EYELID (II)

Dr Pranisha Singh
6th April 2023
 CONTENT

Entropion
Ectropion
Ptosis
Lid tumours
 ENTROPION

• Inward rotation of the eyelid margin.

 TYPES:

• Congenital

• Acquired:
• Cicatricial
• Spastic
• Senile (involutional)
• Mechanical
 CONGENITAL ENTROPION

• Rare condition

• Seen since birth

• Associated with microphthalmos

• Treatment: plastic reconstruction of lid crease

 SENILE ENTROPION

• Common type

• Affects lower lid in elderly people

 PATHOGENESIS:
1) Horizontal lid laxity: caused by stretching of the canthal tendons and tarsal plate
(test by snap back) Pull the eyelid inferiorly.

• If the eyelid springs to its normal position without a blink it means no lid laxity.

• If it remains away from the eye for a time; it means a lax lid.

• Then the degree of lid laxity will be determined by the number of blink required to
bring the lid on contact to the eye.
SNAPBACK TEST
 PATHOGENESIS

• 2) Weakness of lower lid retractors (test by downgaze to see position of lower

lid)

• 3) Overriding of pre septal to pre tarsal orbicularis (test by closure of eyelids)

• 4) Tarsal plate atrophy (test by palpation of tarsal plate)

• 5) Atrophy of retrobulbar fat

 CICATRICIAL ENTROPION:

• Involves the upper lid.

• Caused by cicatricial contraction of palpebral

conjunctiva with or without distortion of tarsal
plate.

• Causes: trachoma, membranous conjunctivitis,

chemical burns, steven Johnson syndrome
 SPASTIC ENTROPION
• Occurs due to spasm of orbicularis muscle
with chronic irritative corneal condition

• After tight ocular bandage

• Occurs in lower lid in elderly people

 MECHANICAL ENTROPION

• Occurs due to lack of support provided by globe to the lids

• Occurs in phthisis bulbi, enophthalmos, after enucleation or

evisceration operation.
 CLINICAL FEATURES
• Symptoms: in turned eyelashes rub against cornea and conjunctiva
irritation
discomfort
watering
redness

• Signs: trichiasis
corneal punctate epithelial erosion
ulceration
pannus formation
 GRADING

• Grade I: only the posterior lid border is inrolled

• Grade II: inturning up to inter-marginal strip

• Grade III: whole lid margin including anterior border is inturned

 TREATMENT
• Temporary: lubricants
lower lid taping
soft bandage contact lens
botulinum toxin injection
• Surgical:
• No excess horizontal laxity: Weiss procedure (transverse lid split and everting suture)

• Excess horizontal laxity: Quickert procedure (weiss+horizontal lid shortening)

• Recurrence of entropion: Jone’s procedure (plication or tucking of lower lid retractors)

 ECTROPION

• Ectropion is malposition in which the eyelid margin is turned out

from its normal apposition to the globe.
 TYPES

• Congenital

• Acquired: Involutional or senile

Cicatricial
Paralytic
Mechanical
Spastic
SENILE ECTROPION
• Commonest type

• Involves the lower lid

• Occurs due to laxity of tissues of the lid

and loss of tone of orbicularis muscle
 CLINICAL FEATURES OF ECTROPION

• Irritation

• Lacrimation

• FB sensation

• Exposure keratopathy
 TREATMENT OF SENILE ECTROPION
• Medial conjunctivoplasty
(excision spindle shaped piece of conjunctiva and
subconjunctival tissue)

• Horizontal lid shortening (full thickness pentagonal

Excision)

• Modified Kuhnt-szymanowski
operation(pentagonal full thickness excision with
CICATRICIAL ECTROPION
• Occurs due to scarring of the skin

• Involve both upper and lower lid

• Causes: skin scarring due to thermal burns,

chemical burns, skin ulcers
 TREATMENT:

• V-Y operation

• Z plasty: Mild localized cases are treated by

excision of scar tissue combined with ‘Z’-plasty

• Severe cases: Excision of scar tissue and full thickness skin graft
 PARALYTIC ECTROPION

