DR.

MUBASHIR REHMAN
ASSISTANT PROFESSOR
Head of department
Department of Ophthalmology NMC

FCPS OPHTHALMOLOGY
FELLOWSHIP IN VITREORETINA UK
FELLOWSHIP IN VITREORETINA GERMANY
EYELID
 ANATOMY
• Eyelid consists primarily of
– skin,
– underlying soft tissue also called a subcutaneous
tissue and
– a thin layer of muscle called the orbicularis oculi.
• Under muscle are other tissues called orbital
septum and tarsi.
• The eyeball is covered by a thin layer of tissue
called the conjunctiva.
• Skin apppendages (adnexae)
– Meibomian glands: modified sebaceous glands
located in the tarsal plates.
• Synthesize lipids (meibum) that form outer layer of tear
film.
• Gland of Zeis: Modified sebaceous glands
associated with lash follicles.
• Gland of Moll: Modified apocrine sweat glands.
• Eccrine sweat glands: Distributed throughout
the eyelid skin.
– Eccrine glands open directly onto the surface of the skin.
– Apocrine glands develop in areas abundant in hair follicles and they
empty into the hair follicle just before it opens onto the skin surface.
 ANATOMY
• Tarsal plates:
– These are dense fibrous tissue within the eyelids
to maintain their shape and integrity.
• superior tarsus and
• inferior tarsus.
 Stye
External hordeolum
 Characteristics
• A stye also known as External hordeolum is
an infection of the sebaceous glands of Zeis at
the base of the eyelashes, or sweat
glands of Moll.

• Styes are usually caused by the

Staphylococcus aureus bacterium.
• Symptoms
– Localized pain of short duration i.e. days.
– Discomfort during blinking.
– Discharge from eye.
• Signs
– A lump on the top or bottom eyelid pointing
anteriorly through skin with usually a lash at the
apex.
– Localized swelling of the eyelid
– Redness of the eyelid
– Tenderness
– Crusting of the eyelid margins
– Mucous discharge in the eye
 Treatment

• Application of hot compresses.

• Topical antibiotics
• Erythromycin ophthalmic ointment. May also be treated
with other antibiotics, such as chloramphenicol
• Oral antibiotics:
– Penicillines if there is associated cellulitis.
 Treatment

• Surgery:
– Styes that do not respond to medical therapy are
usually surgically treated.
• Epilation : removal of the eyelash.
• Incision and drainage: After the incision is made, the
pus is drained out of the gland.
 Complications

• Eyelid cellulitis is a potential complication of

stye, which is a generalized infection of the
eyelid.
Chalazion
 Characteristics
• Also known as a meibomian gland
lipogranuloma OR meibomian cyst.

• Caused by chronic granulomatous inflammation

of a blocked meibomian glands.

• They may become acutely inflamed to

secondarily infected with S. aureus and is known
as internal hordeolum.
 Symptoms

• Gradually enlarging painless nodule.

• A very large chalazion may press on cornea to

induce astigmatism and blurring of vision.
 Signs

• Non tender, roundish nodule.

• Eversion of the eyelid may show polypoidal

granuloma
 Treatment

• Treatment may not be required as a third of

Chalazia will often disappear without
treatment within a few months.

• Persistent cases need treatment.

 Treatment
• Larger ones may be surgically removed using
local anesthesia.
– Incision and curretage: This is usually done from
underneath the eyelid to avoid a scar on the skin
using a vertical incision and contents are curetted.

• Smaller lesions may be injected with a

corticosteroid.
 Complications

• A large chalazion can cause astigmatism due to

pressure on the cornea.

• Hypopigmentation may occur with corticosteroid

injection.

• Recurring chalazia in the same area may sometimes

be a symptom of sebaceous gland carcinoma.
 Stye Chalazion

Involve Gland of Moll and Gland of Zeis Involve Meibomian glands

Infection Granulomatous inflammation

Acute onset Chronic history

Painful Painless

Tender Non-tender

At the lid margin Away from the lid margin

Treated medically Treated surgically

Blepharitis
• Blepharitis is an eye condition characterized
by chronic inflammation of the eyelid.
• Always bilateral.
• Classified as
– Anteior
– Posterior
 Chronic anterior blepharitis

Affect the area surrounding the base of the

eyelashes.
• Seborrhoeic
– Often associated with generalized seborrhea.
• Staphylococcal
– Is caused by infection of the anterior portion of the eyelid by
Staphylococcal bacteria.
 Symptoms

– Burning
– Grittiness
– Mild photophobia
– Loss of eyelashes or broken eyelashes.
– Symptoms are usually worse in the morning.
 Signs
• Staphylococcal blepharitis:

– Hard scales and crusting mainly located around the bases of the lashes
(collarettes).

– Conjunctiva hyperemia.

– Scarring and notching of lid margin.

– Thickness of lid margin (madarosis).

– Trichiasis.
 Signs

• Seborrhoeic blepharitis:
– Hyperemic and greasy anterior lid margins with
sticking together of lashes.

– Scales are soft and located any where on the lid

margin and lashes.
 Complications

• Recurrent Stye formation.

