Diseases of eye lid

Prepared by : Dr. Saad A. Yahya

Head of ophthalmology dept.
Al asmarya Islamic University
Anatomy of eye lid
Embryology
By the 6th week of gestation, the eye lids start to appear
from the surface ectoderm and mesenchyme.
Surface ectoderm
 Epithelial layers of the skin and conjunctiva.
 Hair follicles and cilia,
 Lid glands (meibomian glands, Zeis glands, and glands
of Moll).
Mesenchyme
Tarsal plates, orbicularis muscle, levator LPS muscle, and
Müller muscle.
The eye lid is a mobile, flexible, multi-lamellar structure
that covers the globe anteriorly.
Upper lid covers about 2 mm (1/6th) of the cornea of
cornea.
Lower lid just touches the limbus.
The two lids meet each other at medial and lateral
angles (outer and inner canthi). The medial canthus is
about 2 mm higher than the lateral canthus.
Palpebral fissure:
It is the elliptical space between the upper and the lower lid.
When the eyes are open it measures about 10-11 mm
vertically in the centre and about 28-30 mm horizontally.
 Functions of eye lids:

1. It protects the globe from injuries and excessive light.

2. Converges the eye during sleep.
3. Spreads the tear film over the conjunctiva and cornea
with each blink, which prevent drying of the eyes.
4. Contain the meibomian oil gland which provide the lipid
component of the tear film.
5. Contain the puncta through which the tears flow into
the lacrimal drainage system.
6. Maintains the proper position of the globe within the
orbital contents.
Lid margin
It is about 2-mm broad and is divided into two parts by
the punctum.
1.The medial, lacrimal portion
2.The lateral, ciliary portion.

From anterior to posterior,

the structures seen are:
 Skin.
 Eyelashes (cilia).
 Gray line.
 Meibomian gland orifices.
 Mucocutaneous junction.
 Palpebral conjunctiva.
Gray line which marks junction of skin and conjunctiva
divides the intermarginal strip into an anterior strip
bearing 2-3 rows of lashes and a posterior strip on which
openings of meibomian glands are arranged in a row.
The splitting of the eyelids when required in operations
is done at the level of grey line.
Lid margin
The lid layers ( from anterior to posterior ) :
 The skin (thinnest skin of the body, contains fine
hairs, sebaceous glands, and sweat glands).
 The subcutaneous areolar tissue.
 The layer of striated muscle.
 Submuscular areolar tissue.
 Fibrous layer (orbital septum).
 Layer of non-striated muscles.
 Tarsal plates, contain ( Meibomian glands ) sebaceous
glands that secrete an oily substance onto the eye to
slow the evaporation of the eye’s tear film. The upper
tarsus is wider than the lower tarsus.
 Conjunctiva.
Muscles of eye lid :
Orbicularis muscle which forms an oval sheet
across the eyelids.
It comprises three portions: orbital, palpebral and
lacrimal .
It closes the eyelids.
It is supplied by zygomatic branch of the facial nerve.
Riolan muscle
The muscle of Riolan represents the most superficial
portion of the orbicularis muscle.
It corresponds to the gray line of the eyelid margin.
It arises from the palpebral segment of the orbicularis
muscle.

Levator palpebrae superioris muscle(LPS).

