EYELID

Blok Organ Indra

Dr ARTATI SRI REDJEKI Sp.M
Eyelid Anatomy
 Orbicularis muscle N VII
 Levator palpebra N III
 Eyelid Glands : Meibomian, Moll, Zeis,
Krause & Wolfring
Eyelid Inflamation & Infection
 Hordeolum : - Internum
- Externum
 Chalazion
 Blepharitis : - Squamosa
- Ulcerosa
 BLEPHARITIS
SQUAMOSA

HERPES
ZOSTER

DERMATITIS
ALERGY
Hordeolum

HORDEOLUM

CHALAZION

GRANULOMA
Deformitas of the eyelid
 Coloboma palpebra
 Epicanthus
 Blepharochalasis
 Enteropion involutional,cicatrical,congenital
 Ecteropion + paralytic orbicularis occuli
 Blepharoptosis : neurogenic ;myogenic &
mechanical
Tumors of the eyelid
 Benign Tumors
 Nevus
 Papiloma squamosa & Keratosis sebhoroic
 Capillary haemangioma
 Xanthelasma
 Molluscum contagiosum
 Malignant tumors
 Basal cell carcinoma
 Squamous cell carcinoma
 Meibomian gland carcinoma
 Melanoma
 Kaposi sarcoma
XANTHELASMA

NEVUS

BASAL CELL
CARSINOMA
Basal cell carcinoma
 Most common human malignancy
 Usuallyt affects the elderly
 Slowly growing, locally invasive
 90 % occur on head and neck
 Of these 10% involve eyelids
 Accounts for 90% of eyelid malignancies
Treatment options
 Surgical excision
 Radiotherapy
 Cryotherapy
Lacrimal Apparatus
 Pars Secretorius & excretorius
 Inflamation, Dacryoadenitis, Dacryocystitis
 Obstruction naso lacrimal duct
 Punctal & canalicular stenosis.
 Tumors Benign , Mikulisz’s syndrom
 Malignancy Adeno ca
 Therapy
 Eyelid Anatomy
 Eyelid  covered eye
 Superior & inferior:
 Skin & subcutaneus tissue
 Muscle of protraction
 Orbital septum
 Orbital fat
 Muscle of retraction
 Tarsus
 Conjunctiva
Signs of chalazion (meibomian cyst)

Painless, roundish, firm lesion May rupture through conjunctiva

within tarsal plate and cause granuloma
Signs of chalazion (meibomian cyst)

Painless, roundish, firm lesion May rupture through conjunctiva

within tarsal plate and cause granuloma
 Histology of chalazion

Multiple, round spaces previously Epithelioid Multinucleated

containing fat with surrounding cells giant cells
granulomatous inflammation
 Treatment of chalazion

Injection of local anaesthetic Insertion of clamp Incision and curettage

 Acute hordeola
Internal hordeolum External hordeolum (stye)
( acute chalazion )

• Staph. abscess of meibomian • Staph. abscess of lash follicle and

glands associated gland of Zeis or Moll
• Tender swelling within tarsal plate • Tender swelling at lid margin
• May discharge through skin • May discharge through skin
or conjunctiva
 Molluscum contagiosum
Signs Complications

• Painless, waxy, umbilicated nodule • Chronic follicular conjunctivitis

• May be multiple in AIDS patients • Occasionally superficial keratitis
 Xanthelasma

• Common in elderly or those with

hypercholesterolaemia
• Yellowish, subcutaneous plaques
containing cholesterol and lipid
• Usually bilateral and located medially
 Eyelid cysts
Eccrine sweat gland
Cyst of Moll hidrocystoma

• Translucent • Similar to cyst of Moll

• On anterior lid • Not confined to lid
margin margin
Cyst of Zeis Sebaceous cyst

• Opaque • Cheesy contents

• On anterior lid • Frequently at
margin inner canthus
Viral wart (squamous cell papilloma)
• Most common benign lid tumour
• Raspberry-like surface

