a rare anomaly in which single or multiple strands of connective tissue join the upper and lower lid margins anywhere but never at medial and lateral canthi. Such a congenital ankyloblepharon is also called ankyloblepharon filiforme adnatum (AFA). It should be surgically divided to prevent amblyopia.

11. Oedema Of Eyelids Inflammatory Oedema – Inflammatory Oedema may be caused by inflammation of the lids itself ( dermatitis,style , associated with chemosis ) of the lacrimal sac or by purulent inflammation in the eye. Solid Oedema - It is chronic thickening of the lids. Passive Oedema - Passive oedema is due to circulatory obstruction & is seen in general diseases. Ex. Renal disease, Cardiac failure.

12. Inflammatory Disorders Of Eyelids BLEPHARITIS – Blepharitis is a subacute or chronic inflammation of the lid margin. It is an extremely common disease which can be devided into following clinical types : Bacterial Blepharitis Seborrhoeic or squamous Blepharitis Mixed staphylococcal with seborrhoeic Blepharitis Posterior Blepharitis or Meibomitis Parasitic Blepharitis .

13. Bacterial Blepharitis – Also known as chronic anterior Blepharitis , or staphylococcal Blepharitis or ulcerative Blepharitis is a chronic infection of the anterior part of the lid margin. Common cause of ocular discomfort and irritation. The disorder usually starts in childhood & may continue throughout life. Etiology- Causative Organism- Most commonly involved are coagulase positive staphylococci. Predisposing Factors- Usually none,may rarely include chronic conjunctivitis and dacryocystitis .

14. Symptoms – Chronic irritation ,itching ,mild lacrimation , gluing of cilia , and mild photophobia. The symptoms characteristically worse in the morning. Signs- Yellow crusts are seen at the root of cilia which glue them together. Small ulcers,which bleed easily,are seen on removing the crusts. Red thickened lid margins are seen with dilated blood vessels. Complications- Lash abnormalities – Trichiasis , misdirected cilia . Tylosis - Thickening and scarring of lid margin. Recurrent Styes .

15. Treatment – Lid hygiene- at least twice daily. Warm compresses for 5-10 min . Crust removal and lid margin cleaning with the help of cotton buds dipped in the dilute baby shampoo or solution of 3% sodium bicarbonate. Antibiotics- Eye ointment Antibiotic eyedrops should be used 3-4 times day. Oral antibiotics – erythromycin or doxycycline Topical steroids – Flurometholone Ocular lubricants – Artificial tear drops

16. Seborrhoeic or squamous Blepharitis – Seborrhoeic Blepharitis is primarily anterior Blepharitis with some spill over posteriorly.It is common occurrence. Cause - It is usually associated with seborrhoea of scalp(dandruff). Symptoms- mild discomfort, irritation, watering. Signs- Accumulation of white dandruff like scales is seen on the lid margin Lid margin Thickened. Treatment- Improvement of health & balance diet. Antibiotics – Eye ointment Eye drops

17. Posterior Blepharitis ( Meibomitis )- It is inflammation of meibomian glands occurs in chronic & acute forms. 1 Chronic Meibomitis - Chronic Meibomitis is a commonly occuring meibomian gland dysfunction, seen more commonly in middle aged . Symptoms- Irritation , burning , itching, mild lacrimation. Signs- White frothy, Vertical yellowish streaks shining through conjunctiva, Oily and foamy tear film. 2 Acute Meibomitis - It occurs due to staphylococcal infection.It characterized by painful swelling around the involved gland. Treatment- Lid hygiene , Systemic Tetracycline- doxycycline. Ocular lubricants.

18. External Hordeolum – (Style) It is an acute suppurative inflammation of lash follicle & it’s associated glands of Zeiss or moll. Etiology- Predisposing Factors- Age- it is more common in children & young adults and in patient with eye strain due to muscle imbalance or refractive errors. Rubbing of the eyes . Causative organism- commonly involved is staphylococcus. Symptoms- Acute pain, sweeling of lid , mild watering and photophobia. Signs- Stage of cellulitise is characterized by localised , firm, red ,tender swelling at the lid margin associated with oedema . usually ,there is one stye,but occasionally,these may be multiple.

