eyelid diseases in ophthalmology practice

1. Eye lid (2)
Samhaa Mohammed Abd Elmoneim
Zagazig Ophthalmic Hospital Jan 2019

2. Lid lesions (benign, malignant) √
(look at lid lesion previous ppt)
Lid malposition (ptosis, entropion, ectropion)
Inflamation (allergic, bacterial, viral, anterior, posterior, angular
blepharitis, childhood blepharoconjunctivitis)
Congenital (entropion, epiblepharon, telecanthus, epicanthus
fold, blepharophimosis, coloboma, cryptophthalmos,
eublepharon, ablepharon, ankyloblepharon, lid eversion)
Miscellaneous (floppy lid, blepharochalasis, dermatochalasis,
eye imbrication, lid retraction, varices, trichomegaly, lash
ptosis, madarosis, poliosis, distichiasis)

3. Orbital septum
Levator
aponeurosis
Muller ms
Tarsal plate
LL retractors
Pretarsal OO
Preseptal OO
LPS ms
IO ms

4. Ptosis
Onset
Congenital
Acquired
Anatomical
Neurogenic →
Myogenic →
Aponeurotic →
Mechanical →
Aetiological
3rd n palsy, Horner s.,
aberrant regeneration.
Congenital, MG, myotonic
dystrophy, CPEO
Involutional, post
trauma/ surgery
Scarring, mass, GPC
‫أي‬ ‫الحالة‬ ‫نحدد‬ ‫المطلوب‬
‫من‬ ‫نوع‬which type
(onset,
anatomy& aetiology)
After exclude pseudo
‫من‬(‫قديمة‬ ‫صورة‬)Hx
Exam.
Association

5. Clinical evaluation
1. Exclude Pseudoptosis
• Orbital volume deficit: phthisis bulbi, artificial eye,
microphthalmos, enophthalmos.
• Ipsilateral hypotropia (cover test of normal eye)
• Brow ptosis in excess skin or facial palsy,
dermatochalasis (manual elevating lid).
• Contralateral lid retraction, exophthalmos (normal
UL covering 2mm of cornea)

6. Clinical evaluation
2. Measurement
1. MRD
(normal 4-5mm)

7. Clinical evaluation
2. Measurement
2. Palpebral fissure height (normal 7-10 in male,
8-12 in female).
Normal UL cover 2mm of sup limbus & 1mm of inf
limbus.
Mild: 2mm
Moderate: 3mm
Severe: > 4mm with other eye

8. Clinical evaluation
2. Measurement
3. LFT
Normal: >15mm
Good: 12-14mm
Fair: 5-11mm
Poor: <4mm with other eye

9. Clinical evaluation
2. Measurement
4. UL crease
Normal: 10mm in F,
8mm in M.
High in senile type.

10. Ptosis
Congenital Senile
Age (+ old photo) Since birth old
Laterality Uni/ bi bi
Severity Severe Mild
UL crease Absent Preserved
On downgaze Lid lag Ptosis is worse
LFT Poor Good
Associated signs SR weakness, MG winking,
BPS
Lax lid, deep sulcus
TTT Brow suspension Aponeurotic repair

11. Ptosis
Onset
Congenital
Acquired
Anatomical
Neurogenic →
Myogenic →
Aponeurotic →
Mechanical →
Aetiological
3rd n palsy, Horner s.,
aberrant regeneration.
Congenital, MG, myotonic
dystrophy, CPEO
Involutional, post
trauma/ surgery
Scarring, mass, GPC
‫أي‬ ‫الحالة‬ ‫نحدد‬ ‫المطلوب‬
‫من‬ ‫نوع‬which type
(onset,
anatomy& aetiology)
After exclude pseudo
√
Hx √
Exam. √
Associated signs

12. Clinical evaluation
3. Associated signs
• Horner, 3rd n palsyPupil
• Manual elevate the ptotic lid, the other retracted lid will
drop (warn pt for post op other lid ptosis.Increase innervation
• In congenital, SR -- , surgical repair of hypotropia before lid
• In paralytic, 3rd n palsy, multiple n palsies, aberrant
regerneration
Ocular motility defect
• MGJW
• Ask to chew, move jaw from side to side --- improved
ptosis.
Jaw winking
• AD, Epicathus inversus, telecanthusBlepharophimosis S
• Post op assessment
• Ask pt to close lid and manually evaluate globe elevation
Bell phenomenon
• With MG
• Ask to look upward for 30 sec --- progressive lid drop.
Cogan lid twich during saccade from downgaze to PP
Fatigablity

