By

Azza Mohamed Ahmed Said

Professor of Ophthalmology
Ain Shams University
 Anatomy of
upper eye lid
Lid margin
Keratin or horny layer
(stratum corneum)

Granular cell layer

(stratum granulosum)

Prickle cell layer

(stratum spinosum)

Basal cell layer

(stratum basale)
 Structure of the dermis

•Blood vessels
•Lymphatics
•Nerves

•Fibroblasts
•Macrophages
•Mast cells
Adenxal glands
 Sebaceous glands
 They are located in the caruncle and within eyebrow hairs.

 Tiny sebaceous glands are associated with the thin hairs

covering periocular skin.

 Meibomian glands
 They are modified sebaceous glands found in the tarsal
plates.

 They empty through a single row of 20 - 30 orifices on each

lid.
 A gland consists of a central duct with multiple acini, the
cells of which synthesize lipids (meibum) that form the
outer layer of the tear film.
Adenxal glands
 Glands of Zeis
 They are modified sebaceous glands associated with lash
follicles.

 Glands of Moll
 They are modified apocrine sweat glands opening either into a
lash follicle or directly onto the anterior lid margin between
lashes; they are more numerous in the lower lid.

 Eccrine sweat glands (true sweat glands)

 They are distributed throughout eyelid skin and are not confined
to the lid margin, in contrast to glands of Moll.

 Pilosebaceous units comprise hair follicles and their sebaceous

glands.
Terminology (histology)
 Atypia refers to an abnormal appearance of individual cells, e.g.
abnormal mitotic figures.

 Dysplasia is an alteration of the size, morphology and

organization of cellular components of a tissue. There is disturbance
of normally structured and recognized layers of tissue (e.g. loss of
cell polarity ).

 Carcinoma in situ (intraepidermal carcinoma, Bowen’s disease)

exhibits dysplastic changes throughout the thickness of the
epidermis.
Terminology
 Hyperkeratosis: An increase in thickness of the keratin layer
that appears clinically as scaling. Hyperkeratosis can be a
feature of benign or malignant epithelial tumours.

 Acanthosis: Thickening of the prickle cell layer.

 Dyskeratosis is keratinization other than on the epithelial

surface .

 Parakeratosis is the retention of nuclei into the keratin layer

Terminology (Clinical)
 Macule. Localized area of colour change without infiltration,
depression or elevation, < 1 cm in diameter.
 Papule. A solid elevation < 1 cm in diameter.
 Nodule. A palpable solid area measuring ( > 1 cm)
Terminology (Clinical)
 Vesicle. Circumscribed lesion containing serous fluid;
< 0.5 cm across.
 Bulla. A large (> 0.5 cm) serous fluid-filled lesion.
 Pustule. A pus-filled elevation < 1 cm in diameter.
 Crust. Solidified serous or purulent exudate.

Crust
Terminology (Clinical)
 Cyst. A nodule consisting of an epithelial-lined cavity
filled with fluid or semi-solid material.
 Plaque. A solid elevation of the skin, ( > 1 cm) in
diameter.
 Scale. Readily detached fragments of shed keratin layer.
 Papilloma. A benign neoplastic warty or tag-like
projection of the skin or mucous membrane.
 Ulcer. A circumscribed area of epithelial loss; in skin an
ulcer extends through the epidermis into the dermis.
 Scale

Ulcer
Papilloma
Classification of Eyelid Disorders
Congenital

Inflammatory
Neoplastic

Degenerative; involutional

Vascular

Traumatic
1- Congenital anomalies of the eye
lid
 Isolated
 Associated with other eyelid, facial or
systemic anomalies

 Occur usually during the second month

of gestation
 1- Congenital anomalies of the eye
lid

Blepharophimosis Congenital Congenital Euroblepharon

syndrome ptosis ectropion

Congenital
Ankyloblepharon Epicanthus Epiblepharon
entropion

Congenial Congenital
coloboma distichiasis
1- Congenital anomalies of the eye
lid

Euroblepharon Ankyloblepharon

Epicanthus Epiblepharon
1- Congenital anomalies of the eye lid
Congenital entropion
Congenital ptosis

Congenital ectropion

Congenial coloboma
 1- Congenital anomalies of the eye
lid
 Blepharophimosis
syndrome
 Inheritance: AD
 Clinical features:
○ Telecanthus.

○ Epicanthus inversus (fold

of skin extending from the

lower to upper eyelid).
○ Severe ptosis.
1- Congenital anomalies of the eye
lid
Blepharophimosis syndrome

 Additional findings:
○lateral lower eyelid ectropion secondary to vertical lid
deficiency.
○ A poorly developed nasal bridge.
○ Hypoplasia of the superior orbital rims.
1- Congenital anomalies of the eye
lid
Congenital distichiasis
 1- Congenital anomalies of the eye
lid
 Partial or complete absence of the
eyebrow, palpebral fissure, eyelashes, and
conjunctiva.

 The partially developed adnexa are

fused to the anterior segment of the globe.

