The eyelids are mobile tissue curtains placed in front of the eyeballs. These act as shutters protecting the eyes from injuries and excessive light. These also perform an important function of spreading the tear film over the cornea and conjunctiva and also help in drainage of tears by lacrimal pump system.

1. DISEASES OF EYELID
MS. MEGHNA VERMA
ASSISSTANT PROFESSOR
DEPARTMENT OF OPTOMETRY
RAMA UNIVERSITY

2. CONTENTS
• Anatomy of eyelid
• Glands of eyelid
• Congenital anomalies of eyelids
• Oedema of eyelids
• Inflammatory anomalies of eyelids
• Anomalies in eyelid margin and lashes
• Tumours of eyelids

4. GROSS ANATOMY OF EYELID
Introduction. The eyelids are mobile tissue curtains placed in front of the eyeballs. These
act as shutters protecting the eyes from injuries and excessive light. These also perform
an important function of spreading the tear film over the cornea and conjunctiva and
also help in drainage of tears by lacrimal pump system.
Parts of eyelid. Each eyelid is divided by a horizontal furrow into an orbital and tarsal part.
Position of lids. When the eye is open, the upper lid covers about one-sixth of the cornea
and the lower lid just touches the limbus.
Canthus. The two lids meet each other at medial and lateral angles (or outer canthus and
inner canthus).
Palpebral aperture. It is elliptical space b/w the upper and the lower lid. When the eyes
are open it measures about 10-11 mm vertically in the centre & 28-30 mm horizontally.
Eye lid margin. It is about 2-mm broad and is divided into two parts by the punctum. The
medial, lacrimal portion is rounded and devoid of lashes or glands and lateral, ciliary
portion.

5. MICROSCOPIC ANATOMY OF EYELID
from anterior to posterior, consists of 7 layers-
1. The skin
2. The subcutaneous areolar tissue
3. The layer of striated muscle
4. Submuscular areolar tissue
5. Fibrous layer
6. Layer of non-striated muscle fibres
7. Conjunctiva

6. GLANDS OF EYELID
1.The meibomian gland /the tarsal gland
2.Glands of Zeis
3.Glands of moll
4.Glands of wollfring

8. CONGENITAL ANOMALIES OF EYELIDS
Congenital ptosis
Congenital coloboma
Epicanthus
Cryptophthalmos
Distichiasis
Microblepharon
INFLAMMATORY DISORDERS OF EYELIDS
Blepharitis
Chalazion
External hordeolum (STYE)
Internal hordeolum
ANOMALIES IN THE
EYE LASHES AND LID MARGIN
Trichiasis
Entropion and Ectropion
Symblepharon and Ankyloblepharon
Blepharophimosis
Lagophthalmos
Blepharospasm
Ptosis
TUMOURS OF EYELIDS
Benign tumour
Papilloma
Haemangioma
Neorofibroma
Malignant tumour
Basal cell carcinoma
Squamous cell carcinoma and Sebeceous cell carcinoma
Malignant melanoma
DISEASE
S
OF
EYELID

9. CONGENITAL ANOMALIES OF EYELIDS
Congenital ptosis
Abnormal drooping of the upper eyelid
is called ptosis. Normally, upper lid
covers about upper one-sixth of the
cornea, i.e., about 2 mm.
Therefore, in ptosis it covers more
than 2 mm.

10. Congenital coloboma
It is a rare condition characterised by a
full thickness triangular gap in the tissues
of the lids.
Epicanthus
It is a semicircular fold of skin which
covers the medial canthus.

11. Distichiasis
Distichiasis is a rare anomaly in which
an extra row of cilia. These cilia are
usually directed backwards and when
rubbing the cornea, should be
electro-epilated.
Cryptophthalmos
It is a very rare anomaly in which lids
fail to develop and the skin passes
continuously from the eyebrow to the
cheek hiding the eyeball.