13. Clinical evaluation
3. Associated signs
• MGJW, blepharophimosis, SR (surgery!), DEP,
CFEOM -ve Bell phenomenon, other eye!!
• Absent crease, poor LFT.
Congenital ptosis
• EOM, pupilParalytic
• Fatigability, variable, diplopiaMG
• High crease, good LFT, bil, muller
fatigue variability (milder than MG!!)Involutional
CFEOM (congenital fibrosis of EOM), DEP
(Double Elevator Palsy)

14. MGJW
Congenital

15. Aberrant
regeneration
Involutional Mechanical

16. Surgical rules
Levator advancement with reinsertion/ ant levator repair
→ involutional
Conjunctival-muller resection (Fasanella-Servat)
(mild ptosis 2mm, good LFT) → Horner.
Levator advancement/resection
(moderate LFT > 5mm) → any cause with LFT > 5mm.
Frontalis suspension (with/out disinsertion)
(poor LFT < 4mm)
→ congenital , with disinertion in
MGJW

17. Surgical rules
Treat
first
Hypotropia
Orbit → Ms → Lid
(in congenital)
Telecanthus,
epicanthus inversus
(in
blepharophimosis)
Cause
(in mechanical)

18. Hx, exclude
pseudo
• Old photo
• FH
Exam.
• AHP, EOR (amblyopia)
• Measurement (LFT, MRD, PFH, UL
crease)
Association
• SR --, MGJW, DEP, other eye
• Blepharophimosis
• Bell phenomenon
Ttt
• Treat EOR, amblyopia √
• Surgery (when ?) – preschool /
earlier (if severe).
• Which surgery? (acc to LFT)

19. Hx, exclude
pseudo
• Old photo
• FH
Exam.
• AHP, EOR (amblyopia)
• Measurement (LFT, MRD, PFH, UL
crease)
Association
• SR --, MGJW, DEP, other eye
• Blepharophimosis
• Bell phenomenon
Ttt
• Treat EOR, amblyopia √
• Surgery (when ?) – preschool √ /
earlier (if severe).
• Which surgery? (acc to LFT)

20. Hx, exclude
pseudo
• Old photo
• FH
Exam.
• AHP, EOR (amblyopia)
• Measurement (LFT, MRD, PFH, UL
crease)
Association
• SR --, MGJW, DEP, other eye
• Blepharophimosis
• Bell phenomenon
Ttt
• Treat EOR, amblyopia √
• Surgery (when ?) – preschool /
earlier √ (if severe).
• Which surgery? (acc to LFT)

21. Hx, exclude
pseudo
• Old photo
Exam.
• Measurement (LFT, MRD, PFH, UL
crease)
Association
• Brow ptosis
Ttt
• Surgery?? blepharoplasty
??
Exclude pseudo
(Dermatochalasis)

22. DD
Exam.
Management
17m , rt droopy lid since
birth, chin up posture.
Occasionally lid cover pupil.
Good fix and follow
AHP 15degree.
MRD 0.5, 3.5mm.
LFT 6, 12mm.
Pupil 3mm OU, no RAPD.
Cyclo ref
+0.75, +1.0

23. • AHP, amblyopia (ptosis/
anisometropia)Congenital
• Δ, heterochromiaHorner
• Vertical, xt, mydriasis3rd n palsy
• 5th, 3rd synkinesisMGJW
• Mass restrict elevationMechanical
• Elevation in add, abd. (true, pseudo)DEP
• Acquired, systemic (kearns syres)CPEO
• Acquired, trauma/ senile, slowly progressiveDehiscence
• EOM, ocular/systemicMG
• Hypotropia, volume deficit, contralat!Pseudo

24. Central, steady maintained (CMS) fixation. Fix & follow
If squint (fixated eye/ refixation of covered eye?)
No squint --- 10 D prism base down
Vision
Pupil
Pupil
Dimlight
Horner
Bright light
3rd n palsy
Anisocoria

25. AHP, chin up (amblyopia?)
Measurement (LFT, MRD, PFH, Crease hight)
Bell phenomenon, MGJW
EOM (3rd n, DEP, Cngenital fibrosis $)
No squint --- 10 D prism base down
SLE (hypochromia ant, post segment), cyclo refraction
Exam.

