Download MBBS Ophthalmology PPT 31 Disorders Of Lid Lecture Notes

Disorders of Lid

Department of Ophthalmology

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Learning Objectives

? At the end of this class the students shal be

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able to :

? Understand the structure and function of the

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eyelids

? Recognize common diseases of the eyelids
? Comprehend the principles of managing eyelid

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diseases

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The eyelids

? Mobile structures

placed in front of

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eyeballs.

? Protect eyes
? Spread tear film

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? Help in tear drainage by

lacrimal pump system

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Structure of eyelids

? The skin- elastic and

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thin

? Subcutaneous areolar

tissue- very loose,

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does not contain any

fat.

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? Striated muscle layer-

orbicularis oculi

-- orbital, palpebral

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and lacrimal portions.

? Sub muscular areolar

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tissue- contains

nerves and vessels.

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Structure of eyelids

? Fibrous layer-

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central tarsal

plate and

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peripheral

orbital septum

? Layer of non-

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striated muscle

fibres

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? Conjunctiva ?

nonkeratinized

squamous

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epithelium

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Glands of eyelids

? Meibomian

glands/Tarsal glands

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Modified sebaceous

glands(30 in no.)

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? Glands of Zeis -

sebaceous glands

open into follicles of

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lashes

? Glands of Moll -

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modified sweat glands-

open into

follicles/ducts of Zeiss

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? Accessory Lacrimal

glands

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? Krause

? Wolfring

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Edema of lids

? Inflammatory edema
Dermatitis, stye, insect bite
? Passive edema

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Renal disease, Cardiac failure,
Cavernous sinus thrombosis

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INFLAMMATIONS OF THE EYELIDS

? Blepharitis
Subacute or chronic lid margin inflammation
1. Anterior blepharitis.

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2. Posterior blepharitis.


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INFLAMMATIONS OF THE EYELIDS

? Blepharitis

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INFLAMMATIONS OF THE EYELIDS

1. Anterior blepharitis

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? Squamous/Seborrhoeic

White dandruff like scales on the lid margin among

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eyelashes

? Ulcerative

Chronic staphylococcal infection- hard crusts and ulcers

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Treatment

Warm compresses

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Lid hygiene, cleaning with diluted baby shampoo

Topical : antibiotic, steroids, tear substitutes

Oral : Azithromycin 500 mg OD for 3 days.

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INFLAMMATIONS OF THE EYELIDS

? Posterior blepharitis
Meibomian seborrhoea

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Meibomianitis
Treatment:
Warm compress, lid hygiene & massage.
Oral doxycycline/erythromycin for 6 wks.

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INFLAMMATION OF GLANDS OF LIDS

? Hordeolum externum or

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stye

Suppurative inflammation

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of gland of Zeis.

? Hordeolum internum

Suppurative inflammation

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of meibomian gland

? Chalazion/Tarsal or

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Meibomian cyst

Chronic inflammatory

granuloma of meibomian

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gland.

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Incision and curettage of chalazion

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ANOMALIES IN POSITION OF

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LASHES AND LIDS

? Blepharospasm

? Trichiasis

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? Entropion

? Ectropion

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? Symblepharon

? Ankyloblepharon

? Blepharophimosis

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? Lagophthalmos

? Blepharoptosis

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? Blepharospasm

Involuntary, sustained and forcible closure of

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lids.

Essential blepharospasm-Rare, idiopathic.

Treatment: Botulinum toxin

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Facial denervation

Reflex blepharospasm- Vth nerve reflex

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Sensory stimulation

Treatment: of causative disease(Eg. corneal ulcer)

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? Trichiasis

Misdirection of cilia, directed backwards to rub

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cornea.

Causes:

Trachoma, blepharitis, scars, chemical burns,

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Steven-Johnson syndrome.

Treatment: Epilation

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Electrolysis

Cryosurgery

Argon laser application

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ABNORMALITIES OF THE LASHES

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? Trichiasis

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? Entropion

Inward

rolling/inturning of

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lid margin.

?Involutional
?Cicatricial

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(trachoma, burns,

SJ syndrome)
?Spastic(lower lid)

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?Congenital

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? Involutional Entropion (age related)
v Horizontal lid laxity

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v Vertical lid instability
v Over-riding of pretarsal plate
v Orbital septum laxity

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Surgical procedures for entropion

? Transverse everting sutures (Quickert)

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? Transverse blepharotomy with everting

sutures- Weis procedure

? Jones procedure- tucking of inferior lid

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retractors (recurrences)

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Transverse everting sutures

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Weis procedure

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Jones procedure

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? Cicatricial entropion

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Due to conjunctival scarring
Causes:
Trachoma, chemical burns

Treatment : Tarsal fracture/ wedge resection

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Tarsal Fracture

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ECTROPION

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? Eversion of lid margins and lashes away from

the globe.

