Ophthalmology

Ophthalmology
By
Dr. Laraib Jameel Rph
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Ophthalmology
• Ophthalmology is a branch of medicine and surgery which deals
with the diagnosis and treatment of eye disorders.
• Ophthalmologists. Ophthalmologists are medical doctors who
provide full eye care, such as giving you a complete eye exam,
prescribing corrective lenses, diagnosing and treating complex eye
diseases, and performing eye surgery.
• Optometrists. Optometrists provide many of the same services as
ophthalmologists, such as evaluating your vision, prescribing
corrective lenses, diagnosing common eye disorders and treating
selected eye diseases with drugs. If you have a complex eye
problem or need surgery, your doctor can refer you to an
ophthalmologist.
• Opticians. Opticians fill prescriptions for eyeglasses, including
assembling, fitting and selling them. Some opticians also sell
contact lenses. Opticians do not provide eye health evaluations.

Ophthalmology
• Eyelids: An eyelid is a thin fold of skin that
covers and protects an eye.
• Third eyelid

Anatomy & physiology of eye lids

Position of lids
• When eye is open, the upper lid covers about
1/6th of the cornea & the lower lid just
touches the limbus.

Canthus
• The two lids meet each other at medial and
lateral angles(or outer & inner canthi). The
medial canthus is about 2mm higher than the
lateral canthus.

Palpeberal aperture
• It is the elliptical (oval) space b/w the upper
and the lower lid. • When the eyes are
opened, it measures about 10-11mm
vertically in the centre and about 28-30mm
horizontallly.

Lid margins
• The eyelid margin describes the portion located at the edge
of the eyelid. It is the site of the eyelashes as well as the
orifice (opening) of the meibomian glands.
• It is About 2mm broad
and is divided into two
parts by punctum.
• The medial, lacrimal
portion is rounded and
devoid of lashes or glands.
• The lateral, ciliary portion consist of rounded anterior
border, a sharp posterior border and an inter-marginal
strip.

Glands of eyes
1. Meibomian glands There are approximately 20 to 30 meibomian glands
on the lower lid and 40 to 50 on the upper lid. which is a special oil gland
(sebaceous) unique to the eyelids.
These glands form a single row in
each lid, with the body of the gland
located inside the eyelid, and the
opening located at the edge of the lid,
posterior to the lashes
• Meibomian glands are essential pieces of the homeostatic machinery
function: keep the ocular surface clean, healthy and well-lubricated.

2. Glands of Zeis are unilobar sebaceous glands
located on the margin of the eyelid. The glands of
Zeis service the eyelash. These glands produce an
oily substance that is issued through the excretory
ducts of the sebaceous lobule into the middle
portion of the hair follicle.
3. Glands of moll: In the same area of the eyelid, near
the base of the eyelashes are apocrine glands
called the "glands of Moll".

• 4- Accessory lacrimal glands of Wolfring: are small tubular
accessory lacrimal glands found in the lacrimal caruncle of
the eyelid. There are usually 2 to 5 of these glands in the
upper eyelid, and their function is to produce tears which are
secreted onto the surface of the conjunctiva.

Blepharitis
• Definition: Blepharitis (blef-uh-RYE-tis) is inflammation of the eyelids.
Blepharitis usually involves the part of the eyelid where the eyelashes
grow and affects both eyelids.
• It's a common cause of sore, red eyelids and crusty eyelashes.
• Blepharitis commonly occurs when tiny oil glands located near the base
of the eyelashes become clogged. This leads to irritated and red eyes.
• Blepharitis can be anterior or posterior.
• Anterior: occurs on the outside of your eyelids where your eyelashes are
located. REASON: Dandruff on your eyebrows and allergic reactions in
your eyes can cause anterior eyelid inflammation.
• Posterior: occurs on the inner edge of eyelids closest to your eye.
REASON: A malfunctioning oil gland behind your eyelash follicles usually
causes this form of inflammation.
• Blepharitis is often a chronic condition that is difficult to treat. Blepharitis
can be uncomfortable and may be unsightly. But it usually doesn't cause
permanent damage to your eyesight, and it's not contagious

CAUSES
• Cause:
• The exact cause of blepharitis isn't clear. It may be associated with one or
more factors, including:
• Seborrheic dermatitis — dandruff of the scalp and eyebrows
• is a papulosquamous disorder patterned with red, itchy rash on sebum
rich areas of the scalp, face. Its cause is candida, cold, dry weather.
Symptoms can be: Skin flakes (dandruff) on your scalp, hair, eyebrows,
beard or mustache
• A bacterial infection (DRY EYES)
• Clogged or malfunctioning oil glands in your eyelids
• Meibomian gland dysfunction (MGD)
• cause is dysfunction of the Meibomian glands on the rim of the eyelids.
These glands produce an oily substance that prevents the eye's film of
tears from evaporating.
• Rosacea — a skin condition characterized by facial redness

CAUSES
• Allergies, including allergic reactions to eye
medications, contact lens solutions or eye
makeup
• Side effects of certain drugs like antihistamines.
• Diseases that affect your ability to make tears,
like Sjogren's syndrome, rheumatoid arthritis
• Parasites (Demodex eyelash mites)
• Fungal eyelid infection

Cause
• Dry eyes: Blepharitis and dry eyes often occur at the
same time, causing confusion whether dry eye causes
blepharitis or blepharitis causes dry eye.
• This happens so often that some researchers and eye
doctors now believe these two conditions may be part
of a single chronic eye problem called dry eye
blepharitis syndrome (DEBS).
• According to supporters of this theory, dry eye is
simply the late manifestation of blepharitis, and
treating blepharitis also will prevent, reduce or
eliminate dry eye symptoms.

Causes
• Bacterial eyelid infection
• Parasites (Demodex eyelash mites)
• Explanation: Blepharitis usually is associated with an overgrowth of
bacteria that live along the margins of the eyelids and at the base
of the eyelashes. Over time, these bacteria multiply and create a
structure called a biofilm.
• This biofilm becomes a toxic environment — like the plaque that
forms on your teeth. Parasitic eyelash mites called Demodex feed
on the biofilm, which in turn leads to an overgrowth of these mites
that causes a worsening of the eyelid inflammation.
• 2- Bacteria in the eyelid biofilm also produce substances called
exotoxins that cause inflammation of oil-secreting glands in the
eyelids called meibomian glands. This causes a condition
called meibomian gland dysfunction, which causes (and worsens)
dry eye discomfort.

• Symptoms: The most common symptoms of blepharitis are:
• Burning or stinging eyes
• Crusty (solid, dense, hard layer)debris at the base of eyelashes
• Irritated, watery eyes
• Itchy eyelids
• Grittiness
• Eyelid sticking
• More frequent blinking
• Eyelids that appear greasy
• Depending on the severity of blepharitis, you may have some or all of these
symptoms, and blepharitis symptoms may be intermittent or constant. In some
cases, blepharitis also causes loss of eyelashes (madarosis).
• Madarosis is a condition that results in the loss of eyelashes, and
sometimes eyebrows. The term "madarosis" is Greek for the word "madao"
which means "to fall off.
• A majority of patients with madarosis have leprosy

• Diagnosis: In some cases, a physical examination
of your eye is enough to diagnose the condition.
Your doctor can also closely examine your eyelids
using a specialized magnifying tool. This eye
examination checks your eyes for inflammation as
well as the presence of bacteria, fungi, or viruses,
which can indicate an infection.
• If there are symptoms of an infection, your
doctor will swab your eye and take a sample of
any fluid seeping from your eyes. This sample is
then examined under a microscope.

Diagnosis
• Slit-lamp examination:
• This is a specially developed, low-power
microscope with an intense thin-beam light
source.
• The lamp allows the doctor to look at the
outside of the eyes and the eyelids while the
patient's head is held steady by resting the
chin and forehead against supports.

