Eyelid Anatomy PDF

Eyelid Dr.Ruwida Mohamed Saeed Abdullah MSC, Libyan Board Of Ophthalmology Anatomical eyelid Review The skin consists of the epidermis, dermis and related structures (adnexa). Epidermis : comprises four layers of keratin-producing cells (keratinocytes). It also contains melan...

Eyelid Dr.Ruwida Mohamed Saeed Abdullah MSC, Libyan Board Of Ophthalmology Anatomical eyelid Review The skin consists of the epidermis, dermis and related structures (adnexa). Epidermis : comprises four layers of keratin-producing cells (keratinocytes). It also contains melanocytes, Langerhans cells and Merkel cells. Keratin layer (stratum corneum Granular cell layer (stratum granulosum) Prickle cell layer (stratum spinosum) Basal cell layer (stratum basale) Dermis: much thicker than the epidermis. It is composed of connective tissue and contains blood vessels, lymphatics and nerve fibres in addition to fibroblasts, macrophages and mast cells. In the eyelid the dermis lies on the orbicularis muscle. Adnexa lie deep in the dermis or within the tarsal plates.  Gland Location Type NB Sebaceous glands Located in the caruncle and within Eyebrow sebaceous glands hairs. Meibomian glands located in the tarsal plates consists of a central modified sebaceous form the outer duct with multiple acini, which synthesize glands layer of the tear lipids film. They empty through a single row of 20–30 orifices on each lid. Glands of Zeis Associated with Lash follicles Modified sebaceous glands Glands of Moll Opening either into a lash follicle or directly Modified apocrine onto the anterior lid margin between lashes. sweat glands They are more numerous in the lower lid. Eccrine sweat glands Distributed throughout eyelid skin Are not confined to the lid margin Pilosebaceous units Comprise hair follicles and their sebaceous Glands Function of the eyelids Sensory and protective effects of the cilia surrounding the eye Secretions of the meibomian glands and conjunctival goblet cells , which contribute to the outer lipid and inner mucopolysaccharide layers of the precorneal tear film, respectively Physical protection against trauma Reduction of evaporation of tears Distribution of the precorneal tear film by eyelid movements Pumping of tears down the nasolacrimal duct, preventing epiphora and promoting a precorneal tear film of uniform thickness and optical properties Clinical Classification Macule. Localized area of colour change without infiltration, depression or elevation, less than 1 cm in diameter. Clinical Classification Papule. A solid elevation less than 1 cm in diameter. Clinical Classification Vesicle. Circumscribed lesion Bulla. A large (more than 0.5 Pustule. A pus-filled elevation containing serous fluid (less cm) serous fluid-filled lesion less than 1 cm in diameter. than 0.5 cm across). (plural – bullae). Cyst. A nodule consisting of an epithelial-lined cavity filled with fluid or semi-solid material. Crust. Solidified serous or purulent Scale. Readily detached fragments of shed exudate keratin layer. Plaque. A solid elevation of the skin, greater than 1 cm in diameter. Clinical Classification. Nodule. A palpable solid area measuring more Papilloma. A benign neoplastic warty or tag-like than 1 cm projection of the skin or mucous membrane. Clinical Classification Ulcer. A circumscribed area of epithelial loss. In skin an ulcer extends through the epidermis into the dermis. HISTOLOGICAL CALSIFICATION Tumour : refers only to swelling, though is commonly used to denote a neoplasm. Neoplasia. Abnormal tissue growth. Atypia :an abnormal appearance of individual cells. Dysplasia is an alteration of the size, morphology and organization of cellular components of a tissue. Carcinoma in situ (intraepidermal carcinoma, Bowen disease)exhibits dysplastic changes throughout the thickness of the epidermis. Hyperkeratosis. An increase in thickness of the keratin layer that appears clinically as scaling. Acanthosis. Thickening of the prickle cell layer. Dyskeratosis is keratinization other than on the epithelial surface. Parakeratosis is the retention of nuclei into the keratin layer General considerations Diagnosis The clinical characteristics of benign lesions are a tendency to a lack of induration and ulceration, uniform colour, limited growth, regular outline and preservation of normal lid margin structures. Biopsy may be required if the appearance is suspicious. Incisional biopsy involves removal of a portion of a lesion for histopathology. Excision biopsy is performed on small tumours and fulfils both diagnostic and treatment objectives. Treatment options include: Excision of the entire lesion and a small surrounding portion of normal tissue. Marsupialization involves the removal of the top of a cyst allowing drainage of its contents and subsequent epithelialization. Ablation with laser or cryotherapy. So what are the benign eyelid lesions ? Chalazion (meibomian cyst A chalazion is a sterile chronic (lipogranuloma) of Symptoms the meibomian or Zeiss glands caused by retained sebaceous secretions. ○ Subacute/chronic: gradually enlarging painless rounded nodule. Causes : ○ Acute: sterile inflammation or bacterial  Uncorrected refractive errors infection with localized cellulitis. A secondarily infected meibomian gland is  Blepharitis; rosacea can be associated with referred to as an internal hordeolum. multiple and recurrent chalazia.  