short notes on ( eyelid diseases)

1. Positional eyelid disorders
Presenter :
DR MOUSTAFA HASSAN

2. What we mean by Positional eyelid disorders ?
1. PTOSIS
2. ENTROPION
3. ECTROPION
4. LAGOPHTHALMOS

3. introduction
What is the eyelid ?
It is one of the ( 5 ) ocular adnexa which includes :
1. Orbit
2. EOM
3. Eyelid
4. Lacrimal system
5. Conjunctiva

5. Structural layers
Eye lids can be divided into (5 ) Structural layers
( anatomically )
1) skin and subcutaneous tissue
2) Muscles of protraction i.e. OO + Horner MS
3) Loose CT
4) tarsus
5) conjunctiva

6. Eye lids can be divided into 2 layers ( Surgically )
1) Ant. Lamellae ( skin + muscle )
2) Post. Lamellae ( tarsus + conjunctiva )

7. Normal Values Of Eyelid Structures
Palpebral fissure length 24-30 mm
Palpebral fissure height 8-10 mm
Distance from upper lid margin to
corneal reflex
3 – 5 mm
Distance from upper lid margin to
upper lid crease
8-11 mm

8. PTOSIS
• Def .
• Abnormal drooping of the upper
eyelid i.e. upper lid covers more
than 2 mm from the cornea .
Types and etiology
• Congenital ( bilateral )
• Acquired ( unilateral )

9. Acquired Ptosis
Types :
• Neurogenic :
3rd nerve paresis and Horner syndrome
• Myogenic :
a) Paralysis of levator ( somatic )
b) Paralysis of Muller muscle ( sympathetic )
c) Myasthenia gravis ( easily fatigue of the muscle )

10. What is ( myasthenia gravis ) ??
It is auto-immune disease in which antibodies attack the
receptors of neuromuscular junctions ..
Called ( fluctuating ptosis )
-------------------------------------------------------------------------------------------
• Aponeurotic Ptosis ;
defect in the levator aponeurosis (degenerative changes
= congenital ptosis = ( most common ) ..
Also can occur due to senility ( less common )

11. • Traumatic :
any trauma can affect muscle or nerve
• Mechanical :
mass ( Chalazion ) / tumor
• Hysterical ;
usually affect young girls with emotional disturbance

12. • What is DD of ptosis ?? ( pseudo ptosis )
1. Lack of lid support by the globe ( shrunken eye )
2. Dermatochalasis ( laxity of skin of the lid )
3. Brow ptosis ( paralysis of frontalis muscle )
4. Ipsilateral Hypotropia
5. Contra lateral retraction ( retraction of the other lid )

13. Mechanical ptosis

14. Ipsilateral Hypotropia

15. Contralateral Retraction

16. What is Eyelid Retraction?
 Def .
 It is a condition in which the Upper
eyelid is displaced superiorly or the
lower eyelid displaced inferiorly,
exposing sclera between the limbus and
the eyelid margin.
 Causes .
1. thyroid eye disease,
2. recession of SR , IR
 Treatment .
1. Tt of the cause
2. Artificial tears

17. • C/P :
1. IF mild ptosis = bad cosmetic
2. If severe ( affect visual axis ) = diminution of vision

18. Evaluation of ptosis
• 1- Marginal reflex distance ( MRD ) /
Distance ( ) upp. Lid margin & corneal reflex .
Normal = 4 mm
• Degree of ptosis ( degree of drooping ):
a) Mild ptosis = 2 mm
b) Moderate = 3 mm
c) Severe = 4 mm
• 2 - Vertical fissure height /
Distance ( ) upp. Lid margin & lower lid margin
Normal = 10 mm

21. 3 - Levator function test :
• Ask pt. to look down why ??
To get full relaxation of levator muscle
• Press on eye brow against bone why ??
To abolish action of frontalis muscle
• Ask pt. to look up as much as he can
• Put ruler at lid margin
• Measure excursion
• Normal > or = 15 mm
• Degree of Levator function :
a) Good function = 12- 14 mm
b) Fair = 5 – 11 mm
c) Poor function of the levator < 4 mm

23. • 4 - Distance ( ) upp lid margin & lower limbus in normal gaze
• Ask pt. to look forward .
• Measure the distance
• Normal distance : 9 mm
 upp. Lid cover 2 mm of cornea .
 so degree of drooping = zero
• Degree of ptosis ( Degree of drooping ) :
a) Mild = 1 - 2 mm
b) Moderate = 3 – 4 mm
c) Severe = > 4 mm .

24. • 5 - Skin crease :
• Ask pt. to look down why ??
To be able to see the crease
• Measure distance ( ) upp. Lid margin & skin crease in
down gaze ..
• Normal = 8 mm
• If > 12 mm = high crease = diagnostic aponeurotic
ptosis .