• Home remedies:
• Management of blepharitis involves:
• warm compresses, to loosen crusts
• lid cleansing, to remove crusts
• massage, to express the small oil glands of the
eyelids

• Treatment: Treatment aims to relieve symptoms, but cannot cure the condition.
• Typically, blepharitis treatment includes:
• Eyelid scrubs. Gently scrubbing your eyelids removes the buildup of biofilm and
excess bacteria from your lid margins. Your eye doctor typically will recommend a
daily regimen of warm compresses and lid scrubs to clean your eyelids and reduce
the amount of bacteria and Demodex mites on your lids. Cleaning agents may
include prescription eyelid cleansers (Avenova), non-prescription eyelid cleansing
pads (Ocusoft; Systane), or diluted baby shampoo.
• Composition: moisturizer, ph stabilizer should maintain 5.5 -7.5), modified Ringer's
solution by mixing electrolytes in water.
• Medicated eye drops and/or ointments. Your doctor also may prescribe topical
medicines to destroy excess blepharitis-causing bacteria or other microbes on the
eyelids — particularly if there is a risk of eye infection or it appears you have pink
eye or some other type of eye infection as well as blepharitis.
• Composition: such as bacitracin and erythromycin
• Bacitracin= antibiotic, topically, for bacillus species.

• Procedures:
• Electrochemical lid margin debridement (BlephEx):
• BlephEx™ is a
revolutionary new
patented hand piece, used to
very precisely and
carefully, spin a medical
grade micro-sponge
along the edge of your
eyelids and lashes,
removing scurf and debris and exfoliating your eyelids.

• Thermal pulsation treatment (Lipiflow):
• Thermal pulsation (LipiFlow) consists of the localized application of
heat and therapeutic pressure on the four eyelids (upper and
lower) with the aim of improving drainage of the Meibomian
glands. These glands are responsible for providing the tears with oil
to prevent evaporation and ensure good quality.
• In which cases is it used?
• LipiFlow is used to treat Meibomian gland dysfunction, related
to blepharitis (inflammation) of the lower eyelids and ocular
dryness.
• The application of thermal pulsation takes 12 minutes and is
performed in the consulting room under topical anaesthesia
(drops) to prevent any possible discomfort for the patient.

• Intense pulse light therapy (IPL):
• IPL is that it acts like the "world's best warm
compress.“
• "When the light is absorbed by the blood
vessels, it generates heat in the dermal layer
that melts the secretions and opens the
gland.
• Artificial tears

• Complications: Eyelash problems. Blepharitis can cause your eyelashes to
fall out or grow abnormally (misdirected eyelashes).
• Eyelid skin problems. Scarring may occur on your eyelids in response to
long-term blepharitis. Or the eyelid edges may turn inward or outward.
• Excess tearing or dry eyes. Abnormal oily secretions and other debris
shed from the eyelids, such as flaking associated with dandruff, can
accumulate in your tear film — the water, oil and mucus solution that
forms tears. Abnormal tear film interferes with the healthy lubrication of
your eyelids. This can irritate your eyes and cause symptoms of dry eyes or
excess tearing.
• Difficulty wearing contact lenses. Because blepharitis can affect the
amount of lubrication in your eyes, wearing contact lenses may be
uncomfortable.
• Sty. A sty is an infection that develops near the base of the eyelashes. The
result is a painful lump on the edge (usually on the outside part) of your
eyelid. A sty is usually most visible on the surface of the eyelid.

• Chalazion. (cyst in eyelids) A chalazion occurs when
there's a blockage in one of the small oil glands at the
margin of the eyelid, just behind the eyelashes. The
gland can become infected with bacteria, which causes
a red, swollen eyelid. Unlike a sty, a chalazion tends to
be most prominent on the inside of the eyelid.
• Chronic pink eye. Blepharitis can lead to recurrent
bouts of pink eye (conjunctivitis). (If u rub)
• Injury to the cornea. Constant irritation from inflamed
eyelids or misdirected eyelashes (trichiasis) may cause
a sore (ulcer) to develop on your cornea. Insufficient
tearing could predispose you to a corneal infection.

Stye
• Definition: is a bacterial infection of an oil gland in the eyelid. This
results in a red tender bump at the edge of the eyelid.
• The outside or the inside of the eyelid can be affected.
• External styes, or those outside the eyelid, may turn yellow and
release pus.
• Internal styes that appear inside the eyelid tend to be more painful.
• In most cases, the infection is caused by
the Staphylococcus bacteria.
• Location: They are typically in the middle of the eyelid and not
painful.
• without medical intervention, If a stye persists for more than a
week or affects vision, medical attention should be sought
• Synonym: hordeolum

• Mechanism: Styes occur when a gland in or on
the eyelid becomes plugged or blocked.
• This can occur
1. if the gland's opening is obstructed by scar
tissue or a foreign substance (makeup, dust)
2. if there is thickening of the substance
produced by the gland, causing the material
to flow sluggishly (lazy) or not at all.

• Cause with respect to categories
• External hordeolum
• External styes emerge along the outer edge of the eyelid. They can
become yellow, filled with pus, and painful when touched.
• They can be caused by an infection of the following:
• Eyelash follicle: The small holes in the skin from which eyelashes
grow.
• Sebaceous (Zeis) gland: This gland is attached to the eyelash follicle
and produces sebum. Sebum helps lubricate the eyelash and stop it
from drying out.
• Apocrine (Moll) gland: This gland also helps prevent eyelashes from
drying out. It is a sweat gland that empties into the eyelash follicle.

• Internal hordeolum
• The swelling develops inside the eyelid.
Generally, an internal hordeolum is more
painful than an external one. They are also
referred to as an internal stye and are most
commonly due to an infection in the
meibomian gland. These glands are
responsible for producing a secretion which
makes up part of the film that covers the eye.

Stye
• Symptoms: a lump on the eyelid
• swelling of the eyelid
• pain
• redness
• tenderness
• crusting of the margins of the eyelids
• burning sensation
• droopiness (to hang downword) of the eyelid
• itching of the eye
• blurry vision
• discharge of mucus from the eye (due to allergen= viral/bacterial)
• light sensitivity
• tearing

• Risk factors: The following can increase the risk of developing a stye:
• using cosmetics after their use-by dates
• not removing eye makeup before going to bed
• not disinfecting contact lenses before putting them in
• changing contact lenses without washing hands thoroughly
• adolescents tend to have styes more commonly, but people of any age can
develop them
• poor nutrition (lack of diet rich in omega-3 fatty acids- improvement of
meibomian gland function )
• sleep deprivation
• If a member of the household has a stye, the other residents should not share
wash cloths or face towels to minimize cross infection.
• Sometimes a sty occurs as a complication of blepharitis, an inflammation of the
eyelids. Blepharitis is often caused by a bacterial infection, but can sometimes be a
complication of rosacea, an inflammatory skin condition that mainly affects the
skin of the face.

• Sleep deprivation and sty:
1. Lack of sleep tend to increase the retention
of blood & fluid around the eyes
2. Insomnia prevents eyes from getting needed
fluid circulation, that fluid cleanse & renews
the eye staying awake
3. Another sleep deprivation is eye
spasm(involuntary contraction of muscles)
called myokymia (eye twitching)

• Diagnosis:
• Physical examination: health care professional will
examine the lids to locate the opening of the plugged
gland. This helps to distinguish between a hordeolum
and a chalazion.
• Also, the doctor will look for signs of scar tissue,
foreign bodies, and underlying chronic meibomitis.
• In addition, the doctor will look for any signs that the
gland may have become infected. It is particularly
important to identify infection that has spread from
the gland to the eye, neighboring skin, or orbit.

• Treatment:
• Use a warm compress
• A warm compress is the most effective way to treat a
stye. The warmth helps bring the pus to the surface
and dissolve the pus and oil so the stye can drain
naturally.
• Method: Wet a clean washcloth with warm water.
Make sure the water is not too hot. Wring the cloth so
it’s damp but not dripping. Then gently place it over
your eye for about 5 to 10 minutes. Do not squeeze or
try to puncture the stye.
• You can do this 3 to 4 times each day.