Pedunculated Sessile
 Keratoses
Seborrhoeic Actinic

• Common in elderly • Affects elderly, fair-skinned individuals

• Discrete, greasy, brown lesion • Most common pre-malignant skin lesion
• Friable verrucous surface • Rare on eyelids
• Flat ‘stuck-on’ appearance • Flat, scaly, hyperkeratotic lesion
 Naevi
• Appearance and classification determined by location within skin
• Tend to become more pigmented at puberty

Intradermal Junctional Compound

• Elevated • Flat, well-circumscribed • Has both intradermal

and junctional
• May be non-pigmented • Pigmented components
• No malignant potential • Low malignant potential
 Capillary haemangioma

• Rare tumour which presents soon after birth• May be associated with intraorbital
extension
• Starts as small, red lesion, most frequently
on upper lid • Grows quickly during first year

• Blanches with pressure and swells on crying • Begins to involute spontaneously

during second year
Periocular haemangioma

Treatment options
• Steroid injection in
most cases
• Surgical resection in
selected cases
Occasional systemic
associations
• High-out heart failure
• Kasabach-Merritt syndrome -
thrombocytopenia, anaemia
and reduced coagulant factors
• Maffuci syndrome - skin
haemangiomas,
endrochondromas and
bowing of long bones
Port-wine stain (naevus flammeus)

• Rare, congenital subcutaneous lesion

• Segmental and usually unilateral

• Does not blanch with pressure

Associations
• Ipsilateral glaucoma in 30%

• Sturge-Weber or
Klippel-Trenaunay-Weber
syndrome in 5%
 Progression of port-wine stain

Initially red and flat Subsequent darkening Skin becomes coarse,

and hypertrophy of skin nodular and friable
 Pyogenic granuloma Cutaneous horn

• Usually antedated by surgery or trauma

• Uncommon, horn-like lesion protruding
• Fast-growing pinkish, pedunculated or through skin
sessile mass • May be associated with underlying actinic
• Bleeds easily keratosis or squamous cell carcinoma
Frequency of location of basal cell carcinoma

Lower lid - 70% Medial canthus - 15%

Upper lid - 10% Lateral canthus - 5%

 Squamous cell carcinoma
• Less common but more aggressive than BCC
• May arise de novo or from actinic keratosis
• Predilection for lower lid
Nodular Ulcerative

• Hard, hyperkeratotic nodule • Red base

• May develop crusting fissures • Borders sharply defined, indurated
• No surface vascularization and elevated
Meibomian gland carcinoma
• Very rare aggressive tumour with 10% mortality
• Predilection for upper lid
Nodular

Hard nodule; may Very large tumour

mimic a chalazion
Spreading

Diffuse thickening of lid Conjunctival invasion; may

margin and loss of lashes mimic chronic conjunctivitis
 Melanoma
Nodular Superficial spreading From lentigo maligna
(Hutchinson freckle)

• Blue-black nodule with • Plaque with irregular •Affects elderly

normal surrounding skin outline • Slowly expanding
• May be non-pigmented • Variable pigmentation pigmented macule
 Kaposi sarcoma
• Vascular tumour occurring in patients with AIDS
• Usually associated with advanced disease
• Very sensitive to radiotherapy

Early Advanced

Pink, red-violet lesion May ulcerate and bleed

 Lower eyelid reconstruction
following tumour excision
a b

Direct closure of small defect

b b

Tenzel flap for Mustarde cheek rotation

moderate defect flap for large defect
 Involutional

• Affects lower lid of elderly patients

• May cause chronic conjunctival inflammation

and thickening
 Preoperative assessment

Postition of maximal ectropion Horizontal lid laxity

Medial canthal tendon laxity Lateral canthal tendon laxity

Treatment of medial ectropion

Mild Medial conjunctivoplasty

a b

Severe Lazy-T procedure

 Treatment of extensive ectropion
a b

Without marked excess skin Horizontal lid shortening

a b

With marked excess skin Kuhnt-Szymanowski procedure

 Causes of cicatricial ectropion
• Contracture of skin pulling lid away from globe
• Unilateral or bilateral, depending on cause

Unilateral ectropion due to Bilateral ectropion due to severe

traumatic scarring dermatitis
 Treatment of cicatricial ectropion
Method depends on severity

