ﻋﻴﻮﻥ ﻓﺼﻞ ﺍﻭﻝ
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ﺩ.ﺯﻳﺎﺩ ﻛﺎﻣﻞ ﺍﳉﻨﺎﺏ ﻱ
THE EYELIDS
Anatomy:
The lid contain:
1- Smooth muscles (Müller's muscles).
2- Striated muscles (Orbicularis oculi and Levator palpebrae superioris "LPS").
3- Dense fibrous plates (Tarsal plates).
4- Glands.
5- Nerves and blood vessels.
The contents of the lid are: (from anterior surface to posterior) Skin, the subcutaneous tissue, muscular layer, the submuscular
(areolar tissue) layer, the orbital septum which end as a tarsal plate (that forms the architecture of lid) and finally the conjunctiva
(palpebral) which is situated most posterior.
The free margin of the eyelids contains:
1- The lashes (Cilia).
2- Grey line.
3- Orifices of Meibomian glands.
4- Mucocutaneous junction
5- Superior and inferior puncti of Naso-Lacrimal System (NLS).
Muscles of the eyelids:
1- Orbicularis oculi muscle: It is a thin oval sheet of concentric striated fibrous surrounding the palpebral fissure. It can be
divided into:
a- Peripheral (orbital) part: This is involved in forceful closure of lids.
b- Central (palpebral) part: This is involved in involuntary blinking and participates in forceful closure with the orbital part.
c- Muscle of Rioland's: this part is represented by the gray line of lid margin.
d- lacrimalis muscle: that attached to the fundus of lacrimal sac. This part is involved in pumping lacrimal drainage system.
Nerve supply:
Sensory: Ophthalmic branch of trigeminal nerve . Motor: Facial nerve.
2- Levator palpebrae superioris muscle: It is originates from the periosteum covering the lesser wing of sphenoid bone at the
apex of the orbit. The aponeurosis inserts into:
a- Skin of the upper eyelid, so it forms skin creases on the eyelid.
b- Upper edge and anterior surface of the tarsal plate.
c- Medial and lateral palpebral ligaments.
Function: To keep the palpebral fissure open against gravity.
Nerve supply: Sensory: Ophthalmic branch of trigeminal nerve. Motor: Oculomotor nerve.
3- Superior palpebral muscle (Müller's muscle or superior tarsal muscle): It is a small sheet of smooth muscle originated
from the under surface of the LPS muscle and inserted to the upper edge of the upper tarsal plate.
Nerve supply: Sympathetic nerves.
Function: Like LPS, is to keep the palpebral fissure open against gravity.
Glands in the eyelids:
1- Meibomian glands (Tarsal glands): Modified sebaceous gland located in the tarsal plate. The upper tarsus contains 30-40
glands, while the lower tarsus contains 20-30 glands.
Function: It secret the lipid forms the outer layer of the tear film.
2- Zeis glands: Modified sebaceous gland opened with lash follicles.
3- Glands of Moll: They are modified sweat gland whose ducts also open into lash follicle or directly in the anterior lid margin
between the lashes.
Congenital anomalies of eyelids:
1- Ablepharon: Absence of the eyelids.
Treatment: Reconstructive plastic surgery.
2- Ankyloblepharon: Imperfect separation of the eyelids.
Treatment: Open the adhesion in between.
3- Coloboma of the eyelids: Common congenital anomaly in which there is failure of a portion of the lid to develop leading to
notch in the lid margin.
Treatment: Plastic surgery.
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4- Blepharophimosis: Narrowing of the palpebral fissure.
Treatment: Plastic surgery at pre-school age.
5- Epicanthus: Common anomaly. There is a vertical skin fold in the medial canthal region, which conceals the medial angle
and caruncle giving a picture simulates convergent squint (pseudosquint).
Abnormalities in shape and position:
1- Entropion:
It is an inward rolling of the lid margin causing continuous rubbing of the cornea and foreign body sensation, which leads to
conjunctival congestion, painful watery eye (tears production due to stimulation of cornea) and sometimes epithelial defect and even
corneal ulceration that may be complicated by secondary bacterial infection of the cornea. So, it is a vision threatening disease.
