ANATOMY OF THE EYELIDS

EYELIDS acts as SHUTTER (protect the eye from injurious excessive light) Surface : Anterior surface = skin (cutaneous) Posterior surface = mucous Upper Eyelid Lower Eyelid - covers 1-2mm from the upper part of the cornea - just below the cornea meet in the medial and lateral angles or canthi of the eye

PALPEBRAL FISSURE & LID MARGIN

Lateral Canthus acute 60 when eye opens

Medial Canthus rounded surrounds lacus lacrimalis (tear lake)

= opening of the lacrimal papilla for lacrimal passage - at the junction of medial 1/6 & lateral 5/6 of lid margin - divides the lid margin into ciliary + lacrimal protions

Layers of The Eyelid :D

1. SKIN - thinnest skin in the body - most prominent transverse crease : lies 4-8mm above upper lid margin represents the cutaneous insertion of levator aponeurosis 2. SUBCUTANEOUS AREOLAR TISSUE - loose CT with NO fat extravasation of blood & edematous swelling 3.MUSCLE LAYER Orbicularis Oculi - orbital part - pelpebral part preseptal segment pretarsal segment muscle of Riolan Levator Palpebrae Mullers muscle Retractors of lower lid

Facial nerve (CN7) -----------------------------------------------

close the eye forcibly reflex blinking

-------------------Oculomotor nerve (CN3) Autonomic sympathetic nerve

closely keeps the lid apposition with the globe*paralysis epiphora sustain elevation of upper lid give vertical stability to the lid

4. SUBMUSCULAR AREOLAR TISSUE - between orbicularis muscle & tarsal plate - contains peripheral arterial arcade & main sensory nerves of the lid 5. FIBROUS LAYER i) TARSAL PLATE = dense fibrous tissue forming skeleton of the eyelid - fuse with orbicularis muscle (medially & laterally) forming medial & lateral canthal tendons - contains Meibomian (tarsal) glands secreting oily secretion (sebaceous gland) prevent overflow of tears over the skin & leaves an oily film over the moistened cornea to retard evaporation of tears ii) ORBITAL SEPTUM - arise from the periosteum of orbital rim - attaches to the levator aponeurosis (in upper lid) + lower tarsal border (in lower lid) - acts as DIAPHRAGM keeping fat within the orbit 6. PALPEBRAL CONJUNCTIVA - firmly adherent to the tarsus

DISEASE OF THE EYELIDS

Inflammation of the eyelid Hordeolum Externum (stye) Localized acute suppurative inflammation of the follicle of an eyelash or associated gland of Zeiss Staphylococcus Aureus Hordeolum Internum Acute infection of Meibomeian gland Chalozion Chronic inflammatory granuloma of one of the Meibomian gland in adults

Blepharitis = inflammation of eyelid margin including eyelash & associated glands

Posterior Blepharitis Meibomian Gland Dysfunction - Keratinization of the ductal epithelium & meibomian gland orifices plugging with desquamated epithelium the glands become dilated & cystic with variation in the oil composition of meibomian secretion. - microbial lipases as P.acne produce irritating fatty acids that alter tear film stability

Anterior Blepharitis (anterior to grey line) Staphylococcal Blepharitis Seborrhoeic Blepharitis in children who suffer from dandruff of the scalp * metabolic disorder! * ass with seborrhoea S. aureus & S. epidermidis. Others : Gram -ve bacteria, mites, yeasts excess secretion of lipids by Zeis glands

Etiology

Staphylococcus Aureus

Retention of its secretion

C/P Sympt oms

- fullness/heaviness - heat - acute sharp pain dull throbbing pain (pus) - edema - red indurated area - hyperaemic,tense & tender skin Usually associated with blepharitis, acne vulganis & local infection 1.Antistaphylococcal antibiotic (vancomycin, cloxa, genta) 2. Hot compression 3. Incision, drainage 4. Supportive

Signs

More violent & prolonged than stye *larger tarsal & embedded in dense fibrous tissue - yellow spot through the conjunctiva

- Circumscribed painless swelling - Disfigurement

- firm/hard swelling (adherent to tarsus but not to underlying skin - conjunctiva : red/ grey(granulation tissue)/yellow(pus) *may be multiple

- Burning - Itching eye strain - Photophobia - F.B. sensation *symptoms are worse in the morning -anterior lid margin : red, thickened, dry, ulcerated -lashes : matted together in tufts -scales : brittle, crusting, colarettes - hair follicles : pitted/ulcerated 1. Lid hygiene 2. Topical antibiotic (erythromycin) 3. Systemic antibiotic 4. Artificial tears 5. Topical steroids Chronic complications: - Madarosis - Trichiasis - Eczema - SPK - Chronic Conjunctivitis - Recurrent stye

- itching - irritation - watering

- lid margin : greasy - underlying skin : hyperemic but NO ulcerations - scales :grayish, seen among the lashes

Treatm ent

1. systemic antibiotic 2. Incision *from conjunctival side!

Small

Large

2ry Recur

- Left alone, or - Intralesional injection of triamcinolone acetonide conjunctival incision & curettage of granulation tissue pus evacuation *NO curettage suspect Meibomian Ca.