Bortezomib, a proteasome inhibitor used in the Signs treatment of multiple myeloma, predisposes to ○ A nodule within the tarsal plate, sometimes the formation of chalazia within 3 months of with associated inflammation. initiation of treatment. ○ Bulging inspissated secretions may be  A recurrent chalazion should be biopsied to visible at the orifice of the involved gland. exclude a masquerading malignancy. ○ There may be an associated conjunctival granuloma. Chalazion (meibomian cyst MANGEMENT Conservative. At least a third resolve spontaneously so observation may be appropriate, especially if the lesion is showing signs of improvement. Hot compress application several times daily may aid resolution, particularly in early lesions. Steroid injection Surgery An external hordeolum (stye) : is an acute staphylococcal abscess of a lash follicle and its associated gland of Zeis that is common in children and young adults. A stye presents as a tender swelling in the lid margin pointing anteriorly through the skin, usually with a lash at its apex. Treatment involves topical (occasionally oral) antibiotics, hot compresses and epilation of the associated lash. Benign eyelid lesions(nodular eyelid lesions)  Cyst of Zeis is a small, non-translucent cyst on the anterior lid margin arising from obstructed sebaceous glands associated with the eyelash follicle. Benign eyelid lesions(nodular eyelid lesions)  Cyst of Moll (apocrine hidrocystoma) is a small retention cyst of the lid margin apocrine glands. It appears as a round, non-tender, translucent fluid-filled lesion on the anterior lid margin. Benign eyelid lesions(nodular eyelid lesions)  Sebaceous (pilar) cyst is caused by a blocked pilosebaceous follicle and contains sebaceous secretions; the gland orifice will often be visible. It is only rarely found on the eyelid although it may occasionally occur at the inner canthus. Benign eyelid lesions  Comedones are plugs of keratin and sebum within the dilated orifice of hair follicles that often occur in patients with acne vulgaris. Benign eyelid lesions Milia are caused by occlusion of pilosebaceous units resultingin retention of keratin. They are tiny, white, round, papules that tend to occur in superficial crops Benign eyelid lesions Epidermal inclusion cyst is usually caused by implantation of epidermis into the dermis slow- following trauma or surgery. It is a growing, round, firm, superficial or subcutaneous lesion containing keratin Benign eyelid lesions Dermoid cyst is usually subcutaneous or deeper and is typically attached to the periosteum at the lateral end of the brow. It is caused by skin sequestered during embryon Benign eyelid lesions Xanthelasma It is a subtype of xanthoma ,frequently bilateral condition typically affecting middle-aged and elderly individuals. Hyperlipidaemia is found in about one-third of patients, in whom corneal arcus may also be found In contrast to chalazion, fat in xanthelasmata is mainly intracellular in the dermis Treatment This is principally for cosmesis. Recurrence occurs in up to 50% Simple excision is commonly performed where adequate excess skin is present. Microdissection. Larger lesions can be raised in a flap, the fatty deposits dissected from overlying skin under a surgical microscope using micro scissors and the skin replaced. Benign eyelid lesions Capillary hemangioma It presents shortly after birth as a unilateral, raised bright red lesion , usually in the upper lid. A deeper lesion appears purplish Occasionally the lesion may involve the skin of the face and some patients have strawberry naevi on other parts of the body.  It is important to be aware of an association between multiple cutaneous lesions and visceral haemangioma  The lesion blanches on pressure and may swell on crying.  Ptosis is frequent and there may be orbital extension.  It is three times as common in girls as boys  Mx : beta blocker steroid decrease with age Benign eyelid lesions Port-wine stain is a congenital malformation of vessels within the superficial dermis It manifests clinically as a sharply demarcated soft pink patch that does not blanch with pressure, most frequently located on the face. It is usually unilateral and tends to be aligned with the skin area supplied by one or more divisions of the trigeminal nerve About 10% have associated ocular or CNS involvement, including Sturge–Weber syndrome. Ocular features may include ipsilateral glaucoma, episcleral haemangioma, iris heterochromia and diffuse choroidal haemangioma Treatment with laser (e.g. pulsed-dye) is effective in decreasing skin discoloration, particularly if undertaken early. Benign eyelid lesions Neurofibroma Cutaneous neurofibromas are benign nerve tumours, usually nodular or pedunculated, that can be found anywhere on the skin. An isolated neurofibroma is common in normal individuals, Plexiform neurofibromas typically present in childhood as a manifestation