• Due to paralysis of seventh nerve

• Occurs in lower lids
• Causes: Bell’s palsy, head injury, infections
of middle ear

• Treatment:
• Botulinum toxin (into levator muscle)
• lateral tarrsorrhaphy or palpebral sling surgery
 MECHANICAL ECTROPION

• Lower lid is pulled down due to tumors

• Pushed out and down due to proptosis or

marked chemosis of conjunctiva

• Treatment: treat the cause

 SPASTIC ECTROPION

• Rare type

• Seen in children and young adults following spasm of orbicularis

• Treatment: treating the cause of blepharospasm

 GRADING OF ECTROPION

• Grade I: only punctum is everted

• Grade II: lid margin is everted and palpebral conjunctiva is visible

• Grade III: fornix is visible

 COMPLICATONS:
• Prolonged exposure may cause:
• Dryness
• Thickening of conjunctiva
• Corneal ulceration

• Prolonged epiphora may cause:

• eczema and dermatitis
 PTOSIS

It is an abnormally low position of upper lid or drooping

of upper eyelid.
 TYPES OF PTOSIS:

• Congenital ptosis: associated with congenital weakness or

maldevelopment of levator palpebrae superioris muscle
 ACQUIRED PTOSIS
1) Neurogenic: innervational defect such as 3rd nerve, Horner syndrome,
multiple sclerosis

2) Myogenic: myopathy of levator muscle. Seen in myasthenia gravis,

ocular myopathy, trauma to LPS muscle

3) Aponeurotic: defect in levator aponeurosis

4) Mechanical: gravitational effect of mass or scarring on upper lid

 Neurogenic ptosis Myogenic ptosis

Mechanical ptosis
Aponeurotic ptosis
 CLINICAL EVALUATION OF PTOSIS

• Pseudoptosis/Ptosis

• Pseudoptosis: false impression of ptosis

 Causes of pseudoptosis

Lack of lid support Contralateral lid retraction

Ipsilateral hypotropia Brow ptosis - Dermatochalasis –

excessive excessive
eyebrow skin eyelid skin
• Observe: Unilateral/ bilateral

• Function of orbicularis oculi muscle

• Eyelid crease: present/absent

• Jaw-winking phenomenon present /absent

• Weakness of any extraocular muscle

• Bell’s phenomenon: up and out rolling of eyeball during

forceful closure is present or absent
 JAW WINKING PHENOMENON:

The stimulation of the trigeminal nerve by contraction of the pterygoid muscles

of jaw results in the excitation of the branch of the oculomotor nerve that
innervates the levator palpebrae superioris ipsilaterally (on the same side of the
face), so the patient will have rhythmic upward jerking of their upper eyelid.
MEASUREMENT OF DEGREE OF PTOSIS
• Measure the amount of cornea covered by upper
lid and then subtract 2mm

• Mild ptosis: 2mm

• Moderate ptosis: 3mm

• Severe ptosis: 4mm

 MARGINAL REFLEX DISTANCE
MRD1: Distance between upper lid margin
and corneal light reflex

• Normal MRD1: 4 to 5mm

MRD2: Distance between lower lid and

corneal light reflex

• Normal MRD2: 5 to 6mm

 ASSESSMENT OF LEVATOR FUNCTION
• Burke’s method
• Determined by lid excursion caused by LPS muscle
• Patient is asked to look down, thumb of one hand is placed firmly against the eyebrow of
the patient to block the action of frontalis by the examiner
• Then the patient is asked to look up and the amount of upper lid excursion is measured
with a ruler
• Grading: Normal 15mm
Good: 8mm or more
Fair: 5-7mm
Poor: 4mm or less
 Vertical fissure height

•
Distance between upper and lower lid margins
• Normal upper lid margin rests about 2 mm below upper limbus
• Normal lower lid margin rests 1 mm above lower limbus

• Normal 7-10mm in males; 8-12mm in females

• Tensilon test: performed to rule out myasthenia

• Improvement of ptosis with intravenous injection of edrophonium

(Tensilon) in myasthenia.

