EYELIDS

7th SEMESTER

Dr. Monika Mahat

3rd Year Resident
Ophthalmology Department
LMCTH
EMBRYOLOGY
 INTRODUCTION
• The eyelids are the mobile tissue in front
of the eyeballs
• Upper and lower eyelid
• Functions:
– Act as shutters protecting eyes from injuries
and excessive light
– Spread the tear film over the cornea and
conjunctiva
– Contribute to the facial feature- Information
regarding the state of wakefulness and
attention
 INTRODUCTION
• Extent:
– Upper lid: eyebrows to the free margin
– Lower lid: merges to skin of the cheek
below

• Position of the Eyelids:

– Upper lid covers about 1/6th of the
cornea (2 mm below superior corneal
limbus)
– Lower lid margin just touches the cornea
 PARTS OF EYELIDS
1. Orbital part
2. Tarsal part
Divided by Horizontal Sulcus (Furrow)

Additional folds in lower lid- nasojugal

fold medially and the malar fold
laterally. These folds limit the spread of
blood downward from eyelids to cheek.
CANTHUS

• The upper and lower lids meet at an angle of about

60˚ medially and laterally forming canthus.
• The medial canthus is about 2 mm higher than the
lateral canthus
• Caruncle: Modified skin containing sebaceous glands
and hairs

• Plica Semilunaris- Highly vascular crescent shaped

fold of conjunctiva .Vestigial structure analogous to
nictitating membrane of animals
EYELID MARGIN

• 2 mm wide
• Lacrimal papillae (at the center of which is lacrimal
punctum) divides the margin into medial 1/6th
(Lacrimal Part) and lateral 5/6th part (Ciliary Part)
GREY LINE:
• Represents the line of demarcation between the
anterior portion of the eyelid formed by the skin and
orbicularis muscle (ant. lamina) and the posterior
formed by the tarsus and conjunctiva (post lamina).
• Marks junction of skin and conjunctiva
EYELASHES

• Upper Eyelashes: 100 - 150

• Lower Eyelashes: 50 - 75
• 2 or 3 irregular rows
EYELASHES Contd..

DIRECTION:
• Upper Eyelashes: Directed downward, forward and
upward
• Lower Eyelashes: Directed upward, forward and
downward
 PALPEBRAL APERTURE
• Elliptical space between the upper and the lower
lid.
• Vertical : 9-12 mm in the centre
• Horizontal : 28-30 mm
 LAYERS OF EYELIDS
7 structural layers of the eyelids are:
 SKIN
• Thinnest in the body
• Contains the usual adnexal structures: fine hairs,
sebaceous & sweat glands
• Microscopically epidermis and dermis

SUBCUTANEOUS TISSUE
• Loose connective tissue arrangement
• Rich in elastic fibres
• No fat
 PROTRACTORS
ORBICULARIS OCULI
ORBICULARIS OCULI
• Parts: Orbital and Palpebral (Pre-Septal and Pre-
tarsal)
• Function: Close the eyelids
• Nerve Supply : Temporal and zygomatic branch of
Facial Nerve.
• Paralysis of the orbicularis oculi muscle leads to :
Lagopthalmos - inadequate closure of lids
 ORBITAL SEPTUM
• Thin, fibrous framework, membranous sheet
• Separates the eyelid from the contents of orbital
cavity
• Functions:
– Holds the orbital fat in position
– Barrier function- prevent the transmission of infection
from lids to orbital cavity and viceversa

ORBITAL FAT
• Upper lid : 2 fat pockets
• Lower lid : 3 fat pockets
RETRACTORS

• Upper lid: Levator Palpebrae Superioris (LPS) along

with Mullers muscle
• Lower lid: Capsulopalpebral fascia
• Action of LPS: Opens the upper
lid
• Nerve Supply :
– LPS : superior branch of oculomotor
– Muller: sympathetic nerves from
cervical ganglion

• Paralysis of LPS (3rd nerve

palsy): Ptosis
 TARSUS / TARSAL PLATE
• Dense fibrous tissue.
• Gives shape and firmness to eyelid
• In upper lid: Larger, crescentic ,
11mm in center , orbital septum and
smooth muscle fiber of LPS
attached to its upper edge
• In lower lid: Smaller, 4mm at
centre, Orbital septum attached to
its lower edge.
CONJUNCTIVA