• 2. Clean your eyelid with mild soap and water
• Choose a tear-free baby shampoo and mix it with a bit of warm water.
Use it to gently wipe off your eyelids using a cotton swab or clean
washcloth. You can do this every day until the stye is gone. Cleaning your
eyelids also helps prevent future styes.
• Another option is to use a saline solution. It can help promote drainage
and break down bacterial membranes
• 3. Use a warm tea bag
• Instead of using a warm cloth compress, you can use a warm tea
bag. Black tea works best because it helps reduce swelling and has some
antibacterial properties.
• Method: Boil water and drop the tea bag in a mug of it as if you were
making tea to drink. Let the tea steep for about one minute. Wait until the
tea bag cools enough to place over your eye, then keep it on your eye for
about 5 to 10 minutes. Use a separate tea bag for each eye

• 4. Take over-the-counter painkillers
• Take ibuprofen or acetaminophen (Tylenol) to ease pain
• 5. Avoid using makeup and wearing contact lenses
• Avoid using makeup if you have a stye. Makeup can irritate
the eye even more and delay the healing process. You can
also transfer bacteria to your makeup and tools and spread
the infection to your other eye.
• Wash your reusable brushes regularly. Throw out any eye
products that are over three months old.
• If you wear contact lenses, stick with glasses until your stye
heals. Bacteria from the stye can get onto the contacts and
spread the infection

• 6. Use antibiotic ointments
• stye ointments are available, To use these ointments, pull the lid of the
affected eye and apply about a quarter-inch of ointment inside the eyelid.
• Avoid using topical steroids for your stye. They may cause side effects.
Make sure that any product you use is made to be used in or on the eye.
Also, there is little evidence that antibiotic eye drops work for external
styes.
• 7. Massage the area to promote drainage
• You can massage the area in combination with the lid wipes to promote
drainage. Massage the area gently with clean hands. Once the stye drains,
keep the area clean and avoid touching your eyes. Stop if massaging hurts.
• Medical procedure: When an external stye is extremely painful, the
doctor may remove the eyelash nearest to it, and drain the pus away by
lancing it with a thin needle. This procedure should only be carried out
by a professional. If things do not improve, the patient may be referred
to a specialist, for example, an ophthalmologist.

• Preventions:
• Wash your hands with soap and water before touching
your eyes.
• Clean the eyelids with a Q-tip dipped in warm water
and mild soap or shampoo.
• Remove eye makeup every night before sleeping.
• Avoid sharing towels with someone who has a stye.
• A diet high in omega-3 fatty acids (for example, fish or
flaxseeds) and vegetables is believed to have an anti-
inflammatory effect and is associated with
improvement of meibomian gland function and better
eye health in general.

• Complications: although extremely rare, may sometimes occur.
• These can include:
• Meibomian cyst: This is a cyst of the small glands located in the eyelid.
The glands discharge a lubricant, called sebum in the edge of the eyelid. A
persistent stye on the inside of the eyelid can eventually develop into a
Meibomian cyst, or chalazion, especially if the gland is obstructed. This
type of cyst is easily and effectively treatable.
• periorbital cellulitis: This may develop if the infection spreads to the
tissue around the eye. The layers of skin around the eye become inflamed
and red, making the eyelids go red and swollen. This is treated with
antibiotics.
• If a sty becomes infected, the infection can spread to the eye
(conjunctivitis or corneal keratitis), skin (cellulitis),
• Although the complications can occur, as mentioned previously, most
cases of stye will clear with minimal intervention.

Chalazion
• Definition: chalazion is a small, usually
painless, lump or swelling that appears on
your eyelid due
to blocked
meibomian or
oil gland.

• Causes
• You have glands throughout your body. They make things that your cells, tissues,
and organs need to work properly. The meibomian glands in your upper and lower
eyelids make oil that mixes with your tears to moisten and protect your eyes. If the
oil gets too thick or if the glands are plugged because of inflammation, you may
get a chalazion.
• Sometimes an infection can cause a chalazion, though this is rare.
• A chalazion typically occurs in a person with an underlying inflammatory
condition that affects the eyes or skin.
• Some of these conditions include:
• chronic blepharitis
• acne rosacea
• seborrheic dermatitis
• Less commonly, chalazia develop due to viral conjunctivitis, which is a type of eye
infection.
• Individuals who have had a stye have an increased risk of developing chalazia in
the future.

• Symptoms: It may start with a small area that is red,
swollen, and sore or painful when touched. After a few
days the pain usually goes away and a bump or lump
remains.
• They occur more frequently on the upper lid, probably
because there are more meibomian glands in the upper
eyelid than in the lower eyelid.
• The pain frequently is more pronounced when the
chalazion first forms.
• chalazion feels firm or hard to the touch and may enlarge
to the size of a green pea. Occasionally, a chalazion is
painful, particularly if it's very inflamed or infected.

• Pathophysiology: Each of the meibomian oil glands produces oil that flows
out of the gland onto the eye's surface. There are about 40-50 meibomian
glands within the upper lid and about 25 within the lower lid. They are
actually located within the tarsal plate, which is a firm tissue located
under the skin of the lids. The oil exits from each gland through a tiny
circular opening just behind the eyelashes of the upper and lower lids of
both eyes. A chalazion is caused by the oil in the gland becoming too
thick to flow out of the gland or the opening of the gland being
obstructed. Without anywhere to go, the oil builds up inside of the eyelid
gland and forms a type of meibomian cyst. The trapped oily material can
have the texture of solid butter or even hardened wax. The gland wall
may leak, releasing the oil into the tissue of the eyelid, causing
inflammation and sometimes scar tissue.
• Alternative names for a chalazion include conjunctival granuloma, internal
hordeolum, conjunctival lipogranuloma, or meibomian gland
lipogranuloma.

• Risk factors: Risk factors for a chalazion include
• a prior history of a chalazion,
• meibomian gland dysfunction,
• blepharitis,
• acne rosacea, and
• diabetics (with or without diabetic retinopathy)
are at higher risk of developing chalazia.

• Diagnosis: There are no special tests. Your doctor
usually just checks your eyes. He’ll probably ask you
questions about your symptoms, past eye problems,
and your health history in general. You may have had
chalazia more than once.
• In most cases, a doctor can diagnose this condition by
taking a close look at the lump on your eyelid. Your
doctor will also ask about your symptoms to determine
if the lump is a chalazion, a stye, or something else.

• Treatment: Home care
• First, do not try to squeeze the chalazion. It’s best if you touch it as
little as possible.
• Instead, you should apply a warm compress to your eyelid four
times per day for about 10 minutes at a time. This can reduce the
swelling by softening the oils in the blocked gland. Make sure you
wash your hands before you touch the area.
• Your doctor may also tell you to gently massage the lump a few
times per day or to scrub your eyelid. Your doctor may also
prescribe eye drops or eyelid creams.
• If you are prone to blepharitis, instructions for routine cleaning of
your eyelids also may be given
• The most commonly prescribed oral medicines for blepharitis
and meibomian gland dysfunction are antibiotics such as
doxycycline.

• Medical procedures:
• In the case of a bothersome and persistent chalazion, your
eye doctor may recommend a simple in-office surgery to
excise it.
• Method: An eye surgeon will use local anesthesia to numb
the area before making a small incision, typically from
underneath the eyelid to clear the contents of the eyelid
bump without visible scarring.
• An alternate procedure involves injecting the chalazion
with corticosteroid to get rid of the bump on your eyelid.
A potential side effect of steroid injection is lightening of
the surrounding skin, which can be more problematic in
dark-skinned people.

Difference b/w sty and chalazion
STY
• Is usually painful lump.
• Is due to infected oil gland or
hair follicles.
• Not so
• Not so
• Location: It often appears at
the eyelid’s edge, usually
caused by an infected eyelash
root.
• sometimes affects the entire
eyelid.
CHALAZION
• Painless swelling or lump.
• Results from blocked oil
gland.
• It can develop into sty.
• It can develop after sty.
• Loction: develops farther
back on the eyelid than a
sty.
• Rarely it makes the entire
eyelid swell.

Trichiasis
• Definition: Trichiasis, a very common lid abnormality,
in which there is misdirected growth of Eyelashes with
normal lid margin position. The lashes rub against
the cornea, the conjunctiva, and the inner surface of
the eyelids. This irritates the eye.
• Your eyelashes do more than draw attention to your
beautiful peepers. They help keep gunk (dirt) out of
your eyes.
• But sometimes, they grow in the wrong direction. This
is a common condition called trichiasis. That’s when
your eyelashes turn inward. They can rub against your
eyeball and cause problems.

