eyelid

1. Disorders of Eyelids
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2. The eyelids
• Mobile structures placed in front
of eyeballs.
• Protect eyes
• Spread tear film
• Help in tear drainage by lacrimal
pump system
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3. Structure of eyelids
• The skin- elastic and thin
• Subcutaneous areolar tissue-
very loose,
does not contain any
fat.
• Striated muscle layer-
orbicularis oculi
-- orbital, palpebral
and lacrimal portions.
• Sub muscular areolar tissue-
contains nerves and vessels.
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4. Structure of eyelids
• Fibrous layer- central
tarsal plate and
peripheral orbital
septum
• Layer of non-striated
muscle fibres
• Conjunctiva –
nonkeratinized
squamous epithelium
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5. Glands of eyelids
• Meibomian glands/Tarsal
glands
Modified sebaceous
glands(30 in no.)
• Glands of Zeis -
sebaceous glands
open into follicles of
lashes
• Glands of Moll -modified
sweat glands-open into
follicles/ducts of Zeiss
• Accessory Lacrimal glands
• Krause
• Wolfring
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6. INFLAMMATIONS OF THE EYELIDS
•Blepharitis
Subacute or chronic lid margin inflammation
1. Anterior blepharitis-bacterial,seborrhoeic
2. Posterior blepharitis-MGD,a/c acne rosacea
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7. INFLAMMATIONS OF THE EYELIDS
1. Anterior blepharitis
• Squamous/Seborrhoeic
White dandruff like scales on the lid margin among
eyelashes
• Ulcerative
Chronic staphylococcal infection- hard crusts and ulcers
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8. 8

9. INFLAMMATIONS OF THE EYELIDS
• Posterior blepharitis
Meibomian seborrhoea
Meibomianitis
Symptoms-
Burning sensation
Grittiness
Mild photophobia
Redness of eyelid margins
Crusting
More in early morning
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10. 10

11. Management
• 1.)Lid hygiene
-Warm compresses
-Lid margin cleaning/scrubbing with cotton bud/baby
shampoo/sodium bicarbonate
-Vertical lid massage in meibomitis
2.)Antibiotics
-Topical ointment (chloramphenicol/bacitracin)
-Oral doxycycline 100 mg BD x 7 day f/b 100 mg OD x 6 weeks
(posterior blepharitis)
-Oral azithromycin 500mg OD x 3 day f/b 3 cycles at 1 week
interval(anterior blepharitis)
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12. Management
3.) Dry eyes
-Lubricants
-Topical steroids in active margin inflammation (0.1% fluorometholone)
4.)New theraphy
-Thermal pulsations
-Pulsed light theraphy
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13. Entropion
• Inward rolling and rotation of the
lid margin toward globe
Involutional/senile
Cicatricial (trachoma, burns,
SJ syndrome)
Spastic(lower lid)
Congenital
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14. • Involutional Entropion (age related)
 Horizontal lid laxity
 Vertical lid instability
 Over-riding of pretarsal plate
 Orbital septum laxity
• Cicatricial entropion
Due to conjunctival scarring
Causes:
Trachoma, chemical burns
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15. • Congenital entropion
Lower > upper eyelid
Lower eyelid congenital entropion –improper development of the lower lid
retractors
Upper eyelid congenital entropion-secondary to mechanical effects of
microphthalmos
• Mechanical entropion
• d/t lack of support provided by globe to the lids
• Occur in patients with phthisis bulbi,enophthalmos ,after enucleation or
evisceration
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16. Symptoms
• Foreign body sensation
• Irritation
• Lacrimation
• Photophobia
• d/t rubbing of cilia against cornea and conjunctiva
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17. Signs
1.)Inturning of lid margins-
Grade 1-only post lid border is inrolled
Grade 2 –inturning of intermarginal strip
Grade 3-whole lid inturned
2.)Signs of causative disease-
Scarring of palpebral conjunctiva in cicatricial entropion
Horizontal lid laxity in involutional entropion
3.)Signs of complications- recuurent corneal abrasions,corneal
opacities,ulcers
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18. Surgical procedures for congential entropion
• Congential entropion-hotz procedure
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19. Surgical procedures for senile entropion
•Transverse everting sutures (Quickert)
•Transverse blepharotomy with everting sutures-
Weis procedure
•Jones procedure- tucking of inferior lid retractors
(recurrences)
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20. Transverse everting sutures
• Prevents overriding and provide
temporary correction lasting
several months
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21. Weis procedure
• Full thickness horizontal lid
splitting and insertion of
everting sutures
• Scarring prevents overriding of
pre-septal and pretarsal parts of
orbicularis
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22. Jones procedure
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-Plication of lower lid retractors thus increasing their pull and creating
the barrier b/w preseptal and pretarsal portion of orbicularis
-performed in recurrent cases

