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The eyelids

The eyelids are the moving folds of skin that cover the outer portion of the eyeball. Which protect the eye from injury and excessive light, and prevent excessive dryness of the cornea and conjunctiva Macroscopic anatomy :- 1. The palpebral fissure 2.The canthi

Microscopic Anatomy

The eyelid is formed of 6 layers :- 1. Skin 2. Subcutaneous areolar layer 3. Muscular layer 4. Sub muscular layer 5. Tarsus 6. Palpebral conjunctiva

The lid margin

It is about 2mm broad it had external and internal portion divided by gray line. it is divided into 2 portions :- a. Lacrimal portion: in which content lacrimal papillae b. Ciliary portion: in which eyelashes are present

The muscles of the lid

1. Orbicularis oculi muscle :-a. Orbital portiona. b.Palpebral portionc. Horner’s muscle2. Lavator palpebrae superioris muscle3. Muller’s muscle

The gland of the lid

Meibomian glandZeis glandMoll’s gland

Blood supply of the eyelid

Arteries 1. Superior and inferior medial palpebral arteries from the ophthalmic artery 2. Superior and inferior lateral palpebral arteries from the lacrimal artery the above two anastomose to form two tarsal arcades in the upper lid and one tarsal arcade in lower lid 3. Branches from superficial temporal and facial arteries

Veins:-

Pre tarsal and post-tarsal plexus draining into the ophthalmic vein. Lymphatic drainage of eyelids Medial 1/3 drains to the sub maxillary lymph nodes Lateral 2/3 drain to the pre auricular and parotid lymph nodes

Nerve supply of eyelids

Sensory : ophthalmic division of the trigeminal nerve(V1) through the supra orbital, supra trochlear, infra trochlear and lacrimal branches. maxillary(V2) through the infraorbital branch..2. Motor : 3rd ,7th and sympathetic fibers supply the levator ,orbicularis and Muller’s muscle respectively.

Diseases of the lids

Congenital anomalies of the lids Inflammation of the lids Deformities of the lid margin and palpebral aperture Tumours of the lids

Congenital Anomalies of Eyelids

Ablepharon: extremely rare congenital defect Microblepharon Cryptophthalmos: in which a fold of skin pass continuously from the eyebrow over the eye to the cheek Ptosis

5. Epicanthus: frequently bilateral and often associated with ptosis 6. Distichiasis: extra posterior row of cilia is present 7. Coloboma of the lid: a notch is usually situated at the junction of the middle third and the medial third 8. Entropion and Ectropion

Lid Edema

Traumatic edema Inflammatory edema Non inflammatory edema a. Allergic angioneurotic edema b. Passive systemic edema

Inflammations Of The Lid

A- Inflammations of the lid itself (lid abscess) B- Inflammations of the lid margin (blepharitis) C- Inflammations of the glands of the lid (external hordeolum, internal hordeolum and chalazion)


A- LID ABSCESS
It is a localized suppurative inflammation of the lid Clinical picture: A painful, red, hot and tender swelling within the lid. Treatment: Systemic and local antibiotics Surgical drainage by a transverse incision (better cosmetically). Vertical incisions should be avoided as they may lead to shortening on fibrosis

B- BLEPHARITIS

Blepharitis usually presents as a chronic blepharoconjunctivitis and it is the most common external eye disorder in clinical practice Types: Anterior blepharitis. Posterior blepharitis.

1. Anterior Blepharitis

A- staphylococcal blepharitis - hard scales and crusting around the base of lashes. - mild papillary conjunctivitis. - scarring and notching of lid margin, madarosis, trichiasis and poliosis. - marginal keratitis. - tear film instability and dry eye.

B- Seborrhoeic Blepharitis

Hyperaemic and greasy anterior lid with sticking together of lashes. The scale are soft and located anywhere on the lid margin and lashes.

Treatment

Lifelong treatment may be necessary and that a permanent cure is unlikely: 1- Lid hygiene. 2- Antibiotics: a- topical: like sodium fusidic acid, bacitracin or chloramphenicol b- oral: like azithromycin 500 mg for three days. 3- Weak topical steroid. 4- Tear substitute.

Posterior Blepharitis

Is caused by meibomian gland dysfunction and alteration in meibomian gland secretion. - Excessive and abnormal meibomian gland secretion - Plugging of the meibomian gland orifices. Expression of meibomian fluid by pressure. Tear film is oily. Papillary conjunctivitis and inferior corneal punctate epithelial erosions.


Treatment
Inform the patient that cure is unlikely 1- Lid hygiene. 2- Systemic tetracycline. a- Oxytetracycline 250 mg b.d. for 6 -12 week. b- Doxycycline 100 mg b.d. for one week and then daily for 6-12 wk. c- Minocycline d- Erythromycin 3- Topical therapy (AB, steroid and tear substitute).

Inflamation of eyelids glands1.Stye: (Hordeolum externum)

Acute suppurative inflammation of Zeis gland and the lash follicle, forming a small abscess Treatment: application of antibiotic ointment and removal of the affected cilium

2. Hordeolum internum

Acute suppurative inflammation of the meibomian gland caused by staphylococcus aureus. It may be primary or it may occur on top of a chronic inflammation of the meibomian gland (chalazion) Treatment: surgical drainage

Chalazion (cyst)

It is chronic non-specific inflammatory granuloma of a meibomian gland.

Deformities of the lid margin and palpebral aperture

Trichiasis Entropion Ectropion Symblepharon Ankyloblepharon Blepharophimosis Lagophthalmos Ptosis

TRICHIASIS

Misdirection of eye lashes. Etiology Congenital trichiasis: often in all 4 lids. It is called distichiasis. In this condition, an extra row of lashes is present behind the gray line in the place of the ducts of the meibomian glands.


2. Acquired trichiasis: may be caused by the following: Trachoma is the commonest cause due to fibrosis distorting the hair follicles Ulcerative blepharitis Burns

Entropion

Definition: Entropion is the rolling inwards of the eyelid. The whole row of the lashes will be rubbing against the cornea and finally there will be a deformity of the tarsus.

Types:

Cicatricial (fibrotic) entropion Spastic entropion Involutional (senile) entropion Congenital entropion

ECTROPION

Definition: Ectropion is rolling outwards of the eyelid from the globe. It usually affects the lower lid as it stands against gravity.


Types: Involutional (senile) ectropion Cicatricial (fibrotic) ectropion Paralytic ectropion Mechanical ectropion Congenital ectropion

Symblepharon

A condition where adhesion develops between the lid and the eyeball. Due Membranous conjunctivitis Chemical burns ulcers Operation


Ankyloblepharon
Is the adhesion of the margins of the uper and lower lid either due Congenital Acquired condition due to burn

Blepharophimosis

Is the narrowing of the palpebral aperture Often congenital