12. Microblepharon
In it, eyelids are abnormally small.
It is usually associated with
microphthalmos.

13. INFLAMMATORY DISORDERS OF EYELIDS
BLEPHARITIS
It is an acute or chronic inflammation of the lid margins. It can
be divided into following clinical types:
1. Seborrhoeic or squamous blepharitis
2. Staphylococcal or ulcerative blepharitis
3. Mixed staphylococcal with seborrhoeic blepharitis
4. Posterior blepharitis or meibomitis
5. Parasitic blepharitis

15. 1. Squamous blepharitis
CAUSES
• It is usually associated with seborrhoea of scalp (dandruff).
• In it, Zeiss glands secrete abnormal excessive neutral lipids.
SYMPTOMS
Deposition of whitish material at the lid margin, mild discomfort,
irritation, occasional watering and a history of falling of eyelashes.
SIGNS
• Accumulation of white dandruff-like scales on lid margin & lashes.
• The lashes fall out easily but are usually replaced.

16. 2. Ulcerative blepharitis
CAUSES
• It is a staphylococcal infection of the lid margin.
• The disorder may continue throughout life.
• Chronic conjunctivitis and Dacryocystitis may act as predisposing factors.
SYMPTOMS
• Chronic irritation, itching, mild lacrimation, gluing of cilia & photophobia.
• The symptoms are worse in the morning than noon.
SIGNS
• Yellow crusts are seen at the root of cilia.
• Small ulcers, which bleed easily, seen on removing the crusts.
COMPLICATIONS
• Chronic conjunctivitis, Madarosis, trichiasis, poliosis and tylosis.

17. 3. Mixed staphylococcal with seborrhoeic blepharitis
This type of blepharitis is usually associated with both type of
bacteria, staphylocccal as well seborrhoeic.
4. Parasitic blepharitis
This type of blepharitis associated with Demodex folliculorum infection.
In chronic condition, it is characterized by presence of nits (lice) at the
lid margin and at roots of eyelashes.

18. 5. Posterior blepharitis
• Acute meibomitis occurs mostly due to staphylococcal infection.
• In chronic posterior blepharitis, it is also called a meibomian gland
dysfunction due to seborrhoeic bacteria..
• It is characterized by white foam-like secretion on the eyelid
margins & canthus.
• At the lid margin, openings of the meibomian glands opening
become prominent.

20. TREATMENT OF BLEPHARITIS
• General measures include improvement of health and diet.
• Associated seborrhoea of the scalp should be adequately treated.
• Local measures include removal of scales & crusts from the lid margin with
the help of 3 percent soda bicarb or baby shampoo with hot compresses.
• Antibiotic ointment should be applied at the lid margin, immediately after
removal of scales and crusts, at least twice daily.
• Avoid rubbing of the eyes or fingering of the lids.
• Oral antibiotics such as erythromycin or tetracyclines may be useful.
• Oral anti-inflammatory drugs like ibuprofen help in reducing the
inflammation.
• If nits at the lid margin & lashes than removal with forceps and shampoo
and massage with antibiotic ointment.

21. STYE
• It is an acute inflammation of Zeiss glands or Moll
glands.
PREDISPOSING FACTORS
• It is more commonly infection. There is no age bar.
• Increase chances of stye, patients with eye strain or
refractive errors.
• Habitual rubbing of the eyes or fingering of the lids
and nose, chronic blepharitis and diabetes mellitus.
• Metabolic factors, chronic debility, excessive intake of
carbohydrates & alcohol.
CAUSES
• Commonly involved is Staphylococcus aureus.

22. SYMPTOMS
• Acute pain associated with swelling of lid, mild watering & photophobia.
SIGNS
• Cellulitis stage - localised, hard, red, tender swelling at the lid margin.
• Abscess stage - a visible pus point on the lid margin of affected cilia.

23. TREATMENT
• Hot compresses 2-3 times a day are very useful.
• When the pus is filled, it may be drained by epilating the involved cilia.
• Antibiotic eye drops and eye ointment (at bed time) should be applied
to control infection.
• Anti-inflammatory drugs to reduce oedema.
• Analgesics may be used for relieve pain.
• Systemic antibiotics may be used for early control of infection.
• In recurrent stye, try to find out and treat the associated cause first.