• Causes:
• You can get trichiasis after an eye infection (bleprharitis),
• because you’ve hurt your eye or eyelid.
• Just getting older can also cause it, because
your skin becomes less elastic as you age.
• Like other ingrown hairs Eyelashes can trapped under the
skin & grow inward.
• Autoimmune condition
• Congenital defect
• Eyelid agenesis: Eyelid agenesis is a disorder in which
typically the upper lateral eyelid is not formed during
development.

• Any condition causing scarring of the tarsal
plate and the conjunctiva can cause lash
misdirection.

• The causes can be categorized as follows:
1- Trauma:
• Eyelid injury
• Thermal burns to the face, lids
• Post-surgical changes, e.g., ectropion repair
• Ectropion: is a medical
condition in which the
lower eyelid turns outwards.
Ectropion repair:
skin grafting or eye surgeons
may tighten the tendons that
normally holds eyelid in correct position.

2- Trachoma: trachoma is an infectious disease caused by bacterium
Chlamydia trachomatis. The infection causes a roughening of the inner
surface of the eyelids. This roughening can lead to pain in the eyes,
breakdown of the outer surface or cornea of the eyes, and eventual
blindness.
• Trachoma is the leading
infectious cause of blindness
worldwide and overall is the
eighth-commonest blinding
disease. Trachomatous trichiasis Blindness from trachoma
is the result of multiple infections
with Chlamydia trachomatis resulting in chronic inflammation and
scarring of the tarsal conjunctiva, & the conditions which damages
tarsal conjunctiva are prone to trichiais.

3- Herpes zoster ophthalmicus: Herpes Zoster
Ophthalmicus (HZO), commonly known as shingles, is a
viral disease characterized by a painful skin rash in one
or more distributions
of the fifth cranial nerve,
shared by the eye and orbit.
Eyelids are commonly
involved in herpes zoster
ophthalmicus. Patients may develop blepharitis,
leading to secondary bacterial infections, scarring and
trichiasis.

4- Autoimmune diseases
• Ocular cicatricial pemphigoid:
Cicatrical=caused by a scar pemphigoid= autoimmune blistering skin
disease, ocular= eye
This is a subclass of mucous membrane pemphigoid affecting predominantly
the conjunctiva. OCP is a Type II hypersensitivity response with antibodies
binding at the basement membrane zone, leading to the activation of
complement and recruitment of inflammatory cells. The release of cytokines
causes fibroblast (play role in healing) activation with consequent
progression to scarring.
Type2– antibody binding with membrane—activation of complement—
recruitment of inflammatory cells– release cytokines—causes
fibroblast(healing process)--- scar formation.

• Ocular cicatricial pemphigoid

5- congenital disorder:
• Epiblepharon: This is congenital disorder.
Loose skin around the eye forms a fold. This
causes the lashes to
assume a vertical position.
This is mostly found in
children of Asian ancestry.

• Symptoms
• You may feel like you have something in your eye. It
might be red, sensitive to light, hurt, or tear up easily.
You may have blurred vision. Or, you might have no
symptoms.
• Eyelashes that brush up against your cornea -- the
clear, front part of your eye -- for a long time could
cause eye irritation or a more serious condition on the
surface of your eye. That can lead to infection and
scarring. It could even affect your eyesight.
• Eyelashes that rub against the cornea for a long time
can cause a corneal abrasion or even a corneal ulcer.

• Diagnosis: Diagnosis is usually clinical. Distinguish trichiasis from entropion:
Trichiasis differs from entropion in that the eyelid position is normal.
• Evaluation includes fluorescein staining to exclude corneal abrasion or ulceration.
• This is a test that uses orange dye (fluorescein) and a blue light to detect foreign
bodies in the eye. This test can also detect damage to the cornea. The cornea is
the outer surface of the eye.
• How the Test is Performed
• A piece of blotting paper containing the dye is touched to the surface of your eye.
You are asked to blink. Blinking spreads the dye and coats the tear film covering
the surface of the cornea. The tear film contains water, oil, and mucus to protect
and lubricate the eye.
• The health care provider then shines a blue light at your eye. Any problems on the
surface of the cornea will be stained by the dye and appear green under the blue
light.
• The provider can determine the location and likely cause of the cornea problem
depending on the size, location, and shape of the staining.

• Treatment:
• Trichiasis treatment involves removing the eyelash, follicle
or both, or redirecting eyelash growth.
• Sometimes trichiasis affects only a few eyelashes.
Your ophthalmologist may simply remove them with
forceps (tweezers). There is a chance the eyelashes may
grow back again in the wrong direction.
• This is the most common way to treat it. He’ll numb your
eyeball with drops and pull the lash out of its follicle. It
usually comes out easily and doesn’t hurt.
• You may need artificial teardrops for a couple of days. Your
lashes will grow back in 3 to 5 months, but there’s still a
chance they’ll come in the wrong way.

• If you have many lashes growing toward your eye, surgery can
remove them permanently.
• Other surgical treatments include:
• Electrolysis. This process uses
electricity and ultrafine needles
to permanently remove hair. While
effective, electrolysis is time-consuming
and can be painful.
• Cryosurgery. Cryotherapy is effective for segmental trichiasis. The
cryoprobe is applied to the affected segment for approximately 25
seconds, allowed to thaw, (melt) and then refrozen for 20 seconds
(double freeze-thaw technique). The lashes are then mechanically
removed with forceps.

• Caryotherapy: Cryotherapy is a pain treatment that
uses a method of localized freezing temperatures to
deaden an irritated nerve. Cryotherapy is also used as a
method of treating localized areas of some cancers
(called cryosurgery), such as prostate cancer and to
treat abnormal skin cells by dermatologists.
• In cryotherapy, a probe is inserted into the tissue next
to the affected nerve. The temperature of the probe
drops to then effectively freeze the nerve. The freezing
inactivates the nerve and, as a result, painful nerve
irritation is relieved. Cryotherapy is a relatively safe and
effective means of treating localized nerve irritation.

• Ablasion surgery: uses radiofrequencies or lasers to
remove the lashes and hair follicles. Your
ophthalmologist will numb your eye before the
outpatient procedure.
• Argon laser photocoagulation can be performed to
ablate (to remove)a few isolated lashes. In this, the
laser is fired into the depths of the eyelid, at the base
of the errant lash to burn/freeze the follicle, which is
then pulled out. Hence, this procedure works best in
pigmented individuals. Complications include mild
hypopigmentation and lid notching

Entropion
• Definition: Entropion is a medical condition in which the eyelid
folds inward so that your eyelashes and skin rub against the eye
surface. This causes irritation and discomfort.
• It usually occurs in the lower eyelid, but it can affect either.
• When you have entropion, your eyelid may be turned in all the
time or only when you blink hard or squeeze your eyelids shut
• If the condition affects both eyes, this is called bilateral entropion.
• Entropion is very rare in children and young adults, but it may
affect up to 2.1 percent of people over the age of 60 years,
according to the American Academy of Ophthalmology.

• Causes
• Muscle weakness (aging). As you age, the muscles under your eyes tend
to weaken (more loose skin around the eyelids), and the tendons stretch
out (relaxes). This is the most common cause of entropion .
• Scars or previous surgeries. Skin scarred by chemical burns, trauma or
surgery can distort the normal curve of the eyelid.
• Eye infection. a bacterial infection, such as trachoma, can cause the inner
surface of the eyelids to become rough and scarred. The infection is
uncommon in developed nations, but it affects tens of millions of people
globally.
• Inflammation. An irritation of the eye caused by dryness or inflammation
can lead you to try to relieve the symptoms by rubbing the eyelids or
squeezing them shut. This can lead to a spasm of the eyelid muscles and a
rolling of the edge of the lid inward against the cornea (spastic entropion).
• In addition, eye surgery can lead to eyelid spasms, which can cause the
eyelid to fold inward.

• Developmental complication. When
entropion is present at birth (congenital), it
may be caused by an extra fold of skin on the
eyelid that causes turned-in eyelashes.

• Symptoms:
• irritation and a feeling that something is stuck in the eye
• excessive watering of the eyes, which is called epiphora
• crusting, or mucous discharge, on the eyelid
• pain in the eye
• sensitivity to light, which is called photophobia
• sensitivity of the eye to wind
• sagging skin around the eye
• redness in the whites of the eyes
• Vision problems can also occur, especially if there is
damage to the cornea.