• Thin mucous membrane lining the eyelids

(posterior layer of lids).
• Composed of non keratinizing squamous
epithelium
• Contains:
– Goblet cells
– Accessary lacrimal glands ( Wolfring and Krause )
GLANDS OF EYELIDS
1. Meibomian Glands (Tarsal Glands)
• These are modified sebaceous glands
• 20 -30 in number embedded in the tarsal plate.
• They are directed vertically and open on the lid
margin
• Therefore vertical incision is given while incising
the chalazion.
2. Zeis’s Gland: Modified Sebaceous Gland, Situated in
close association with cilia.

3. Moll’s Gland :
• Modified Sweat glands & lie between the cilia
• Discharge directly into the eyelash follicles.

4. Accessory glands of Wolfring

• Present along upper border of superior tarsus and lower
border of inferior tarsus.
• 2-5 in upper lid
• 2-3 in lower lid
 CONGENITAL ANOMALIES
1. Ablepharon: Rare, Lids are not developed,
autosomal recessive genetic disorder

2. Microblepharon : Rare, Lids are abnormally

small

3. Cryopthalmos: partial or complete absence of

eyebrow, palpebral fissure eyelashes, and
conjunctiva. The partially developed adnexa
are fused with anterior segment of globe.
4. Coloboma of lid: notch in the edge of
eyelid

5. Congenital Ptosis: Common, drooping

of eyelid

6. Epicanthus : A vertical fold of skin on

either side of the nose sometime
covering the inner canthus. (the outer or
inner corner of the eye )
7. Ankyloblepharon :
Partial or complete fusion of eyelids by
webs of skin

8. Symblepharon : Adhesion of lid to the

globe

9. Distichiasis: Additional row of lashes

10.Trichiasis: Acquired misdirection of eyelashes

11.Madarosis: Decrease in number of eyelashes.

12.Lash Poliosis: Premature graying of the lashes

13.Trichomegaly: Excessive eyelash growth

 OEDEMA OF EYELID
• Owing to the looseness of the tissues, oedema of the lids is of
common occurrence.
• It may be classified as inflammatory, solid and passive
oedema.
• Inflammatory Edema: Found in conjunctivitis, tarsitis ( infl of
gland and lashes) dacryo-cystitis, (inflammation of lacrimal
sac ),orbital cellulitis (infl of eye tissue ), drug allergy (atropine).
• Passive edema: cavernous sinus thrombosis
INFLAMMATORY DISORDER OF
EYELID
1. BLEPHARITITS
2. EXTERNAL HORDEOLUM (STYE)
3. CHALAZION
4. INTERNAL HORDEOLUM
5. MOLLUSCUM CONTAGIOSUM
BLEPHARITIS

• Chronic inflammation of eyelid margin

• TYPES:
– Seborrhoeic or squamous blepharitis
– Staphylococcal or ulcerative blepharitis
– Mixed staphylococcal with seborrhoeic blepharitis,
– Posterior blepharitis or meibomitis
– Parasitic blepharitis
 SQUAMOUS / SEBORRHOEIC
• Associated with generalized seborrhoeic dermatitis
that characteristically involves the scalp (dandruff),
nasolabial folds, skin behind the ears and the
sternum.
• Glands of Zeis secrete abnormal excessive neutral
lipids which are split by Corynebacterium acne into
irritating free fatty acids
 Squamous Contd..
CLINICAL FEATURES:
• Mild discomfort, irritation, watering
• Fall of eyelashes
• Numerous white dandruff like scales in eyelid margin
• Removal of scales – underlying surface is hyperemic and
greasy (no ulcer)
• Lid margin thickened
• Long term: Epiphora
 SQUAMOUS Contd…
TREATMENT
• General improvement of health & diet
• Seborrhoea of scalp should treated
• Removal of scales with luke warm sol. (3%
NaHco /baby samphoo)
• Antibiotics (erythromycin/doxycycline)
ULCERATIVE / STAPHYLOCOCCAL

