DISEASES OF THE EYELIDS

1. CONGENITAL ABNORMALITIES
- Ankyloblepharon → adhesion between eyelids
- Ablepharon → absence of eyelids
- Coloboma → notching of upper lid
- Epichanthus → medial skin fold obscuring caruncle
- Epiblepharon → the pretarsal muscle and skin ride above the lid margin to form a
horizontal fold of tissue
- Ptosis
- Ectropion
- Entropion

2. EYELID INFLAMMATION

Bacterial infections:
- Impetigo → superficial skin lesion caused by S. aureus or S. pyogenes and cahracterized
by painful erythematous macules rapidly developing into blisters, which develop golden-
yellow crusts on rupturing

- Erysipelas (St. Anthony’s fire) → is an uncommon acute, potentially severe, dermal and
superficial lymphatic infection usually caused by S. pyogenes → an inflamed
erythematous plaque develops

- Necrotizing fasciitis → rare but very severe infection involving subcutaneous soft tissue
and skin, with associated rapidly progressive necrosis → commonly caused by S. pyogenes

- External hordeolum → acute staphylococcal abscess of a lash follicle and its associated
gland of Zeis → tender swelling in the lid margin pointing anteriorly through the skin

- Internal hordeolum → arises from bacterial infection of a meibomian gland

Viral infections:
- Molluscum contagiosum → skin infection caused by
human specific poxvirus that typically affects healthy
children → transmission is by contact and
autoinoculation.
Single or multiple pale, waxy, umbilicated nodules
develop

- Herpes zoster ophthalmicus

- Herpes simplex → results by either primary infection or

reactivation of herpes simplex virus dormant in the
trigeminal ganglion.
Facial and lid tingling is followed by the development of
eyelid and periocular skin vesicles that break down after 48
hours

Inflammation of the eyelid margin:

- Chalazion → hordeolum externum can lead to superficial chalazion, while internal

hordeolum can lead to deep chalazion.
Chalazion is a chronic lipogranuloma residing within eyelid usually affecting the upper
eyelid due to increased presence of meibomian glands → if the outflow of sebaceous
secretion is obstructed, the oily secretions are retained and may leak into the adjacent tissue
→ chronic granulomatous inflammation → lipogranuloma.

- Chronic blepharitis → inflammatory condition of the eyelid margin, common cause of

ocular discomfort and irritation.
Blepharitis can be divided into:
1. Anterior blepharitis → affects the eyelid skin, base of the eyelashes and the eyelash
follicles → staphylococcal and seborrheic blepharitis

2. Posterior blepharitis → affects meibomian glands and gland orifices → range of

potential etiologies
Signs and symptoms include:
- Burning
- Grittiness
- Photophobia
- Crusting and redness of lid margins

Staphylococcal blepharitis → crusting mainly located around the bases of the lashes, mild
papillary conjunctivitis.
Long-standing cases may develop scarring and notching of the lid margin and trichiasis.
Dry eye syndrome and atopic keratoconjunctivitis may be present

Seborrheic blepharitis → hyperaemic and greasy anterior lid margins with adherence of
lashes to each other

Posterior blepharitis → excessive and abnormal meibomian gland secretion,

hyperaemia and telangiectasis of the posterior lid margin and tear fim is oily and foamy

Secondary changes include papillary conjunctivitis, corneal scarring, ulceration and

bacterial keratitis

Treatments:
- Lid hygiene
- Topical antibiotics + steroids
- Lubricants
- Systemic antibiotics (severe cases)

- Acute allergic oedema → usually caused by exposure to pollen or by insect bites and
manifests with sudden onset of bilateral boggy periocular oedema, often accompanied by
conjunctival swelling
3. EYELID MALPOSITION

- Ptosis → abnormally low position of the upper lid, which may be congenital or acquired.
There are different type of ptosis:
1. Neurogenic ptosis → caused by an innervation defect, such as III nerve paresis and
Horner syndrome (lesion to the sympathetic pathways that supply head and neck,
including oculosympathetic fibres)

2. Myogenic ptosis → caused by myopathy of the levator muscle, or by impairment of

transmission of impulses at the neuromuscular junction → this type occurs in myasthenia
gravis, myotonic dystrophy

3. Aponeurotic ptosis → caused by defect in the levator aponeurosis

4. Mechanical ptosis → caused by tumour or inflammation

Clinical features of congenital ptosis are:

- Unilateral or bilateral ptosis
- Absent upper lid crease and poor levator function
- Amblyopia → ‘lazy eye’ → reduction in VA
- Downgaze → ptotic lid is higher than the normal due to poor relaxation of levator
muscle
- Compensatory chin elevation in severe bilateral cases

About 5% of all cases of congenital ptosis → Marcus Gunn jaw-winking syndrome.

The main clinical sign is retraction of the ptotic lid in conjunction with stimulation of the
ipsilateral pterygoid muscles by chewing, sucking, opening the mouth.
Surgery should be considered if jaw-winking or ptosis represents a significant functional or
cosmetic problem.