26. • Rt UL congenital ptosis
with chin up.
• Chin up → No amblyopia.

27. Treatment
.
Amblyopia.
Anisometropia.
Psychological.
FU (thoughout
child hood years
to ensure
amblyopia
recurrence.
Medical
Cosmotic.
VF.
AHP.
↓ surgical dose
if absent Bell
phenomenon.
Surgical

28. Surgical rules
Levator advancement with reinsertion/ ant levator repair
→ involutional
Conjunctival-muller resection (Fasanella-Servat)
(mild ptosis 2mm, good LFT) → Horner.
Levator advancement/resection
(moderate LFT > 5mm) → any cause with LFT > 5mm.
Frontalis suspension (with/out disinsertion)
(poor LFT < 4mm)
→ congenital , with disinertion in
MGJW

29. Frontalis
suspension
Sutures
(supramid,
nylon, prolene,
Gore-tex)
Silicon
Synthetic
Fascia lata
(autogenous,
banked)
Organic

30. 66 y old , ↑droppy lid over 20y,
upgaze view in photo.
BCVA 6/18 ou, EOM↓ even
with Doll̛s, -ve FDT, absent
Bell̛s.
DD:
CPEO
MG
MD
dorsal midbrain lesion
vertical gaze palsy
TED

32. Surgical videos

33. Lid lesions (benign, malignant) √
(look at lid lesion prevous ppt)
Lid malposition (ptosis, entropion, ectropion)
Inflamation (allergic, bacterial, viral, anterior, posterior, angular
blepharitis, childhood blepharoconjunctivitis)
Congenital (entropion, epiblepharon, telecanthus, epicanthus
fold, blepharophimosis, coloboma, cryptophthalmos,
eublepharon, ablepharon, ankyloblepharon, lid eversion)
Miscellaneous (floppy lid, blepharochalasis, dermatochalasis,
eye imbrication, lid retraction, varices, trichomegaly, lash
ptosis, madarosis, poliosis, distichiasis)

34. Entropion

35. Entropion
Pathogenesis
• Overriding of preseptal
over pretarsal
orbicularis.
• Horizontal lid laxity.
• LL retractors weakness.
• Tarsal plate atrophy.
• Retrobulbar fat atrophy.

36. Entropion
Onset
Congenital Acquired
Aetiological
Involutional Cicatricial
Infectious:
trachoma
Non infectious:
OCP, SJS,
chemical injury,
posterior
blepharitis
Acute
spastic
(OO
spasm)

37. Entropion
Pathogenesis
• Overriding of preseptal
over pretarsal
orbicularis.
• Horizontal lid laxity.
• LL retractors weakness.
• Tarsal plate atrophy.
• Retrobulbar fat atrophy.
Tests
• Lid closure.
• Snap back.
• Lid position in downgaze
• Palpation of tarsus

38. Entropion ttt
Coservative
or
Surgical?
• Cause
• Severity
• Pathogenesis
• Duration of
cure

39. Entropion ttt
Treatment
Involutional
Temporary
(everting
sutures)
Weis
(transverse
lid
split+everti
ng sutures)
Quickert
(weis+horiz
ontal lid
shortening)
Jones
(plication
of LL
retractors)
Cicatricial
Ant lamellar
reposition
Tarsoconj.
Rotation+pos
t lamellar
graft
Congenital
Hotz
procedure
(tarsus
fixation to
OO&skin
Acute
spastic
Cause
Taping,
everting
sutures,
botox.
Trichiasis
(epilation, cryo,
electrolysis)

40. Surgical videos

41. Ectropion

42. Ectropion
Pathogenesis
• Weakness of preseptal
orbicularis.
• Horizontal lid laxity.
• Tarsal plate atrophy.
• MCT, LCT laxity
Tests
• Lid closure.
• Snap back.
• Palpation of tarsus.
• Stretching >2mm.