19. Stages of abscess formation is characterized by a visible pus point on the lid margin in relation to the affected cilia. Treatment- Hot compresses 2-3 times Surgical incision is required rarely for a large abscess. Antibiotic eyedrops .

20. Chalazion - Chalazion , also called a tarsal or meibomian cyst, is a chronic non infective inflammation of the meibomian glan Symptoms- Painless swelling in the eyelid. Mild heaviness Blurred vision Watering Signs- Reddish purple area. marginal chalazion , occuring ocassionally,may present as small reddish grey module on the lid margin

21. Treatment – Conservative treatment – In a small, soft and recent chalazion , self – resolution may be helped by conservative treatment in the form of hot formentation,topical antibiotic eye drops and oral anti inflammatory drugs. Incision & curettage

22. Internal Hordeolum - It is a suppurative information of the meibomian gland associated with blockage of the duct. Symptoms- Acute pain, swelling of the lid , mild watering & photophobia. Signs- Red, tender swelling of the lid Treatment- it is similar to Hordeolum externum,except that , when pus is formed, it should be drained by a vertical Incision from the tarsal conjunctiva.

23. TRICHIASIS - It refers to inward misdirection of cilia with normal position of the lid margin. Pseudotrichiasis - The inward turning of lashes along with the lid margin (seen in entropion ) is called Pseudotrichiasis . Etiology- Common causes of Trichiasis are: ulcerative blepharitis , Hordeolum externum , mechanical injury,burns , & operative scar on the lid margin Symptoms- Foreign body sensation & photophobia, irritation,pain & lacrimation. Signs- misdirection cilia , conjunctiva may be congested

24. Treatment – Epilation – (mechanical removal with forceps). It is a temporary measure, as recurrence occurs within 3-4 weeks. Cryoepilation – It is also an effective method of treating trichiasis . After infiltration anaesthesia , the cryoprobe is applied for 20-25 sec.to the external lid margin. it’s main disadvantage is depigmentation of the skin.

25. Anomalies in the position of lid margin Entropion – Entropion refers to inward rolling and rotation of the lid margin toward globe. Etiological types- Congenital entropion - It is a rare condition seen since birth. Seen more commonly in lower than upper eyelid. Cicatricial entropion - It is a common variety usually involving the upper lid. It is caused by Cicatricial contraction of the palpebral conjunctiva. Common cause are trachoma, chemical burns. 3. Senile entropion - It is common occurrence & affects only the lower lid in the elder people.

26. 4. Mechanical entropion – It occurs due to lack of support provided by the globe to the lids. Symptoms- Foreign body sensation, irritation, lacrimation & photophobia Signs- Inturning of lid margin Signs of causative disease e.g scarring of palpebral conjunctiva in Cicatricial entropion , & horizontal lid laxity. Treatment- Lubricants take care of surface disorders & antibiotics of conjunctiva or lid inflammation.If the condition is due to bandaging it is often curred by simply removing bandage.

27. Ectropion - Out rolling or outward turning of the lid margin is called ectropion . Etiological types- Congenital ectropion - This is rare entity & is usually associated with other eyelid malformations such as ankyloblepharon , ptosis, epicanthus. It may occur in both the upper & lower lids & is due to a congenital shortage of the skin. Involutional ectropion - It is commonest variety & involves only the lower lids. It occurs due to age related changes: Horizontal laxity of Eyelid . Cicatricial ectropion – It occurs due to scarring of the skin & can involve both the lids. Common causes of skin scarring: thermal burns, chemical burns, lacerating injuries skin ulcer. Paralytic ectropion - It results due to paralysis of the seventh nerve. It mainly occurs in the lower lids.Common causes: facial nerve palsy,head injury, infection of the middle ear.

