The Eye LidsThe Eye Lids

Prof. Dr. Rengin YıldırımProf. Dr. Rengin Yıldırım

Normal AnatomyNormal Anatomy

Both the upper & lower eyelids have Both the upper & lower eyelids have similar structure similar structure

They consist of an anterior lamella (skin & They consist of an anterior lamella (skin & orbicularis muscle) and a posterior lamella orbicularis muscle) and a posterior lamella (tarsal plate & conjunctiva)(tarsal plate & conjunctiva)

The orbital septum extends from the The orbital septum extends from the orbital rim and separates the preseptal orbital rim and separates the preseptal orbicularis muscle from the preaponeurotic orbicularis muscle from the preaponeurotic fat pad.fat pad.

The lid retractors lie between the The lid retractors lie between the preaponeurotic fat pad and the globe.preaponeurotic fat pad and the globe.

Lid RetractorsLid Retractors

The upper lid retractors consist of levator The upper lid retractors consist of levator palpebra superior muscle and its palpebra superior muscle and its aponeurosis and the superior tarsal aponeurosis and the superior tarsal muscle (Muller’s muscle)muscle (Muller’s muscle)

The lower lid retractors arise from the The lower lid retractors arise from the sheat of the inferior rectus muscle and are sheat of the inferior rectus muscle and are similarly composed of aponeurosis and the similarly composed of aponeurosis and the inferior tarsal muscle inferior tarsal muscle

The structure eye lid marginThe structure eye lid margin

The gray line divide s The gray line divide s eye lid margin into eye lid margin into anterior and posterior anterior and posterior partspartsEye lashes, moll & Eye lashes, moll & zeis glands orifices zeis glands orifices takes place at the takes place at the front partfront partMeibomian gland Meibomian gland orifices are placed orifices are placed behind the gray line.behind the gray line.

Disorders of the eye lashesDisorders of the eye lashes

Trichiasis:Posterior Trichiasis:Posterior misdirection of eye misdirection of eye lashes from their lashes from their normal sites of normal sites of origin.origin.

Metaplastic lashes: Metaplastic lashes: which originate which originate from the from the meibomian gland meibomian gland orificesorifices

Distichiasis in which Distichiasis in which partial or complete partial or complete second row of second row of lashes arises from lashes arises from or behind the or behind the meibomian gland meibomian gland orificesorifices

Madorosis is decrease in number or is decrease in number or complete loss of lashescomplete loss of lashes

Poliosis Premature whitening of lashes Premature whitening of lashes sometimes may involve eye browssometimes may involve eye brows

BlepharitisBlepharitis

Common bilateral symmetrical conditionCommon bilateral symmetrical condition

Anterior form is usually because of Anterior form is usually because of stayphlococcal infection in sebborrhoeic stayphlococcal infection in sebborrhoeic patientspatients

Posterior form is associated with Posterior form is associated with meibomian gland dysfunctionmeibomian gland dysfunction

(ocular rosasea)(ocular rosasea)

Anterior BlepharitisAnterior Blepharitis

Posterior BlepharitisPosterior Blepharitis

EntropionEntropion

Entropion or inversion of Entropion or inversion of the lid margin may be the lid margin may be congenital and acquired.congenital and acquired.

The acquired variety can The acquired variety can be the result of ageing be the result of ageing changes (involutional changes (involutional entropion) or the entropion) or the cicatricial changes cicatricial changes (cicatricial entropion) (cicatricial entropion)

Pathogenesis of Senile EntropionPathogenesis of Senile Entropion

1.1. Horizontal Lid Laxity Horizontal Lid Laxity as well as medial as well as medial and lateral tendon laxityand lateral tendon laxity

2.2. OverridingOverriding of preseptal orbicularis over of preseptal orbicularis over pretarsal orbicularispretarsal orbicularis

3.3. Lower lid retractor weakness Lower lid retractor weakness which is which is recognized clinically by decreased recognized clinically by decreased excursion of the lower lid in downgaze.excursion of the lower lid in downgaze.

Cicatricial entropion can effect either the Cicatricial entropion can effect either the upper and the lower lid. upper and the lower lid.

Common causes include trachoma, acid Common causes include trachoma, acid and alkali burns and chronic conjunctival and alkali burns and chronic conjunctival inflammations such as ocular pemphigoid.inflammations such as ocular pemphigoid.