 Unilateral or bilateral.

 Histologically: the levator, orbicularis,

tarsus, conjunctiva, and meibomian glands
are attenuated or absent.
2-Inflammation

Chronic
 Anterior blepharitis
1. Seborrheic (scaly) blepharitis
It is strongly associated with generalized seborrhoeic
dermatitis that characteristically involves the scalp,
nasolabial folds, skin behind the ears and the sternum.
 Anterior blepharitis
2. Staph blepharitis
Abnormal cell mediated response to components of
cell wall of staph aureus..m/c with atopic dermatitis
 Anterior blepharitis
2. Staph blepharitis
 Anterior blepharitis
3. Angular
blepharoconjunctivitis

 Causative organism:
Moraxella lacunata or
S. aureus
 C/p: Red, scaly, macerated
and fissured skin is seen at
the lateral and/or medial
canthi of one or both eyes).
 Anterior blepharitis
4. Parasitic infestation
 Demodex infestation
 Pubic louce (Phthiriasis palpebrarum)
 Posterior blepharitis
 Meibomian gland
dysfunction
 Corynbacterium acne ---
lipase ---Free FAs---increase
melting point of meibum---
prevents expression of it---
Irritation/Tear film instability
due to loss of its ph lipids—
excess tear evaporation.
 Characteristic of chronic blepharitis
Feature Staph Seborrheic posterior

Lashes Scale Hard Soft

Loss ++ +
Distorted or ++ +
trichiasis
Lid margin Ulceration +
Notching + +
Cyst Hordeolum ++
Meibomian ++
Conjunctiva Allergic ++

Tear film Foaming ++

Dry eye + ++
Cornea PEE + + ++
Vascul + + ++
infiltr + + ++
++
Commonly Atopic Seborrheic Acne rosacea
associated skin dermatitis dermatitis
disease
 Localized lid margin inflammations
 Exernal hordeolum = stye
 Acute staphylococcal inflammation of hair
follicle and zeis gland.

 PFs

 Painful swelling
○ Diffuse stage
○ Localized stage
 Localized lid margin inflammations

 Chalazion
 Chronic
lipogranulomatous
inflammation of
Meibomian gland.

 Painless swelling

 PFs
 Complications
 DD
Empty space contained fat dissolved
out during processing

Chronic
inflammatory cells
Other eye lid cysts
 Cyst of Zeis is a small, non-translucent cyst on the
anterior lid margin arising from obstructed sebaceous
glands associated with the eyelash follicle.
Other eye lid cysts
 Cyst of Moll
(apocrine hidrocystoma) is a small retention cyst of the
lid margin apocrine glands. It appears as a round, non-
tender, translucent fluid-filled lesion on the anterior lid
margin.
Other eye lid cysts
 Sebaceous (pilar) cyst is
caused by a blocked
pilosebaceous follicle and
contains sebaceous
secretions; the gland orifice
will often be visible. It is only
rarely found on the eyelid
although it may occasionally
occur at the inner canthus.
Other eye lid cysts
 Comedones are plugs of
keratin and sebum within the
dilated orifice of hair follicles that
often occur in patients with acne
vulgaris.
 They may be either open
(blackheads) containing a
darkened plug of oxidized
material or closed (white
heads).
Other eye lid cysts
 Milia are caused by
occlusion of pilosebaceous
units resulting in retention
of keratin. They are tiny,
white, round, superficial
papules that tend to occur
in crops.
Other eye lid cysts
 Epidermal inclusion
cyst is usually caused by
implantation of epidermis
into the dermis following
trauma or surgery. It is a
slow-growing, round, firm,
superficial or
subcutaneous lesion
containing keratin.
Epidermal inclusion cyst
 Epidermoid cysts are lined with stratified
squamous keratinizing epithelium and contain
keratin
Other eye lid cysts
 Dermoid cyst is usually subcutaneous or deeper and
is typically attached to the periosteum at the lateral end of
the brow. It is caused by skin sequestered during
embryonic development.
Other eye lid cysts
 Dermoid cyst is uncommon and usually
developmental, occurring along embryonic lines of
closure. It is similar in appearance to an epidermal
inclusion cyst but they have skin adnexal structures
such as hair follicles and sebaceous glands in the wall.
The lumen contains hair and sebum in addition to
keratin.
Other eye lid cysts
 Eccrine hidrocystoma is less common but similar in
appearance to a cyst of Moll except that it is usually
located along the medial or lateral aspects of the lid, and
is close to but does not involve the lid margin itself.
Ductal cyst
 Within the eyelid are the ducts of numerous
structures, including the apocrine and
eccrine sweat glands and the lacrimal
gland. Any of these ducts may give rise to 1
or more cysts
Ductal cyst
 Ducts are typically lined with a double layer of cuboidal
epithelium, as are ductal cysts.

 The lumen of the cyst typically appears empty

histologically. Cysts arising from sweat ducts are
referred to as either apocrine or eccrine hidrocystomas.
 Cyst arising from the duct of the lacrimal gland is called
a dacryops.