It arises from apex of the orbit and is inserted by three
parts on the skin of lid, anterior surface of tarsal plate
and conjunctiva of superior fornix.
It raises the upper lid.
It is supplied by a branch of occulomotor nerve.
Superior tarsal (Müller) muscle
It is non-striated muscles
it lies deep to the orbital septum in both the lids. In the
upper lid it arises from the fibers of LPS muscle and in
the lower lid from prolongation of the inferior rectus
muscle.
Glands of eye lid :
Meibomian glands
They are holocrine sebaceous glands that lie within the
tarsus. Their ducts open at the lid margin.
They produce oil which forms the oily layer of the tear
film.
There are more meibomian orifices in the upper eyelid
(30-40) compared to the lower eyelid (20-30).
Glands of Zeis
These are also sebaceous glands which open into the
follicles of eyelashes.
Glands of Moll
These are modified sweat glands situated near the hair
follicle .
They open into the hair follicles or into the ducts of Zeis
glands .
Accessory lacrimal glands of Wolfring
These are present near the upper border of the tarsal
plate.
BLOOD SUPPLY
Arteries
Arterial supply is by 3 arcades that form anastomoses
between the medial palpebral artery (from the terminal
ophthalmic artery) and the lateral palpebral artery
(from the lacrimal artery).
• In the upper lid, there is a marginal arcade 2mm
above the margin and a peripheral arcade at the top of
the tarsal plate.
• In the lower lid, the arcade lies 4mm below the
margin.
Veins
Venous drainage is to superficial temporal vein laterally
and to the ophthalmic and angular veins medially.
Lymphatics
Lymphatic drainage from lateral half of the lids drain
into preauricular lymph nodes and those from the
medial half of the eyelids drain into submandibular
lymph nodes.
Nerves
1. Motor supply :
 Facial N. supplies orbicularis muscle.
 Oculomotor supplies LPS muscle
 Sympathetic fibers supply the Mullers muscle.
Sensory supply :
Sensory nerve supply is derived from branches of the
trigeminal nerve
 lacrimal, supraorbital and supra-trochlear nerves for
upper lid.
 Infraorbital nerve with infra-trochlear branch for
lower lid.
 Congenital eye lid disorders
Congenital coloboma.
 It is a full thickness triangular defect of the lids.
 Usually occurs near the nasal side.
 Involves the upper lid more than the lower lid.
 Treatment: plastic surgery repair of the defect and
prevent exposure keratitis.
Epicanthus
It is a semicircular fold of skin which covers the medial
canthus of the eye.
It is a bilateral condition and may disappear with the
development of nose.
It is a normal facial feature in Mongolian races.
It is the most common congenital anomaly of the lids.
It may be associated with Down syndrome,
blepharophimosis, ptosis.
Treatment plastic surgery repair of the deformity.
Ankyloblepharon
It refers to the adhesions between margins of the
upper and lower lids. It may be complete or partial.
It may occur as a congenital anomaly or may result
after healing of chemical burns, thermal burns, ulcers
and traumatic wounds of the lid margins.
It is usually associated with symblepharon.
Treatment
Surgical excision of adhesions between the lid
margins.
Blepharophimosis
In this condition the extent of the palpebral fissure is
decreased.
It appears contracted at the outer canthus.
It may be congenital or acquired, due to formation of
a vertical skin fold at the lateral canthus (epicanthus
lateralis) following eczematous contractions.
Treatment: Surgical repair.
Lagophthalmos
This condition is characterised by inability to
voluntarily close the eyelids.
Causes :
paralysis of orbicularis oculi muscle, cicatricial
contraction of the lids, symblepharon, severe
ectropion, proptosis, following over-resection of the
levator muscle for ptosis, and in comatosed patients.
Physiologically some people sleep with their eyes open
(nocturnal lagophthalmos)
Complications include conjunctival and corneal xerosis
and exposure keratitis.
Ptosis
Abnormal drooping of the upper eyelid.
Drooping of the upper lid to a level that covers more
than 2 mm of the superior cornea.
1. Congenital: congenital weakness or maldeveloped
levator palpebrae superioris (LPS) muscle.
2. Acquired:
 Neurogenic
 Myogenic
 Aponeurotic
 Mechanical
Neurogenic ptosis:
 Third nerve palsy.
 Horner’s syndrome.
 Multiple sclerosis.
Myogenic ptosis:
 Myasthenia gravis.
 Dystrophia myotonica
 Following trauma to the LPS muscle.
Aponeurotic ptosis: (defect in levator aponeurosis).
 Involutional (senile) ptosis.
 Postoperative ptosis
 Blepharochalasis.
 Traumatic dehiscence of the aponeurosis.
Mechanical: (excessive weight on the upper lid).
Lid tumors.
Inflammation.
Multiple or huge chalazia.
Oedema or hemorrhage.
Measurement of amount (degree) of ptosis.
In unilateral ptosis: difference between the vertical
height of the palpebral fissures of the two sides
indicates the degree of ptosis.
In bilateral ptosis: it can be determined by measuring
the amount of cornea covered by the upper lid and
then subtracting 2 mm.
Ptosis is graded depending upon its amount as:
1. Mild ptosis : 2 mm
2. Moderate ptosis : 3 mm
3. Severe ptosis : 4 mm

Assessment of levator function (Burke’s method):