Mild localized cases are treated Severe cases require transposition flaps
by excision of scar tissue or free skin grafts
combined with ‘Z’-plasty
 Mechanical ectropion
Mechanical lid eversion by tumour

Treatment
• Removal of the cause, if possible
• Correction of significant horizontal lid laxity
 Involutional entropion

Affects lower lid because upper lid If longstanding may result in corneal
has wider tarsus and is more stable ulceration
 Pathogenesis of involutional entropion

• Horizontal lid laxity • Overriding of preseptal over

pretarsal orbicularis during lid
• Canthal tendon laxity closure
• Weakness of lower lid retractors
 Treatment options for involutional entropion

· Transverse everting · Weis procedure · Jones procedure

sutures (temporary) (permanent) (for recurrences)
 Cicatricial entropion

• Severe scarring of palpebral conjunctiva

which pulls lid margin towards globe
• May affect lower or upper eyelid
• Causes include cicatrizing conjunctivitis,
trachoma and chemical burns
Treatment options for cicatricial entropion
• Corneal protection from lashes by epilation or contact lenses
• Mucous membrane grafts to replace contracted conjunctival
tissue for severe cases

Tarsal fracture procedure for mild cases

 Congenital entropion

• Very rare - not to be confused with epiblepharon

• Inturning of entire lower eyelid and lashes
• Absence of lower lid crease
• When skin is pulled down lid also pulls away from globe
• Does not resolve spontaneously
CLASSIFICATION OF PTOSIS
1. Neurogenic
• Third nerve palsy
• Third nerve misdirection
• Horner syndrome
• Marcus Gunn jaw-winking syndrome
2. Myogenic
• Myasthenia gravis
• Myotonic dystrophy
• Ocular myopathies
• Simple congenital
• Blepharophimosis syndrome
3. Aponeurotic
4. Mechanical
 Causes of pseudoptosis

Lack of lid support Contralateral lid retraction

Ipsilateral hypotropia Brow ptosis - excessive Dermatochalasis - excessive

eyebrow skin eyelid skin
Marginal reflex distance
• Distance between upper lid
margin and light reflex (MRD)

• Mild ptosis (2 mm of droop)

• Moderate ptosis (3 mm)

• Severe ptosis (4 mm or more)

Upper lid excursion

• Reflects levator function

• Normal (15 mm or more)

• Good (12 mm or more)

• Fair (5-11 mm)

• Poor (4 mm or less)
 Upper lid crease Pretarsal show

crease fold

• Distance between lid margin and lid • Distance between lash line and skin fold
crease in down-gaze in primary position of gaze
• Normals - females 10 mm; males 8 mm
• Absence in congenital ptosis indicates
poor levator function
• High crease suggests an aponeurotic
defect
 Bell’s phenomenon
Upward rotation of globe on lid closure

Good Poor - risk of postoperative

corneal exposure
Marcus Gunn jaw-winking syndrome
• Accounts for about 5% of all cases of congenital ptosis
• Retraction or ‘wink’ of ptotic lid in conjunction with
stimulation of ipsilateral pterygoid muscles

Opening of mouth Contralateral movement of jaw

 Simple congenital ptosis
• Developmental dystrophy of levator muscle
• Occasionally associated with weakness of superior rectus

Unilateral or bilateral ptosis of varying In downgaze ptotic eyelid is slightly

severity higher

Frequent absence of upper lid crease Usually poor levator function

Blepharophimosis syndrome

• Rare congenital disorder

• Dominant inheritance

•Moderate to severe symmetrical ptosis

• Short horizontal palpebral aperture
• Telecanthus (lateral displacement
of medial canthus)
• Epicanthus inversus (lower lid
fold larger than upper)
• Lateral inferior ectropion

• Poorly developed nasal bridge

and hypoplasia of superior orbital
rims
 Aponeurotic ptosis
• Weakness of levator aponeurosis
• Causes - involutional, postoperative and blepharochalasis

Mild

High upper lid crease Good levator function

Severe

Absent upper lid crease Deep sulcus

 Mechanical ptosis
Causes

Dermatochalasis Large tumours

Severe lid oedema Anterior orbital lesions