24. CHALAZION
• It is also called a tarsal cyst or meibomian cyst.
• It is a chronic inflammation of the meibomian
gland.
PREDISPOSING FACTORS
• It is more commonly infection. There is no age
bar.
• Increase chances of stye, patients with eye strain
or refractive errors.
• Habitual rubbing of the eyes or fingering of the
lids and nose, chronic blepharitis and DM.
• Metabolic factors, chronic debility,
excessive intake of carbohydrates & alcohol.

25. SYMPTOMS
• Painless swelling in the lid and mild heaviness.
SIGNS
• Small, firm to hard, non-tender swelling of meibomian gland.
• On everting the lid, by means, conjunctival side seen a red, purple or grey area.
• Frequently, multiple chalazion may be seen involving one or more eyelids.
COMPLICATIONS
• A large chalazion of the upper lid induced astigmatism.
• A large chalazion of the lower lid may cause ectropion.
• After long time chalazion, meibomian gland carcinoma may be seen because of
meibomian cyst.

26. TREATMENT
• Treatment in the form of hot fomentation, topical antibiotic eye drops
and oral anti-inflammatory drugs.
• Incision and curettage is the conventional and effective treatment for
chalazion.

27. INTERNAL HORDEOLUM
It is a suppurative inflammation of meibomian gland associated with blockage of the duct.
CAUSES
• It may occur as primary staphylococcal infection of the meibomian gland or due to
secondary infection in a chalazion.
SYMPTOMS
• Painfull swelling of lid and heaviness.
SIGNS
• On everting the lid, swelling is away from the lid margin & pus usually points on the
tarsal conjunctiva and not on the root of cilia. Sometimes, pus point may be seen at the
opening of meibomian gland.
TREATMENT
• When the pus is formed, it should be drained by a vertical incision from the tarsal
conjunctiva.
• Hot fomentation, topical antibiotic eye drops and oral anti-inflammatory drugs may be
used.

28. ANOMALIES IN THE
EYE LASHES AND EYELID MARGIN
TRICHIASIS
• It refers to inward misdirection of cilia (Lashes).
• The inward turning of lashes along with the lid margin (entropion) is called
pseudotrichiasis.
CAUSES
• Trachoma, ulcerative blepharitis, conjunctivitis, stye, mechanical injuries, burns.
SYMPTOMS
• Foreign body sensation and photophobia, irritation, pain and lacrimation.
SIGNS
• Misdirected cilia touching the cornea. Reflex blepharospasm and photophobia occur
when cornea is abraded. Conjunctiva may be congested.

29. COMPLICATIONS
• Recurrent corneal abrasions, superficial corneal opacities, corneal vascularisation and
non-healing corneal ulcer.
TREATMENT
• Epilation (mechanical removal with forceps), is a temporary method.
• Electrolysis, is a method of destroying the lash follicle by electric current using
anaesthesia, through a fine needle inserted into the lash root & removed with forceps.
• Cryoepilation, is also an effective method of treating trichiasis. After infiltration
anaesthesia, using cryoprobe is applied. Drawback is depigmentation of the skin.
• Surgical correction, When many cilia are misdirected operative treatment similar to
cicatricial entropion should be employed.

31. ENTROPION
• It is inward turning of the lid margin.
Types
1. Congenital entropion.
2. Cicatricial entropion.
3. Spastic entropion
4. Senile entropion
5. Mechanical entropion

32. 1. Congenital entropion
• It is a rare condition seen since birth & associated with microphthalmos.
2. Cicatricial entropion
• It usually involving the upper lid. Causes are trachoma, membranous conjunctivitis,
chemical burns and Stevens-Johnson syndrome.
3. Spastic entropion
• It occurs due to spasm of the orbicularis muscle & usually involves the lower lid.
4. Senile entropion
• It affects the lower lid in elderly people. weakening of capsulopalpebral fascia,
degeneration of palpebral connective tissue separating the orbicularis muscle fibres
and horizontal laxity of the lid.
5. Mechanical entropion
• It occurs due to lack of support provided by the globe to the lids and associated with
phthisis bulbi, enophthalmos and after enucleation or evisceration operation.