 Ask the patient to look down.
 Put the thumb of one hand firmly against the
eyebrow to block the action of frontalis muscle.
 Then ask the patient to look up and the amount of
upper lid excursion is measured with a ruler.
Levator function is graded as follows:
Normal : 15 mm
Good : 8 mm or more
Fair: : 5–7 mm
Poor : 4 mm or less
Treatment of ptosis
Congenital ptosis:
 It almost always needs surgical correction.
 Mild and moderate ptosis, surgery should be delayed
until the age of 3- 4 years.
 Severe ptosis, surgery should be performed at the
earliest to prevent stimulus deprivation amblyopia.
Operations:
For congenital ptosis and acquired ptosis.
1. Tarso-conjunctivo-Mullerectomy (Fasanella-Servat
operation).
2.Levator resection.
3.Frontalis sling operation (Brow suspension).
1. Tarso-conjunctivo-
Mullerectomy (Fasanella-
Servat operation).
2.Levator resection.
3.Frontalis sling operation
(Brow suspension).
INFLAMMATORY DISORDERS OF EYELIDS
Blepharitis
It is a subacute or chronic inflammation of the lid
margins.
It can be divided into following clinical types:
1. Seborrhoeic or squamous blepharitis.
2. Staphylococcal or ulcerative (bacterial) blepharitis.
3. Posterior blepharitis or meibomitis.
4. Parasitic blepharitis.
Bacterial (ulcerative) blepharitis
Clinical features
 Involvement is usually bilateral and symmetrical, with
no visual disturbance.
 Remissions and exacerbations are characteristic.
 The symptoms are characteristically worse in the
morning.
 Burning, grittiness and mild photophobia
 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.
 Mild papillary conjunctivitis is a common associations.
Complications :
 Chronic conjunctivitis.
 Madarosis (sparseness or absence of lashes).
 Ectropion and trichiasis.
 Poliosis (greying of lashes).
 Tylosis (thickening of lid margin).
 Eversion of the punctum (epiphora).
 Recurrent styes is a very common complication.
Treatment
1. Crusts should be removed.
2. Antibiotic ointment should be applied at the lid margin,
immediately after removal of crusts, twice daily.
3. Antibiotic eye drops 3-4 times / day.
4. Oral antibiotics such as erythromycin or tetracyclines may
be useful.