• Chronic infection of the anterior

part of lid margin
• Causative Organisms : Cogulase
+ve Staphylococci
• Rarely streptococci ,
propionibacterium acnes &
Moraxella
 ULCERATIVE Contd…
CLINICAL FEATURES
• Itching, redness, lacrimation and photophobia
• Hard yellow crusts glue ( sticky) the lashes
together
• On removing the crust there are small ulcers
seen around the bases of lashes
• Hyperemia
• Symptoms are worse in the morning
• Remissions and exacerbations in symptoms
are quite common
 ULCERATIVE Contd…
COMPLICATIONS
• Trichiasis
• Poliosis
• Madarosis
• Epiphora
• Eczema of skin & ectropion
• Recurrent styes
• Marginal keratitis
• Tear film instabillity → dry eye
 ULCERATIVE Contd…
TREATMENT
• Lid Hygiene (twice daily):
– Warm compress
– Crust removal (3% sodium bicarbonate)
– Avoid rubbing of eyes
• Antibiotics:
– Topical Eye Ointment and drops
– Oral antibiotics (erythromycin, doxycycline)
• Topical steroids (Fluoromethalone)
• Ocular lubricants
SEBORRHOIC
 POSTERIOR BLEPHARITITS
(MEIBOMITIS)
• Posterior blepharitis, the more common condition
• Inflammation of the inner portion of the eyelid, at the level of the
meibomian glands
• Described as meibomian gland dysfunction
• Corynbacterium acne convert lipase into free fatty acids and
causes increase melting point of meibum which prevents
expression of it
• Irritation/Tear film instability due to loss of its PH lipids— excess
tear evaporation.
MEBOMITIS
SYMPTOMS
• Chronic irritation
• Burning
• Mild lacrimation
• Symptoms are more worse in morning
 MEBOMITIS Contd…
SIGNS:
• Lid margins – shows foam like secretions
• Meibomian glands -openings are prominent with
secretions expressed by pressure on lids with
toothpaste appearance
• Orifice shows capping with oil globules, plugging
• Vertical yellowish streaks shining through conjunctiva
• Hyperemia and telangectisia of post. lid margin
• Secondary changes - papillary conjunctivitis - inferior
corneal punctate epithelial erosions
TREATMENT
• Lid hygiene (warm compress , massage)
• Topical antibiotics (immediately after massage)
• Systemic tetracyclines (doxycycline-blocks lipase
production)
• Ocular lubricants
• Topical steroids (fluoromethalone-for papillary
conjunctivitis)
PARASITIC BLEPHARITIS

• Associated infestation of lashes by lice

• Common in people living in poor hygienic
conditions
 PARASITIC Contd…

• Chronic irritation, Itching, Burning, lacrimation

• Lid margin – red & inflamed
• Slit lamp examination – Lice anchoring lashes
with claws
• Nits – seen as opalescent pearls adherent to
base of cilia
• Conjunctiva congestion on land standing cases
PARASITIC Contd..

TREATMENT
• Mechanical removal of lashes with forceps
• Application of antibiotic ointment & yellow mercuric
oxide 1% to lid margins and lashes
• Delousing of patient
 EXTERNAL HORDEOLUM (STYE)

• Localized infection or inflammation of the

eye lid margin
• Acute staphylococcal abscess of a lash
follicle and is associated with gland of the
Zeis or Moll
• Can be in upper/ lower eyelid
 STYE Contd…
Predisposing Factors:

• Age: Common in children and young adults and in patients

with eye strain due to muscle imbalance or refractive
errors
• Habitual rubbing of the eyes or fingering of the lids and
nose: chronic blepharitis and DM: associated with
recurrent styes
• Metabolic factors, chronic debility, excessive intake of
carbohydrates and alcohol also act as predisposing
factors
STYE Contd…
Clinical Features: Symptoms
• Localized swelling of the eyelid
• Mild pain and redness over the swelling
• Burning sensation, irritation, watering of eyes
• Eyelid may appear full or droopy

Signs
• Tender swelling, edema near the lid margin
 STYE Contd…
TREATMENT:
Non – Pharmacologic:
• Warm Compression( to apply a warm compressor eye ) twice daily for
2 to 4 weeks
• Epilation of involves eyelash
• Incision and drainage if not resolved

