1. Chalazion 2. Management options include: - Warm compresses to promote drainage - Oral antibiotics if preseptal cellulitis is present - Surgical excision if conservative measures fail

1. Lid malposition
Lid
retraction
Ptosis
EctropionEntropion

2. Entropion
Rolling IN of the lid margin (usually the lower)
Symptoms
FB sensation
Lacrimation, phtophobia (Corneal affection)
Signs
Abnormally inward directed lashes and lid margin
The cause e.g. conjunctival scarring
🤔

3. Causes
Affects lower lid because upper lid has wider tarsus and is more
stable
If longstanding may result in corneal ulceration

4. Pathogenesis of involutional entropion
Horizontal lid laxity
Canthal tendon laxity
Overriding of preseptal over
pretarsal orbicularis during lid
closure

5. Treatment options for involutional entropion
Transverse everting
sutures (temporary)
Jones procedure
(for recurrences)
Plication of LL retractorsTransverse lid split +
everting sutures

6. Treatment options for involutional entropion

7. Severe scarring of palpebral conjunctiva which pulls lid margin towards globe
May affect UL or LL
Causes: Trachoma, chemical burns, cicatrising conjunctivitis

8. Treatment options for cicatricial entropion
Corneal protection from rubbing lashes; by epilation or contact lenses
Tarsal fracture for mild cases

9. Mucus membrane graft in sulcus subtarsalis (Webster)
Snellen operation
Skin incision in
lid crease
Wedge
shaped
part of
tarsus is
removed
Tarsal
wedge
resection

10. Caused by spasm of muscle of Riolan e.g. conjunctivitis
Treatment is directed toward the cause

11. Caused by lack of lid support by the globe e.g. atrophy bulb enucleated
eye

12. Treatment options for spastic & mechanical entropion
Artificial eye T-shaped adhesive plaster

13. weakens the muscle of Riolan temporarily weakens the muscle of Riolan permanently

14. Congenital Entropion Epiblepharon
Rare Common especially in Orientals
In-turning of the entire LL & lashes Extra-horizontal skin fold across lid margin
Absent LL crease Present LL crease
When skin is pulled down, lid also pulls away from the globe
When skin is pulled down, lashes turn out but lid remains opposed to the
globe

15. Treatment options for congenital entropion
Hotz procedure
(Skin & Muscle)
A horizontal strip of skin & muscle is excised and
the crease is fixed to the tarsus

16. Entropion
Patho-
genesis
Overriding of pre-
septal over pre-tarsal
Temporary Everting sutures
Permanent Wies
Recurrences Jones
Corneal
protection
Lubricants
Contact lenses
Epilation
Mild Tarasl fracure
UL Snellen
LL Webster
Treat the
cause
Conjunctivitis
Artificial eye
Temporary
T-shaped
plaster
Hotz Skin & muscle

17. Ectropion
Rolling OUT of the lid margin (usually the lower)
Symptoms
Signs
Poor cosmosis
Lacrimation
Mild: rolling out of the punctum
Moderate: Exposure of the palpebral conjunctiva
Severe: Exposure of the conjunctival fornix

18. Complications
Exposure
Dryness - Inflammation
Dryness - Ulcers
Epiphora
Eczema

19. Causes
Age related changes leads to horizontal lid laxity
Weakness of canthal tendons, pre-tarsal orbicularis

20. Treatment options for involutional ectropion
Conjunctival Cauterisation
Inverting
sutures
sutures are passed from
conjunctiva just below inferior
tarsus through orbicularis &
tied on the skin at a lower
level
Palpepral conjunctiva is cauterised to induce fibrosis

21. Kuhnt Symanowksi procedure
excess skin is excised as a
lateral triangle from a
blepharoplasty flap
full thickness pentagon
resection
Horizontal lid shortening

22. Lesions near lid margin cause traction
leading to ectropion eg tumours, conjuctival
Cysts, oedema
BCC

23. Lid pulled from globe by vertical shortening of the anterior lamella of the lower eyelid,
- caused by:
trauma
burns
skin conditions (dermatitis, eczema)
iatrogenic (post-op bleph, laser)

24. Treatment options for cicatricial ectropion
Z-plasty
VY-plasty

25. Skin graft

26. Occurs secondary to Facial nerve palsy
LMNL: Bell’s palsy
Ramsey-Hunt Syndrome (Herpes
Zoster)
Parotid tumour or infiltration
Cerebello-pontine angle lesion
NB: not UMNL
The part of
facial
nucleus
supplying
the upper
1/2 of the
face takes
innervation

27. Treatment options for paralytic ectropion
"In the 1st 3 – 6 months"
-Lubricants
-Galvanic stimulation to orbicularis
muscle
-Temporary ptosis: botox to levator
- Temporary lateral tarsorrhaphy

28. Support the paralysed lid
Medial tarsorrhaphy Lateral tarsorrhaphy

29. Support the paralysed lid
Facial sling:- a strip of fascia lata is passed through LL from MCT to lateral orbital wall