Causes (Types) of entropion:
a- Congenital: which is very rare.
b- Spastic entropion: secondary to any condition that causing severe & persistant spasm of orbicularis oculi, e.g. ocular irritation
(irritation leads to overriding of orbicularis oculi muscle fibers), conjunctivitis, keratitis and ocular surgery or in hemi facial spasm.
c- Senile entropion (involutional entropion): affecting elderly patients and usually involves the lower lid as the balance between
the orbicularis oculi muscle and the lower lid retractors is impaired with age leading to entropion.
d- Cicatricial entropion: secondary to any condition causing scaring and shrinkage of conjunctiva, e.g.:
i- Chlamydial conjunctivitis.
ii- Chemical conjunctivitis (whether it is acidic or alkaline).
iii- Autoimmune conjunctivitis. e.g. Cicatricial pemphigoid and Stevens-Johnson syndrome
iv- Irritation conjunctivitis.
Management:
Usually surgical in addition to the corneal protection from the lash rubbing by frequent epilation and contact
lenses. Conjunctival scarring might need graft to repair the scarred area.
2- Ectropion:
It is an outward rolling of the lid margin causing exposure of the palpebral and bulbar conjunctiva. This exposure leads to
exposure conjunctivitis, exposure keratitis and watery eye. Long-standing cases lead to:
i- Dry and thick conjunctiva and even keratinization.
ii- Corneal ulceration. So, it is vision threatening disease.
iii- Redness, crusting and dermatitis of skin.
Causes (types) of ectropion:
a- Congenital ectropion.
b- Paralytic ectropion (Atonic): seen in cases of facial nerve palsy.
c- Senile ectropion (involutional):
commonly seen in the lower lid of elderly patients due to atrophy of orbicularis oculi muscle
and tarsal plate.
d- Cicatricial ectropion: which is occur secondary to:
i- Chemical burns of skin. ii- Infection of skin. iii- Radiation of skin. iv- Improper suturing of lid wound. v- Trauma to the lid.
e- mechanical : as in bulky eyelid tumour.
Management: Involutional ,permanent paralytic and cicatricial ectropion are managed surgically. Mechanical one is treated by
treating the cause. Paralytic ectropion, if recovery is expected then the patient is given lubricants and the cornea might be thought of
being protected by performing tarsorraphy (temporary closure of the lids by suturing them together).Sometimes botulinum toxin
injection to induce a protective ptosis is chosen to protect the cornea while waiting for recovery
3- Blepharoptosis:
It is an abnormal low position or dropping of the upper eyelid
that may interfere with vision in severe forms. It could be
unilateral or bilateral, and both of them could be partial or complete
and could be asymmetrical. Usually the upper lid covers only 2
mm from cornea. If more, is called blepharoptosis.
Differential diagnosis:
Pseudoptosis: is to be excluded in any case suspected to have dropped upper lid.
1. lack of lid support as in cases of sunken eyes (enophthalmos) gives an asymmetrical appearance like ptosis.
2. Contralateral lid retraction, proptosis or large fellow eye.
3. Ipsilateral hypotropia.
4. Brow ptosis in which there is excessive brow skin hanging down.
5. Dermatochalasis: excessive skin of the eyelid mimicking ptosis.
Causes (Classification)of blepharoptosis:
a- Congenital blepharoptosis: the LPS muscle is very poor and there is absence of skin creases.
b- Neurogenic blepharoptosis:
i- Oculomotor nerve palsy: causing severe unilateral ptosis with defects in adduction elevation and depression of the eyeball +/-
pupillary dilatation.
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ii- Horner's syndrome: oculosympathetic palsy in which there is mild ptosis and miosis. Pupillary reaction is normal. It could be
congenital in which we can see iris heterochromia.
iii- Marcus Gunn Jaw-winking syndrome: it is a congenital anomaly in which, nerve to LPS is a branch from nerves to
mastication muscle (i.e. from trigeminal nerve).
iv- 3
rd
nerve misdirection: either acquired or congenital.
c- Myogenic blepharoptosis:
i- Myasthenia gravis: there is a defect in the neuromuscular junction (damage to acetyl choline receptors). Treatment : medical
treatment.
ii- Myotonic dystrophy.
iii- Ocular myopathy (localized defect similar to myasthenia gravis).
iv- Simple congenital myogenic blepharoptosis.
v- Blepharophimosis syndromes: it is a rare congenital ptosis with dominant inheritance in which, there are bilateral ptosis,
bilateral palpebral fissure narrowing, bilateral ectropion, and increase in the distance between the two medial canthi (telecanthus).
d- Aponeurotic blepharoptosis:
weakness of the levator aponeurosis
i- Involutional (senile). ii- Post operative.
e- Mechanical blepharoptosis: deformity and increases weight of the eyelid
as in large lid tumour, dermatochalasis, lid edema or anterior orbital lesion.