26. 6- Pupillary examination
a) Miosis plus ptosis = Horner's syndrome
b) Mydriasis plus ptosis = oculomotor nerve palsy

28. Congenital Ptosis
• Def.
oIt is drooping of the upper lid since birth .
oUsually bi-lateral
• Cause
mal development of levator muscle OR CN3..

29. • Usually associated with :
1) SR weakness
2) Defect in ocular motility .
3) Poor relaxation of levator muscle
4) No skin crease
5) Refractive errors
6) Marcus Gunn jaw winking phenomenon. ??
7) Belpharophemosis ??

30. • What is (Marcus Gunn jaw winking phenomenon ) ?
oIt is elevation of ptotic lid while moving the jaw why ?
oDue to abnormal branch from mandibular br. Of CN5 which
supply levator .
• Cause
mal development of levator muscle OR CN3..
• What is (Belpharophemosis ) ?
It is congenital anomalies ch.ch. With /
Ptosis
Ectropion of upp. Lid

32. • What are complications of congenital ptosis ?
a) If unilateral ptosis = unilateral amblyopia= squint
b) If bilateral ptosis = bilateral amblyopia = nystagmus

33. Treatment of congenital ptosis .
a) Tt. Of the cause
b) Surgical tt. ( depends on levator function test )
If > 10 mm ( mild ptosis ) :
F. servant operation
If ( 5 – 10 ) mm
Levator resection operation
If < 4 mm ( severe )
Frontalis suspension ( sling )
• Other aids
1. Eyelid crutches are attached to eye glass frame
2. Taping of upper eyelid open during appropriate time – almost impractical

34. Contraindications of Ptosis surgery
1. Myasthenia gravis .
2. Acute CN3 Palsy .
3. NO corneal sensation
4. No bells phenomenon ..
What is age of surgery for congenital ptosis ??
It depends on the severity of ptosis .
a) If severe = urgent to avoid complications
b) If not = 6 years old

38. ENTROPION & ECTROPION

39. ENTROPION
• Def.
a) It is rolling in of the lid margin making the lashes against the cornea
b) It is called ( pseudo-trichiasis )
c) It is mostly affect LL > UL except ( cicatricial entropion )
• Why ???
• Types :
1. Senile
2. Spastic
3. Congenital
4. Cicatricial

40. SENILE ENTROPION
• Def.
a) It is rolling in of the lid margin making the lashes against the
cornea .
• Cause .
• Degeneration of fibrous & elastic tissues of the lid .
• Pathological Types :
1. Horizontal laxity
2. Vertical instability
3. Overriding

42. tt. Of Senile Entropion
• It is classified into 2 ways .
• Horizontal laxity present or not .
• If horizontal laxity present /
• It means we have 3 pathology = need 3 steps = qulkar operation.
• Steps are /
1. Shortening of the tarsus + / - stretch of canthal tendon
( horizontal )
2. Tighten or transverse everted suture . ( vertical )
3. Full thickness lid splitting ( overriding )

43. • If horizontal laxity absent /
• It means we have 2 pathology = need 2 steps .
• Steps are /
1. transverse everted suture + Full thickness lid splitting =
weis operation ..
2. Tightening + Full thickness lid splitting = Jons operation

44. CICATRICIAL ENTROPION
• Def.
a) It is rolling in of the lid margin making the lashes against
the cornea .
b) It is the only type which can affect both UL & LL ..
• Cause .
• Fibrosis / scar of conjunctiva = shortening of conjunctiva =
pull the tarsus inwards

45. tt. Of Cicatricial Entropion
• Principal :
• Straight of deformed tarsus either by add or cut .
• Upper lid ;
• Wedge resection ( snellen operation ) why ??
• Because upp tarsus is thick then can remove
• Contraindicated in :
1. LL entropion ( it is weak )
2. Failure of previous snellen
• Lower lid ;
• Webster operation ( insert mucous graft in sulcus subtarsalis )

46. SPASTIC ENTROPION
• Def.
a) It is rolling in of the lid margin making the lashes against the
cornea .
• Cause .
• Spasm of Riolan muscle + lid is not well-supported with the
globe ..
• It is Due to :
1. Infections ( muscle spasm )
2. Enophthalmos & shrunken eye ( lid not well supported )

47. tt. Of Spastic Entropion
• Tt of the cause + temporary paralysis of the muscle .
• why ??
• Tt of the cause may take time to be treated
• How ??
1. Inject ( alcohol ) or ( Botulinum toxin ) which cause temporary paralysis of the
muscle for 2 – 3 weeks ..
2. T shaped plaster
If failed ,,,
Canthoplasty ( cut lateral canthus )
Disadvantages .
It will not cut Riolan muscle fibers only ..