• Phenylephrine test: in Horner’s syndrome (miosis, ptosis, anhydrosis,

enophthalmos)

• Neurological tests: to find out cause in case of neurogenic ptosis

• Photographic record: for comparision

 TREATMENT:

• Congenital Ptosis: needs surgical correction

• In severe ptosis surgery should be performed earliest to prevent

stimulus deprivation amblyopia.

• In mild and moderate ptosis : surgery at the age of 3-4 years

 PTOSIS SURGERY:
• Fasanella – servat operation : mild ptosis with good levator function

• Upper lid is everted and upper tarsal border with attached Muller
muscle and conjunctiva are resected
 LEVATOR RESECTION
• For moderate and severe ptosis
• LPS muscle resection depend upon severity and function of LPS
muscle
 FRONTALIS SLING OPERATION
• Brow suspension
• Severe ptosis with no levator function
• Lid is anchored to the frontalis muscle via
a sling
• Fascia lata or non absorbable material
used as sling
 LID TUMOURS
Benign tumours:
• Squamous cell papilloma
• Basal cell papilloma
• Inverted follicular keratosis
• Actinic keratosis
• Keratoacanthoma
• Melanocytic naevus
• Capillary haemangioma
• Pyogenic granuloma
• Xanthelasma
• Neurofibroma
 MALIGNANT TUMOURS

• Basal cell carcinoma

• Squamous cell carcinoma
• Meibomian gland carcinoma
• Melanoma
• Kaposi sarcoma
• Merkel cell carcinoma
BASAL CELL CARCINOMA - IMPORTANT FACTS

1. Most common human malignancy

2. Usually affects the elderly

3. Slow-growing, locally invasive
4. Does not spread to regional lymph nodes.
5. 90% occur on head and neck
6. Of these 10% involve eyelids
7. Accounts for 90% of eyelid malignancies
8. Also called as rodent ulcer
 LOCATION:

Lower lid - 70%

Medial canthus - 15%
Upper lid - 10%
70%
Lateral canthus - 5% 15%

10% 5%
 CLINICAL TYPES

1. Nodular

2. Ulcerative

3. Sclerosing
 NODULAR

• Starts as small, indurated nodule with surface vascularization

• Slowly progress and destroy large surface of eyelid

Early Advanced
 ULCERATIVE

Tumours grow by burrowing and destroying the tissues like a rodent:

Rodent Ulcer
 SCLEROSING

Indurated plaque with loss of Spreads radially beneath normal

lashes epidermis, margin impossible to delineate
TREATMENT:

• Surgery: Local surgical excision of

tumour with 3 mm surrounding area of
normal skin

• Radiotherapy: palliative treatment.

Not used for canthal lesions

• Cryotherapy: unable to tolerate surgery

 SQUAMOUS CELL CARCINOMA

• Second commonest malignant tumor

• More aggressive than BCC
• Metastasis to regional lymph node in 20% of cases
• Metastatise in preauricular and submandibular LN
• Accounts for 5-10% of eyelid malignancies
• Common site: upper and lower lids equally
 TYPES:
Nodular: hard, hyperkeratotic • Ulcerative: ulcerated growth
nodule, no surface
vascularization, may develop with elevated and indurated
crusting fissures. margin
 TREATMENT

1) Surgical excision

2) Radiotherapy
MEIBOMIAN GLAND CARCINOMA
• Arises from the meibomian glands in the tarsal plate.
May mistaken for chalazion

• Present as a nodule in upper eyelid later destroys the

meibomian gland orifice.

• Metastasizes to regional lymph nodes

• Full thickness biopsy: helps in diagnosis

• Surgical excision with reconstruction of lid.

 MALIGNANT MELANOMA

• May develop from pre-existing melanotic nevus

• Involve eyelid in form of superficial spreading

malignant melanoma, lentigo maligna melanoma
or nodular melanoma

• Treatment: surgical excision with reconstruction

of lid
• THANK YOU