23. Surgical procedures for cicatricial entropion
• Anterior lamellar resection
• Tarsal wedge resection
• Transposition of tarsoconjunctival wedge(modified ketssey’s
operation)
• Posterior lamellar graft
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24. Tarsal wedge resection
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25. Transposition of tarsoconjunctival wedge
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26. Posterior lamellar graft
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27. ECTROPION
• Eversion of lid margins and lashes away from the globe.
Acquired – Involutional/senile-lower lid
Cicatricial- burns and injuries
Paralytic- 7th nerve paralysis
Mechanical-tumors/proptosis
Congenital
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29. • Involutional Ectropion (Age Related)
 Horizontal lid laxity
 Medial canthal tendon laxity
 Lateral canthal tendon laxity
 Disinsertion of lower lid retractors
• Cicatricial Ectropion
Due to burn, trauma, chronic inflammation of skin or surgical
scarring.
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30. • Paralytic Ectropion
Due to Facial nerve palsy
Treated by:
Tarsorrhaphy
Medial canthoplasty
Lateral canthal sling
Upper lid lowering
• Mechanical ectropion (tumours)- corrected by treating the underlying
cause.
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31. Symptoms
• Epiphora
• Irritation
• Discomfort
• Mild photophobia
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32. Signs
1.)Lid margin is outrolled
Grade 1- only punctum is everted
Grade 2-lid margin is everted & palpebral conjunctiva is visible
Grade 3-fornix also visible
2.)signs of the cause-
Skin scars in cicatricial ectropion
7th nerve palsy in paralytic ectropion
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33. Surgical procedures for senile ectropion
• Treatment
 Wedge resection for horizontal lid laxity
 Diamond excision for medial ectropion
 Kuhnt-Szymanowski Procedure modified
by Byron Smith for lateral ectropion
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34. Wedge resection for horizontal lid laxity
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35. Diamond excision for medial ectropion
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36. Modified Kuhnt-Szymanowski Procedure
for lateral ectropion
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37. Surgical procedures for cicatricial ectropion
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V-Y Plasty

38. PTOSIS
• Abnormal drooping of the upper lid to a level that covers more than 2mm
of the superior cornea.
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39. 1.Congenital ptosis
Simple -absence of lid crease,lid lag sign+ on downgaze
Complicated -blepharophimosis syndrome,double elevator
palsy,Marcus gunn jaw winking
2. Acquired ptosis
Neurogenic- 3rd Nerve palsy, Horner’s syndrome
Myogenic – Myasthenia , Myotonic dystrophy
Aponeurotic- Involutional, postoperative
Mechanical- lid tumors
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40. Examination
• Evaluation
• Measurement of amount(degree) of ptosis
• Margin reflex distance
• Assessment of levator function
• Special investigation
• Photographic record
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41. Evaluation
• Pseudoptosis (simulated ptosis) should be excluded on
inspection
• Points to be observed:
-Whether ptosis is unilateral or bilateral.
-Function of orbicularis oculi muscle.
-Eyelid crease is present or absent.
-Jaw-winking phenomenon is present or not.
-Associated weakness of any extraocular muscle.
-Bell's phenomenon up and outrolling of the eyeball during
forceful closure) is present or absent.
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42. Measurement of amount (degree) of
posis
• In unilateral cases, difference between the vertical height of the
palpebral fissures of the two sides indicates the degree of
ptosis.
• In bilateral cases it can be determined by measuring the
amount of cornea covered by the upper lid and then subtracting
2mm
• Ptosis is graded depending upon its amount as :
• Mild ptosis: 2mm
• Moderate ptosis: 3mm
• Severe ptosis: 4mm
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43. Margin reflex distance (MRD)
• Margin reflex distance (MRD) refers to the distance between
the upper lid margins and corneal light reflex
• Normal value of MRD is 4-5 mm.
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44. Assessment of levator function
• It is measured by the lid excursion caused
by LPS muscle (Burke's method)
• Patient is asked to look down, and thumb of
one hand is placed firmly against the
eyebrow of the patient by the examiner
• Then the patient is asked to look up and the
amount of upper lid excursion is measured
with a ruler held in the other hand by the
examiner
• Levator function is graded as follows:
• Normal: 15mm
• Good: 8mm or more
• Fair: 5-7 mm
• Poor: 4mm or less
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45. Special investigation
• Tensilon test is performed when myasthenia is suspected
• Phenylephrine test is carried out in patients suspected of
Horner's syndrome
• Neurological investigations may be required to find out the
cause in patient with neurogenic ptosis
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46. Photographic records
• Photographic records of the patient should be maintained for
comparison.
• Photographs should be taken in primary position as well as in
up and down gazes.
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47. SURGICAL TREATMENT
• Fasanella-Servat operation
LPS action good
Mild ptosis < 2mm
Horner’s syndrome
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48. SURGICAL TREATMENT
• LPS Resection (Conjunctival
approach)
LPS action fair
Any type of ptosis
Moderate congenital or
acquired ptosis
• LPS Resection (Skin approach)
• Most preferred surgery for
ptosis correction
LPS action fair
Any type of ptosis
For larger resection in
congenital or acquired ptosis.
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49. SURGICAL TREATMENT
• Frontalis Sling surgery (Brow suspension)
LPS action poor
Ptosis >2 mm
Congenital ptosis
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50. Thank You
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