Eyelids

Eyelids and
and Adnexal
Adnexal
Disorders
Disorders
Dr. Halimah Pagarra. SpM
Ophthalmology Department
Medical Faculty
Hasanuddin University

INTRODUCTION
INTRODUCTION

Eyelids :
- Physical Protection to the eyes
- Ensuring drainage of the tear
film
Major features of
the normal
eyelid.
a. Eyelid margin
with cilia
b. upper eyelid
crease
c. medial
canthus
d. lateral

Abnormalities of
the eyelids : Ptosis
Entropion,
ectropion
Eyelids lump :
Chalazion, Cyst,
Hordeolum, nevus,
squamous cell
pailloma,
xantelasma, etc

Inflamation of the
eyelids : Blefarities

Abnormalities of
lashes Trichiasis

1.
1.
PTOSIS
PTOSIS
This is an abnormally low position of
the upper eyelid

Ptosis of
Left
upper
eyelids

PATHOGENESIS of
PTOSIS

1.

Mechanical factors
(a) Large lid lesions (tumour)
pulling down the lid.
(b) Lid oedema.
(c) Tethering of the lid by
conjunctival scarring.
(d) Structural abnormalities
including a disinsertion of
the aponeurosis of the
levator muscle, usually in
elderly patients.

Pre op

Post op

PATHOGENESIS OF PTOSIS
2. Neurological factors
(a)Third nerve palsy.
(b)Horners syndrome,
due to a sympathetic
nerve lesion.
(c)MarcusGunn jawwinking syndrome.
congenital ptosis, a
mis-wiring of the nerve
supply to the pterygoid
muscle of the jaw and
the levator of the eyelid

Marcus Gun Jawwingking ptosis

(synkinesi lingking
cranial N V to canial N
III)

PATHOGENESIS OF PTOSIS

3. Myogenic factors
(a)Myasthenia gravis
(b)Some forms of muscular
dystrophy.
(c)Chronic external
ophthalmoplegia.

SIGN and SYMPTOMS OF

PTOSIS
Cosmetic effect
Vision may be impaired
Reduced eye movement
in a third nerve palsy
Diplopia
Reduced of function of
M. Levator Eyelid
Reduction in size of the
interpalpebral aperture.

Management
Exclude an underlying cause whose
treatment could resolve the problem (e.g.
myasthenia gravis, Third N. III Palsy).
Surgical correction.
In very young children this is usually
deferred but may be expedited if pupil
cover threatens to induce amblyopia.

Management of
ptosis
Ptosis repair is challenging oculoplastic surgical
procedure that requires correct:
- Diagnosis
- Thoughtful planning
- Thorough understanding of eyelid anatomy,
- Experience
- Good surgical technique
Medical and surgical history whether
surgical repair ptosisi is appropriate for that
individual
- History : Dry eye syndrome, Thyroid eye
disease,, previous eye or eyelid surgery and
prior periorbital trauma , coagulation status

ENTROPION
ENTROPION

2.
2.

Turning inward, usually of the lower lid and caused

irritation of lashes to cornea and conjunctiva.
Classification :
Congenital Entropion : primary dan secondary)
Acquired Entropion : spastic, senile, mechanical and
cicatrical

Congenital Entropion
Primary :
Overriding of M.
orbicularis Oculus
Secondary:
Anophthalmus ,
enophthalmus ,
microphthalmus

Acquired Entropion
1. Spastic . E : - Chronical inflamation and chronic pressure
2. Mechanical. E : - Reduced of orbital fat.
- Anoftalmus
- Microftalmus
3. Cicatrical E. : - Chronical inflamation
( Trachoma, Steven Johnson Syndrome
- thermis/chemical trauma
- radiation burn
- surgical trauma
4. Senile E. : ( 70-75 y.o) reduced of orbital fat,
, elastisitacity of skin.

Symptoms : Irritation

Lacrimation
Phototofobia
Pain
Corneal Ulcer
Cicatrical cornea
Vascularitation of cornea
DD : Trichiasis)

Management
Non Surgical Entropion Spastik :
1. Using prothesa ( atrophy bulbi / post
enucleation)
2. Eversion of palpebra with plester
adhesive
3. Epilation

Entropion:
inturning
eyelashes may
scratch
and damage the
cornea

Temporary
treatment of
entropion

Management
Surgical :
1. Spastic E, failed with non surgical :
a. entropion suture (Gaillard arlt tehnik)
c. Snellen suture
d. Technic author
e. AuthorModification (Wheeler orbicularis strip
technique)
2. Senile E.
a. Kauterisasi Ziegler cicatrics
b. Modification Ziegler
c. Skin resection

Management of Entropion

3. cicatricial Entropion
a. upper eyelid:
- Streatfield-Snellen
- Horizontal tarsal section
- Tarsal resection with mucosal graft
- Von Milliagen tarsochilloplasty
b. Lower eyelid :
- Skin and muscle excision (graft)
- Tarsal section

3.
3.
Ectropion
Ectropion

Turning outward of eyelids

conjunctiva exposed
Classification:
Congenital (rare)
Acquired : Spastic, mechanic,
cicatricals, paralytic, senile.

Etiologi
Spastical spasme of m.orbicularis (young
teenagers), irritation, edema of conjungtiva
Mechanical tumor/inflamation
Cicatrical post trauma
Paralitik parese N.VII (morbus
hansen,lues)
Senile loss of tonus of Orbicularis oculi.

Types of ectropion:
- Involutional:
- Horizontal eyelid
laxity(medial or lateral
canthal tendons
Cicatricial

Paralytic

- Mechanical

Sign and Symptom

Subjektif
Red eye, epifora
Objektif
eyelid turning outward
Incomplete eyelid closure
Epifora pungtum eversion.