Pharmocologic:
• Usually no treatment needed, resolve spontaneously
• If does not resolves then:
– Topical antibiotic
– Anti-inflammatory and analgesics relieve pain and reduce oedema
– In recurrent styes, try to find out and treat the associated
predisposing condition
 CHALAZION (Meibomian Cyst)

• Chronic non-infective lipogranulomatous inflammation

of the meibomian gland
• Caused by proliferation of the epithelium and
infiltration of the walls of the ducts causing blockage
of meibomian gland orifices and stagnation of
sebaceous secretion
• Due to organism of low virulence
• Acne rosacea or seborhoeic dermatitis are at
increased risk
• Malignant change into meibomian gland carcinoma
CHALAZION Contd…
CLINICAL FEATURES:
• Swelling
• Painless unless secondary infected
• Single / multiple

• Small non tender hard swelling in the lid, slightly away from lid margin
• On everting, palpebral conjunctival seen red or purple, grey in later stages
 CHALAZION Contd…
TREATMENT
• Conservative: Small, soft and recent
chalazion: self-resolution
• Hot fomentation, topical antibiotic
eyedrops and oral anti-inflammatory
drugs
• Intralesional injection of steroid
(triamcinolone) – Directly into chalazion
causes complete resolution
• Incision and Curettage
 INTERNAL HORDEOLUM
• Suppurative inflammation of the meibomian gland
associated with blockage of the duct
• Staphylococcal infection of meibomian gland or
infected chalazion
• Symptoms are similar to stye except that pain is
more intense, due to the swelling being embedded
deeply in the dense fibrous tissue.
• Differentiated from stye: Point of maximum
tenderness and swelling is away from the lid
margin and that pus usually points on the tarsal
conjunctiva
INTERNAL HORDEOLUM

Treatment
• Similar to Stye, except when pus formed – Incision
and drainage by vertical incision on tarsal
conjunctiva
 MOLLUSCUM CONTAGIOSUM

• Multiple nodular or papular lesion with

umbilicated centre .
• Caused by a large poxvirus
• The enlargement and distension of epidermal
cells with viral inclusions
• Treatment: Skin lesions is incised and the
interior cauterized with tincture of iodine or pure
carbolic acid
 TUMORS
Benign Tumors
• Nevus
• Hemangioma
• Papilloma
• Xanthelasma
• Sebaceous Adenoma
• Neurofibroma

Malignant Tumors
• Squamous cell carcinoma
• Basal cell carcinoma
• Malignant melanoma
• Sebaceous gland adenocarcinoma
SQUAMOUS CELL CARCINOMA

• Seen at the edge of the lid (transition zone) where the

epithelium changes
• Starts as a nodule that ulcerate
• Preauricular lymph nodes are enlarged
• Spreads slowly in the surrounding structures and are
painless
• Metastasis common
 BASAL CELL CARCINOMA /
RODENT ULCER
• most common malignant tumor of the
eyelids and constitutes 85%–90% of all
malignant epithelial eyelid tumors at this
site
• Most common seen in lower lid near the
inner canthus
• Locally malignant
• Epithelial growth spreads under the skin in
all direction
 BCC Contd…
TYPES
• Nodular-ulcerative
• Pigmented
• Morphea or sclerosing
• Superficial
• Fibroepithelioma

Noduloulcerative basal cell carcinoma is the most common presentation -

nodule grows in size, central ulceration may occur surrounded by a rolled
border. This appearance is often described as a “rodent ulcer.”
Etiology:
• Excessive ultraviolet light exposure in fair-skinned
individuals
• Ionizing radiation
• arsenic exposure
• Scars.
 BCC Contd…
TREATMENT:
• Surgery - Local surgical excision of the tumour along with a 3 mm surrounding
area of normal skin with primary repair is the treatment of choice.
• Cryotherapy - Cryotherapy is often used to treat BCCs outside the periorbital
area
• Chemotherapy - Topical, intralesional, and systemic chemotherapeutic agents
—including topical 5% imiquimod, 5 fluorouracil, cisplatinum, doxorubicin,
bleomycin, and interferon—have been used to treat BCC
• Radiotherapy: Radiation therapy is generally not recommended in the initial
treatment of periocular BCC,
– However, it may be useful in the treatment of advanced or recurrent lesions
THANK YOU