- Lid hygiene : cleaning the lid margin with diluted solution of baby shampoo or 3% Na bicarbonate lotion -Treating associated scalp seborrhea by anti-dandruff shampoo

- chronic posterior lid margin: spotty hyperemic areas - telangiectasia - pouting of Meibomian gland orifice - thick yellowish expressible oil - foam in canthi - scales: fine, grey, bran-like, loosely attached 1. Eyelid hygiene 2. Massage & expression of Meibomian gland 3. Topical steroid (chronic case) 4. Oral tetracycline & doxycycline Complications : - blepharitis, chronic conjunctivitis, marginal keratitis, recurrent chalazia

BLEPHAROPTOSIS = drooping of the upper eyelid below its normal position covering more than 2mm of superior limbus in primary position PSEUDOPTOSIS : apparent drooping of upper eyelid, often seen in: - lack of lid support by the globe (enophthalmos) - redundancy of the lid (dermatochalasis) - hypotropia CONGENITAL levator muscle fibers replaced by fibrous /adipose tissue diminished contraction & relaxation PARALYTIC destructive lesion of oculomotor nerve, nucleus or supranuclear connection SYMPATHETIC lesions of sympathetic supply of Mullers muscle MYOGENIC disease of the levator muscle APONEUROTIC defect in levator aponeurosis function, may be: - localized dehiscence - disinsertion - generalized stretching - high/absent upper lid crease - good levator fx - thinning of eyelid above tarsal plate MECHANICAL weight of lid from inflammatory infiltration (trachoma, edema, spring catarrh ,tumor) TRAUMATIC direct injury to muscle, aponeurosis or its nerve supply

cause

- lid is smooth & unwrinkled - tarsal fold is lost dt absent pull of the levator

associated *may be with - defective sup rectus motility - Marcus Gunn & blepharophimosis syndrome Rx 1. good levator fx levator resection 2. absent levator fx frontalis sling

common causes: - diabetic neuropathy - injuries, toxins, inflammation, aneurysms, neoplasms -usually associated with paralysis of the EOM supplied by CN3 - may be isolated in supranuclear lesion

*destruction of cholinesterase receptor

Horners syndrome - unilateral ptosis - miosis - anhydrosis

Myasthenia gravis - bilateral asymmetric ptosis - convergence deficiency - diplopia (50% cases) anti-cholinesterase - prostigmine

common cause: - degeneration (senile proptosis) - follows cataract & RD surgery 2ry to manipulation of eyelid/superior rectus treat cause of heaviness

ANOMALIES OF THE EYELID

TRICHIASIS = Backward direction of the eyelashes, rubbing against the ocular surface Causes: - Isolated due to scarring of the eyelid margin. - Associated with entropion. - Distichiasis ENTROPION Rolling in of the lid margin Types: - congenital (LL) - spastic (LL) - senile (LL) - cicatricial (only one in both LL & UL) ECTROPION Rolling out of the lid margin Sequelae: Epiphora, lagophthalmos, chronic conjunctivitis Types: - congenital - mechanical - spastic - senile - cicatricial

C/P

Irritation, F.B. sensation, lacrimation,pain, blepharospasm

compl. Recurrent ulcers, scarring, vascularization

Irritation, pain, congestion, lacrimation, photophobia Corneal erosion/ulcer/nebular/vascularisation

Entro. cause

CONGENITAL

SPASTIC occurs equally in children & adults in prolonged blepahrospasm, as in: - chronic conjunctivitis, corneal disease or after ocular surgery (bandaging) in predisposing structural changes (enophthalmos) only in the LOWER lid *irritation from inturned lash increases spasm spasm disappears with ceasation of spasm Remove the cause - remove bandage - treat chronic conjunctivitis or keratitis - wear CL to protect cornea Pulling LL down with adhesive plaster

C/P

SENILE (INVOLUNTIONAL) elderly pt (70-75 y/o) normal orbicularis tone, but maybe dt - vertical lid laxity - horizontal lid laxity. - degeneration of the submuscular CT - enophthalmos only affects LOWER lid

CICATRICIAL commonest type in Egypt (trachoma) follows scarring of palpebral conjunctiva, which may be dt : - trachoma - chemical burns - membranous conjunctivitis Only type that can occur in the UL - shortening of the posterior lamella

Rx

- Transverse blepharotomy (Wies) . - Tucking of LL retractors (Jones). - Horizontal shortening (LTS).

- Snellens operation - Webster operation

Ectro C/P

MECHANICAL

cause

pushing of the lids from behind without the occurrence of blepharospam - conjunctival hypertrophy - swelling/tumor of tarsus - buphthalmos/proptosis removal of cause

PARALYTIC/ SPASTIC - incomplete blinking - lacrimation - lagophthalmos + affection of other facial muscles CN 7 palsy

SENILE - in old age only in LOWER lid - eversion of punctum epiphora constant wiping of tears (aggravating) - horizontal lid margin laxity - MCT laxity - punctual eversion - favoured by hypertophic conjunctivitis

CICATRICIAL

Rx

*aims to prevent exposure of cornea - Temporary measures (artificial tear, ointment) - Surgery : tarsorrhaphy, horizontal tightening, silicone sling, temporalis flap

- Horizontal laxity : shortening of the lid, modified Kuhnt-Szymanowski operation. - Punctal eversion : Ziegler cautery, excision of a diamond piece of tarsus & conjunctiva. - MCT laxity: tucking

- Burns - Skin disease : scleroderma, fungal, tumors, - Lupus vulgaris, fistula of nasal sinuses. - Eczema. - Postoperative or trauma. - Local plastic procedure release tension of linear scar - Skin graft