2. The eyelids
• Mobile structures placed in front
of eyeballs.
• Protect eyes
• Spread tear film
• Help in tear drainage by lacrimal
pump system
2
3. Structure of eyelids
• The skin- elastic and thin
• Subcutaneous areolar tissue-
very loose,
does not contain any
fat.
• Striated muscle layer-
orbicularis oculi
-- orbital, palpebral
and lacrimal portions.
• Sub muscular areolar tissue-
contains nerves and vessels.
3
4. Structure of eyelids
• Fibrous layer- central
tarsal plate and
peripheral orbital
septum
• Layer of non-striated
muscle fibres
• Conjunctiva –
nonkeratinized
squamous epithelium
4
5. Glands of eyelids
• Meibomian glands/Tarsal
glands
Modified sebaceous
glands(30 in no.)
• Glands of Zeis -
sebaceous glands
open into follicles of
lashes
• Glands of Moll -modified
sweat glands-open into
follicles/ducts of Zeiss
• Accessory Lacrimal glands
• Krause
• Wolfring
5
6. INFLAMMATIONS OF THE EYELIDS
•Blepharitis
Subacute or chronic lid margin inflammation
1. Anterior blepharitis-bacterial,seborrhoeic
2. Posterior blepharitis-MGD,a/c acne rosacea
6
7. INFLAMMATIONS OF THE EYELIDS
1. Anterior blepharitis
• Squamous/Seborrhoeic
White dandruff like scales on the lid margin among
eyelashes
• Ulcerative
Chronic staphylococcal infection- hard crusts and ulcers
7
9. INFLAMMATIONS OF THE EYELIDS
• Posterior blepharitis
Meibomian seborrhoea
Meibomianitis
Symptoms-
Burning sensation
Grittiness
Mild photophobia
Redness of eyelid margins
Crusting
More in early morning
9
13. Entropion
• Inward rolling and rotation of the
lid margin toward globe
Involutional/senile
Cicatricial (trachoma, burns,
SJ syndrome)
Spastic(lower lid)
Congenital
13
14. • Involutional Entropion (age related)
Horizontal lid laxity
Vertical lid instability
Over-riding of pretarsal plate
Orbital septum laxity
• Cicatricial entropion
Due to conjunctival scarring
Causes:
Trachoma, chemical burns
14
15. • Congenital entropion
Lower > upper eyelid
Lower eyelid congenital entropion –improper development of the lower lid
retractors
Upper eyelid congenital entropion-secondary to mechanical effects of
microphthalmos
• Mechanical entropion
• d/t lack of support provided by globe to the lids
• Occur in patients with phthisis bulbi,enophthalmos ,after enucleation or
evisceration
15
16. Symptoms
• Foreign body sensation
• Irritation
• Lacrimation
• Photophobia
• d/t rubbing of cilia against cornea and conjunctiva
16
17. Signs
1.)Inturning of lid margins-
Grade 1-only post lid border is inrolled
Grade 2 –inturning of intermarginal strip
Grade 3-whole lid inturned
2.)Signs of causative disease-
Scarring of palpebral conjunctiva in cicatricial entropion
Horizontal lid laxity in involutional entropion
3.)Signs of complications- recuurent corneal abrasions,corneal
opacities,ulcers
17
21. Weis procedure
• Full thickness horizontal lid
splitting and insertion of
everting sutures
• Scarring prevents overriding of
pre-septal and pretarsal parts of
orbicularis
21
22. Jones procedure
22
-Plication of lower lid retractors thus increasing their pull and creating
the barrier b/w preseptal and pretarsal portion of orbicularis
-performed in recurrent cases
27. ECTROPION
• Eversion of lid margins and lashes away from the globe.
Acquired – Involutional/senile-lower lid
Cicatricial- burns and injuries
Paralytic- 7th nerve paralysis
Mechanical-tumors/proptosis
Congenital
27
32. Signs
1.)Lid margin is outrolled
Grade 1- only punctum is everted
Grade 2-lid margin is everted & palpebral conjunctiva is visible
Grade 3-fornix also visible
2.)signs of the cause-
Skin scars in cicatricial ectropion
7th nerve palsy in paralytic ectropion
32
33. Surgical procedures for senile ectropion
• Treatment
Wedge resection for horizontal lid laxity
Diamond excision for medial ectropion
Kuhnt-Szymanowski Procedure modified
by Byron Smith for lateral ectropion
33
38. PTOSIS
• Abnormal drooping of the upper lid to a level that covers more than 2mm
of the superior cornea.
38
39. 1.Congenital ptosis
Simple -absence of lid crease,lid lag sign+ on downgaze
Complicated -blepharophimosis syndrome,double elevator
palsy,Marcus gunn jaw winking
2. Acquired ptosis
Neurogenic- 3rd Nerve palsy, Horner’s syndrome
Myogenic – Myasthenia , Myotonic dystrophy
Aponeurotic- Involutional, postoperative
Mechanical- lid tumors
39
40. Examination
• Evaluation
• Measurement of amount(degree) of ptosis
• Margin reflex distance
• Assessment of levator function
• Special investigation
• Photographic record
40
41. Evaluation
• Pseudoptosis (simulated ptosis) should be excluded on
inspection
• Points to be observed:
-Whether ptosis is unilateral or bilateral.
-Function of orbicularis oculi muscle.
-Eyelid crease is present or absent.
-Jaw-winking phenomenon is present or not.
-Associated weakness of any extraocular muscle.
-Bell's phenomenon up and outrolling of the eyeball during
forceful closure) is present or absent.
41
42. Measurement of amount (degree) of
posis
• In unilateral cases, difference between the vertical height of the
palpebral fissures of the two sides indicates the degree of
ptosis.
• In bilateral cases it can be determined by measuring the
amount of cornea covered by the upper lid and then subtracting
2mm
• Ptosis is graded depending upon its amount as :
• Mild ptosis: 2mm
• Moderate ptosis: 3mm
• Severe ptosis: 4mm
42
43. Margin reflex distance (MRD)
• Margin reflex distance (MRD) refers to the distance between
the upper lid margins and corneal light reflex
• Normal value of MRD is 4-5 mm.
43
44. Assessment of levator function
• It is measured by the lid excursion caused
by LPS muscle (Burke's method)
• Patient is asked to look down, and thumb of
one hand is placed firmly against the
eyebrow of the patient by the examiner
• Then the patient is asked to look up and the
amount of upper lid excursion is measured
with a ruler held in the other hand by the
examiner
• Levator function is graded as follows:
• Normal: 15mm
• Good: 8mm or more
• Fair: 5-7 mm
• Poor: 4mm or less
44
45. Special investigation
• Tensilon test is performed when myasthenia is suspected
• Phenylephrine test is carried out in patients suspected of
Horner's syndrome
• Neurological investigations may be required to find out the
cause in patient with neurogenic ptosis
45
46. Photographic records
• Photographic records of the patient should be maintained for
comparison.
• Photographs should be taken in primary position as well as in
up and down gazes.
46
48. SURGICAL TREATMENT
• LPS Resection (Conjunctival
approach)
LPS action fair
Any type of ptosis
Moderate congenital or
acquired ptosis
• LPS Resection (Skin approach)
• Most preferred surgery for
ptosis correction
LPS action fair
Any type of ptosis
For larger resection in
congenital or acquired ptosis.
48
