Patient Assessment in Ocular Conditions

Eyelid Anatomy and Diseases

• Eyelids are two mobile muco-cutaneous folds covering the orbital content.
• The edges of the eyelids meet when the eyes are closed; the anterior border has rows of lashes (100 upper, 50 lower).
• The posterior border is angled. Meibomian glands are anterior to the posterior border.
• Modified sebaceous (Zeis) and sweat (Moll's) glands secrete into lash follicles.
• The lid fits the globe about 2mm below the upper limbus (for the upper lid) and nearly on the lower limbus (for the lower lid).
• The lacrimal portion of the lid margin is small, medial to the puncta, and lacks lashes.

Eyelid Anatomy - Minute Anatomy

• The eyelid has several layers including skin, subcutaneous tissue, muscle, a fibrous tarsus, and the palpebral conjunctiva.
• The eyelids are supported by palpebral fascia (orbital septum), skin of the eyelid, superficial fascia, palpebral part of orbicularis oculi, lash follicles, Zeis glands, eyelashes, and Moll's glands.
• Skeletal muscle layer includes the palpebral part of the orbicularis oculi (which is innervated by the 7th cranial nerve), the insertion of the levator palpebrae superioris (3rd cranial nerve), and Muller's muscle (involuntary, sympathetic innervation).
• The submuscular areolar tissue contains vessels, nerves, and lymphatics, traversing the levator fibers, marked as a gray line on the lid margin.
• The tarsus is a condensed fibrous tissue forming the eyelid's skeleton, with meibomian glands arranged within it (30 lower, 40 upper). It connects to the orbital margins and the orbital septum both laterally and medially.

Congenital Anomalies of the Eyelid

• Ankyloblepharon: Adhesion between both eyelid margins.
• Coloboma: Full-thickness defect in the eyelid and lid margin that can cause exposure keratitis, requiring surgical repair.
• Epicanthus: Skin fold over the medial canthus and caruncle, sometimes causing a pseudo-convergent squint.
• Telecanthus: Increased distance between medial canthi, producing pseudo-convergent squint.
• Blepharophimosis syndrome: Narrowing of the palpebral fissure (25-30 mm to 18-20mm), often accompanied by ptosis, epicanthus inversus, and ectropion or telecanthus.
• Congenital ectropion: Outward turning of eyelid.
• Congenital entropion: Inward turning of eyelid.
• Distichiasis: Extra row of lashes in the site of meibomian gland ducts.

Ptosis

• Ptosis is the dropping of the upper eyelid below its usual level (usually covering the upper 1/6 of the cornea, 2 mm).
• Congenital ptosis often appears bilateral and is usually hereditary. It involves myogenic or neurogenic poor development of the levator palpebrae superioris muscle or nerve supply.
• Acquired ptosis can be neurogenic (e.g., oculomotor nerve palsy, Horner's syndrome), myogenic (e.g., myasthenia gravis, myotonic dystrophy), mechanical (e.g., lid swelling), or senile (involutional) (degenerative changes).
• Pseudo-ptosis results from a lack of lid support, such as in microphthalmos or enophthalmos.
• Hysterical ptosis can be associated with emotional distress in young women
• Traumatic ptosis is due to injury to the levator muscle or its nerve supply

Evaluation of Ptosis

• History (age of onset, trauma, family history)
• Exclude pseudo-ptosis through visual acuity and visual deprivation amblyopia diagnosis
• Frontalis muscle elevation measurement by marking the brow position & measuring the difference in the primary position.
• Observe for absence of eyelid crease, corneal sensation abnormality, or unusual head posture
• Measure marginal reflex distance and vertical fissure height.
• Assess levator function (measured in mm)

Surgical Repair of Ptosis

• Indications: Congenital or acquired ptosis (excluding hysterical, pseudo-ptosis, and myasthenic ptosis). Exclude any 3rd nerve palsy or corneal anesthesia.
• Timing varies based on severity, pre-school (mild) vs. younger age (possible amblyopia)
• Surgical choices include Fasanella-Servat operation (mild ptosis), Levator resection (moderate-severe ptosis), or Frontalis suspension (severe ptosis).

Disorders of Eye Lashes

• Trichiasis: Misdirected lashes rubbing against the cornea or conjunctiva
• Etiology: Entropion (most common), old age, bandaging, burn injuries, trachoma
• Polyosis: Whitening of lashes
• Madarosis: Permanent loss of lashes

Entropion

• Rolling of the eyelid margin & tarsal plate inward.
• Etiology: Cicatricial (scarring), spastic (muscle spasm), involutional (senile).
• Types: Cicatricial (post-inflammatory, post-traumatic), spastic (due to blepharospasm), senile (involutional), mechanical (empty socket, atrophic globe).
• Treatment: Varies by type but generally involves correction of the underlying cause (post-traumatic injury) & temporary (eg, collodion, adhesive strips), and permanent options.
• Causes: Scar tissue, burns, mechanical irritation/detachment issues, muscle spasm, and natural causes of aging.)

Ectropion

• Rolling of the eyelids outward, usually affecting the lower lid, due to gravity.
• Symptoms: Epiphora (excessive tearing), eczema, conjunctiva/corneal issues.
• Types: Cicatricial (scarring), spastic, senile (involutional), mechanical.
• Treatment: Varies by type. Some common treatments are correcting the underlying cause (scar tissue), temporary measures (eg, moistening eye drops), and surgical options (eg, grafting, wedge resection)

Other Eyelid Diseases

• Xanthelasma: Subcutaneous cholesterol deposits often in the medial canthus; treated by therapies or surgical removal.
• Dermatochalasis: Redundancy of eyelid skin in old age; treated by blepharoplasty.
• Blepharochalasis: Recurrent edema of the eyelid in young age.

Blepharitis

• Chronic inflammation of the eyelid margin often caused by external irritants(dust, wind, heat), metabolic issues, and or conditions affecting eyelid margin:
• Types: Squamous, Ulcerative, Parasitic, Angular.
• Etiology: Predisposing (external irritants, eye strain, etc.) & Excitatory (bacterial, seborrhea, parasites).
• Clinical picture: Vary by type, ranging from sebaceous discharge to redness and scales.
• Treatment: General (health, scalp care, diet) and local (cleaning, ointment, antibiotics).

Inflammation of Glands

• Stye (Hordeolum Externum): Acute infection of Zeis gland or eyelash follicle, usually causing pain, swelling, redness
• Hordeolum Internum : infection of the meibomian gland; more painful.
• Chalazion: Chronic inflammation of the meibomian gland.

References

• Wills Eye Manual
• Kanski's Clinical Ophthalmology

This quiz focuses on key elements of patient assessment related to ocular conditions, particularly ptosis and trichiasis. Participants will test their understanding of history-taking, visible effects of muscle hyperaction, and potential impacts on eye health. Ideal for healthcare professionals in ophthalmology or optometry.