Eyelids 1.pdf

Anatomy Epidermis- keratin layer Dermis- connective tissue, blood vessels, lymphatics and nerve fibers ○ Fibroblasts, macrophages, and mast cells The dermis lies on the orbicularis muscle Sebaceous glands ○ Located in the caruncle and within eyebrow hairs Meibom...

Anatomy Epidermis- keratin layer Dermis- connective tissue, blood vessels, lymphatics and nerve fibers ○ Fibroblasts, macrophages, and mast cells The dermis lies on the orbicularis muscle Sebaceous glands ○ Located in the caruncle and within eyebrow hairs Meibomian glands ○ Modified sebaceous glands found in the tarsal plates Glands of Zeis ○ Modified sebaceous glands associated with lash follicles Glands of Moll ○ Modified apocrine sweat glands opening either into a lash follicle Pilosebaceous units ○ Comprise hair follicles and their sebaceous gland Eyelashes (cilia) Grey line ○ Behind the grey line are the meibomian glands Meibomian gland orifices Anterior layers ○ Muscle of Riolan (grey line) ○ Gland of Moll ○ Lash follicle ○ Gland of Zeis ○ Orbicularis oculi muscle Posterior layers ○ Meibomian gland orifices ○ Mucocutaneous junction ○ Meibomian gland ○ Conjunctiva Mucocutaneous junction ○ Keratinized epithelium of the skin merges with conjunctival mucous membrane Orbital septum ○ Multilayer fascia ○ Separates eyelid and orbit (barrier) Levator muscle ○ ~15 mm ○ Main retractor ○ Posterior fibers insert into the lower third of the anterior surface of the tarsal plate ○ Levator aponeurosis skin insertion ○ Asians due to the low insertion of the levator aponeurosis, closer to the lashes Muller muscle (retracts ~3 mm of eyelid) ○ Minor retractor ○ Inserted into the upper border of the tarsal plate  Inferior retractors: ○ Inferior tarsal aponeurosis Consists of the capsulopalpebral expansion of the inferior rectus muscle Analogous to the levator aponeurosis ○ Inferior tarsal muscle Is analogous to Muller muscle Orbital fat ○ Protective eyelid cushion ○ Superior and inferior pads Lateral, medial, central Orbicularis oculi ○ Main protractor (closes lid) ○ CN VII innervation ○ Function: narrow palpebral fissures and close eyelids ○ Orbital and preseptal portions ○ Role in lacrimal pump Horners muscle Vertical palpebral fissure: 10 mm Horizontal palpebral fissure: 30 mm Congenital malformations Epicanthic folds ○ ○ Bilateral vertical folds of skin that extend from the upper or lower lids towards the medial canthi ○ The folds may involve the upper or lower lids or both ○ Common in children, can disappear within a few years ○ Normal in Asian ethnicity ○ Pseudoesotropia Looks like esotropia but because of the epicantal fold -> pseudoesotropia ○ Lower lid folds extending upwards to the medial canthal area is called epicanthus inversus ○ Treatment: V-Y or Z-plasty ○ Epicantal folds Types Palpebralis ○ Fold symmetrically distributed between upper and lower lids ○ Most common in Caucasians ○ Tarsalis ○ Folds originate in the medial aspect of the upper lids and extend medially ○ Most common in orientals/Asains ○ Inversus ○ Folds start in lower lids and extends upwards to the medial canthal area ○ Associated to the blepharophimosis (decrease in vertical distance in palpebral fissure) ○ Superciliaris ○ Folds arise above the brow and extends downwards to the lateral aspect of the nose ○  Telecanthus ○ Increased distance between the medial canthi ○ Telecanthus with blepharophimosis sx ○ Uncommon condition that may occur in isolation or in association with blepharophimosis and some systemic syndromes Waardenburg - deafness, abormal iris pigmentation and uvea patching of hair Mobious - 6th and 7th CN palsy Teacher Collins Turner Syndrome Females with short stature Ovaries underdeveloped  ○ Etiology: abnormally long medial canthal tendons ○ Do not get confused with hypertelorism in which there is wide bony separation of the orbits Normal values Inner canthal distance (ICD) - 30 mm Interpupillary distance (IPD) - 61-64 mm Outer canthal distance (OCD) - 85 mm Palpebral fissure length (PFL) 28-30 mm ○ Treatment: involves shortening and refixation of the medial canthal tendons to the anterior lacrimal crest Blepharophimosis Syndrome ○ A rare of AD inherited syndrome (mutation in FOXL2 gene chromosome 3) ○ Blepharophimosis-Ptosis-Epicanthus Inversus Syndrome (BPES) Palpebral fissure 20-22 mm Poor levator muscle function ○ Presenting with Telecanthus Epitcanthus inversus Ptosis Blepharophimosis ○ Treatment Surgical correction Epicantus and telecantus and bilateral frontalis suspensions Treat amblyopia (50% is present) Epiblepharon ○ NOT epicanthus, do not have excessive fold of skin ○ An extra horizontal fold of skin stretching across the anterior lid margin ○ Lashes are directed vertically (go up, can have trichiasis but most part lashes go straight up ○ Commonly found in Eastern Asian ethnicity  ○ Treatment is not required in the majority of whites because spontaneous resolution with age is usual If it is affecting the cornea, surgical correction is required Epiblepharon Hotz Procedure ○ Congenital Entropion ○ Upper lid entropion: secondary to the mechanical effects of microphthalmos ○ Lower lid entropion: caused by maldevelopment of the inferior retractor aponeurosis ○ ○ Treatment: excision of a strip of skin and muscle and fixation of the skin crease to the tarsal plate (Hotz procedure