of neurofibromatosis type 1 with a characteristic S-shaped deformity of the upper eyelid. Treatment of solitary lesions involves simple excision, but removal of the more diffuse plexiform lesions may be difficult. What are the features of NF? MALIGNANT EYE LID LESIONS ? Enlist malignant eyelid tumors ? The most common malignancies of the eyelid include basal cell and squamous cell carcinoma. Other malignant eyelid lesions such as Merkel cell carcinoma, melanoma, sebaceous carcinoma, lymphoma, Kaposi sarcoma and metastatic cancer are less common but should be considered Basal Cell Carcinoma BCC typically affects older individuals , is by far the most common malignant eyelid tumour, accounting for 90% of all cases ,the most important risk factors are fair skin, inability to tan and chronic exposure to sunlight. 90% of cases occur in the head and neck and about 10% of these involve the eyelid It most frequently arises from the lower eyelid, followed in relative frequency by the medial canthus, upper eyelid and lateral canthus. The tumour is slowly growing and locally invasive but non- metastasizing. Tumours located near the medial canthus are more prone to invade the orbit and sinuses, are more difficult to manage than those arising elsewhere and carry the greatest risk of recurrence. Tumours that recur following incomplete treatment tend to be more aggressive. Can be : nodular ,nodulo-ulverative , sclerosing (mimics Rodent Ulcer : is centrally ulcerated with pearly chronic blepharitis ) raised rolled edges and dilated and irregular blood vessels (telangiectasis) over its lateral margins Squamous Cell Carcinoma  SCC is less common accounts for 5–10% of eyelid malignancies , but more aggressive tumour than BCC, with metastasis to regional lymph nodes in about 20% of cases. Histopathology shows dysplastic changes throughout the thickness of the epidermis.  The tumour may also exhibit perineural spread to the intracranial cavity via the orbit. SCC and may arise de novo or from pre-existing actinic keratosis or carcinoma in situ (Bowen disease, intraepidermal carcinoma –  Immunocompromised individuals, such as those (AIDS) or following renal transplantation are at increased risk, as are those with a predisposing syndrome such as xeroderma pigmentosum.  The tumour has a predilection for the lower eyelid and the lid margin. It occurs most commonly in older individuals with a fair complexion and a history of chronic sun exposure.  Can you Identify each of abnormal eyelid positions on photographs, describe its causes, complications and management ? Entropion Complications Mangement Entropion Management : Temporary protection must be as short-term as possible. Options include lubricants, taping, soft bandage contact lenses Orbicularis chemo-denervation with botulinum toxin injection. Surgical treatment aims to correct the underlying problems : Complications : The constant rubbing of the Transverse everting sutures lashes on the cornea in long-standing entropion The Wies procedure (pseudotrichiasis) may cause irritation corneal Lower lid retractor reinsertion punctate epithelial erosions and, in severe cases, pannus formation and ulceration Ectropion  Complications : Dry eye ,epiphora , exposure keratopathy ,corneal ulcer – non healing and vascularization Management : Generalized ectropion is treated with repair of horizontal lid laxity. This is achieved with a lateral tarsal strip procedure, in which the lower canthal tendon is tightened by shortening and reattachment to the lateral orbital rim Excision of a tarsoconjunctival pentagon is an alternative that can be placed to excise an area of misdirected lashes or keratinized conjunctiva. Ptosis Ptosis is an abnormally low position of the upper lid, which may be congenital or acquired. Neurogenic ptosis is caused by an innervational defect such as 3RD nerve paresis and Horner syndrome (Ptosis +miosis +heterochromia ) Myogenic ptosis is caused by a myopathy of the levator muscle itself, or by impairment of transmission of impulses at the neuromuscular junction (neuromyopathic). Acquired myogenic ptosis occurs in myasthenia gravis, myotonic dystrophy and progressive external ophthalmoplegia Aponeurotic or involutional ptosis is caused by a defect in the levator aponeurosis Congenital Ptosis Congenital ptosis probably results from a failure of neuronal Treatment migration or development with muscular sequelae secondary to This Treatment should be carried out during the preschool SIGNS : years onceaccur ate measurements can be obtained, Unilateral or bilateral ptosis of variable severity but may be considered earlier in severe cases to Absent upper lid crease and poor levator function prevent amblyopia. In downgaze the ptotic lid is higher than the normal because of Levator resection is usually required. poor relaxation of the levator muscle. This is in contrast to Frontalis suspension acquired ptosis, in which the affected lid is either level with or lower than the normal lid on downgaze. Associations  Superior rectus weakness may be present because of its close embryological association with the levator.  Compensatory chin elevation in severe bilateral cases.  