30. Tighten the paralysed lid
Kuhnt Symanowksi procedure
excess skin is excised as a
lateral triangle from a
blepharoplasty flap
full thickness pentagon
resection
Horizontal lid shortening

31. Ectropion
Patho-
genesis
Lax canthal
tendons,
orbicularis, skin
Mild Conj cautery
Moderate Inverting sutures
Severe Kuhnt Symanowksi
Small scar
VY plasty
Z plasty
Large scar Skin graft
Treat the
cause
Remove tumor, cyst
1st 3-6
months
Protect cornea
Galvanic stimulation
Temporary ptosis
Medial Tarsorrhaphy
Lateral Tarsorrhaphy
Central Facial sling
Tighten Kuhnt Symanowksi

32. Ptosis
Drooping of the upper UL below its normal position
Congenital Acquired
Neurogenic
Myogenic
Aponeurotic
Mechanical
Contralateral lid retraction
Ipsilateral hypotropia
Ipsilateral lack of support
Ipsilateral Brow ptosis
Ipsilateral Dermatochalasis
Simple congenital
Blepharophimosis

36. Congenital Ptosis
Simple congenital ptosis
Developmental dystrophy of levator muscle
Occasionally associated with weakness of superior rectus (same embryological origin)
Poor levator contraction (ptosis) & relaxation (Ptotic lid is higher in down gaze)
The levator muscle is replaced by
fibrous tissue.

38. Clinical picture
70
%

39. Associations

40. Accounts for about 5% of all cases of congenital ptosis
Retraction or ‘wink’ of ptotic lid in conjunction with
stimulation of ipsilateral pterygoid muscles
Opening of the mouth Contralateral jaw movement

41. Treatment
Carried out during pre-school years for accurate measurement
Levator resection
Levator dis-insertion
Levator resection
Frontalis suspension
Poor levator function
Amblyopia may be caused by the HIGH REFRACTIVE ERROR not
the ptosis in mild cases
Except if there is a risk of
amblyopia, where ptosis
correction should be done
as soon as possible

42. Congenital Ptosis
Blepharophimosis
Clinical picture
+ lateral LL ectropion

43. Treatment
Double Z-plasty

44. Acquired Ptosis
Causes

45. Symptoms
Cosmetic; sleepy appearance
Defective vision

46. Signs (Evaluation)
Visual Acuity

47. Normal
MRD 4 mm
MRD 2
mm
MRD 1
mm
MRD 0
mm

49. Crease
Distance between lid margin and lid crease in down-gaze
Normals : females 10 mm; males 8 mm
Fold
Absence in congenital ptosis indicates poor levator function
High crease suggests an aponeurotic defect
Distance between lash line and skin fold in
primary position of gaze

51. Accounts for about 5% of all cases of congenital ptosis
Retraction or ‘wink’ of ptotic lid in conjunction with
stimulation of ipsilateral pterygoid muscles
Opening of the mouth Contralateral jaw movement

52. Good
Poor - risk of postoperative
corneal exposure
Upward rotation of globe on lid closure
• Ptosis surgery is contraindicated

53. Dilated pupil Spared pupil
• In theses cases, correct the squint first then correct the pto

54. Miosis

55. NB
Ptosis surgery is
contra-indicated
in cases of
corneal
anaesthesia;
because of the
risk of exposure
keratopathy

56. Myasthenia
gravis
Autoimmune disease marked by
muscular weakness and
fatigability, and caused by a
defect in the action of
acetylcholine at neuromuscular
junctions
Variability Fatigability

57. Ice pack test
Improvement in the severity of ptosis improves after an ice pack is placed on the eyelid for 2
minutes as cold improves neuromuscular transmission.

58. Dehiscence of levator aponeurosis
Causes - involutional (old age), postoperative
High lid crease
Good levator function
Absent lid crease
Deep sulcus

59. Treatment is directed toward the cause

61. Treatment
e.g. Myasthenis; medical treatment (Prostigmine)
treatment of the cause e.g. removal of the chalazion
wait 6 months for nerve regeneration, if no improvement; surgery
Surgery
Corneal anesthesia (exposure keratopathy)
Prior to correction of squint in III nerve palsy

62. Systems for ptosis surgery

63. mild ptosis (MRD > 2 mm) with good levator function (>10 mm)
Excision of upper border of tarsus, lower border of Muller muscle and
overlying conjunctiva

64. any ptosis provided levator function is at least 5 mm
Shortening of levator complex
Amount determined by levator function and severity of ptosis

65. In case of aponeuretic
dis-insertion,
dehiscence or defect
(aging)
Re attachment of
levator aponeurosis to
the tarsus.