33. SYMPTOMS
• Foreign body sensation, irritation, lacrimation and photophobia.
SIGNS
• On examination, lid margin is found inward turned.
• Depending upon the degree of inturning it can be divided into three grades:-
• In grade I, only the posterior lid border is inrolled.
• Grade II, inturning up to the inter-marginal strip.
• Grade III, the whole lid margin including the anterior border is inturned.
COMPLICATIONS
• These are similar to trichiasis.

34. TREATMENT
1. Congenital entropion requires plastic reconstruction of the lid crease.
2. Cicatricial entropion, is treated by a plastic operation, which is based
on any of the following (i) Altering the direction of lashes, (ii)
Transplanting the lashes, (iii) Straightening the distorted tarsus.
3. Spastic entropion. (i) Treat the cause of blepharospasm. (ii) Adhesive
plaster pull on the lower lid may help during acute spasm. (iii)
Injection of botulinum toxins in the orbicularis muscle to relieve the
spasm.
4. Senile entropion, used surgical pocedures.

35. ECTROPION
• Outward turning of the lid margin is called ectropion.
Types
1. Senile entropion.
2. Cicatricial entropion.
3. Spastic entropion
4. Paralytic entropion
5. Mechanical entropion

36. 1. Senile ectropion
• It involves only the lower lids and due to senile laxity of the tissues of the lids and
decrease tone of the orbicularis muscle.
2. Cicatricial ectropion
• It occurs due to scarring of the skin and can involve both the lids. Common causes
are: thermal burns, chemical burns, lacerating injuries and skin ulcers.
3. Spastic ectropion
• It is a rare, seen in children & adults due to spasm of the orbicularis.
4. Paralytic ectropion
• It results due to paralysis of the seventh nerve, occurs in the lower lids. Common
causes Bell’s palsy, head injury and infections of the middle ear.
5. Mechanical ectropion
• It occurs in conditions where either the lower lid is pulled down (tumours) or pushed
down (proptosis and chemosis of the conjunctiva).

37. SYMPTOMS
• Epiphora is the main symptom. Irritation, discomfort and mild photophobia.
SIGNS
• Lid margin is outward rotate.
• Depending upon the degree, ectropion can be divided into three
grades:-
• In grade I ectropion only punctum is everted.
• In grade II lid margin is everted and palpebral conjunctiva is visible.
• Grade III the fornix is also visible.
COMPLICATIONS
• Dryness and thickening of the conjunctiva and corneal ulceration (exposure
keratitis).
• Eczema and dermatitis may occur due to prolonged epiphora.

38. TREATMENT
• Cicatricial ectropion, depending upon the degree it can be corrected by
i. V-Y operation, Z-plasty and skin grafting.
• Paralytic ectropion, can be corrected by a lateral tarsorrhaphy or
palpebral sling operation.
• Mechanical ectropion, corrected by treating the underlying cause.
• Spastic ectropion, corrected by treating the cause of blepharospasm.

39. SYMBLEPHARON
In this condition, lids become adherent with the eyeball.
In other words, adhesions between the palpebral and bulbar conjunctiva.
ETIOLOGY
It results from healing of the kissing raw surfaces upon the palpebral and bulbar
conjunctiva.
CAUSES
Thermal or chemical burns, conjunctivitis, injuries, conjunctival ulcers and Stevens-
Johnson syndrome.
SYMPTOMS
Difficulty in lid movements, diplopia, inability to close the lids, and cosmetic
disfigurement.
SIGNS
Adhesion may be present only in the anterior part (anterior symblepharon), or fornix
(posterior symblepharon) or the whole lid (total symblepharon).

40. COMPLICATIONS
Dryness, thickening, corneal ulceration and exposure keratitis.
TREATMENT
Prophylaxis. During the stage of adhesions, may be prevented by lubricant
around the fornices several times a day. A large-sized, therapeutic, soft
contact lens also helps in preventing the adhesions.
Curative treatment consists of symblepharectomy.

41. ANKYLOBLEPHARON
• In this condition, the adhesions between
upper lid margin and lower lid margin.
CAUSES
• Chemical burns, thermal burns, ulcers and
traumatic wounds of the lid margins.
• Ankyloblepharon may be complete or
incomplete.
• It is usually associated with symblepharon.
TREATMENT
• Lids should be separated by excision of
adhesions between the lid margins and
kept apart during healing process.