Refractive errors are common and more frequently responsible for amblyopia than the ptosis itself. TIP A weak Bell phenomenon can result in exposure keratopathy after ptosis surgery. Identify the common symptoms, signs, complications and treatment of trichiasis. Trichiasis refers to misdirection of growth from individual follicles , rather than a more extensive inversion of the lid or lid margin. It is commonly due to inflammation such as chronic blepharitis or herpes zoster ophthalmicus, but can also be caused by an injury or by surgery Common trichiasis symptoms may include: Eye redness , irritation foreign body sensation. Tearing. (Photophobia). Treatment Signs : 1. Epilation Misdirected lashes 2. Electrolysis Conjunctival congestion 3. Laser ablation Epiphora 4. Cryotherapy corneal opacity ,ulcer ,pannus and vascularization which may end up 5. Surgery : by perforation 1. Tarsal facture 2. full-thickness eyelid pentagon resection 3. Lid splitting Poliosis Poliosis is a premature localized whitening of hair, which may involve the lashes and eyebrows. Causes 1. Ocular Chronic anterior blepharitis Sympathetic ophthalmitis Idiopathic uveitis 2. Systemic Vogt–Koyanagi–Harada syndrome Waardenburg syndrome Vitiligo Marfan syndrome Tuberous sclerosis Madarosis is the term used for the loss of lashes The main causes are 1. Local Chronic anterior lid margin disease Infiltrating lid tumours Burns Radiotherapy or cryotherapy of lid tumours 2. Skin disorders Generalized alopecia Psoriasis 3. Systemic diseases Myxoedema Systemic lupus erythematosus Acquired syphilis Lepromatous leprosy 4. Following removal Procedures for trichiasis Trichotillomania – psychiatric disorder of hair removal  Differentiate between chronic marginal blepharitis on the basis of clinical presentation with Describing the associated complications, treatment and prevention strategies for each type. Chronic blepharitis (chronic marginal blepharitis) is a common cause of ocular discomfort and irritation. The poor correlation between symptoms and signs, the uncertain aetiology and mechanisms of the disease process all combine to make management difficult. Blepharitis may be subdivided into anterior and posterior forms, although there is considerable overlap and both types are often present (mixed blepharitis).  Anterior blepharitis : Posterior Blepharitis Affects the area surrounding the bases of the eyelashes Is caused by meibomian gland dysfunction and alterations in and may be staphylococcal or seborrhoeic. meibomian gland secretions. Bacterial formation of free fatty Abnormal cell-mediated response to components of the acids, contributing to ocular surface irritation and possibly cell wall of s. Aureus, which may also be responsible for enabling growth of S. Aureus. the red eyes and peripheral corneal infiltrates. It is more Loss of the tear film phospholipids that act as surfactants common and more marked in patients with atopic results in increased tear evaporation and osmolarity and an dermatitis. unstable tear film. There is an association with acne rosacea. Seborrhoeic blepharitis is strongly associated with Demodex and other microorganisms may play a causative role generalized seborrhoeic dermatitis that characteristically in some patients involves the scalp, nasolabial folds, skin behind the ears and the sternum Treatment There is limited evidence to support any particular treatment protocol for blepharitis. Patients should be advised that a permanent cure is unlikely, but control of symptoms is usually possible. The treatment of anterior and posterior disease is similar for both types, particular as they commonly co-exist, but some treatments are fairly specific for one or the other. 1. Lid hygiene 2. Antibiotics 3. Topical steroid 4. Tear substitutes 5. Novel therapies include topical ciclosporin, pulsed light application and purpose-designed devices to probe, heat and/ or express the meibomian glands (e.g. Lipiflow™) in posterior disease. Mention the causes or associated systemic and ocular disease for diffuse eyelid inflammation Preorbital cellulitis Orbital cellulitis contact dermatitis Eyelid atopic dermatitis ocular rosacea Blephatitis Herpes (simplex / zoster ) Hordeulum Chalazi Maliganacy Psoriasis, discoid lupus erythematosus, and dermatomyositis By the end you should keep in mind Classify diseases of the eyelid. Identify the common symptoms, signs, complications and treatment of trichiasis. Enlist the causes & risk factors of madarosis and poliosis. Differentiate between chronic marginal blepharitis on the basis of clinical presentation with Describing the associated complications, treatment and prevention strategies for each type. Mention the causes or associated systemic and ocular disease for diffuse eyelid inflammation. Identify each of abnormal eyelid positions on photographs, describe its causes, complications and management. Mention the differential diagnosis on nodular eyelid lesions, define the chalaizon and mention its treatment. To know the benign eyelid lesions. Enlist malignant eyelid tumors, and differentiate between basal cell carcinoma & squamous cell carcinoma