Coloboma ○ Uncommon ○ Unilateral or bilateral ○ ○ Partial - or full thickness eyelid defect ○ Eyelid development is incomplete Due to failure of migration of lid ectoderm to fuse the lid folds ○ Associated to CHARGE syndrome Coloboma Heart disease (malformed heart) Atresia chonae (lack of opening in lacrimal system [oropharynx & nasopharynx] ) Retarded growth (short stature, retardation) Genital hypogonadism (underdeveloped reproductive system) Ear anomalies (lower positioned ears) ○ Treatment: small defects involve primary closure, while large defects require skin grafts and rotation flaps ○ Upper lid coloboma Occurs at the junction of the middle and inner third ○ Lower lid coloboma Occurs at the junction of the middle and outer third  ○ Treacher Collins Syndrome AKA mandibulofacial dysostosis Characterized by mandibular and ear anomalies Lower eyelid colonoma and other ocular anomalies Slanted palpenral apertures Cataract Microphthalmos Lacrimal atresia Coloboma Syndromes Associated ○  Cryptophthalmos ○ Rare congenital anomaly in which the eyelids are absent ○ ○ Incomplete cryptophthalmos Characterized by rudimentary lids and microphthalmos ○ Fraser Syndrome Cryptophthalmos and other features as syndactyly, urogenital and craniofacial anomalies Euryblepharon ○ Horizontal enlargement of the palpebral fissure ○ Lateral canthal malpositon and lateral ectropion ○ ○ Which may result in lagophthalmos and exposure keratopathy ○ Treatment: tarsorrhaphy (lateral canthal tightening)  Microblepharon ○ Small eyelids ○ Often associated with anophthalmos ○ ○ Ablepharon ○ Deficiency of the anterior lamellae of the eyelids (skin and orbital muscles) ○ Treatment: reconstructive skin grafting ○ Abelpharon-marostomia Syndrome Characterized by an enlarged fish-like mouth, ear, skin and genital anomalies  Congenital upper lid eversion ○ A rare condition more frequently seen in infants of Afro-Caribbean origin, in down syndrome and in congenital ichthyosis (having dry, thick skin - do no receive adequate moisture -> hard skin) ○ Tarsal plate is too big and easily inverts ○ Typically bilateral and symmetrical ○ May resolve spontaneously with conservative treatment or require surgery ○ Anklyoblepharon filiforme adnatum ○ Upper and lower eyelids are joined by thin tags ○ Most cases are sporadic ○ Treatment involves transection with scissors, usually without anesthesia ○ Disorders of the eyelashes Misdirected eyelashes ○ Trichiasis Misdirection of growth from individual follicles Associated with inflammatory diseases Symptoms: FBS Irritation Tearing Redness Commonly acquired due to inflammation such as  Chronic blepharitis Herpes zoster ophthalmicus Also can be caused by an injury or by sx Pseudo-trichiasis is secondary to entropion Signs: Posterior misdirection of lashes Trauma to corneal epithelium Corneal punctate epithelial erosions (PEE) Corneal ulceration in severe-long-standing cases Causes: Marginal entropion ○ A very common cause of eyelash misdirection ○ Congenital entropion  ○ Acquired entropion ○ Districhiasis Aberrant lashes Rare Congenital distichiasis AD inherited A partial or complete second row of lashes is seen to emerge at or slightly behind the meibomian gland orifices Acquired distichiasis Lashes are thinner and shorter Directed posteriorly Most important cause is intense conjunctival inflammation ○ Trauma ○ Chemical injury  ○ Stevens-Johnson Syndrome ○ Ocular cicatricual pemphigoid Prevent trauma to the corneal epithelium may cause Punctate epithelial erosions Corneal ulceration and pannus formation may occur in severe cases ○ Treatment: Epilation Recurrent Lashes grow every 4-6 weeks Electrolysis Isolated lashes Tedious, need multiple treatments Laser ablation (Argon) Forms craters Cryotherapy Very effective cryoprobe @ -20 degree celsius Complications ○ Skin necrosis ○ Depigmentation skin ○ MG damage ○ Notching of the lid margin Surgery: only in resistant cases Eyelash ptosis ○ Downward sagging of the upper lid lashes ○ Idiopathic or associated to: Floppy eyelid syndrome Dermatochalasis with anterior lamellar slip Long-standing facial palsy  Trichomegaly ○ Excessive eyelash growth ○ ○ Causes: Drug-induced (most common reason) Topical prostaglandin analogues, phenytoin and cyclosporin Malnutrition AIDS Hypothyroidism Familiar congenital: Oculocutaneous albinism type 1 Cornelia de Lange ○ Synophrys (unibrow) and myoia Goldstein-Hutt ○ Cataracts and spherocytosis  Hermansky-Pudlak Syndrome ○ Albinism and bleeding diathesis Madarosis ○ Term used for the loss of lashes ○ Etiology: Local Chronic anterior lid margin disease ○ Infiltrating lid tumors Burns Radiotherapy or cryotherapy of lid tumors Skin disorders Generalized alopecia Psoriasis Systemic diseases Myxoedema Systemic lupus erythematosus ○ Acquired syphilis Lepromatous leprosy Following removal Procedures for trichiasis Trichotillomania - psychiatric disorder of hair removal Trichotillomania ○ Intense impulses to pull out their hair ○ Psychological support ○ Lack of hair, patches appearance ○ Associated to stress, schizophrenia  ○ Poliosis ○ Premature localized whitening of hair, may involve the lashes and eyebrows ○ ○ Etiology: Ocular Chronic anterior blepharitis Sympathetic ophthalmia Idiopathic uveitis Systemic Vogt-Koyanagi-Harada Syndrome Waardenburg Syndrome  Vitiligo Marfan syndrome