Eye lid disorder

2. Introduction
1-Eye lids: Two movable folds with eye lashes.
Layer present are skin, areolar tissue; muscles- orbicularis
oculi, levator palpebrae superiors& Muller’s muscle; thin
sheet of dense connective tissue, tarsal plate; thin lining of
palpebral conjunctiva.
2-Eye lid Margin:
•
Covered with stratified squamous epithelium.
•
Anterior border is round, posterior is sharp& lies closely in
contact with the eyeball.
* Eyelashes originate anterior to the grey line and ducts of
meibomian are located posterior to the grey line.

3. 3-Glands of Eyelids:
# Zeis’s Gland: Sebaceous gland situated in close
association with cilia.
# Moll’s Gland: Sweat glands& lie between the cilia.
# Meibomian Gland: Enormously developed
sebaceous gland embedded in tarsal plate, secretes
oily secretion that lubricate the eye.
# Palpebral Fissure: Space between the two lids
when the eye is open.
# Outer Canthus: Outer or lateral angle of palpebral
fissure.
# Inner Canthus: Inner or Medial angle of the
palpebral fissure.
# Blood supply: Ophthalmic & lacrimal arteries &
ophthalmic vein.
# Nerve supply: 7th, 3rd& 5th cranial nerve.

4. A- Congenital Anomalies
i- Able-pharon: Macrostomia syndrome,
extremely rare, the lid is not developed
autosomal recessive genetic disorder.
ii- Micropharon: Rare, lids are abnormally
small.
iii- Cryptopharon: Rare anomaly in which a
fold of skin passes from the eyebrow over the
malformed eye to the cheek.
Iv- Ptosis: Common, drooping of eyelid.
V- Epicanthus: A vertical fold of skin either side
of the nose sometime covering the inner
canthus ( the outer or inner corner of the eye).
Vi- Distichiasis: an additional row of lashes
occupies the position of meibomian glands,
abnormal growth of lashes.
Vii- Coloboma: condition where normal tissue
in or around the eye is missing from birth.

5. B- Edema
# A swelling eyelid occurs when there is inflammation or excess fluid (edema) in
the connective tissue surrounding the eye.
# Common due to looseness of tissues.
1- Inflammatory Edema: Found in conjunctivitis, tarsitis (inflammation of gland &
lashes) dacryocystitis (inflammation of the lacrimal sac), orbital cellulitis, drug
allergy (atropine).
2- passive Edema: common features of cavernous sinus thrombosis (formation of
blood clot with in the cavernous sinus a cavity at the base of the brain which
drains deoxygenated blood from the brain back to the heart).

6. C- Inflammations: It includes;
1- Blepharitis.
2- Hordeolum (stye).
3- Chalazion (tarsal or meibomian cyst)
4- Internal Hordeolum.
# An eyelid infection is any abnormal condition that affect eyelids.
# Infection of an oil gland on the surface of the upper and lower parts of eyelids.
# A bacterial infection of an oil gland, hair follicle or sweat gland are caused drooping,
twitching, inflammation, itching, burning, crustiness, redness, edema, tearing, irritation.

7. 1- Hordeolum (Stye):
is a localized infection or inflammation of the eyelid margin
involving hair follicles of eyelashes or meibomian gland.
Etiology: Associated with staphylococci infection, common in young
adults, debilitated persons.
Symptoms: Pain& tenderness over inflamed Zeis’s gland.
Signs: Localized pain, redness& edema near the lid margin.
Treatment:
1- Hot fomentation, to apply a warm compressor eye, evacuation
of pus.
2- Epilation of involved eyelashes.
3- Antibiotic eye drops “ tobramycin” it is killing or slow the growth
of certain type of bacteria.
4- Analgesics & anti- inflammatory drugs control pain &
inflammation.

8. 2- Chalazion:
It is chronic granulomatous inflammation (produced in response to
infection, inflammation) or the presence of a foreign substance at
meibomian gland.
Etiology: due to chronic irritation due to organism of low virulence,
where the granular tissue is replaced by granulation tissue containing
giant cells. More common in adults.
Symptoms: No pain unless secondary infected.
Signs: Small non tender hard nodular swelling slightly at the tarsal plat
of the eyelid, swelling is red or purple, can be grey in later stages,
yellow when secondary infected with pyogenic organisms. May
cause astigmatism.
Treatment:
1- Most cases resolve spontaneously.
2- Surgery.
3- Injection of steroid in the lesion.
4- Tetracycline systemically.