66. Severe ptosis with poor levator function ( 4 mm or less )
Marcus Gunn jaw winking
Attachment of tarsus to frontalis muscle with sling (fascia lata,
prolene, …)

67. ‫الصورة‬ ‫لي‬ ‫وضح‬ ‫فضلك‬ ‫من‬😇
Entropion
Ectropion
Ptosis

68. Lid retraction
Causes

69. Lagophthalmos
Incomplete closure of the palpebral fissure when lids are gently closed
Causes
A. Lid coloboma
B. Ectropion
C. VII palsy
D. Post ptosis
surgery
E. Proptosis
Severe illness

70. Complications
Exposure Dryness - Inflammation
Dryness - Ulcers
Treatment
1. Protect the cornea: lubricants, tarsorrhaphy, contact lenses
2. of the cause

71. Xanthelasma

72. Final
Exam
Qs

73. Mention the aetiology of ptosis. Jun 2010, Sep 2010
✤ Definition
✤ Causes:
Psudo-ptosis: 4 (same side) + 1 (opposite side)
True:
Congenital:
1. Simple (muscle dystrophy; poor contraction and relaxation, absent lid crease, Marcus Gunn)
2. Blepharophimosis (Ptosis + Epicanthus + Telecanthus + lateral LL ectropion)
Acquired:
1. Neurogenic: III nerve palsy (exotropia, dilated pupil), Horner syndrome (mild ptosis, miosis)
2. Myogenic: Myasthenia (fatiguability, variability)
3. Aponeurotic: Post-op, Senility (high lid crease, good levator function)
4. Mechanical: tumours, chalazia

74. • What is chalazion and how do you treat it?
Jul 2011
Definition
Treatment
Chronic Granulomatous inflammation of Meibomian gland
Pathogenesis Obstruction of Meibomian gland
ducts
Retaining of secretions FB granuloma
C/P Painless lid swelling - fixed to tarsus - not attached to skin
Fate Resolution - Infection - Pointing
Complications Mechanical ptosis - Mechanical ectropion - Astigmatism

75. Investigate a case of congenital ptosis, enumerate the differential
diagnosis and treatment.
Oct 2012
Congenital Ptosis Simple congenital ptosis
Developmental dystrophy of levator muscle
Occasionally associated with weakness of superior rectus (same embryological origin)
Poor levator contraction (ptosis) & relaxation (Ptotic lid is higher in down gaze)
Clinical picture

76. Associations
Chin elevation
Might cause amblyopia
Accounts for about 5% of all cases of congenital ptosis
Retraction or ‘wink’ of ptotic lid in conjunction with stimulation
of ipsilateral pterygoid muscles
Psudo-ptosis: Ipsialteral Lack of support, Hypotropia, Contralateral Lid
retraction
Blepharophimosis (Ptosis + Epicanthus + Telecanthus)Acquired ptosis:
1. Neurogenic: III nerve palsy (Ptosis + Exotropia + Pupil dilatation), Horner syndrome
(Ptosis + Miosis + Anhydrosis)
2. Myogenic: Myasthenia (Variability, Fatigability, Cogan lid twitch, Ice pack test.
Edrophonium test)

77. Treatment
Carried out during pre-school years for accurate measurement
Levator resection
Levator dis-insertion
Levator resection
Frontalis suspension
Poor levator function
Amblyopia may be caused by the HIGH REFRACTIVE ERROR not
the ptosis in mild cases
Except if there is a risk of
amblyopia, where
ptosis correction
should be done as
soon as possible

78. QUIZ

79. Which of the following is the most common cause for eyelid swelling:
a) Infectious conjunctivitis.
b) Local allergic reaction.
c) Eyelid tumor.
d) Blepharitis.
Mar 2016

80. One of the following is NOT a cause of lagophthalmos:
A. Facial nerve palsy
B. Proptosis
C. Cicatricial ectropion
D. Third nerve paralysis
Feb 2015

81. Ptosis with weakness of the orbicularis oculi is a feature of:
A. 4th nerve palsy
B. 6th nerve palsy
C. Myasthenia gravis
D. 7th nerve palsy
E. 3rd nerve palsy
Feb 2015

82. 1 - Diagnosis
2 - Enumerate 2
Complications
3 - Provided the cause
the Involutional lid
changes, How would you
manage

83. This child is complaining
of upper lid painful
swelling of 5 days
duration,
a - Diagnosis
b - Management

84. 1 - Diagnosis
2 - Enumerate 2
Complications

85. 1 - Diagnosis
2 - Enumerate 2 Surgeries for management

86. Superior tarsal muscle (Muller's muscle) is supplied by the :
a- Third cranial nerve
b- Sympathetic nerve fibres
c- Parasympathetic nerve fibres
d- Seventh cranial nerve

87. The anterior most structure in the eyelid margin is the :
a- mucocutaneous junction
b- gray line
c- meibomian gland orifices
d- lash line

88. Chalazion :
a- is also called as tarsal cyst
b- can result in preseptal cellulitis if untreated
c- heals if the affected lash is pulled out
d- is a non-suppurative inflammation of a Zeis gland

91. 1 - Diagnosis
2 - Management