• Diagnosis
• A physician can usually diagnose entropion with a routine examination of the eye.
They may also pull on the eyelid and ask the person to close their eyes tightly or
blink hard. Special diagnostic tests do not tend to be necessary.
• If the condition could have resulted from scar tissue or surgical intervention, the
doctor will also check the surrounding tissue and the inside of the eyelids.
• Identifying the cause of entropion will help a doctor determine the most
effective treatment.
• Special Tests
• Horizontal lid laxity can be evaluated with the snap back test. The examiner pulls
the lower lid down and observes the lid returning to its original position without
allowing the patient to blink. Normally, the lid returns promptly without a blink,
but in cases of increased laxity(looseness) a blink may be needed to reestablish
proper position. The examiner can also pull the lower lid anteriorly away from the
globe. In involutional entropion, the lower lid can be displaced 6-15mm from the
globe, compared to only 2-3mm in a normal lid

• Types of entropion.
• Cicatricial entropion cicatricial=caused by a scar
• is caused by scarring
of the conjunctiva and
relative shortening of
the posterior(inner side)
lamella.
This is the result of
chronic
autoimmune, infectious,
inflammatory, thermal,
or traumatic insult.

• Congenital entropion is a rare
condition characterized by
1. shortened
posterior lamella (beginning
of conjunctiva & tarsus)
2- structural weakness
• of the tarsal fascia.
• An unusual form of congenital
• entropion includes a tarsal kink
• in which the upper
tarsus is bent, causing the cilia and the eyelid margin to come
in direct contact with the globe.

• Spastic entropion develops in response to
acute ocular irritation or inflammation. It
often occurs in patients with underlying
involutional (endofunction) eyelid changes
(aging) and is further exacerbated by the
corneal irritation caused by the entropion

• Treatment:
• In mild cases, eye drops or artificial tears may soothe some
symptoms.
• A person may need to use a contact lens to protect the surface of
the eye.
• Ocular lubrication and tear preparations are helpful for protecting
the ocular surface and also may break the cycle in patients with
spastic entropion due to dry eye syndrome.
• Eyelid hygiene, antibiotics, and corticosteroids are useful for the
treatment of blepharitis, which may cause spastic entropion.
• Severe entropion can cause pain and loss of vision. Significant
irritation can cause a corneal ulcer to develop, and this can become
infected.
• If the health of the eye is at risk, the doctor may recommend
surgery.

• Botox
• Injecting botox into the lower eyelid can relax(paralyze) the lid
muscles and prevent them from contracting inward.
• Small amounts of onabotulinumtoxinA (Botox) injected into the
lower eyelid can turn the eyelid out.
• This is especially effective when entropion results from spasms.
• However, the effects are temporary, lasting from 8–26 weeks, so
some people require a series of injections. People with temporary
entropion may prefer this treatment method.
• Botox-Botulinum toxin is a neurotoxic protein produced by the
bacterium Clostridium botulinum and related species. It prevents
the release of the neurotransmitter acetylcholine (muscle activator)
from axon endings at the neuromuscular junction and thus causes
flaccid paralysis

• Stiches: The surgeon will place up to three stitches
along the eyelid. These will force it to turn outward.
• Usually, the stitches are absorbable and will dissolve
or fall off in a few weeks. After the procedure, the
eyelid tends to stay in position for several months.
• A person can have the stitches at a doctor's office, with
local anesthesia, but this is a temporary solution.
• The procedure also increases the risk of bruising,
granuloma, and trichiasis, and it may not be effective in
some people.

• Other surgical options
• If entropion results from aging and the relaxation of muscles, ligaments,
or tendons, a surgeon can remove a small part of the lower eyelid. This
will tighten the tendons and muscles.
• After the procedure, the person will have some stitches on the outside
corner of the eye or just under the lower eyelid.
• If entropion develops because of scar tissue or a previous surgical
procedure, the surgeon may take some skin from behind the ear or the
upper eyelid and graft it onto the lower eyelid.(skin grafting)
• If you have scar tissue on the inside of your lid or have had trauma or
previous surgeries, your surgeon may perform a mucous membrane graft
using tissue from the roof of your mouth or nasal passages.
• Before surgery you'll receive a local anesthetic to numb your eyelid and
the area around it. You may be lightly sedated to make you more
comfortable, depending on the type of procedure you're having and
whether it's done in an outpatient surgical clinic.

• Transparent skin tape
• Sticking transparent skin tape to the eyelid can
stop it from folding inward.
• The doctor will teach the person to place one end
of the tape near the lower eyelashes and the
other end on the upper cheek.
• Soft contact lens. Your eye doctor may suggest
that you use a type of soft contact lens as a sort
of corneal bandage to help ease symptoms.
These are available with or without a refractive
prescription.

• Complications
• Entropion can cause irritation and damage the
cornea.
• It can also lead to a corneal ulcer, which can
become infected and lead to a severe loss of
vision if a person does not receive prompt
treatment.
• Entropion can cause corneal abrasions, which
can cause a person to lose the surface of the
cornea's epithelial layer.

Ectropion
• Definition: Ectropion (ek-TROH-pee-on) is when your lower eyelid
turns or sags outward,
away from your eye,
exposing the surface
of your inner eyelid.
• Ectropion is more common
in older adults, and it
generally affects only the
lower eyelid.
• In severe
ectropion, the entire length of
the eyelid is turned out.
• In less
severe ectropion, only one
segment of the eyelid sags away from the eye.

• Causes:
• Muscle weakness. As you age, the muscles under
your eyes tend to weaken, and tendons stretch
out. These muscles and tendons hold your eyelid
taut against your eye. When they weaken, your
eyelid can begin to droop.
• Facial paralysis. Certain conditions, such as Bell's
palsy, and certain types of tumors can paralyze
facial nerves and muscles. Facial paralysis that
affects eyelid muscles can lead to ectropion.

• Bell's palsy is a condition in which the muscles on
one side of your face become weak or paralyzed.
It affects
only one side of the face
at a time, causing it to
droop or become stiff on
that side. It's caused by
some kind of trauma to
the seventh cranial nerve.
This is also called the “facial nerve.”

• Scars or previous surgeries.
• Skin that has been damaged by burns or trauma, can affect the way
that your eyelid rests against your eye. Previous eyelid surgery
(blepharoplasty) can cause ectropion, particularly if a considerable
amount of skin was removed from the eyelid at the time of surgery.
• growths on the eyelid:
• Benign or cancerous growths on your eyelid can cause the lid to
turn outward.
• Genetic disorders.
• Rarely is ectropion present at birth (congenital). When it is, it's
usually associated with genetic disorders, such as Down syndrome
birth defects (due to genetic disorders such as Down syndrome)

• Down syndrome (DS), also known as trisomy 21, is a genetic
disorder
• Typically, the nucleus of each cell contains 23 pairs of
chromosomes, half of which are inherited from each parent.
• Down syndrome
occurs when an individual
has a full or partial extra
copy of chromosome 21.
It is usually associated with
physical growth delays, mild
to moderate intellectual
disability, and characteristic facial features.

• Symptoms:
• Normally when you blink, your eyelids distribute
tears evenly across your eyes, keeping the
surfaces of the eyes lubricated. These tears drain
into small openings on the inner part of your
eyelids (puncta).
• If you have ectropion, your lower lid pulls away
from your eye and tears don't drain properly into
the puncta.
• The resulting signs and symptoms can include:

• Watery eyes (excessive tearing). Without proper
drainage, your tears may pool and constantly flow over
your eyelids.
• Excessive dryness. Ectropion can cause your eyes to
feel dry, gritty and sandy.
• Irritation. Stagnant tears or dryness can irritate your
eyes, causing a burning sensation and redness in your
eyelids and the whites of your eyes.
• Sensitivity to light. Stagnant tears or dry eyes can
irritate the surface of the cornea, making you sensitive
to light.

• Risk factors:
• Age. The most common cause of ectropion is
weakening muscle tissue associated with aging.
• Previous eye surgeries. People who have had
eyelid surgery are at higher risk of developing
ectropion later.
• Previous cancer, burns or trauma. If you've had
spots of skin cancer on your face, facial burns or
trauma, you're at higher risk of developing
ectropion.