Management
NonSurgical :

Mild Case
Spastical ( Tapping eyelids, sweep tear film
from down to up)
Senile & Paralitic
Snellen suture
Elektrocauter (Galvanocauter Ziegler)

4.Blepharitie
4.Blepharitie
ss

Chronic eyelid inflammation

Staphylococcal infection.
The condition causes squamous
debris, inflammation of the lid margin,
skin and
eyelash follicles (anterior blepharitis).
The meibomian glands may be
affected independently (meibomian
gland disease or posterior blepharitis).

Sign and
Symptoms
Tired, sore eyes, worse in the morning
Crusting and scalling of the lid margin.
debris in the form of a rosette around the
eyelash, ulcerated, a sign of
staphylococcal infection
reduction in the number of eyelashes
obstruction and plugging of the
meibomian ducts
injection of the lid margin;

Fig.
(a)A diagram showing the signs of
blepharitis.
(b) The clinical appearance of the lid margin.
Note (1) the scales on the lashes,
(2) dilated blood vessels on the lid

Fig. Chronic staphyloccal blepharitis, (a)

Collarettes,
(b) Papillari conjunctivitis Scarring of the
lid margin,
(d) Madarosis and trichiasis

Fig. Chronic Seborrhoic blepharitis,

(a) Grasy lid margin with sticky lashes
(b) Soft scales

Fig. Posterior blepharitis, (a) Capping of Meibomian

gland orifices by oil globules,(b) Plugging og MG
orifices and teleangiectasis, expressed toothpastelike plaques(d) Froth on the lid margin

Treatment
Difficult and must be long term.
A cotton bud wetted with bicarbonate solution or
diluted baby shampoo removed squamous
debris .
Abnormal meibomian gland secretions (hot
bathing) Lid massage .
Topical (fusidic acid gel) and, occasionally, with
systemic antibiotics (oral tetracyclin).
Steroids may improve an anterior blepharitis but
frequent use is best avoided.
Posterior blepharitis can be associated with a dry
eye which
requires treatment with artificial tears.

The term adnexa

refers to skin
appendages that
are located within
the dermis but
communicate
through the
epidermis to the
surface.
- Oil glands,
(Meybom)
- The lash follicle
have a sweat
glands (apocrine)
gland of Moll
- modified sebaceus
gland (of Zeis)

Figure 4. Anatomic section of

eyelid skin
showing major dermal adnexal

Hordeolum
An abscess (internal
hordeolum) may also
form within the
meibomian gland
A stye (external
hordeolum) is a painful
abscess of an eyelash
follicle
It is painfull ( Unlike
chalazion, painless )

Fig. Internal hordeolum. An acute infection

of a meibom gland produces a swelling
directed internally toward the conjunctiva. The
figure demonstrates a discret, circumscribed
area of inflammation highlighted by a

EXTERNAL HORDEOLUM
(STYE)
It is an acute suppurative
inflammation of gland of the
Zeis
or Moll.
Etiology
1. Predisposing factors. It is more common in children
and young adults (though no age is bar) 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 diabetes mellitus
are usually associated with recurrent styes. Metabolic
factors, chronic debility, excessive intake of
carbohydrates and alcohol also act as predisposing
factors.
2. Causative organism commonly involved is
Staphylococcus aureus.

Fig. External hordeolum. This large, acute

swelling, wich is red and painful, involves the
haie follicle or associated glands of Zeis or
Moll and points toward the skin

Chalazion
Obstructed meibomian
gland within the tarsal
plate
It is painless.
Symptoms are of an unsightly
lid swelling which usually
resolves within 6 months.
If the lesion persists it can be
incised and curetted from
the conjunctival surface.

Eyelids Lumps
This umbilicated lesion
found on the lid margin is
caused by the pox virus.
It causes irritation of the
eye. The eye is red and
small elevations of
lymphoid tissue (follicles)
are found on the tarsal
conjunctiva.
Treatment
requires excision of the
lesion.

Molluscum Contangiosum

Trichiasis

Aberrant eyelashes are directed slow growing;

locally invasive; non-metastasizing.
The lashes rub against the cornea and cause irritation
and abrasion. It may result from any cicatricial process.
In developing countries trachoma is an important cause.

Treatment

Epilation of the offending lashes

Cryotherapy or electrolysis
recurrance
Surgical Underlying abnormality
of lid position

5. Congenital
Anomalies
Isolated or associated with other
eyelid, facial, or systemic anomalies.

Blepharophimosis syndrome

Congenital eyelid
eversion

Congenital eyelid deformities; A, Ankyloblepharon. B,

Epiblepharon. C, Epicanthus. D, Euryblepharon.

Ankyloblepharon.

Epiblepharon.

Epicanthal fold

Euryblepharon

True coloboma of upper

eyelid.

Cryptophthalmos

Thank you

The term adnexa refers to skin appendages that are

located within the dermis but communicate through the
epidermis to the surface.
They include oil glands, sweat glands, and hair foll icles.
The eyelids contain both the speC ialized eyelashes and
the normal vellus hairs found on skin throughout the body.
Periocular adnexal oil glands include the meibomian
glalnds within the tarsal plate, the glalnds of Zeis
associated with eyelash follicles, and normal sebaceous
glands that are present as part of the
pilosebaceous units in the skin hair.
Sweat glands in the periocular region include the
eccrine sweat glands, which have a general
distribution throughout the body and are responsible for
thermal regulation, and the eccrine glands with apocrine

Figure 2 Anatomic section of

eyelid skin
showing major dermal adnexal