The Eyelids

Dr. Mohamed A.
 Basic Knowledge
• Protective function of the eyelids: The eyelids
are folds of muscular soft tissue that lie anterior
to the eyeball and protect it from injury.
• Their shape is such that the eyeball is
completely covered when they are closed.
• Strong mechanical, optical, and acoustic stimuli
(such as a foreign body, blinding light, or
sudden loud noise) “automatically” elicit an eye
closing reflex.
• The cornea is also protected by an additional
upward movement of the eyeball (Bell’s
phenomenon).
• Regular blinking (20–30 times per minute)
helps to uniformly distribute glandular
secretions and tears over the conjunctiva and
cornea, keeping them from drying out.
• Structure of the eyelids: The eyelids consist of
superficial and deep layers.
 Superficial layer:
– Thin, well vascularized layer of skin.
– Sweat glands.
– Modified sweat gland and sebaceous glands (ciliary
glands or glands of Moll) and sebaceous glands
(glands of Zeis) in the vicinity of the eyelashes.
– Striated muscle fibers of the orbicularis oculi muscle
that actively closes the eye (supplied by the facial
nerve).
 Deep layer:
– The tarsal plate gives the eyelid firmness and
shape.
– Smooth musculature of the levator palpebrae that
inserts into the tarsal plate (tarsal muscle). The
tarsal muscle is supplied by the sympathetic
nervous system and regulates the width of the
palpebral fissure. High sympathetic tone contracts
the tarsal muscle and widens the palpebral
fissure; low sympathetic tone relaxes the tarsal
muscle and narrows the palpebral fissure.
– The palpebral conjunctiva is firmly attached to
the tarsal plate.
• It forms an articular layer for the eyeball.
• Every time the eye blinks, it acts like a
windshield wiper and uniformly distributes
glandular secretions and tears over the
conjunctiva and cornea.
– Sebaceous glands (tarsal or meibomian glands),
tubular structures in the cartilage of the eyelid,
which lubricate the margin of the eyelid.
• Their function is to prevent the escape of tear
fluid past the margins of the eyelids. The fibers of
Riolan’s muscle at the inferior aspect of these
sebaceous glands squeeze out the ducts of the
tarsal glands every time the eye blinks.
• The eyelashes project from the anterior
aspect of the margin of the eyelid.
• On the upper eyelid, approximately 150
eyelashes are arranged in three or four rows;
on the lower eyelid there are about 75 in two
rows.
• Like the eyebrows, the eyelashes help prevent
dust and sweat from entering the eye.
Possible causes of abnormal width of the palpebral fissure