?Acquired ? Involutional/senile-lower lid

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Cicatricial- burns and injuries
Paralytic- 7th nerve paralysis
Mechanical-tumors/proptosis
?Congenital

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ECTROPION

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? Involutional Ectropion (Age Related)
? Horizontal lid laxity
? Medial canthal tendon laxity

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? Lateral canthal tendon laxity
? Disinsertion of lower lid retractors

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? Treatment
? Wedge resection for horizontal lid laxity
? Diamond excision for medial ectropion
? Kuhnt-Szymanowski Procedure modified

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by Byron Smith for lateral ectropion

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Wedge resection for horizontal lid

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laxity

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Diamond excision for medial ectropion

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Modified Kuhnt-Szymanowski Procedure

for lateral ectropion

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? Cicatricial Ectropion
Due to burn, trauma, chronic inflammation of

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skin or surgical scarring.

Treated with Z/ V-Y Plasty or skin grafts.

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V-Y Plasty

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? Paralytic Ectropion

Due to Facial nerve palsy

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Treated by:

Tarsorrhaphy

Medial canthoplasty

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Lateral canthal sling

Upper lid lowering

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? Mechanical ectropion (tumours)- corrected by

treating the underlying cause.

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SYMBLEPHARON

? Adhesion of palpebral

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and bulbar conjunctiva

? Causes:
Chemical injuries
Burns

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Trauma

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ANKYLOBLEPHARON

? Partial or complete

fusion of margins of

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upper and lower lids.

? Congenital or acquired

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BLEPHAROPHIMOSIS SYNDROME

? Autosomal dominant

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? Blepharophimosis
? Ptosis
? Epicanthus inversus
? Telecanthus

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BLEPHAROPTOSIS

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? Abnormal drooping of the upper lid to a level that

covers more than 2mm of the superior cornea.

1. Congenital

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Simple
Complicated
2. Acquired
Neurogenic- 3rd Nerve palsy, Horner's syndrome
Myogenic ? Myasthenia , Myotonic dystrophy

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Aponeurotic- Involutional, postoperative
Mechanical- lid tumors

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BLEPHAROPTOSIS

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? MRD (margin reflex distance)
Normal 4mm ? 1mm

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Severity
? Mild ptosis- < 2mm
? Moderate - 3mm
? Severe ? 4mm

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? Levator Palpebrae Superioris (LPS) Action
Good > 8mm

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Fair 5-7
Poor 4mm

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SURGICAL TREATMENT

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? Fasanella-Servat operation
LPS action good
Mild ptosis < 2mm
Horner's syndrome

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SURGICAL TREATMENT

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? LPS Resection (Conjunctival approach)
LPS action fair
Any type of ptosis
Moderate congenital or acquired ptosis

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SURGICAL TREATMENT

? LPS Resection (Skin approach)

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? Most preferred surgery for ptosis correction
LPS action fair
Any type of ptosis
For larger resection in congenital or acquired

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ptosis.



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SURGICAL TREATMENT

? LPS Resection with aponeurotic reinsertion
LPS action fair

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Any type of ptosis
Acquired ptosis.


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SURGICAL TREATMENT

? Frontalis Sling surgery (Brow suspension)
LPS action poor
Ptosis >2 mm

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Congenital ptosis

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NEOPLASMS OF LIDS

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? Benign lesions
? Xanthelasma
? Naevus or mole
? Haemangioma

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? Neurofibromatosis

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XANTHELASMA

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? Yellow plaques on eyelids
? Lipid laden macrophages

in superficial dermis and

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subdermal tissue

? May be associated with

diabetes mellitus and

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hypercholesterolemia

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? Malignant tumours
?Basal cell carcinoma
?Squamous cell carcinoma
?Sebaceous gland carcinoma
?Malignant melanoma

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BASAL CELL CARCINOMA

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? Commonest malignant

lid tumour/Rodent ulcer

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? Noduloulcerative
? Sclerosing
? Pigmented
? Treated by surgery
At least 3mm clear

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margins with lid
reconstruction

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SQUAMOUS CELL CARCINOMA

? More aggressive tumour
? Ulcerative or fungating
? Treated by surgery

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Surgical excision with
wide margins with lid
reconstruction

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SEBACEOUS GLAND CARCINOMA

? Occurs more commonly

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on the upper lid

? Masquerades as benign

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lesions like chalazia

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MALIGNANT MELANOMA

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? Rare tumour
? Lentigo maligna

melanoma

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? Nodular melanoma

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Thank You

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