9. 3- Blepharitis:
Is an inflammation of the eyelids in which they become red, irritated and
itching with dandruff like scales from on the eyelashes.
A- Squamous Blepharitis.
B- Ulcerative Blepharitis.
C- Phthriasis Palpebrarum “ Carb Louse”.
A- Squamous Blepharitis
# It is due to abnormal metabolism (abnormal chemical in the body) &
seborrhea usually associated with the dandruff of the scalp, numerous white
colored small scales accumulate among the eyelashes.
B- Ulcerative Blepharitis
# It is an infective condition. The yellow crusts glue (sticky) the lashes
together. On removing the crust there are small ulcers seen around the bases
of the lashes.
Symptoms: Itching, redness, soreness, lacrimation and photophobia.
Treatment:
Local; removal of scales, crusts & diseased lashes is done by bathing the lid
margin with 3% NaHCO3 (sodium bicarbonate)lotion.
Topical antibiotics, systemic azithromycin 500 mg 3 times per day, weak
mild steroid and tear substitute.
General; Improvement of general health & personal hygiene, Dandruff of the
scalp is to be adequately treated.

10. PHTHIRIASIS PALPEBRARUM.
Crab louse
Also called lousephthriasis living in the pubic hair
causes chronic irritation and itching of the eyelids,
it occurs in the patients living in very unhygienic
conditions.
Treatment:-
1- Mechanical removal.
2- Topical yellow mercuric oxide.
3- Delousing of the patient.
4- Change clothes and bed.

11. 4- Internal Hordeolum:
It is an acute suppurative inflammation of the meibomian glands.
etiology: Occurs due to secondary infection of Chalazion.
Symptoms: More violent than stye because the gland is larger & embedded deeply in the
dense fibrous tissue.
Signs: Yellow spot (pus) seen shining through the conjunctiva on the remaining lid.
Treatment:
# Warm compresses and massage of the lesions for 10 minutes 4 times per day.
# Topical antibiotic ointment.
# Amoxicillin.
# Doxycycline.
# Erythromycin.

12. Anomalies & Position of Eyelids
It includes;
1- Trichiasis; abnormally positioned eyelashes.
2- Entropion; the lid margin rolls inwards.
3- Ectropion; lid margin rolls outwards.
4- Symblepharon; the adhesions between lids and the globe.
5- Ankyloblepharon, adhesion of the margins of the two eyelids.
6- Lago-ophthalmus; inability to close the eyelids completely.
7- Ptosis; drooping of the upper lid.

13. Trichiasis
Posteriorly misdirection of eyelashes arising from
normal origin, it may includes few lashes or the
whole lid margin.
Etiology: Recurrent stye, Ulcerative Blepharitis, Tight
bandaging, scars of lid following burn, injury or
operation.
Symptoms: Foreign body sensation of photophobia
due to corneal involvement, irritation, pain &
lacrimation.
Treatment:
1- Epilation.
2- Electrolysis.
3- Cryotherapy.
4- Argon laser ablation.
5- Surgery.

14. Entropion:
Conditions in which the lid margin rolls inwards. Usually
lower lid but it can involve upper also.
Etiology:
(a
# Spastic entropion; Due to the spasm of orbicularis
oculi muscle as may occur after tight bandaging
after operation or following irritative corneal
condition.
# Cicatricial Entropion; Ulcerative Blepharitis, burns,
operations, diphtheritic membranous conjunctivitis.
Symptoms & Signs: Same as for Trichiasis.
Treatment:
# Spastic; Basic cause of blepharospasm is treated.
# If due to prolonged & tight bandaging, discontinue it.
# Topical antibiotic & Lubricants.
# Botulinum toxin using in eyelid spasm.
# Surgical correction.

15. Ectropion:
It is a condition in which lid margin rolls outwards.
Symptoms: * Most common epiphora.
Signs: 1- Conjunctiva become dry in appearance.
2- Chronic conjunctivitis & corneal ulcers.
Types: 1- Involutional. 2- Cicatricial.
3- Paralytic (facial nerve palsy).
4- Mechanical.
Treatment:
1- Medical: Lubricant ointment and sometimes
needs mild steroid eye drops.
2- Botulinum toxins.
3- Temporary tarsoraphy.
4- Surgical correction.

16. Symplepharon:
It is a condition of the adhesions between lids and the globe.
Etiology: due to; burns, ulcers, diphtheria, operation.
Symptoms: # Lagophthalamus; inability to close lids properly.
# Diplopia.
Treatment:
# Lysis and removal of subconjunctival scar tissue.

17. Ankyloblepharon:
It is a condition of the adhesion of the
margins of two eyelids, adhesions may be
partial or complete.
Etiology: Congenital or acquired due to
chemical burn.
Treatment:
# Separation of lid margins along with
mucus membrane or conjunctival grafting is
recommended.

18. Lagophthalamus
It is a condition of incomplete closure of
palpebral aperture when eye closed or
inability to close the eyelids completely.
Etiology:
# Loss of function of the facial nerve inhibits
eyelid as well as the blinking reflex.
# Congenital deformity of lids, Ectropion,
proptosis, absence of reflex.
Treatment:
# Application of antibiotic eye ointment &
bandage during sleep is recommended.
# Levofloxacin.