Increased palpebral fissure

 Peripheral facial paresis (lagophthalmos)
 Grave’s disease
 Perinaud’s syndrome
 Buphthalmos
 High-grade myopia
 Retrobulbar tumor
Decreased palpebral fissure
 Congenital ptosis
 Ptosis in oculomotor nerve palsy
 Ptosis in myasthenia gravis
 Sympathetic ptosis (with Horner’s syndrome)
 Progressive ophthalmoplegia (Graefe’s sign)
 Microphthalmos
 Enophthalmos
 Shrinkage of the orbital fat (as in senile
enophthalmos)
 Developmental Anomalies
Coloboma
• Definition: a normally unilateral triangular
eyelid defect with its base at the margin of the
eyelid occurring most often in the upper
eyelid.
• Epidemiology and etiology. Colobomas are
rare defects resulting from a reduction
malformation (defective closure of the optic
cup). They are only rarely the result of an injury.
• Diagnostic considerations: The disorder is often
accompanied by additional deformities such as
dermoid cysts or amicrophthalmos.
• Treatment: Defects are closed by direct
approximation or plastic surgery with a skin
flap.
 Epicanthal Folds
• A crescentic fold of skin usually extending bilaterally
between the upper and lower eyelids and covering
the medial angle of the eye.
• This rare congenital anomaly is harmless and typical
in eastern Asians. However, it also occurs with
Down’s syndrome (trisomy 21 syndrome).
• 30% of newborns have epicanthal folds until the age
of six months. Where one fold is more pronounced,
it can simulate esotropia. The nasal bridge becomes
more pronounced as the child grows, and most
epicanthal folds disappear by the age of four.
 Blepharophimosis
• This refers to shortening of the horizontal palpebral
fissure without pathologic changes in the eyelids.
• The palpebral fissure, normally 28–30mm wide, may
be reduced to half that width.
• Blepharophimosis is a rare disorder that is either
congenital or acquired (for example, from scar
contracture or aging).
• As long as the center of the pupil remains
unobstructed despite the decreased size of the
palpebral fissure, surgical enlargement of the
palpebral fissure (by canthotomy or plastic surgery)
has a purely cosmetic purpose.
 Ankyloblepharon
• This refers to horizontal shortening of the
palpebral fissure with fusion of the eyelids at
the lateral and medial angles of the eye.
• Usually, the partial or total fusion between the
upper and lower eyelids will be bilateral, and the
palpebral fissure will be partially or completely
occluded as a result.
• Posterior to the eyelids, the eyeball itself will be
deformed or totally absent. Ankyloblepharon is
frequently associated with other skull
deformities.
Deformities
Ptosis
• Definition: Paralysis of the levator palpebrae muscle with
resulting drooping of one or both upper eyelids (from the
Greek ptosis, a falling).
• The following forms are differentiated according to their
origin:
 Congenital ptosis
 Acquired ptosis:
– Paralytic ptosis.
– Sympathetic ptosis.
– Myotonic ptosis.
– Traumatic ptosis.
 Symptoms
• The drooping of the upper eyelid may be
unilateral (usually a sign of a neurogenic cause)
or bilateral (usually a sign of a myogenic cause).
• A characteristic feature of the unilateral form is
that the patient attempts to increase the
palpebral fissure by frowning (contracting the
frontalis muscle).
• Congenital ptosis generally affects one eye only;
bilateral symptoms are observed far less
frequently (7%).
 Treatment
 Congenital ptosis: This involves surgical retraction
of the upper eyelid, which should be undertaken as
quickly as possible when there is a risk of the
affected eye developing a visual impairment as a
result of the ptosis.
 Acquired ptosis: Treatment depends on the cause.
As palsies often resolve spontaneously, the patient
should be observed before resorting to surgical
intervention. Conservative treatment with special
eyeglasses may be sufficient even in irreversible
cases.
Entropion
• Definition: entropion is characterized by
inward rotation of the eyelid margin.
• The margin of the eyelid and eyelashes or
even the outer skin of the eyelid are in contact
with the globe instead of only the conjunctiva.
• The following forms are differentiated
according to their origin
Congenital entropion
Spastic entropion
Cicatricial entropion.
 Etiology:
• Congenital entropion: This results from fleshy
thickening of the skin and orbicularis oculi
muscle near the margin of the eyelid.
• Usually the lower eyelid is affected. This
condition may persist into adulthood.
• Spastic entropion: This affects only the lower
eyelid. A combination of several pathogenetic
factors of varying severity is usually involved
• Cicatricial entropion: This form of entropion is
frequently the result of postinfectious or post-
traumatic tarsal contracture (such as
trachoma; burns and chemical injuries).
• Causes can also include allergic and toxic
reactions (pemphigus, Stevens-Johnson
syndrome, and Lyell’s syndrome).
• Symptoms and diagnostic considerations:
• Constant rubbing of the eyelashes against the
eyeball (trichiasis) represents a permanent
foreign-body irritation of the conjunctiva
which causes a blepharospasm that in turn
exacerbates the entropion.
• The chronically irritated conjunctiva is
reddened, and the eye fills with tears. Only
congenital entropion is usually asymptomatic.
 Treatment:
 Congenital entropion: To the extent that any treatment
is required, it consists of measured, semicircular
resection of skin and orbicularis oculi muscle tissue that
can be supplemented by everting sutures where
indicated.
 Spastic entropion: Surgical management must be
tailored to the specific situation. Usually treatment
combines several techniques such as shortening the
eyelid horizontally combined with weakening or
diverting the pretarsal fibers of the orbicularis oculi
muscle and shortening the skin vertically.
 Cicatricial entropion: The surgical management of this
form is identical to that of spastic entropion.
 Ectropion
• Definition: ectropion refers to the condition in
which the margin of the eyelid is turned away
from the eyeball. This condition almost
exclusively affects the lower eyelid.
• The following forms are differentiated
according to their origin:
Congenital ectropion.
Senile ectropion.
Paralytic ectropion.
Cicatricial ectropion.
 Etiology:
• Congenital ectropion: is very rare and is usually
associated with other developmental anomalies of
the eyelid and face such as Franceschetti’s
syndrome..
Senile ectropion: The palpebral ligaments and
tarsus may become lax with age, causing the tarsus
to sag outward (Fig. 2.8).
Paralytic ectropion: This is caused by facial
paralysis with resulting loss of function of the
orbicularis oculi muscle that closes the eyelid.
Cicatricial ectropion: Like cicatricial entropion, this
form is usually a sequela of infection or injury.
 Symptoms and diagnostic considerations:

• Left untreated, incomplete closure of the

eyelids can lead to symptoms associated with
desiccation of the cornea including ulceration
from lagophthalmos.
• At the same time, the eversion of the
punctum causes tears to flow down across the
cheek instead of draining into the nose.
Wiping away the tears increases the
ectropion. This results in chronic conjunctivitis
and blepharitis.
 Treatment:
 Congenital ectropion: Surgery.
 Senile ectropion: Surgery is indicated. A proven
procedure is to tighten the lower eyelid via a tarsal
wedge resection followed by horizontal tightening of
the skin.
 Paralytic ectropion: Depending on the severity of the
disorder, artificial tear solutions, eyeglasses with an
anatomic lateral protective feature, or a “watch glass”
bandage. In severe or irreversible cases, the
lagophthalmos is treated surgically via a lateral
tarsorrhaphy.
 Cicatricial ectropion: Plastic surgery is often required to
correct the eyelid deformity.
 Trichiasis
• Trichiasis refers to the rare postinfectious or
post-traumatic inward turning of the eyelashes.
• The deformity causes the eyelashes to run
against the conjunctiva and cornea, causing a
permanent foreign-body sensation, increased
tear secretion, and chronic conjunctivitis.
• The eyelash follicles can be obliterated by
electrolysis. The disorder may also be
successfully treated by cryocautery epilation or
surgical removal of the follicle bed.
 Blepharospasm
• Definition: this refers to an involuntary spasmodic
contraction of the orbicularis oculi muscle supplied
by the facial nerve.
• Etiology: In addition to photosensitivity and
increased tear production, Blepharospasm will also
accompany inflammation or irritation of the anterior
chamber.
• Causes of the disorder include extrapyramidal
disease such as encephalitis or multiple sclerosis.
• Trigeminal neuralgia or psychogenic causes may also
be present.
• Symptoms: Clinical symptoms include
spasmodically narrowed or closed palpebral
fissures and lowered eyebrows.
• Treatment: This depends on the cause of the
disorder. Mild cases can be controlled well with
muscle relaxants. Severe cases may require
transection of the fibers of the facial nerve
supplying the orbicularis oculi muscle. The
disorder may also be successfully treated with
repeated local injections of botulinum toxin.
THANKS