28. 5 Mechanical ectropion – It occurs in condition where either the lower lids is pulled down & pushed out and down. Symptoms- Irritation, discomfort & mild photophobia. Signs- Lid margin out rolled, medial canthal tendon laxity- normally on pulling the lid laterally the inferior punctum. Treatment- Relaxation of the scarred tissues & an elongation of the skin muscle lamina by some form of blepharoplasty.

29. Symblepharon – In this condition lids become adherent with the eyeball as a result of adhesions between the palpebral and bulbar conjunctiva. Common cause- chemical burns, injuries, conjunctival ulceration. Clinical features – ocular movement become restricted , diplopia, cosmetic disfigurement is a common complaint. Types- 1. Anterior symblepharon - adhesion present only in the anterior part. 2.posterior symblepharon - adhesion present in the fornices . 3.Total symblepharon - adhesion involving whole of the lid. Complications – Dryness, thickening of conjunctiva due to prolonged exposure & corneal ulceration.

30. Treatment – The prevention of symblepharon by the early & frequently use of a glass rod or therapeutic bandages contact lens is of the utmost importance.

31. PTOSIS- Abnormal drooping of the upper eyelid is called ptosis. Normally, upper lid covers about upper sixth of the cornea, i.e. about 2mm . Therefore in ptosis it covers more than 2 mm. Etiological types- Congenital ptosis- It is associated with congenital weakness of the levator palpebral superioris . There may be defect in the upward movement of the eye. Acquired ptosis- Depending upon the cause it can be Neurogenic ptosis- it is caused by innervational defect such as: third nerve palsy. Aponeurotic ptosis- it develops due to defects of the levator aponeurosis in the presence of a normal functioning muscle .

32. Treatment – . Congenital ptosis- It almost always needs surgical correction. In severe ptosis. Tarso conjunctivo-mullerectomy - It is performed in cases having mild Ptosis and good levator function. In it, upper lid is everted & the upper tarsal border along with its attached Mullers muscle & conjunctiva are resected. Acquired ptosis- Surgical procedure- when required for acquired Ptosis are essentially the same as described as congenital ptosis

33. TUMOURS OF EYELIDS Almost all types of tumours arising from the skin, connective tissue, blood vessels, nerves & muscles can involve the eyelids. Classification : benign tumors – these include : simple papilloma, naevus , angioma , haemangioma , neurofibroma & sebaceous adenoma. Malignant tumours – commonly observed tumours include squamous cell carcinoma, malignant melanoma.

34. Benign Tumours Papillomas – most common benign tumours arising from the surface epithelium. Xanthelasma – these are creamy-yellow plaque like lesions which frequently involve the skin of upper & lower lids near the inner canthus - Xanthelasma occurs more commonly in middle-aged women. Haemangioma – haemangioma of the lids are common tumours . Treatment – Intralesional steroid (triamcinolone) injection is effective in small to medium size tumours . Neurofibroma – Lids & orbits are commonly affected in neurofibromatosis.

35. Malignant Tumours Basal cell carcinoma – malignant tumours of the lids (90%) usually seen in elderly people. It is locally malignant & involves most commonly lower lid followed by medial canthus, upper lid & outer canthus. Clinical features- It starts as a small nodule which undergoes central ulceration with pearly rolled margins. The tumours grows by burrowing & destroying the tissues locally like rodent and hence the name rodent ulcer. Treatment- Surgery – local surgical excision of the tumours along with 3mm surrounding area of normal skin with primary repair is the treatment choice.

36. 2. Squamous cell carcinoma – It forms the second commonest malignant tumour of the lid. It incidence (5%) is much less than the basal cell carcinoma. It commonly arises from the lid margin in elderly patients. Histologica features – It is characterized by an irregular downward proliferation of epidermal cells into the demis . 3. Sebaceous gland carcinoma – It is rare tumour arising from the meibomian glands. Clinical features: It usually present initially as nodule more frequently on the upper eyelid. Which then grows to form a big growth. Treatment: Surgical excision with reconstruction of the lids is the treatment of choice.Recurrences are common.

37. Reference: Comprehensive ophthalmology (A.K Khurana ) Parson Diseases of the eye.( Ramanjit Sihota )

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