• Diagnosis:
• Ectropion can usually be diagnosed with a routine
eye exam and physically. Your doctor may pull on
your eyelids during the exam or ask you to close
your eyes forcefully. This helps him or her assess
each eyelid's muscle tone and tightness.
• If your ectropion is caused by a scar, tumor,
previous surgery or radiation, your doctor will
examine the surrounding tissue as well.

• Treatment:
• The type of surgery you have depends on the condition of the
tissue surrounding your eyelid and on the cause of your ectropion:
• Ectropion caused by muscle and ligament relaxation due to
aging. Your surgeon will likely remove a small part of your lower
eyelid at the outer edge. When the lid is stitched back together,
the tendons and muscles of the lid will be tightened, causing the
lid to rest properly on the eye. This procedure is generally relatively
simple.
• Ectropion caused by scar tissue from injury or previous
surgery. Your surgeon might need to use a skin graft, taken from
your upper eyelid or behind your ear, to help support the lower lid.
If you have facial paralysis or significant scarring, you might need a
second procedure to completely correct your ectropion.

• Lifestyle and home remedies
• These lifestyle tips may relieve your discomfort from
ectropion:
• Use eye lubricants. Artificial tears and eye ointments
can help keep your cornea lubricated and prevent
vision-threatening damage. Using an eye ointment
and wearing a moisture shield over your eye is
particularly useful overnight.
• Wipe your eyes carefully. Constantly wiping watery
eyes can make your under-eye muscles and tendons
stretch even further, worsening your ectropion. Wipe
from the outer eye up and in toward the nose.

Eyelid Tumor
• Definition: A tumor is a mass or lump of tissue
that may resemble swelling.
• a mass of abnormal tissue that arises without
obvious cause from preexisting body cells, has
no purposeful function, and is characterized
by a tendency to independent and
unrestrained (uncontrolled) growth.
• Synonym: Neoplasm

• Clinical manifestation:
• Abnormal cells—the kind that generally make up tumors—differ
from normal cells in having undergone one or more of the following
alterations:
• (1) hypertrophy Hyper= increase Trophy= suffix-growth
• an increase in the size of individual cells; this feature is
occasionally encountered in tumors but occurs commonly in other
conditions;
• (2) hyperplasia, or an increase in the number of cells within a
given zone; in some instances it may constitute the only criterion of
tumor formation;
• (3) anaplasia, Ana= backward Plasia= formation
• Loosing morphological characteristics of mature cells
• this is an almost constant feature of malignant tumors,

Tumor nomenclature
• The human body is composed of two major classes of
tissue:
1. parenchymal or epithelial tissues
2. mesenchymal tissues, comprising connective tissues,
muscle and blood vessel.
• Benign tumors of most tissues are usually simply
designated the suffix -oma.
• Malignant tumors of the parenchyma are designated the
term carcinoma,
• while malignant tumors of mesenchymal tissues are
designated the term sarcoma
• Carcinoma & sarcoma ---- Malignant

• Types of tumors
• Tumors are groups of abnormal cells that form lumps or growths. They can
start in any one of the trillions of cells in our bodies. Tumors grow and
behave differently, depending on whether they are cancerous (malignant),
non-cancerous (benign) or precancerous.
• Non-cancerous tumors/ Benign:
• Tumors that aren’t cancerous are called non-cancerous tumors. Non-
cancerous tumors:
• stay in one place and don’t spread to other parts of the body
• don’t usually come back after they are removed
• may be moved easily in the tissue
• However, they can cause pain or other problems if they press against
nerves or blood vessels or if they trigger the overproduction of hormones,
as in the endocrine system.

• All benign tumors tend to remain localized at the site of origin.
• Why they remain localized?
• tend to have a regular and smooth shape and have a covering called
a capsule
• Many benign tumors are enclosed by a capsule consisting
of connective tissue derived from the structures immediately
surrounding the tumor.
• Well-encapsulated tumors are not anchored(resides) to their
surrounding tissues. These benign tumors enlarge by a gradual
buildup, pushing aside the adjacent tissues without involving them
intimately (closely).
• Malignant tumors, by contrast, do not usually possess a capsule;
they invade the surrounding tissues, making surgical removal
more difficult or risky.

• Premalignant: In these tumors, the cells are not yet cancerous, but
they have the potential to become malignant.
• Cancerous tumors/ Malignant :
• Cancer can start in any part of the body. When cancer cells form a
lump or growth, it is called a cancerous tumor.
• A tumor is cancerous when it:
• grows into nearby tissues
• has cells that can break away and travel through the blood or
lymphatic system and spread to lymph nodes and distant parts of
the body
• Cancer that spreads from the first place it started (called the
primary tumor) to a new part of the body is called metastatic
cancer. When cancer cells spread and develop into new tumors, the
new tumors are called metastases.

• Mechanism:
• The total number of cells composing the human body is determined
not only by the rate of proliferation of cells but also by the rate of
cell loss.
• Excess cells and those that are aged or have sustained damage that
impairs normal functioning are eliminated to prevent accumulation
of abnormal numbers of cells.
• The mechanism for regulating the removal of excess and impaired
cells is known as apoptosis.
• Apoptosis: Also referred to as cell suicide or programmed cell
death, apoptosis is an orderly process during which internal cellular
structures are progressively dismantled, the impaired cell shrinks
and finally is rapidly destroyed by immune cells.

• Cause:
• In a healthy body, cells grow, divide, and replace each other in the
body. As new cells form, the old ones die.
• When a person has cancer:
• 1- new cells form when the body does not need them. If there are
too many new cells, a group of cells, or tumor, can develop.
• A neoplasm/tumor can be caused by an abnormal proliferation of
tissues, which can be caused by genetic mutations.
• a mutation occurs near or around tumor suppressor
• Tp53 gene (Tumor protein) that normally inhibits the growth of
tumors) resulting in inability to stop uncontrolled cell division.

Eyelid tumor
• Tumors of the eyelids may be benign:
• cysts (chalazion)
• inflammations (blepharitis)
• (styes)
• Tumors of the eyelids may be malignant tumors (skin cancers)
• The most common type of eyelid cancer is basal cell carcinoma.
Most basal cell carcinomas can be removed with surgery. If left
untreated, these tumors can grow around the eye ---orbit-----,
sinuses (The sinuses are a connected system of hollow cavities in
the skull ) ---- brain.
• Other eyelid cancers include squamous cell carcinoma, sebaceous
cell carcinoma, and malignant melanoma. Together, these tumors
make up the remaining 10% of eyelid malignancies.

Stye/hordeolum (BENIGN TUMOR)
• Definition: is a bacterial infection of an oil gland in the eyelid. This
results in a red tender bump at the edge of the eyelid.
• The outside or the inside of the eyelid can be affected.
• External styes, or those outside the eyelid, may turn yellow and
release pus.
• Internal styes that appear inside the eyelid tend to be more painful.
• Styes occur when a gland (miebomian gland)in or on the eyelid
becomes plugged or blocked.
• This can occur
1. if the gland's opening is obstructed by scar tissue or a foreign
substance (makeup, dust)
2. if there is thickening of the substance produced by the gland,
causing the material to flow sluggishly (lazy) or not at all

Blepharitis (benign tumor)
• Definition: Blepharitis (blef-uh-RYE-tis) is inflammation of the
eyelids. Blepharitis usually involves the part of the eyelid where
the eyelashes grow and affects both eyelids.
• It's a common cause of sore, red eyelids and crusty eyelashes.
• Blepharitis commonly occurs when tiny oil glands located near the
base of the eyelashes become clogged. This leads to irritated and
red eyes.
• Blepharitis can be anterior or posterior.
• Anterior: occurs on the outside of your eyelids where your
eyelashes are located. REASON: Dandruff on your eyebrows and
allergic reactions in your eyes can cause anterior eyelid
inflammation.
• Posterior: occurs on the inner edge of eyelids closest to your eye.
REASON: A malfunctioning oil gland behind your eyelash follicles
usually causes this form of inflammation.

Chalazion (Benign tumor)
• Definition: chalazion is a small, usually
painless, lump or swelling that appears on
your eyelid due
to blocked
meibomian or
oil gland.