43. Ectropion
Onset
Congenital
(blepharop
himosis,
ecthyosis)
Acquired
Aetiological
Involutional Cicatricial
Infectious
Non infectious:
OCP, SJS,
chemical injury,
posterior
blepharitis
Paralytic
(Facial
palsy)

44. Ectropion ttt
TTT
Cause
Extent
Horizontal
laxity or not.

45. Ectropion ttt
Treatment
Involutional
Medial laxity
Zeigler
cautery
Diamond
tarso-
conjunctiv
al excision
Lazy T
procedure
(2 +
wedge
excision)
Entire lid laxity
Khunt-
Szymano
wski
Lateral
tarsal
strip LTS
Wedge +
LTS
Cicatrici
al
Z plasty
Skin
flap/
graft .
Congenit
al
Skin
graft
Paralyti
c
Surgery
> 6m

46. Lid lesions (benign, malignant) √
(look at lid lesion previous ppt)
Lid malposition (ptosis, entropion, ectropion) √
Inflamation (allergic, bacterial, viral, anterior, posterior, angular
blepharitis, childhood blepharoconjunctivitis)
Congenital (entropion, epiblepharon, telecanthus, epicanthus
fold, blepharophimosis, coloboma, cryptophthalmos,
eublepharon, ablepharon, ankyloblepharon, lid eversion)
Miscellaneous (floppy lid, blepharochalasis, dermatochalasis,
eye imbrication, lid retraction, varices, trichomegaly, lash
ptosis, madarosis, poliosis, distichiasis)

47. Pollen, insect bite.
Antihistaminic.
Acute allergic
odema
Atopy, asthma, VKC,
AKC.
Thickened, fissured
skin, staph blepharitis.
Emollient , weak
steroid.
Atopic
dermatitis
Drug, cosmotic, metal
exposure.
Sensittize 1st exposure
then toxic reaction in
further times (tye 4)
Skin scales, angular
fissures, PEE, papillary
conjunctivitis.
Stop agent, cold
compress, topical
antihistaminic
Contact
dermatitis
Allergic
disorders

48. Acute staph
infection of zeis
gland
Pointing at lash.
Topical AB, hot
fomentation,
lash epilaion.
Stye (external
hardeolum)
Children, Highly
contagious
Streptococcus
pyogenes, staph
areus.
Erythematous
macules, blisters
Topical AB
Impetigo
Uncommon,
immunecompro
mised,
recurrent.
Streptococcus
pyogenes.
Well-defined
raised borders
Oral AB
Erysipelas
Rare, v severe
upto death.
Streptococcus
pyogenes.
Extremities,
trunk, perineum.
IV AB,
debridement
Necrotizing
fasciitis
Infectious
(Bacterial )

49. Pale waxy
umbulicated nodule
with cheesy material.
Lid margin lesion ---
follicular
conjunctivitis.
Self limited, shaving,
cautery
Molluscum
contagiosum
Unilateral with
trigeminal
distribution.
Old age,
immunecompromised
in young.
Atopic blepharitis!.
HZO
Individual
distribution.
Severity --- eczyma
herbeticum.
2ry bacterial infection.
HSV
Infectious
(Viral)

50. Staphylococcus
(atopic dermatitis) -
-- hard scales at
lash base.
Seborrhoeic
(seborrhoeic
dermatitis)---
greasy soft scales .
Anterior
Meibomian gland
Frothy tear film,
telangectasia
Tooth paste
expression
Posterior
Moraxella lacunata
Topical
chloromephnicol,
erythromycin.
Angular
Chronic
blepharitis

51. Lid lesions (benign, malignant) √
(look at lid lesion previous ppt)
Lid malposition (ptosis, entropion, ectropion) √
Inflamation (allergic, bacterial, viral, anterior, posterior, angular
blepharitis, childhood blepharoconjunctivitis) √
Congenital (entropion, epiblepharon, telecanthus, epicanthus
fold, blepharophimosis, coloboma, cryptophthalmos,
eublepharon, ablepharon, ankyloblepharon, lid eversion)
Miscellaneous (floppy lid, blepharochalasis, dermatochalasis,
eye imbrication, lid retraction, varices, trichomegaly, lash
ptosis, madarosis, poliosis, distichiasis)