• Recurrent chalazion formation.

• Dry eyes.
 TREATMENT
• Warm compress to soften crusts at the base of the lashes.

• Eyelid hygiene: This consists of proper cleaning of the

eyelid, removing crusts and debris with baby shampoo.

• Topical antibiotics ointment: Fusidic acid is usually the

choice of antibiotic.

• A short course of topical steroids are administered to

control the inflammation.
 Posterior blepharitis

• Posterior blepharitis is inflammation of the

eyelids secondary to dysfunction of the
meibomian glands.

• Like anterior blepharitis it is a bilateral chronic

condition.
 Symptoms

• Similar to anterior blepharitis.

 Signs
• Capping of meibomian gland orifices with oily
globules.
• Hyperemia and telengiectasis of posterior lid
margin.
• Pressure on lid margin results in expression of
meibomian fluid like toothpaste.
• Froth accumulation on lid margin like soapy
discharge.
 TREATMENT

• Lid hygiene: as for anterior blepharitis.

• Systemic tetracyclines: for about 6-12 weeks are the

mainstay of treatment.

• Topical steroids.

• Artificial tears.
Trichiasis
 Trichiasis

• Trichiasis is characterized by posterior

misdirection of lashes arising from normal
site of origin.
 Trichiasis
• Causes:
– Infection e.g herpes zoster.
– Inflammation e.g blepharitis
– autoimmune eye conditions
– congenital defects
– trauma such as burns or eyelid injury
– Repeated cases of trachoma infection may cause
trichiasis
 Trichiasis

• Symptoms:
– Itching
– Red eye
– Lacrimation
– Photophobia
– Pain if corneal epithhelial damage occur
 Trichiasis

• Signs:
– Misdirected eyelashes.
– Normal eyelid margin.
– Corneal ulceration.
– Pannus formation.
 Trichiasis
• TREATMENT
– Standard treatment involves removal.
• Epilation: In many cases, removal of the affected
eyelashes with forceps resolves the symptoms, although
the problem often recurs in a few weeks when the
eyelashes regrow.
– Destruction of the affected eyelashes with
– electrology,
– Argon laser, or
– surgery.
 Trichiasis

• Complications:
• corneal ulcer.
• Severe cases may cause scarring of the cornea and lead to
vision loss if untreated.
Entropion
 Entropion

• Entropion is a medical condition in which the

eyelid (usually the lower lid) folds inward.
• It is very uncomfortable, as the eyelashes
constantly rub against the cornea and irritate
it.
 Causes

• Congenital
• Aging creating loose skin and stretched and
loose ligaments and muscles.
• Scarring
• Trachoma
• Burn
 Symptoms

• Redness and pain around the eye

• Epiphora

• Decreased vision, especially if the cornea is

damaged
 Treatment

• Temporary treatment is with lubricants, soft

bandage contact lens or botulinum toxin
injection.
 Surgery
• Lateral Tarsal strip

• Transverse everting sutures

• Weis procedure
Ectropion
 Ectropion

• Ectropion is a medical condition in which the

lower eyelid turns outwards.
 Causes

– Congenital
– Aging
– Scarring
– Mechanical
– Facial nerve palsy
 Ectropion

• Symptoms:
– Lacrimation.
– Red eye.
– Pain if exposur keratopathy occur.
 Ectropion

• Signs:
– Lax lower eyelid.
– Incomplete closure of eyelids.
– Lower lid eversion.
 Ectropion

• Complications:
– Exposure keratopathy.
– Corneal ulcer.
– Corneal scarring.
 Ectropion

• Treatment: depends upon the cause.

– General measures include artificial tears and taping

during sleep to avoid exposure keratopathy.

– Ectropion secondary to facial nerve palsy improves

with time with recovery of facial nerve palsy.

– Senile ectropion requires lid surgery.

Basal cell carcinoma
• Basal cell carcinoma (BCC) is a nonmelanocytic
skin cancer (i.e. an epithelial tumor) that arises
from basal cells (ie, small, round cells found in
the lower layer of the epidermis).
• Commonest human malignancy.
• Typically affect elderly patients.
• The prognosis for patients with BCC is excellent,
but if the disease is allowed to progress, it can
cause significant morbidity.
• Risk factors:
– Fair skin
– Chronic exposure to sunlight.
 Characteristics
• Occurs mostly on the face, head, neck, and hands.
• Most prevalent eyelid tumor.
• Periocular tumors most commonly involve the
following:
– Lower eyelid: 48.9-72.1%
– Medial canthus: 25-30%
– Upper eyelid: 15%
– Lateral canthus: 5%
• Slow growing, locally invasive, and non metastasizing.
 Signs and symptoms