Seborrhoeic or squamous blepharitis

It is usually associated with seborrhoea of scalp
dandruff.
Some constitutional and metabolic factors play a part in
its etiology.
Clinical features
 Accumulation of white dandruff-like scales is seen on
the lid margin.
 Hyperemic, thickened and greasy lid margin (no
ulcers), with soft scales and adherence of lashes to
each other.
 The lashes fall out easily.
 Epiphora.
Treatment
 General measures include improvement of health and
balanced diet.
 Associated seborrhoea of the scalp should be
adequately treated.
 Local measures include removal of scales from the lid
margin with the help of baby shampoo.
 Application of combined antibiotic and steroid eye
ointment at the lid margin (maxidrol / tobradex).
Posterior blepharitis (meibomitis)
Meibomitis is the inflammation of Meibomian glands
occurs in acute and chronic forms.
Acute meibomitis occurs mostly due to staphylococcal
infection.
Chronic meibomitis is a meibomian gland dysfunction,
seen more commonly in middle-aged persons with acne
rosacea and seborrhoeic dermatitis.
It is often associated with facial rosacea.
Treatment of meibomitis
1. Lid hygiene
 Warm compresses for several minutes.
 Expression of accumulated secretions by repeated
vertical massage of lids in the form of milking.
2. Topical antibiotics
Eye ointment massage at night.
Eye drops may be used 3–4 times a day.
3. Systemic tetracyclines, e.g., doxycycline 100 mg.
4. Ocular lubricants i.e., artificial tear drops.
5. Topical steroids (weak) such as fluoromethalon.
HORDEOLUM EXTERNUM (STYE)
It is an acute suppurative inflammation of gland of the
Zeis or Moll.
Causative organism
Commonly involved is Staphylococcus aureus.
Symptoms
 Acute pain
 Swelling of lid
 Watering and photophobia.
1. Predisposing factors
 It is more common in children and young adults.
 Habitual rubbing of the eyes or fingering of the lids
and nose, blepharitis and diabetes mellitus are
usually associated with recurrent styes.
 Excessive intake of carbohydrates and alcohol.
Signs
Stage of cellulitis is characterised by localised, hard, red,
tender swelling at the lid margin associated with
marked oedema.
Stage of abscess formation is characterised by a visible
pus point on the lid margin.
Usually there is one stye, but occasionally, is multiple.
Treatment
 Hot compresses 2-3 times a day to relieve the
cellulitis.
 Evacuation of the pus should be done by epilating
the involved cilia.
 Surgical incision is required rarely for a large
abscess.
 Antibiotic eye drops (4 times a day) and eye
ointment (at bed time).
 Systemic anti-inflammatory and analgesics relieve
the pain and reduce oedema.
 Systemic antibiotics may be used depending on
severity of cellulitis.
HORDEOLUM INTERNUM
It is a suppurative inflammation of the meibomian
gland associated with blockage of the duct.
Causes:
1. Primary staphylococcal infection of the meibomian
gland
2.Secondary infection in a chalazion (infected
chalazion).
Symptoms are similar to hordeolum externum, except
that more pain.
On examination
 The swelling is away from the lid margin
 Pus usually points on the tarsal conjunctiva.
Treatment
1. It is similar to hordeolum externum.
2.when the pus is formed, it should be drained by
a vertical incision from the tarsal conjunctiva.
Chalazion
It is a chronic non-infective granulomatous
inflammation of the meibomian gland (meibomian
cyst).
There is a retention of secretions (sebum) in the
gland, causing its enlargement.
It is painless swelling in the lid
On examination usually reveals small, firm to hard,
non-tender swelling present slightly away from the
lid margin.
Complete spontaneous resolution may occur.
Large chalazion of the upper lid may press on the
cornea and causes astigmatism and blurred vision.
On the conjunctival side, may form a mass of
granulation tissue – conjunctival granuloma.
Secondary infection leads to formation of hordeolum
internum.
Malignant change into meibomian gland carcinoma may
be seen occasionally in elderly people.
Tumors of eye lid
1. Benign tumors: Papilloma, naevus, angioma,
haemangioma, neurofibroma and sebaceous
adenoma.
2. Pre-cancerous conditions: solar keratosis,
carcinoma-in-situ and xeroderma pigmentosa.
3. Malignant tumours.
 Squamous cell carcinoma,
 Basal cell carcinoma,
 Malignant melanoma
 Sebaceous gland adenocarcinoma.
Basal-cell carcinoma
It is the commonest malignant tumor of the lids (90%).
It is usually seen in elderly people.
It is locally malignant and involves most commonly
lower lid (50%) followed by medial canthus (25%), upper
lid (10-15%) and outer canthus (5-10%).

Clinical features:
It may present in 4 forms:
1. Noduloulcerative basal cell carcinoma
2. Non-ulcerated nodular carcinoma.
3. Sclerosing or morphea carcinoma.
4. Pigmented basal cell carcinoma.
Noduloulcerative basal cell carcinoma:
It is the most common presentation.
It starts as a small nodule which undergoes central
ulceration with pearly rolled margins.
The tumor grows by burrowing and destroying the
tissues locally like a rodent and hence the name
rodent ulcer.
Treatment
 Surgery: Local surgical excision of the tumor along
with a 3 mm surrounding area of normal skin with
primary repair is the treatment of choice.
 Radiotherapy and cryotherapy should be given only
in inoperable cases for palliation.
Squamous cell carcinoma
It forms the second commonest malignant tumor of
the lid.
Its incidence (5%) is much less than the basal cell
carcinoma.
It commonly arises from the lid margin
(mucocutaneous junction) in elderly patients.
Affects upper and lower lids equally.
Clinial features
It may present in two forms:
An ulcerated growth with elevated and indurated
margins is the common presentation .
The second form, fungating or polypoid verrucous
lesion without ulceration, is a rare presentation.
Metastasis in preauricular and submandibular lymph
nodes.
Treatment on the lines of basal cell carcinoma.
Malignant melanoma (melanocarcinoma)
It is a rare tumor of the lid (less than 1% of all eyelid
lesions).
It may arise from a pre-existing naevus, but usually
arises de novo from the melanocytes present in the
skin.
Clinically appears as a flat or slightly elevated naevus
which has variegated pigmentation and irregular
borders.
It may ulcerate and bleed.
Metastasis. spreads locally as well as by lymphatics
and blood stream.
Treatment:
It is a radio-resistant tumor.
Therefore, surgical excision with reconstruction of the
lid is the treatment of choice.

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