Different types of surgery:

- Conjunctiva-Muller resection
Involves excision of Muller muscle and overlying conjunctiva, with reattachment of
resected edges

- Levator resection
Levator complex is shortened through either an anterior-skin or posterior-conjunctival
approach → extent of resection depends on severity of the ptosis and the amount of levator
function

- Brow suspension
Used for severe ptosis with very poor levator function → the tarsal plate is suspended from
the frontalis muscle with a sling consisting of non-absorbable material like silicone
- Ectropion → outward turning of the eyelid margin.
There are different types of ectropion:
1. Involutional ectropion → age-related ectropion affects the lower lid of elderly
individuals. It causes epiphora (tear overflow) and exacerbate ocular surface disease.
In long-standing cases, the tarsal conjunctiva may become chronically inflamed, thickened
and keratinized.
Main aetiological factors are horizontal lid laxity and orbicularis weakness.

2. Cicatricial ectropion → caused by scarring or contracture of the skin and underlying

tissues, which pulls the eyelid away from the globe.
Main aetiological factors are trauma, lacerations, burns, surgery, tumours, infections.

3. Paralytic ectropion → cause by ipsilateral facial nerve palsy and is associated with
retraction of the upper and lower lids and brow ptosis.
Complications include exposure keratopathy and watering caused by malposition of the
inferior lacrimal punctum.

4. Mechanical ectropion → caused by tumours on or near the lid margin

- Entropion → inward turning of the eyelid margin.
There are different type of entropion:
1. Involutional entropion → age-related entropion affects mainly the lower lid. Constant
rubbing of the lashes on the cornea in long-standing entropion may cause pseudotrichiasis,
corneal punctate epithelial erosions and in severe cases, pannus formation and
ulceration.
Trichiasis is a consequence of eyelid inflammation and scarring → constant irritation can
lead to eye pain, vision changes, corneal abrasions or corneal ulcers.
Main aetiological factors include horizontal lid laxity, vertical lid instability, over-riding
of the pretarsal and orbital septum laxity.

2. Cicatricial entropion → scarring of the palpebral conjunctiva can rotate the upper or
lower lid margin towards the globe.
Among aetiological factors we can find cicatrizing conjunctivitis, trachoma, trauma and
chemical injuries.

3. Congenital entropion → caused by lower eyelid retractor dysgenesis, structural

defects in tarsal plate or relative shortening of the posterior lamella
- Lagophthalmos → inability to close the eyelids completely → portion of the eye remains
open during blink and during sleep and is subject to damage from exposure.
Main aetiologic factors include facial nerve dysfunction, eyelid dysfunction, excessive
scar tissue, medication effect.
The most common type is the paralytic lagophthalmus.

4. EYELID TUMOURS

BENIGN TUMOURS

- Basal cell papilloma (Seborrhoeic keratosis)→ expansion of

the squamous epithelium of the epidermis by proliferating basal
cells. Extremely common slowly growing lesion,
sometimes with keratin-filled horns or cystic inclusions.

- Squamous cell papilloma → characterized by

finger-like projections of fibrovascular connective
tissue covered by irregular acanthotic and
hyperkeratotic squamous epithelium → very
common benign epithelial tumour, with some cases
resulting from HPV.
- Solar keratosis → characterized by irregular dysplastic epidermis with hyperkeratosis,
parakeratosis and cutaneous horn formation → rarely develops on the eyelids, typically
affecting elderly and areas of sun-damaged skin.

- Haemangioma → also called ‘strawberry naevus’,

is one of the most common tumour in infancy.
Histopathology shows proliferation of varying-sized
vascular channels in the dermis and subcutaneous
tissue → usually unilateral, raised bright red lesion,
usually in the upper lid. Ptosis is frequent

- Neurofibroma → benign nerve tumours, usually

nodular or pedunculated, that can be found
anywhere on the skin. Plexiform neurofibromas
typically present in childhood as a manifestation of
neufibromatosis type 1, with a characteristic S-
shaped deformity of the upper eyelid.

MALIGNANT TUMOURS

- Basal cell carcinoma → is the most common malignant eyelid tumour (90% of cases),
frequently arising from the lower eyelid → one of the most important risk factor is hisotry
of chronic sun exposure.
The tumour is slowly growing and locally invasive (orbit, sinuses) but non-metastasizing
→ it arises from basal cells found in the epidermis, sometimes showing hyperkeratotic
type of BCC.
Nodular BCC is a shiny, firm, pearly nodule with small overlying dilated blood vessels.
Other types may be Nodulo-ulcerative BCC or Sclerosing BCC
- Squamous cell carcinoma → less common but more
aggressive tumour than BCC, with metastasis to
regional lymph nodes.
Histopathology shows dysplastic changes throughout the
thickness of the epidermis → important aspect is
surveillance of regional lymph nodes in initial stages.
Individuals with AIDS or following renal
transplantation are at increased risk → predisposition
for lower eyelid and the lid margin, in elderly with
history of chronic sun exposure.

- Malignant melanoma → histopathology shows large atypical

melanocytes invading the dermis → superficial spreading
melanoma is characterized by a plaque with an irregular outline
and variable pigmentation.
Nodular melanoma is typically a blue-black nodule surrounded
by normal skin.

- Sebaceous gland carcinoma → very rare, slowly growing tumour

frequently affecting the elderly, mostly females → usually arises from
Meibomian glands in the upper eyelid.
Main clinical features are:
1. Yellowish material within the tumour
2. Nodular SGC → discrete, hard nodule most commonly within the
upper tarsal plate containing lipid
3. Spreading SGC → infiltrates into dermis and causes a diffuse
thickening of the lid margin