• Waxy papules with central depression

• Pearly appearance
• Erosion or ulceration: Often central and
pigmented
• Rolled (raised) border
• Telangiectases over the surface
• Slow growing: 0.5 cm in 1-2 years
 Types of BCC
• Nodular: the most common type of BCC; usually presents
as a round, pearly, flesh-colored papule with telangiectases
• Noduloulcerative: (rodent ulcer) has central ulceration,
pearly raised rolled edges and dilated and irregular blood
vesseles (telangiectasis) over its lateral margins.
• Sclerosing BCC (morphoeic): difficult to diagnose because it
infiltrates laterally beneath the epidermis as an indurated
plaque. Margins of tumor are impossible to delineate
clinically.
• Cystic.
• Pigmented.
• Multiple superficial.
 Diagnosis

• Given that BCC rarely metastasizes, laboratory and imaging

studies are not commonly clinically indicated in localized lesions.
• Imaging studies may be necessary when involvement of deeper
structures, such as bone, is clinically suspected. In such cases,
CT scans or radiography can be used.
• Biopsy
– Shave biopsy: performed with a knife and involved removal of
superficial part of the lesion. Most often, the only biopsy that is
required.
– Punch biopsy: is performed using a skin dermatome. Examination of
deeper part of the lesion is possible.
– Excisional biopsy.
 Management

• Surgery
• In nearly all cases of BCC, surgery is the recommended
treatment modality. Techniques used include the following
– Excisional surgery: entire tumour should be removed with preservation
of as much as possible of normal tissue. Most small BCC are cured by
excision of the tumour together with a 4mm margin of tissue which
looks clinically normal.
– Standard frozen section: involves histopathological examination of the
margins of the excised specimen at the time of surgery to ensure that
they are tumour free. If tumour cells are detected further excision is
performed.
– Mohs’ micrographic surgery: involve excision of serial horizontal frozen
sections from under surface of the tumour.
– Cryotherapy:
• Small superficial tumours.
– Radiation therapy
• BCCs are usually radiosensitive; radiation therapy (RT)
can be used in patients with advanced and extended
lesions, as well as in those for whom surgery is not
suitable.
• RECONSTRUCTION:
– It is important to reconstruct both anterior and
posterior lamellae.
– Anterior lamellae may be closed directly or with
local flap or skin graft.
– Posterior lamellae may involve an upper lid free
graft, buccal mucous memberane or hard palate
graft.
PTOSIS
• Ptosis is a drooping or falling of the upper or
lower eyelid.
 Classification

• Neurogenic ptosis which includes

– oculomotor nerve palsy
– Horner's syndrome
– Marcus Gunn jaw winking syndrome
– third cranial nerve misdirection.
• Myogenic ptosis which includes
– myasthenia gravis
– myotonic dystrophy
– ocular myopathy,
– simple congenital ptosis,
– Blepharophimosis syndrome
– tumors of the upper lid
 Classification

• Aponeurotic ptosis which may be

– involutional or
– post-operative
• Mechanical ptosis which occurs due to
– edema or tumor.
• Pseudo ptosis due to:
– Lack of lid support: empty socket or atrophic globe.
– Higher lid position on the other side: as in lid
retraction
 Examination of the patient with ptosis

• Lid height or palpebral fissure height:

– is the distance from the bottom of the upper eyelid
margin to the top of the lower eyelid margin taken at
the center of the eyelid. A normal measurement
ranges from 8 to 10 mm.
• Margin reflex distance (MRD): is the distance
between upper lid margin and corneal reflection
when patient is looking straight ahead.
– Normal is 4 - 4.5 mm.
 Examination of the patient with ptosis

• Levator function is obtained by measuring the

movement of the upper eyelid from down-
gaze to up-gaze while stabilizing the
eyebrow/frontalismuscle
• Normal levator function is considered to be
greater than 11 mm.
 Examination of the patient with ptosis

• The eyelid crease is the measurement of the

distance from the eyelid margin to the eyelid
crease when the patient is looking down.
• The normal crease measurement is 7 to 8 mm
in males and 9 to 10 mm in females.
• Pretarsal show: distance between lid margin
and skin fold in primary position of gaze.
 Examination of the patient with ptosis

• Bell’s phenomenon must also be evaluated;

this is the ability of the eyeball to move
upward with eyelid closure.
 Examination of the patient with ptosis

• Fatigability: is tested by asking to look up

without blinking for 30 seconds. Progressive
drooping of eyelid is suggestive of myesthenia.
 Examination of the patient with ptosis

• Margus gunn jaw winking phenomenona: ask

the patient to chew or move jaw side to side
and notice winking of eyelid.
 Complications

• If severe enough and left untreated, the

drooping eyelid can cause amblyopia or
astigmatism.
 Systemic associations

• Myasthenia gravis
• Horner's Syndrome
• ChronicProgressiveExternal
Ophthalmoplegia (CPEO)
 Treatment

• Aponeurotic and congenital ptosis may require surgical

correction if severe enough to interfere with vision or if
cosmetics is a concern.
• Treatment depends on the type of ptosis and amount of ptosis.
• Surgical procedures include:
– Levator resection
– Müller muscle resection
– Frontalis sling operation
– Non-surgical modalities like the use of "crutch" glasses or special
scleral contact lenses to support the eyelid may also be used.

• Ptosis that is caused by a disease will improve if the disease is

treated successfully e.g myesthenia gravis.