Treatment of ptosis:
Exclude pseudoptosis,then the treatment of all types is surgical except in myasthenia gravis, where the treatment is medical.
Surgical procedures are:
a- Levator resection.
b- Frontalis brow suspension (Sling operation).
c- Tarso-conjunctival resection (Fasanella servete procedure).
Choice of one of these three types depends on:
a- Aetiology of ptosis.
b- Severity of ptosis: Mild, moderate or severe.
c- Function of LPS: Good, fair or poor.
4- Trichiasis:
It is a posterior misdirection of the lashes arising from their normal sites of origin, most annoying during blinking. It causes
punctuate epithelial erosions of the corneal epithelium followed by corneal ulceration and pannus formation in severe chronic
cases.This is a common acquired unilateral or bilateral condition which can occurs in isolation or may be associated with scarring of
the lid margin as in chronic blepharitis, herpes zoster ophthalmicus, chemical burn and trachoma.
Treatment:
a- Epilation: Repeated every few weeks.
b- Electrolysis: Destruction to hair follicles by cauterization.
c- Cryosurgery: Destruction to hair follicles by freezing.
d- Laser ablation: Destruction to hair follicles by laser.
5- Blepharospasm:
Involuntary sustained closure of the eyelids which occurs spontaneously (essential) or by sensory stimuli (reflex). Treatment: Is
to treat the underline cause and in sever, and resistance cases Botulinum toxin injection is indicated. It is temporary measure and can
be repeated frequently.
6- Madarosis:
It is a decrease in number or complete loss of lashes.
Causes:
Local Causes: chronic blepharitis, burns, radiation and infiltrating tumor.
Systemic causes: generalized alopecia, psoriasis, SLE, syphilis and leprosy.
7- Poliosis:
It is premature whitening of the hair which may include the lashes and eyebrows, common ocular associations are chronic
blepharitis and the commonest systemic association include Vogt Koyanagi Harada syndrome.
Benign nodules and cysts:
1- Chalazion (Meibomian cyst):
It is a chronic lipogranulomatous inflammatory lesion caused by blockage of meibomian gland orifices and stagnation of
sebaceous secretions and there is NO infection. It is more frequent and multiple in patients with acne rosacea or seborrhoeic
dermatitis and other sebaceous gland dysfunctional diseases.
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Presentation: Painless nodule and occasionally blurred vision.
Signs: a- Round, firm lesion in the tarsal plate. b- Polypoid granuloma on eversion of lid (i.e. seen from the palpebral part of
conjunctiva). c- Sometimes there is associated chronic blepharitis.
Treatment:
Small lesions might disappear without treatment and persistent large cyst is treated surgically by incision and curette
through the tarsal conjunctiva. Intralesional triamcinolone injection is an alternative way of treatment that may require repeated
injections. Systemic tetracyclines are given in cases of recurrent chalazia specially if the patient have rosacea or seborrhoic
dermatitis.Recurrent chalazion should raise the suspicion of meibomian gland carcinoma or basal cell carcinoma.
2- Internal Hordeolum (meibomianitis):
It is a small abscess caused by an acute staphylococcal infection of Meibomian glands.
Signs: Tender, inflamed swelling within the tarsal plate.
Treatment:
a- which is done through using topical antibiotics. Systemic antibiotics are needed if there is associating lid infection.
b- Incision and curettage for the residual nodule after the acute infection has subsided.
3- External hordeolum (Stye):
It is an acute small staphylococcal abscess of a lash follicle and its associated gland of Zeis.
Signs: i-Tender inflamed swelling in the lid margin, which points anteriorly through the skin. ii- More than one lesion may
present. iii- Occasionally minute abscess may involve the entire margin.
Treatment:
a- Hot compresses to produce vasodilatation of blood vessels: is to increase the circulation in the area and also for liquefaction of
sebum to prevent stagnation in the duct of affected gland.
b- Topical antibiotics to prevent infection of neighboring glands.
c- Epilation (removal of eyelashes by a forceps) to enhance drainage of pus.
d- Systemic antibiotics if there is severe preseptal cellulitis.
Benign tumors
1.Viral wart( sequamous cell papiloma)Is the commonest benign lid tumour seen in adults as a pedunculated or sessile lesion
with a characteristic raspberry like surface. Treatment is by excision or laser ablation.