48. • Skin & muscle operation :
• Steps /
1. Excision elliptical skin area just below root of lashes .
2. Excise MS of Riolan fibers only
3. Re suture
Why skin excision ??
It will cause stretch of the skin = pull the lid outwards

49. CONGENITAL ENTROPION
• Def.
a) It is rolling in of the lid margin making the lashes against
the cornea .
• Cause .
• Abnormal development of LL Retractors ..
• Treatment :
Re attach LL Retractors with lower border of tarsus

51. Def.
Out rolling of the lid margin .
Complications .
1- epiphora how ??
Epiphora = eczema = fibrosis
of the skin = ++ Ectropion = ++
epiphora . ( vicious circle )
2 – Lagophthalmos
ECTROPION

52. Grades .
1 = visible punctum
2 = visible punctum + conj.
3 = visible punctum + conj. + lower fornix .
NB :
Normally ,, punctum is NOT visible ..
Types .
Senile
spastic
Cicatricial
mechanical
paralytic

53. SENILE ECTROPION
• Def.
It is rolling OUT of the lid margin .
• Cause .
• Degeneration of fibrous & elastic tissues of the lid .
• Pathological Types :
1. Horizontal laxity ( the main cause )
2. Medial canthal tendon laxity
3. Lateral canthal tendon laxity .

55. TT. OF SENILE ECTROPION
• if mild horizontal laxity ( G1 )
• cautery of lower fornix why ??
• To induce fibrosis of conj. = shortening of conj. = tract on
lid margin inwards .
• If moderate ( G2 )
• Snellen sutures
• If severe ( G3 )
• Kuhnt operation

56. CICATRICIAL ECTROPION
• Def.
It is rolling OUT of the lid margin ..
Cause .
• Fibrosis / scar of the skin = shortening of skin = pull the
tarsus outwards
• It is Due to :
1. Trauma
2. Wound
3. Post. Operative

58. TT. OF CICATRICIAL ECTROPION
• Principal :
• Depends on size of the scar
• Small scar ;
V – Y operation
a) Incision of skin v-shaped
b) Re suture by y – shaped
• Big scar :
1. Skin graft
2. Skin flap ( the best ) ???

59. SPASTIC ECTROPION
• Def.
It is rolling OUT of the lid margin ..
Cause .
• Spasm of Riolan muscle + Exophthalmos ..

60. TT. OF SPASTIC ECTROPION
• Tt of the cause + temporary paralysis of the muscle .
• why ??
• Tt of the cause may take time to be treated
• How ??
1. Inject ( alcohol ) or ( Botulinum toxin ) which cause temporary
paralysis of the muscle for 2 – 3 weeks ..
2. T shaped plaster
If failed ,,,
Snellen suture .

61. PARALYTIC ECTROPION
• Def.
It is rolling OUT of the lid margin ..
• Cause .
• CN7 palsy = paralysis of orbicularis muscle
• Treatment :
Conservative ( 3- 6 months )
1. Vitamins ( nerve regeneration )
2. Massage & electrical stimulation ( to prevent contracture )
3. Lubricant at bed time ( to prevent exposure keratitis )

62. • What is muscle contracture ??
• it is continuous contraction of muscle NOT followed by
relaxation
• Surgical tt ( if failed )
1. Stretch of canthal tendon .
2. Silicon / wire sling around the lid
3. Tarsorraphy

63. MECHANICAL ECTROPION
• Def.
It is rolling OUT of the lid margin ..
• Cause .
• Mass or tumor
• Treatment :
Excision

64. What are the complications of Ectropion ??
1. Lagophthalmos .
2. Epiphora how ??

65. Epiphora
Skin
fibrosis
++
Ectropion
++
epiphora
Ectropion

67. Lagophthalmos

68. Def .
Incomplete closure of palpebral fissure when
the eye is lightly shut .
Types .
 Mild /
 when it can be closed forcedly ( orbital part
of orbicularis muscle is normal )
 Severe /
 when it cant be closed even by force ( both
orbital & palpebral part affected )

69. Etiology
• Nerve /neurogenic :
CN7 Palsy .
• Muscle /
Paralysis of orbicularis oculi .
• Skin /
Fibrosis /scar ( chemical burn , SJS )
• Others /
1) Symblepharon
2) Proptosis
3) Floppy lid syndrome
4) Nocturnal Lagophthalmos

70. Treatment
1. Treat the cause .
2. Artificial tear drops
3. Antibiotic eye ointment
4. Soft bandage contact
5. Tarsorraphy.
What is the most common complications of
Lagophthalmos ??
Exposure keratitis

71. References
1. Ophthalmology by Yanoff & Ducker, 3rd Edition.
2. Clinical Ophthalmology, A systemic approach, 7th edition,
J.Kanski.
3. Med.web.com

72. Thanks for attention