Basal cell & Squamous cell carcinoma
(Malignant Tumor)
• Basal and squamous
cell skin cancers are
the most common
types of skin cancer.
• They start in the top
layer of skin
(the epidermis),
and are often related to sun exposure.

Ultraviolet rays
• Ultraviolet (UV) designates a band of
the electromagnetic
spectrum with wavelength from 10 nm to
400 nm, shorter than that of visible light but
longer than X-rays.
• Ultraviolet rays are invisible to most humans.
The lens of the human eye blocks most radiation
in the wavelength range of 300–400 nm; shorter
wavelengths are blocked by the cornea.

• The most common types of cancer occurring on the eyelid are:
• Basal cell carcinoma:
• Under the squamous
cells (flat, scale-like cells)
in the lower epidermis are
round cells known as basal
cells.
• About 80% of skin cancers
arise from this layer in skin, and
they are directly related to
exposure to the sun.
• Basal cell carcinoma is the most
common type of eyelid cancer. It usually
appears in the lower lid and occurs most
often in individuals with fair or pale skin.

• Basal cells constantly divide to form new cells to replace the
squamous cells that wear off the skin’s surface. As these cells move
up in the epidermis, they get flatter, eventually becoming
squamous cells. Skin cancers that start in the basal cell layer are
called basal cell skin cancers or basal cell carcinomas.
• Cancer starts when cells in the body begin to grow out of control.
Cells in nearly any part of the body can become cancer cells.
Location: These cancers usually develop on sun-exposed areas,
especially the face, head, and neck. They tend to grow slowly. It’s
very rare for a basal cell cancer to spread to other parts of the body.
But if it's left untreated, basal cell cancer can grow into nearby
areas and invade the bone or other tissues beneath the skin.
• Eyelids---- orbits---- sinuses------brain

• Symptoms:
• BCCs can look like open sores,
• red patches, pink growths, shiny bumps, scars
• or growths with slightly elevated, rolled edges
and/or a central indentation.(cut)
• At times, BCCs may ooze, crust, itch or bleed.
• The lesions commonly arise in sun-exposed areas
of the body.
• In patients with darker skin, about half of BCCs
are pigmented (meaning brown in color)

Squamous cell carcinoma
• Squamous cell carcinoma
• About 2 out of 10 skin cancers are squamous cell carcinomas.
• Squamous cells: These are flat cells in the upper (outer) part of the epidermis,
which are constantly shed as new ones form. When these cells grow out of control,
they can develop into squamous cell skin cancer (also called squamous cell
carcinoma).
• Location: These cancers commonly appear on areas of the body damaged by UV
rays from the sun or tanning beds OR sun-exposed areas of the body such as the
face, ears, neck, lips, and backs of the hands. They can also develop in scars or
chronic skin sores elsewhere. They sometimes start in actinic keratoses
• although they are more likely than basal cell cancers to grow into deeper layers of
skin and spread to other parts of the body. SCC is a fairly slow-growing skin cancer.
• Actinic keratosis (AK), also known as solar keratosis, is a pre-cancerous skin
condition caused by too much exposure to the sun. AKs are usually small , rough
or scaly spots that may be pink-red or flesh-colored. Usually they start on the face,
ears, backs of the hands, and arms of middle-aged or older people with fair skin,
although they can occur on other sun-exposed areas. People who have them
usually develop more than one

• Symptoms
• SCC usually begins as a dome-shaped bump or a red,
scaly patch of skin.
• It’s usually rough and
crusty, and can bleed
easily when scraped.
• Large growths may itch
or hurt.
• It may also pop through
scars or chronic skin sores.

Melanoma
• Melanocytes: These cells make the brown pigment
called melanin, which gives the skin its tan or brown
color.
• Melanin acts as the body’s natural sunscreen,
protecting the deeper layers of the skin from some of
the harmful effects of the sun. Melanoma skin cancer
starts in these cells.
• Cause: Exposure to ultraviolet (UV) rays is a major
cause for most melanomas.
• How: UV rays damage the DNA (genes) inside skin
cells. Skin cancers can begin when this damage affects
the DNA of genes that control skin cell growth.

• Diagnosis:
• Dr will ask about your medical history, your history of
severe sunburns or indoor tanning, any pain or
symptoms you're having, and when the spot first
appeared
• have a physical exam to check the size, shape, color,
and texture of the spot. The dermatologist will also
look for other spots on your body and feel your lymph
nodes to make sure they aren’t bigger or harder than
normal. If your doctor thinks a bump looks
questionable, he'll remove a sample of the spot
(a skin biopsy) to send to a lab for testing.

• Treatment:
• Squamous cell carcinoma can usually be treated with minor surgery.
doctor may choose to use any of the following techniques to remove it:
• Excision: cutting out the cancer spot and some healthy skin around it,
then stitching up the wound.
• Mohs surgery: excision and then inspecting the excised skin using a
microscope; this requires stitching up the wound.
• Precautions: not used for non-melanoma skin & less than 1cm in size.
• Lymph node surgery: remove a piece of the lymph node; uses general
anesthesia
• Dermabrasion: "sanding" your affected area of skin with a tool to make
way for a new layer
• Cryosurgery: freezing of the spot using liquid nitrogen.
• apply a cold liquid to cancerous cells. The cells are allowed to warm up
and then are frozen again. The cycle of freezing and thawing damages the
abnormal cells.

• Topical chemotherapy: a gel or cream applied to the
skin, these are Powerful drugs that attack cancer cells
throughout the body sometimes with microneedling.
• Targeted drug treatment: Newer treatments that
target specific aspects of a cancer to curb cancer
growth and spread.
• Photodynamic therapy (a photosensitizing solution
applied to your skin then activated with a light or
daylight, or sometimes with intense pulsed light.
Targets cancer cells with a special laser light.
• Solution uses: improves efficiency of procedure,
selectivity, targeted method

• Preventions/How to Protect Yourself:
• Avoid the sun during peak hours.
• Use a broad spectrum sunscreen daily, even
when it’s cloudy and raining, to exposed skin,
and reapply frequently when outside.
• Wear clothing to cover exposed areas.
• Avoid tanning beds.

Ptosis
• Definition: ptosis (TOE-sis) is when the upper eyelid droops (to
hang downward) downward, In this condition, the border of the
upper eyelid falls to a lower position than normal.
• In severe cases, the drooping eyelid can cover all or part of the
pupil and interfere with vision.
• Synonym: blepharoptosis, drooping eyelids.
• This condition is called unilateral ptosis when it affects one eye and
bilateral ptosis when it affects both eyes. (Lateral= to the side)
• Anyone can get droopy eyelids, and there aren’t substantial
differences in prevalence between men and women or between
ethnicities.
• However, it’s most common in older adults because of the natural
aging process.

• Mechanism of drooping eyelids:
• First the levator muscle is responsible for lifting the eyelid. Ptosis is the result of
dysfunctioning of one or both upper eyelid elevator muscles. These elevator
muscles are the levator palpebrae superioris
• The levator palpebrae superioris also known as elevating muscle of upper eyelid)
is the muscle in the orbit that elevates the superior (upper) eyelid.
• Levator- elevater palpebrae- eyelid superioris- higher
• Function: The levator palpebrae superioris muscle elevates and retracts (to pull
back)the upper eyelid.
• Nerve supply: The levator palpebrae superioris is a striated muscle innervated by
the superior division of the oculomotor nerve (cranial nerve III).
• Damage to this muscle or its innervation can cause ptosis, which is drooping of
the eyelid.
• Lesions in CN III can cause ptosis, because without stimulation from the
oculomotor nerve the levator palpebrae cannot oppose the force of gravity, and
the eyelid droops.

• Secondly The superior tarsal muscle, a smooth muscle, is
• 1- attached to the levator palpebrae superioris, and
• 2- inserts on the superior tarsal plate as well.
• Ptosis can
also result
from damage
to the adjoining
superior tarsal
muscle or its
sympathetic
innervation.
Such damage to the
sympathetic supply occurs
in Horner's syndrome( It is
caused by damage to the
sympathetic nerves of the face,
characterized by (constriction of the pupil), ptosis (drooping of the upper eyelid), and anhidrosis). This
condition presents as a partial ptosis.