2.Simple naevus They become darker at puberty, might be pigmented or not, elevated or flat depending on their location within
the skin layers. At the lid margin they might have lashes growing through them. Some have malignant potentials.
3.Strawbwrry naevus(capillary haemangioma)Is an uncommon tumour with a female predilection. Appears just after birth as
a pinkish swelling that blanches with pressure and might increase in size upon crying. if it is on the upper lid it might cause
mechanical ptosis interfering with vision and leading to amblyopia. It might have orbital extension causing squint or proptosis.
Usually it enlarges in size progressively then involute after the second year of age so that by the age of 4 years about 40%
disappears and at 7years 70% disappear. Treatment is by steroid injection intralesionally and in selected cases surgical excision.
4.Port-wine stain (cavernous haemangioma) Is a rare congenital tumour of the skin, lesions are to start with flat red swelling
and doesn't blanch on pressure. They contain thin walled vessels within the skin. As the patients grows the lesion darken and the
skin becomes hypertrophied and might become friable and easily bleed or infected. Treatment is by laser early in life because it
helps in flat lesions without much skin hypertrophy.
Eyelid malignancies
1- Basal cell carcinoma BCC is the commonest human malignant tumour affecting elderly. It is locally invasive non metastasizing
tuomur.90% of BCC affect the head and neck and 10% of those affect the eyelids.
Clinical forms:
1.nodular BCC: slowly growing shiny indurated nodule with surface vascularization that may destroy large portion of the lid.
2.ulcerative BCC( rodent ulcer): Chronic lid ulceration with raised rolled edge that may bleed.
3.sclerosing BCC : indurated plague with loss of lashes resembling chronic blepharitis. It spreads radially beneath the epidermis
making it difficult to delineate the margin of the lesion.
2-Sequamous cell carcinoma
This is less common but more aggressive than BCC with a predilection to the lower lid. May arise de novo or from a preexisting
actinic keratosis.
Clinical forms:
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a.nodular: hard keratotic nodule the surface of which might show crustation and fissuring but not vascularization.
b.ulcerative: red base with a sharply defined-punched out- indurated and elevated borders
3-Meibomian gland carcinoma
Very rare malignant eyelid tumour with 10% mortality rate. It has an upper lid predilection with two main clinical forms:
1.nodular:just like chalazion
2.spreading:diffuse thickening of the lid margin and loss of lashes. Conjunctival spread might occur giving a picture mimicking
chronic conjunctivitis.
Allergic disorders
1.Acute allergic lid oedema Caused by insect bites, angioedema, urticaria and rarely caused by drugs e.g. ACEI specially
enalapril.
Signs:Unilateral or bilateral, painless pitting periorbital and lid edema. Systemic antihistamines may be helpful in treatment.
2.Contact dermatitis:It is a common unilateral or bilateral localized oedema and crusting frequently caused by hypersensitivity
to topical medication. Treatment is by identification and removal of the cause and topical application of a mild steroid such as
1%hydrocortisone.
3.Atopic dermatitis: Eczema is a very common idiopathic skin condition frequently associated with asthma and hay fever.
Usual presentation is with irritation and itching, eyelid involvement is usually uncommon but if it occurs it is always associated with
a generalized skin lesion.
Signs are bilateral thickening, crusting and fissuring of the upper eyelids.
Treatment: is by emollients like oily cream to hydrate the skin and mild steroids. Secondary bacterial infection may require
antibiotics.
ocular associations with generalized atopic dermatitis like: i. staphylococcal blepharitis. ii.chronic keratoconjunctivitis in
adults. iii. Keratoconus. iv. presenile posterior sub capsular cataract
Infections:
1.Herpes Zoster ophthalmicus:
It is a common unilateral condition typically affects elderly patients or those with immunodeficiency states. Usual presentation is
with pain along the distribution of the trigeminal nerve. Signs include forehead maculopapular rash ,vesicles, pustules, crusting and
ulceration. In severe cases secondary bacterial infection causes periorbital oedema that may give an erroneous impression that it is
bilateral.
Hutchinson sign is the involvement of the side of the nose which is associated with high intraocular complications.
Treatment is by systemic and topical antiviral agents e.g. acyclovir, famciclovir, valaciclovir plus a steroid-antibiotic
combination cream topically.
2.Herpes simplex: Primary HS infection is an uncommon unilateral condition, typically affects children. It might be so severe in
patients with atopic dermatitis or immunodeficiency. Signs are crops of small vesicles and lid oedema, vesicles may rupture then
crust and heal within few days. There might be associated ipsilateral follicular conjunctivitis and keratitis. Treatment is by topical
antiviral cream.