EctropionEctropion

Ectropion or the eversion of the lid margin Ectropion or the eversion of the lid margin can be congenital and acquired.can be congenital and acquired.

The acquired forms are the result of either The acquired forms are the result of either ageing changes (involutional ectropion), or ageing changes (involutional ectropion), or mechanical reasons (caused by tumors) or mechanical reasons (caused by tumors) or the scarring of the anterior lamella the scarring of the anterior lamella (cicatricial ectropion) or weakness of the (cicatricial ectropion) or weakness of the orbicularis muscle (paralytic ectropion) orbicularis muscle (paralytic ectropion)

Ptosis: Ptosis: Abnormally low position (drooping) of the Abnormally low position (drooping) of the

upper lid.upper lid.

Neurogenic Neurogenic Third nerve palsyThird nerve palsy Horner syndromeHorner syndrome Marcus Gun jaw-winking syndromeMarcus Gun jaw-winking syndrome Third nerve misdirectionThird nerve misdirection

PtosisPtosis

MyogenicMyogenic Myastenia gravisMyastenia gravis Myotonic dystophyMyotonic dystophy Ocular myopathyOcular myopathy Simple congenitalSimple congenital Blepharophimosis syndromeBlepharophimosis syndrome

PtosisPtosis

MechanicalMechanical

AponureticAponuretic InvolutionalInvolutional PostoperativePostoperative

Blepharophimosis Syndrome:Blepharophimosis Syndrome: Telecanthus, epicanthus inversus,bilateral Telecanthus, epicanthus inversus,bilateral

ptosisptosis

Simple Congenital PtosisSimple Congenital Ptosis

This is caused by a developmental dystrophy of This is caused by a developmental dystrophy of the levator muscle.the levator muscle.It can be bilateral or unilateralIt can be bilateral or unilateralIn down gaze the ptotic eye lid is slightly higher In down gaze the ptotic eye lid is slightly higher then the normal eye lid as a result of poor then the normal eye lid as a result of poor relaxationrelaxationFrequently there is absence of the upper eye lid Frequently there is absence of the upper eye lid creasecreaseUsually levator function is poorUsually levator function is poorSometimes weakness of the superior rectus Sometimes weakness of the superior rectus muscle may accompanymuscle may accompany

Simple Congenital PtosisSimple Congenital Ptosis

Marcus Gunn Jaw-winking:Marcus Gunn Jaw-winking: A retraction of the ptotic lid in A retraction of the ptotic lid in conjunction with stimulation of the ipsilateral pterygoid muscleconjunction with stimulation of the ipsilateral pterygoid muscle

Third nerve misdirectionThird nerve misdirection: Bizarre : Bizarre movements of the upper lid which movements of the upper lid which

accompany various eye movementsaccompany various eye movements

Evaluation of the patient with ptosisEvaluation of the patient with ptosis

Margin-reflex distance : This is the Margin-reflex distance : This is the distance between the upper lid margin and distance between the upper lid margin and the light reflex in pupil is normally 4-the light reflex in pupil is normally 4-4.5mm. If this distance decrases then 4.5mm. If this distance decrases then there is ptosis.there is ptosis.

Evaluation of the patient with ptosisEvaluation of the patient with ptosis

Vertical fissure height: This is the distance Vertical fissure height: This is the distance between upper and lower eye lids between upper and lower eye lids margins. Normally upper eye lid margin margins. Normally upper eye lid margin rests 2 mm below the upper limbus, and rests 2 mm below the upper limbus, and lower eye lid margin rests 1 mm above the lower eye lid margin rests 1 mm above the lower limbus. VFH is 9mm in males and lower limbus. VFH is 9mm in males and 11mm in females. 11mm in females.