42. BLEPHAROPHIMOSIS
• In this condition, the palpebral aperture is
decreased.
ETIOLOGY
• It may be congenital or acquired, due to
formation of a vertical skin fold at the
lateral canthus.
TREATMENT
• Usually no treatment is required.
• Canthoplasty operation is performed.

43. LAGOPHTHALMOS
• In this condition, inability to voluntarily close the eyelids.
CAUSES
• Paralysis of orbicularis oculi muscle, symblepharon, severe ectropion, proptosis,
over-resection of the levator muscle for ptosis.
• Physiologically some people sleep with their eyes open (nocturnal lagophthalmos).
SYMPTOMS
• Incomplete closure of the palpebral aperture.
COMPLICATIONS
• Conjunctival and corneal xerosis and exposure keratitis.
TREATMENT
• Artificial tear drops should be instilled for prevent exposure keratitis & antibiotic eye
ointment during sleep. Soft bandage contact lens may be used to prevent exposure
keratitis.

45. BLEPHAROSPASM
• It refers to the involuntary and forceful closure of the eyelids.
ETIOLOGY
Blepharospasm occurs in two forms:
1. Essential blepharospasm - It is a rare idiopathic condition involving patients between
45 and 65 years of age.
2. Reflex blepharospasm - It usually occurs due to reflex stimulation such as : keratitis,
corneal foreign body, corneal ulcers and iridocyclitis.
CLINICAL FEATURES
• Oedema of the lids.
TREATMENT
• In essential blepharospasm, Botulinum toxin, injected subcutaneously over the
orbicularis muscle.
• In reflex blepharospasm, to treat the cause first.

46. PTOSIS
• Abnormal drooping of the upper eyelid is called ptosis.
• Normally, upper lid covers about upper one-sixth of the cornea, i.e.,
about 2 mm. Therefore, in ptosis it covers more than 2 mm.
CONGENTAL
PTOSIS ACQUIRED
PTOSIS

47. CONGENITAL PTOSIS
• It is associated with congenital weakness
(mal-development) of the LPS muscle.
1. Simple congenital ptosis, not associated
with any other anomaly.
2. Congenital ptosis with associated
weakness of superior rectus muscle.
3. Blepharophimosis syndrome, includes
congenital ptosis, telecanthus &
epicanthus.
4. Congenital synkinetic ptosis (Marcus
Gunn jaw winking ptosis), retraction of
the ptotic lid with jaw movements.

48. ACQUIRED PTOSIS
It may be:
1. Neurogenic ptosis, caused by third nerve palsy, Horner’s syndrome,
migraine and multiple sclerosis.
2. Myogenic ptosis, due to disorders of the LPS muscle. It may be seen in
patients with myasthenia gravis, ocular myopathy, oculo-pharyngeal
muscular dystrophy.
3. Aponeurotic ptosis, due to defects of the levator aponeurosis in the
presence of a normal functioning muscle. It includes (senile) ptosis,
postoperative ptosis after cataract and retinal detachment surgery.
4. Mechanical ptosis, due to excessive weight on the upper lid by lid
tumours, multiple chalazia and lid oedema.

49. CLINICAL EVALUATION
[A] History - age of onset, family history, trauma history, eye surgery & degree of
the ptosis.
[B] Examination
1. Inspect pseudoptosis - common causes are: microphthalmos, enophthalmos
and phthisis bulbi.
2. Observe the following points
i. ptosis is unilateral or bilateral.
ii. Function of orbicularis oculi muscle.
iii. Eyelid crease is present or absent.
iv. Jaw-winking phenomenon is present or not.
v. Associated weakness of any extraocular muscle.
vi. Bell’s phenomenon is present or absent.