52. Congenital lid anomalies
Epicathal folds
Pseudo XT
From UL to LL
VY surgery

53. Congenital lid anomalies
Blepharophimosis
Ptosis
epicanthus inversus
telecanthus

54. Congenital lid anomalies
Telecanthus
↑distance
between two MCT
DD hypertelorism
Hypertelorism
↑ distance
between 2 orbits

55. Congenital lid anomalies
Epiblepharon
With manual pulling
down skin fold Entropion
Hotz procedure (skin
crease to tarsus)

56. Congenital lid anomalies
UL coloboma
Goldenhar $
LL coloboma
Treacher collin $

57. Congenital lid anomalies
Cryptophthalmos
Continous skin layer over
globe with absent lid

58. Congenital lid anomalies
Eublepharon
Horizontal ↑ PF
Microblepharon
with
anophthalmos
Ankyloblepharon
Thin tags bet UL LL
Transection without
anasthesia

59. Congenital lid anomalies
Lid eversion
Ecthyosis, down
Bilateral, symmetrical
May resolve spontanously
Ablepharon
No lid

60. Lid lesions (benign, malignant) √
(look at lid lesion previous ppt)
Lid malposition (ptosis, entropion, ectropion) √
Inflamation (allergic, bacterial, viral, anterior, posterior, angular
blepharitis, childhood blepharoconjunctivitis) √
Congenital (entropion, epiblepharon, telecanthus, epicanthus
fold, blepharophimosis, coloboma, cryptophthalmos,
eublepharon, ablepharon, ankyloblepharon, lid eversion) √
Miscellaneous (floppy lid, blepharochalasis,
dermatochalasis, eye imbrication, lid retraction, varices,
trichomegaly, lash ptosis, madarosis, poliosis, distichiasis)

61. Floppy lid syndrome
Floppy eye lid $
Obese middle age male,
snoring, SAS
Lid over pillow… OSD
Rubbery tarsus, papillary
conjunctivitis, PEK
TTT
Mild – taping,
lubricants
Severe – pentagon
excision

62. Blepharochalasis
Blepharochalasis
Bil recurrent episodes of ,
lid non-pitting odema,
resolving after few days.
Atrophies,wrinked skin,
LCT & LPA dehescience, fat
prolapse.
TTT
Redundant skin
blepharoplasty.
Aponeurotic ptosis
repair.

63. Dermatochalasis
Dermatochalasis
Pseudoptosis
Post surgery

64. lid retraction
Lid retraction
No loss or tightness of lid
TTT Muller/ LPS recession
Lid spacer.

65. Lid retraction
Causes
• Myasthenia gravis (cogan
lid twitch, contralateral
ptosis).
• Marcus gunn jaw winking.
• Parinaud $ (collier sign).
• Ptosis of opposite eye.
• Parkinsonism.
• Metabolic (uremic).
• Myotonic (↓/↑ k).
• Aberrant 3rd regeneration.

66. Madarosis: loss of lashes.
chronic blepharitis, lid tumor, burn, radiotherapy.
Leprosy, syphilis, myxodema, SLE, psoriasis.
Poliosis: premature localized lash whitening.
VKH, Vitiligo, waardenburg.
Trichomegaly: excessive lash growth.
PG, phenytoin, cyclosporin, AIDS,
malnutrition,porphyria, familial, hypothyroisism.

67. Lid lesions (benign, malignant) √
(look at lid lesionprevious ppt)
Lid malposition (ptosis, entropion, ectropion) √
Inflamation (allergic, bacterial, viral, anterior, posterior, angular
blepharitis, childhood blepharoconjunctivitis) √
Congenital (entropion, epiblepharon, telecanthus, epicanthus
fold, blepharophimosis, coloboma, cryptophthalmos,
eublepharon, ablepharon, ankyloblepharon, lid eversion) √
Miscellaneous (floppy lid, blepharochalasis,
dermatochalasis, eye imbrication, lid retraction, varices,
trichomegaly, lash ptosis, madarosis, poliosis, distichiasis) √