19. Ptosis
It is a condition in which there is drooping of the upper lid below its
normal position.
Etiology:
1- Congenital ptosis; Occurs in 80% of cases, due to maldevelopment
of levator muscle; congenital weakness of superior rectus muscle.
2- Acquired ptosis; a- Neurogenic: partial / complete paralysis of 3rd
nerve.
b- Mechanical: due to increased weight of upper
lid as a result of edema, hypertrophy or tumor formation.
c- Myogenic: due to trauma of levator muscle,
muscular dystrophy & myasthenia gravis.
Symptoms: Visual disturbance, visible drooping of the upper eyelid.
Presentation; History, Old photograph of patient, Margin reflex
distance (4,4.5 mm), Palpebral fissure height (distance between upper
and lower lid margin, male 7….10mm, female8….12 mm)

20. Mild 2 mm.
Moderate 3 mm.
Severe 4 mm, or more.
Pupil reaction.
Ocular motility.
Jaw winking phenomenon.
Bell phenomenon.

21. Jaw winking phenomenon Bell’s phenomenon

22. Viral Infection of the Eyelid
Molluscum Contagiosum
Skin infection caused by human specific double stranded DNA poxvirus in
immunocompromised patients.
# Single.
# Multiple.
# Pale waxy umblicated lesion.
Treated by:
1-Excision shave.
2- Cauterization.
3- Cryotherapy.
4- Laser.

23. Herpes Zoster Ophthalmicus
# Unilateral.
# Varicella virus.
# Elderly age.
# Immunocompromised patients.
# Maculopapular rashes.
# Periorbital edema.
# Dendritic ulcer (peripheral cornea).
Treatment:
1- Anti-viral treatment;
Oral acyclovir 800 mg 7 ……10 days.
Topical acyclovir ointment.

24. Herpes Simplex
# Eyelid and periorbital edema
# Vesicles.
# Papillary conjunctivitis.
# Dendritic ulcer.
# Young patients.
Treatment:
1- Topical anti-viral ointment.
2- Oral acyclovir 400 ;;;; 800 mg 3…..5 days.

25. Tumors
1- Benign Tumors:
# Nevus.
# Hemanangioma.
# Papilloma.
# Xantholasma.
# Neurofibroma.
2- Malignant Tumors:
# Squamous cell carcinoma.
# Basal cell carcinoma
# Sebaceous cell carcinoma

26. Nevus (mole on the skin red patches):
A choroidal nevus is a flat, benign pigmented area that appears in accidental fundus
examination.
Hemangioma:
Is a non-cancerous (benign) tumor caused by abnormal growth of blood vessels.
Cavernous hemangioma occurs in the deeper layers of the skin or around the eye.
Papilloma:
A benign tumor derived from epithelium. Papilloma's may arise from skin, mucous
membrane or glandular duct.
Xanthelasma:
Are yellowish plaques that occur most commonly near the inner canthus of the eyelid,
more often on the upper eyelid than the lower lid.
Neurofibroma:
It is a generalized disease that may involve the lid& cause mechanical ptosis. It is
associated with unilateral infant glaucoma, small, multiple tumors are distributed along
the hypertrophied nerves.

27. Malignant Tumors
A- Squamous cell carcinoma.
B- Basal cell carcinoma.
C- Sebaceous cell carcinoma.
A- Squamous cell carcinoma:
# Seen at the edge of the lid (transition zone) where the epithelium changes. It starts as
nodule that ulcerate. The preauricular lymph nodes are enlarged. It spreads slowly the
surrounding structures and are painless. Metastasis common.
B- Basal cell carcinoma:
# It is most common seen in lower lid near the inner canthus. It is locally malignant.
Epithelial growth spreads under the skin in all direction.
Etiology:
1- Environmental toxins e.g. as exposure to radiation.
2- Genetics.
3- Diet ----deficiency of minerals & vitamins.
4- Stress. 5- Local trauma . 6- Inflammation.

28. Clinical Presentation:
1- Bulging of one eye.
2- Pain in or around the eye.
3- Blurred vision.
4- Change in the appearance of the eye.
5- Edema, redness, itching and burning sensation.
Diagnosis:
# Ultra sound, CT scan, MRI and biopsy.
Treatment:
1- Medical treatment.
2- Chemotherapy, radiation.
C- Sebaceous carcinoma:
# Arises from the sebaceous glands & it is more common BCC, SCC.
# Clinical presentation; nodule on an eyelid, yellowish, loss of lashes.
# Shows lymphatic & hematogenous spread.
Management: # Biopsy. # Surgical excision. # Radiotherapy. # Cryotherapy.

29. Coloboma
It is uncommon condition in which unilateral or
bilateral, partial or full thickness eyelid defect. It
occur when eyelid development is incomplete
due to either failure of migration of lid ectoderm to
fuse the lid fold, or to mechanical forces such as
amniotic bands.
It may appear in :
# eyelids.
# crystalline lens.
# iris.
# optic disc.
# choroid.