for medical students

1. The Eyelids
Othman Al-Abbadi, M.D

3. Anatomy of the eye lids
Layers of the lid
Anterior and posterior lamellae
Skin ,SC ,tarsus and s
Eyelashes
Important of proper opposition of upper and
lower eyelids

4. Functions of eyelids
Provide physical protection to the globe
Tear surfacing
Tear drainage

5. Diseases of the eyelids
Abnormal lid position
Inflammation
Lid lumps
Eyelashes abnormalities

6. Lid position abnormalities
Ptosis
Entropion
Ectropion

9. Ptosis
Abnormally low position of the upper lid .
Pathogenesis : Mechanical
Neurological
Myogenic
Aponeurotic

10. Mechanical causes of Ptosis
Large lid lesions pulling down the lid.
Lid oedema.
Tethering of the lid by conjunctival
scarring.
Structural abnormalities including a
disinsertion of the aponeurosis of the
levator muscle, usually in elderly patients

11. Neurological causes of ptosis
CN III palsy
Horner”s syndrome
Marcus-Gunn jaw winking syndrome :
where there is mis-wiring of the nerve
supply to the pteregoid muscles and levator
muscle ,so the lid moves with jaw
movement .

13. Myogenic causes
Mysthenia Gravis
Muscular dystrophies
Chronic external ohthalmoplegia

14. Symptoms
Upper lid dropping and cosmesis
Impairment of vision due to visual axis
block
Associated symptoms of the primary cause
as diplopia ,reduced eye movements and
anisocria

15. Signs
Reduction in size of the interpalpebral
fissure
Upper lid margin dropping
Impaiered levator muscle function
(normally 15–18mm)
If myasthenia is suspected the ptosis should
be observed during repeated lid movement.
Signs of Horner’s syndrome or a third nerve
palsy, may be present

16. Management
Treat the underlying cause if present as MG
Surgery if no underlying cause

17. Entropion
Inturning of the lid (usually lower)
On looking downwards or by forced lid closure
Causes
 Elderly patients where the orbicularis muscle becomes weakened
 Cicatricial entropion: conjunctival scarring distorting the lid
Complications:
 Red inflamed eye
 Corneal irritation by inturned lashes
Treatment
 Temporary: lubricants or eyelid taping
 Permanent: surgery

19. Ectropion
Eversion of lid .
Causes :
Involutional due to Orbicularis laxity
Periorbital skin scarring
Facial nerve palsy
Complications :Epiphora
Eye irritation
Treatment : surgical

21. Inflammation of the eye lid
Blepharitis
A very common condition
Anterior blepharitis : squamous debris ,
inflammation of the lid margin skin and
lash follicles .
Posterior blepharitis : Meibomian gland
dysfunction

26. Symptoms
Tiredness ,sore eye
FB sensation
Crusting of the lid margin
Tearing

27. Signs
Scaling of the lid margin
Inflammation of the lash follicles
Decreased number of lashes
plugging of meibomian gland ducts .
Foamy tear film and tear film abnormalities
In severe cases : blepharokeratitis and
marginal keratitis
Conjuctival injection .

28. Associations
Seborrhic dermatitis .
Atopic dermatitis
Acne rosacea where there is facial skin
telangectasia and rhinophima (bulbous
irregular swelling of the nose with
hypertrophy of the sebaceous glands ) .

29. Management
A tough task for both physician and patient .
Lid hygiene for anterior and posterior
Worm compresses
Topical antistaphylococcal ( anterior )
Topical steroids
Systemic Tetracyclin ( posterior )
Lubricants .
Mixture of all of these .

30. Lid lumps and masses
Chalazion
Molluscum contagiosum
Cysts
Squamous cell papilloma
Xanthelasma
Keratoacanthoma
Nevuses

31. Chalazion
Tarsal plate granuloma
Common painless swelling
Caused by obstructed meiobomian gland
Presentation is with unsighty mass
Usually resolves spontaneously if not
incision can be done .

33. Internal and external hordeolum
Internal : is a meiobomian gland abscess
usually painful and require topical AB
treatment and may be incision
External : (Stye) hair follicle abscess and
needs the removal of the lash , application
of worm compresses and topical or systemic
AB .

36. Molluscum contagiosum
It is umbilicated lesion found on the lid
margin
Caused by POX virus .
Red eye and follicular reaction found .
Treatment is excision

39. Cysts
Sebaceous cysts are opaque ,painless and
may be removed for cosmesis
Cyst of Moll : sweat gland obstruction
giving translucent mass .
Cyst of Zeis is an opaque cyst caused by
accessory sebaceous gland obstruction.
All can be excised for cosmosis.

41. Squamous cell papilloma
Frond like lesion with fibrovascular core
and thickened squamous epithelium
Usually asymptomatic
Treatment ,if needed, with cautery .

43. Xanthelasmas
Lipid containing bilateral lesions .
May be associated with
hypercholestrolemia
May be excised for cosmosis

45. Keratoacanthoma
Fast growing lesion with central crater filled
with keratin .
Passes into a fast growing phase then
stationary stage .
Treatment with excision if needed .

47. Naevus (mole)
From melanocytes
Can be pigmented or none
No treatment needed

48. Malignant tumours
Basal cell carcinoma
Squamous cell carcinoma
Malignant melanoma

49. Basal Cell Carcinoma
Most common malignant tumour
Lid BCC accounts for 10% of all BCC
90% of lid malignancies
It is a slow growing locally invasive and
non-metastasing tumour

51. BCC presentation
Painless lesion of the lid
Can be : Nodular
Sclerosing
Ulcerative ( Rodent ulcer )
It is with pale pearly margin .
High index of suspicion .

52. BCC Management
Excision biopsy
Frozen section
Cryotherapy
Radiotherapy
Prognosis in general very good unless deep
invasive tumour

53. Squamous Cell Carcinoma
SCC
Less common
More malignant
Can metastatize to lymph nodes
Can be : De novo
From pre-malignant lesion
Presentation with nodule or scaly patch .
UV exposure is a risk factor .
Treatment : excision with healthy margin.

55. Eye lashes abnormalities
Trichiasis : abnormally backward directed eye
lashes .
Can be primary or secondary to cicatrization or
inflammation as in Trachoma .
Continuous rubbing of the cornea can cause many
complication as corneal opacity
Treatment : epilation of the abnormal lashes
manually ,laser ,electrolysis or surgery .

58. Thank you