• TYPES
• Congenital ptosis: Children born with ptosis
have what is called congenital ptosis. This can
be caused by problems with the muscle that
lifts the eyelid. The most common cause of
congenital ptosis is the levator muscle not
developing properly.

• Involutional ptosis
• Involution- complicated, to stretch an organ)
• Adults get ptosis
• 1- when the levator muscle stretches or separates
away from their eyelid. This can be caused by
aging or an eye injury. (Senile ptosis)
• 2- Sometimes ptosis happens as a side effect
after certain eye surgery. (ex- entropion)
• Rarely, diseases or tumors can affect the eyelid
muscle, causing ptosis.

• Causes:
• Some of the causes of ptosis include:
• Congenital ptosis — In this condition, an infant is born with ptosis because
of a developmental problem involving the muscle that raises the upper
eyelid (levator muscle).
• In approximately 70% of cases, the condition affects only one eye.
• If the drooping eyelid obscures part of the baby's visual fields, surgery
must be done to correct the problem early in life to prevent permanent
loss of vision.
• Aponeurotic ptosis (senile or age-related ptosis) — Aging is the most
common cause of ptosis that is not present at birth. In senile ptosis, the
long-term effects of gravity and aging cause stretching of a wide, tendon-
like tissue that helps the levator muscle lift the eyelid.
• Although both eyes usually are affected, drooping may be worse in one
eye.

• Myasthenia gravis — Ptosis can be one of the
first symptoms of myasthenia gravis, a rare
disorder that affects the ways muscles
respond to nerves. Myasthenia gravis can
cause progressive muscle weakness, not only
in the eyelids but also in the facial muscles,
arms, legs and other parts of the body.

Myasthenia gravis
• Myasthenia gravis is a chronic autoimmune neuromuscular disease that causes weakness in the
skeletal muscles, which are responsible for breathing and moving parts of the body, including the
arms and legs.
• The hallmark of myasthenia gravis is muscle weakness that worsens after periods of activity and
improves after periods of rest. Certain muscles such as those that control eye and eyelid
movement, facial expression, chewing, talking, and swallowing are often (but not always) involved
in the disorder.
• Causes: It occurs when normal communication between the nerve and muscle is interrupted at
the neuromuscular junction—the place where nerve cells connect with the muscles they control.
• Neurotransmitters are chemicals that neurons, or brain cells, use to communicate
information. Normally when electrical signals or impulses travel down a motor nerve, the nerve
endings release a neurotransmitter called acetylcholine. Acetylcholine travels from the nerve
ending and binds to acetylcholine receptors on the muscle. The binding of acetylcholine to its
receptor activates the muscle and causes a muscle contraction.
• In myasthenia gravis, antibodies (immune proteins) block, alter, or destroy the receptors for
acetylcholine at the neuromuscular junction, which prevents the muscle from contracting.
• These antibodies are produced by the body's own immune system. Myasthenia gravis is an
autoimmune disease because the immune system—which normally protects the body from
foreign organisms—mistakenly attacks itself.

• Nerve problems — Because the eye muscles are
controlled by nerves that come from the brain, conditions
that injure the brain or its cranial nerves sometimes can
cause ptosis.
• These conditions include
• stroke, brain tumor, a brain aneurysm (a grapelike swelling
on a blood vessel inside the brain), and nerve damage
related to long-term diabetes. Another cause of ptosis is
Horner's syndrome, which also can cause an abnormally
small pupil and loss of the ability to sweat — on half the
face. Local eye problems — In some cases, an eyelid droops
because of an infection or tumor of the eyelid, a tumor
inside the eye socket, or a blow to the eye.

• Symptoms:
• Doctors assess the severity of eyelid droop by taking precise
measurements of the eyelid and eye opening.
• You can screen for the problem yourself by looking straight ahead in a
mirror. As you look at your eye, a sizable part of your iris (the eye's
colored circle) should be visible above your pupil, and no part of the pupil
itself should ever be covered by the eyelid.
• If you have ptosis, the drooping eyelid narrows your eye's opening,
which makes your affected eye appear smaller than normal. You also may
lose the crease (fold of skin) that normally lies between your upper
eyelid and eyebrow.
• If ptosis covers your pupil and limits your vision, you may try to
compensate unconsciously by raising your eyebrows. This can cause
tension headaches and give your eyes an odd, surprised appearance. You
also may tilt your chin up and look down your nose as a way of seeing
out from under your eyelid's lower margin.

• If you have simple, uncomplicated ptosis, you won't
have any other symptoms. If your ptosis is caused by a
more serious medical problem, however, you may
have additional symptoms that are related to the
underlying illness. For example, myasthenia gravis may
also cause double vision, weakness in the arms or legs,
and difficulty speaking, swallowing or breathing.
Among infants with congenital ptosis, approximately
30% also have crossed eyes (strabismus) or some other
disorder that affects the eye's position or movement.
In ptosis caused by Horner's syndrome, the pupil of
the affected eye is unusually small.

• The degree of droopiness varies from one
person to the next. If you think you may have
ptosis, compare a recent photo of your face with
one from 10 or 20 years ago, and you'll likely see
a difference in the eyelid skin.
• Other symptoms include:
• migraine headaches
• aching, which can also cause you to look tired.
• you may also have extremely dry or watery eyes
(bcz eyelids are no longer functioning), and you
may notice that your face looks weary or tired.

• Diagnosis:
• Your doctor will likely perform a physical exam and ask you about your
medical history. Once you’ve explained how often your eyelids droop and
the length of time this has been happening, your doctor will run some
tests to find the cause.
• They may perform a slit lamp exam so that your doctor can take a close
look at your eye with the help of high-intensity light. Your eyes may be
dilated for this exam, so you may experience some slight eye discomfort.
• Another exam that can be used to diagnose issues such as droopy eyelid is
the Tensilon test.
• Your doctor may inject a drug called Tensilon, known generically as
edrophonium, into one of your veins. You may be asked to cross and
uncross your legs or stand up and sit down several times.
• Your doctor will monitor you to see if the Tensilon improves your muscle
strength. This will help them determine whether a condition
called myasthenia gravis is causing the droopy eyeli

• special diagnostic tests are necessary. For
example, you may need a computed
tomography (CT) scan or magnetic resonance
imaging (MRI) scan if you have signs of a
neurological problem or if your eye
examination reveals evidence of a mass or
swelling inside your eye socket.

• Treatment:
• The treatment for droopy eyelid depends on the
specific cause and the severity of the ptosis.
• If the condition is the result of age or something you
were born with, your doctor may explain that nothing
needs to be done because the condition isn’t usually
harmful to your health. However, you may opt for
plastic surgery if you want to reduce the drooping.
• If your doctor finds that your droopy eyelid is caused
by an underlying condition, you will likely be treated
for that. This should typically stop the eyelids from
sagging.

• Glasses that can hold the eyelid up, called a
ptosis crutch, are another option.
• This treatment is often most effective when
the droopy eyelid is only temporary.
• Glasses may also be
recommended if you
aren’t a good candidate
for surgery.

• Ptosis crutch
• The ptosis crutch is a nonsurgical option that involves
adding an attachment to the frames of your glasses. This
attachment, or crutch, prevents drooping by holding the
eyelid in place.
• There are two types of ptosis crutches: adjustable and
reinforced. Adjustable crutches are attached to one side of
the frames, while reinforced crutches are attached to both
sides of the frames.
• Crutches can be installed on nearly all types of eyeglasses,
but they work best on metal frames. If you’re interested in
a crutch, consult an ophthalmologist or plastic surgeon who
works with people who have ptosis.

• Surgery
• Your doctor may recommend ptosis surgery. During this
procedure, the levator muscle is tightened. This will lift the
eyelid up into the desired position.
• However, there are risks associated with surgery, including
dry eye, a scratched cornea, and a hematoma(a solid
swelling of clotted blood within the tissues.).
• Overcorrecting is also a potential complication. This leaves
the eyelid either too high or too low and requires further
surgery
• Another alternative is a “sling” operation, in which the
forehead muscles are used to elevate the eyelids.

• This surgery connects the eyelid to the brow
with a sling material and utilizes the power of
the frontalis muscle to elevate the poorly
functioning eyelid.

Ophthalmology

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