50. 3. Measurement of amount of ptosis –
Mild - 2 mm
Moderate - 3 mm
Severe - 4 mm
4. Assessment of levator function - Patient is asked to look down, and
thumb of one hand is placed firmly against the eyebrow of the patient (to
block the action of frontalis muscle) by the examiner. Then the patient is
asked to look up and the amount of upper lid movement is measured with
a ruler.
Normal - 15 mm
Good - 8 mm or more
Fair - 5-7 mm
Poor - 4 mm or less

51. 5. Photographic record of the patient should be maintained for comparison.
• 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.
TREATMENT
Congenital ptosis
• It almost always needs surgical correction.
• In severe ptosis, surgery should be performed at the earliest to prevent
stimulus deprivation amblyopia.
• In mild and moderate ptosis, surgery should be delayed until the age of 3
to 4 years.

52. SURGERY FOR CONGENITAL PTOSIS
1. Fasanella-Servat operation - It is performed in mild ptosis and good
levator function.
2. Levator resection - It is performed for moderate and severe grades of
ptosis. It is contraindicated in patients having severe ptosis with poor
levator function.
3. Frontalis sling operation (Brow suspension) - It is performed in patients
having severe ptosis with no levator function.
B] Acquired ptosis
• Efforts should be made to find out the underlying cause and if possible
treat it.

53. TUMOURS OF THE LIDS
• Papilloma
• Xanthelasma
• Haemangioma
• Neurofibroma
BENIGN
TUMOURS
• Basal cell carcinoma
• Squamous cell carcinoma
• Sebeceous cell carcinoma
• Malignant melanoma
MALIGNENT
TUMOURS

54. PAPILLOMAS
• This type of tumour is most common,
arising from the epithelium surface.
• These occur in two types -
i. Squamous papillomas, occur in adults, as
very slow growing, raspberry-like growths,
usually involving the lid margin & treated
by simple excision.
ii. Seborrhoeic keratosis, occurs in middle-
aged and older persons. Their surface is
friable, verrucous and slightly pigmented.

55. XANTHELASMA
• These are creamy-yellow plaque-like
lesions which frequently involve the skin
of upper and lower lids around medial
canthus.
• Xanthelasma occurs in middle-aged
females (most common).
• Xanthelasma represents lipid deposits in
histiocytes in the dermis of the lid.
• These may be associated with diabetes
mellitus or high cholesterol levels.
• Excision treatment may be advised for
cosmetic reasons.

56. NEUROFIBROMA
• Eyelids and orbits are commonly affected in neurofibromatosis.

57. BASAL-CELL CARCINOMA
It usually seen in elderly people. It involves most commonly lower lid (50%)
followed by medial canthus, upper lid and outer canthus.
Clinical features It may present in four forms:
 Nodulo-ulcerative basal cell carcinoma is the most common.
 Non-ulcerated nodular basal cell carcinoma, rarely.
 Sclerosing type basal cell carcinoma, rare.
 Pigmented basal cell carcinoma, rare.
Treatment
Surgery. Local surgical excision of the tumour.
Radiotherapy and cryotherapy should be given in non-operable cases.

59. SQUAMOUS CELL CARCINOMA
• It is the second most common type of
tumour.
• It arises from the lid margin in elderly
patients.
• It affects upper and lower lids equally.
Clinical features. It may present in two forms,
 First, an ulcerated growth with elevated
margins, is most common.
 Second, fungal lesion without ulceration, is a
rare.
Treatment
Surgery. Local surgical excision of the tumour.
Radiotherapy and cryotherapy should be given
in non-operable cases.

60. SEBACEOUS GLAND CARCINOMA
• It is a rare tumour arising from the meibomian glands.
• It usually start as a nodule and then grows to form a big growth (by
chalazion)
• Rarely, a diffuse tumour along the lid margin may be mistaken as
chronic blepharitis.
• Surgical excision with reconstruction of the lids is the treatment.

61. MALIGNANT MELANOMA
(MELANOCARCINOMA)
• It is a very rare tumour of the lid.
• It may arise from a pre-existing naevus, but
usually arises from the melanocytes
present in the skin.
• It appears as a flat or slightly elevated
naevus which has irregular borders.
• It may ulcerate and bleed.
• The tumour spreads locally as well as to
distant sites by lymphatics and blood
stream.
• Treatment. Surgical excision with
reconstruction of the lids.