3. Molloscum contagiosum This is an uncommon skin lesion caused by poxvirus. On the lid it shows as a small umblicated
waxy pale nodule which may be multiple and can be associated with follicular conjunctivitis and keratitis. Treatment is by shave
excision , destruction by laser ,cautery or cryotherapy.
Marginal Chronic Blepharitis
Chronic blepharitis is a very common condition which is usually bilateral symmetrical.
Types of chronic blepharitis:
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1- Anterior: a- Staphylococcal infection. b- Seborrheic dysfunction. c- Mixed.
2- Posterior: a- Meibomianitis. b- Meibomian seborrhea.
3- Mixed (any one of the anterior type plus any one of the posterior).
Pathogenesis of chronic blepharitis:
1- Anterior chronic staphylococcal blepharitis: due to staphylococcal infection.
2- Anterior chronic seborrhoeic blepharitis: is usually associated with seborrhoeic dermatitis e.g. scalp, naso labial folds, retro
auricular area and sternum.
Neutral lipids are converted by Bacterial lipase into irritating fatty acids responsible for increase of symptoms.
3- Posterior chronic blepharitis: Associated with dysfunction of Meibomian gland (ocular rosacea) which is in some patients
associated with acne rosacea of the face.
Symptoms of chronic marginal blepharitis: (anterior and posterior)
They are: Burning, grittiness, mild photophobia, and crusting and redness of the lid margin. The symptoms are characterized by
remissions and exacerbations. The symptoms are usually worse in the mornings.
Signs of anterior blepharitis:
a- The anterior lid margins show (by slit-lamp) hyperaemia and telangiectasia. In longstanding cases the lid margin became
scarred and hypertrophied (due to recurrent infections), intrafollicular abscess may be present (staphylococcal blepharitis).
b- Two types of scales: (important in differentiation)
i- Staphylococcal blepharitis: Are hard and brittle and are centered around the lashses (collarettes).
ii- Seborrhoeic blepharitis: Are soft and greasy and located anywhere on lid margin or on the lashes.
c- In longstanding cases, trichiasis, madarosis and occasionally poliosis (whitening of the eyelashes) will occur.
Complications of anterior blepharitis:
a- External hordeolum (stye).
b- Tear film instability (due to the abnormal lipid secretion that affects the tear film).
c- Hypersensitivity to staphylococcal exotoxins , papillary conjunctival reaction, punctuate epitheliopathy and marginal keratitis.
Treatment:
a- Lid hygiene: removing crusts and toxic products by scrubbing the lid margins daily with either commercially lid scrub or a
cotton bud tipped in 25% solution of baby shampoo.
b- Topical antibiotic ointment: fusidic acid or chloramphenicol.
c- Weak topical steroids: e.g. fluorometholone to control hypersensitivity to exotoxins.
d- Tear substitutes.
Posterior blepharitis (Meibomian seborrhea or meibomianitis):
that may be alone or in association with anterior blepharitis, it may be secondary to meibomian gland dysfunction or meibomianitis.
Meibomian glands are modified sebaceous glands within the tarsal plates of the lids and are responsible for the tear lipid layer
secretion which is responsible for prevention of rapid evaporation of tear and help maintaining its smooth stable surface. in posterior
blepharitis with meibomian gland seborrhea or dysfunction the symptoms are severe but the signs are minimum. Signs: There is oily
secretion of the glands localized on the orifices of the glands and on the lid margin and sometimes you can express the oily secretion
by gentle pressure on the lid margin. When there is meibomienitis, the margin looks inflamed around the meibomian orifices, in
long standing cases it is hypertrophied and notched. The oil secretion may be turbid or toothpaste like and when the gland ducts are
blocked no secretion can be expressed and meibomian oil filled cysts might be formed at the lid margin.
The condition might be complicated by tear film instability, conjunctivitis and inferior punctuate epitheliopathy.
Treatment:
a- Systemic tetracyclines (Corynebacterium acnes) for 6-12 weeks
b- Erythromycin when (a) is contraindicated.
c- Lid hygiene.
d- Topical steroids.
e- Tear substitutes.
f- Warm compresses to melt solidified sebum and mechanical expression (to evacuate meibomian glands from their contents).
ﺩ. ﺯﻳﺎﺩ ﻛﺎﻣﻞ ﺍﳉﻨﺎﺑﻲ
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