Evaluation of the patient with ptosisEvaluation of the patient with ptosis

Levator Function can be assesed by the upper Levator Function can be assesed by the upper the lid excursion. It is measured after eliminating the lid excursion. It is measured after eliminating frontalis muscle function by pressing above the frontalis muscle function by pressing above the eye brow and ask the patient to look down, and eye brow and ask the patient to look down, and up. The amount of excursion is measured with a up. The amount of excursion is measured with a ruler.ruler.Normal:15mm or moreNormal:15mm or moreGood: 12mm Good: 12mm Fair:5-11mmFair:5-11mmPoor:4mm or lessPoor:4mm or less

Treatment of ptosisTreatment of ptosis

Congenital ptosis in which levator Congenital ptosis in which levator function is poor,function is poor,

1.1. Levator resection is the most chosen Levator resection is the most chosen operationoperation

2.2. Other procedures: Other procedures: Frontalis Brow SuspensionFrontalis Brow Suspension

Treatment of ptosisTreatment of ptosis

Involutional and aponeurotic ptosis: In this Involutional and aponeurotic ptosis: In this condition levator function is mostly good condition levator function is mostly good and the pathology is the detachment of the and the pathology is the detachment of the levator muscle from the upper border of levator muscle from the upper border of the tarsus so we just attach the levator the tarsus so we just attach the levator back to the upper tarsal border.back to the upper tarsal border.

DermatochalasisDermatochalasis

It is very common in It is very common in elderly,elderly,

The eye lids have The eye lids have baggy appearance baggy appearance with indistint lid with indistint lid creases.creases.

Treatment is Treatment is blepharoplastyblepharoplasty

Lid RetractionLid Retraction

This condition is This condition is suspected when the suspected when the upper lid margin is upper lid margin is above the superior above the superior limbus.limbus.

It is most commonly It is most commonly seen in thyroid eye seen in thyroid eye diseasedisease

Epicanthal foldsEpicanthal folds

These are very These are very common,common,

Bilateral vertical skin Bilateral vertical skin folds that overhangs folds that overhangs from the upper or from the upper or lower lid towards the lower lid towards the medial canthus.medial canthus.

They may give rise to They may give rise to a pseudo-esotropia.a pseudo-esotropia.

TelecanthusTelecanthus

This is an uncommon This is an uncommon condition.condition.

There is increased There is increased distance between the distance between the medial canthi as a result medial canthi as a result of abnormally long medial of abnormally long medial tendons.tendons.

It should not be confused It should not be confused with hypertelorism in with hypertelorism in which there is wide which there is wide separation of the orbits.separation of the orbits.

ColobomaColoboma

This is uncommon This is uncommon congenital partial or full-congenital partial or full-thickness eye lid defect.thickness eye lid defect.

The upper lid coloboma is The upper lid coloboma is not associated with not associated with systemic anomaliessystemic anomalies

The lower lid coloboma is The lower lid coloboma is frequently associated with frequently associated with systemic anomalies such systemic anomalies such as Treacher Collins Syn.as Treacher Collins Syn.

Strawberry NaevusStrawberry Naevus(Capillary Haemangioma)(Capillary Haemangioma)

Unilateral, red, raised Unilateral, red, raised lesionlesionMost common during Most common during first year of lifefirst year of lifeResolves Resolves spontaneously by the spontaneously by the age 4-7age 4-7Steroid injections can Steroid injections can be given for vision be given for vision threatening casesthreatening cases

Pyogenic GranulomaPyogenic Granuloma

Fast growing Fast growing granulamatous granulamatous hemangioma hemangioma which is usually which is usually after surgery or after surgery or traumatrauma

KeratoacanthomaKeratoacanthoma

Uncommon benign Uncommon benign but rapidly growing but rapidly growing tumourtumour

Most common in Most common in immunsuppressive immunsuppressive patientspatients

Solar (Actinic ) KertosisSolar (Actinic ) Kertosis

Most common pre-Most common pre-malign skin lesionmalign skin lesion

Basal Cell CarcinomaBasal Cell Carcinoma

Most comman human Most comman human malignancymalignancy

90% cases occur in 90% cases occur in head and neck, 10% head and neck, 10% of these involve eye of these involve eye lid.lid.

Slow groving, locally Slow groving, locally invasive but non invasive but non metastasizingmetastasizing

Squamoous cell carcinomaSquamoous cell carcinomaIt accounts for 5-10 It accounts for 5-10 % of eye lid % of eye lid malignanciesmalignancies

Potentially more Potentially more aggressive tumour aggressive tumour than BCCthan BCCThere are 3 main clinical types There are 3 main clinical types

1.1. Plaque likePlaque like

2.2. NodularNodular

3.3. UlceratingUlcerating