layers of the lid
1. Skin
2. Subcutaneous tissue
3. Orbicularis oculi muscle
4. Sub-muscular areolar tissue
4. The fibrous layer consisting of
the tarsi and the orbital septum, lid
retractors of the upper and lower
eyelids "levator palpebrae ",
5. Retro-septal fat pad
6. Conjunctiva
🔹 Lid coloboma:
🔹
Is a congenital absence of a part of the eyelid.
Epicanthic folds: Are bilateral vertical folds of
skin that extend from the upper or lower lid towards
🔷 Edema of lids:
This is common and owing to looseness of the tissue may be so
the medial canthus >>> give rise to pseudo- great as to close the eye.
🔹
esotropia.
Epiblepharon:A congenital extra horizontal fold
of skin below the lower lid margin, and the lashes
🔹
Causes
a-Inflammatory edema
1-Inflammation of the lids –allergic dermatitis due to atropine,
are directed vertically. cosmetics, insect bite.
- When we pull the lower lid, every part turns to its 2-Acute conjunctivitis
normal location. DISEASES OF THE LIDS 3-Acute dacryocystitis
- Spontaneous resolution with age. 4-Acute iridocyclitis
5-panophthalmaitis
Simple congenital Ptosis 🔹
6-Obital cellulites]
b-Passive edema due to circulatory obstruction.
1-Nephrotic syndrome
Developmental dystrophy of levator muscle
2-cardiac failure
Occasionally associated with weakness of superior rectus 3-Cavernous sinus thrombosis
Drooping of upper eye lid.
Absent eye lid crease. Blepharitis: is a chronic inflammation of the eyelids that primarily affects the eyelid margins.
🔷
Other less common forms of anterior blepharitis:
Compensatory mechanisms:
-Corrugations of the forehead 🔷
Blepharitis is classified as:
🔹 Anterior blepharitis (also known as Anterior Lid Margin Disease)
Bacterial
Angular blepharitis:
- Is a form of anterior blepharitis.
-Arching of eye brow ( astonished look). -Staphylococcal (usually) : - Affecting the skin of the outer & the inner canthi.
-Chin elevation: in bilateral cases, head is throw backwards & caused by: - Caused by Moraxella species or staphylococcal
(1) direct infection. species.
eyes roll downwards CONGENITAL (2) reaction to staphylococcal exotoxin. -Proteolytic enzymes elaborated by these bacteria can
-Face turn: in unilateral cases, head is tilted to one side. produce maceration, and crusting of the skin.
ABNORMALITIES (3) allergic response to staphylococcal antigen.
🔹
Complications: Demodex folliculorum: Demodex mites are a natural part of the human microbiome Treatment:
Of THE LIDS 🔹 Seborrhoeic (disorder of the ciliary sebaceous glands of Zeis). - Lid hygiene.
Amblyopia in severe cases.
Less common type of Anterior blepharitis : - Topical Antibiotics ointment. & Zinc sulphate oint.
Lumber lordosis. Angular blepharitis (neutralizes the offending enzymes).
Torticollis and contracture sternomastiod ms. Parasitic blepharitis
🔷 Posterior blepharitis (also known as Posterior Lid Margin Disease)
The -meibomian glands inside the eyelid have an opening on the eyelid margin, and they normally contribute oils to 🔷 Parasitic blepharitis (pthiriasis palpebrarum):
Myotonic dystrophy the tears that protect the eyes. Typically, posterior blepharitis develops due to meibomian gland dysfunction, which is - Is an infestation of the eye lashes with the crab louse (pthirus
irregular oil production in the glands of the eyelids (meibomian blepharitis). The oil can create a favorable environment for pubis).
bacterial growth. - Typically affecting children living in poor hygienic conditions
-Meibomian gland dysfunction is very common, and mild cases often go undiagnosed. causing severe itching.
-Full, complete blinks are important to meibomian gland secretion. - The eye lashes are covered with nits (brownish pearly) adherent to
Ptosis: -Decreased blink rates can contribute to blepharitis by decreasing the excretion of meibomian gland content. Additionally, the base of the cilia, a single louse could be seen occasionally.
when the eye remains open and exposed for longer, increased evaporation of tears can contribute to eyelid margin disease. Treatment:
also known as blepharoptosis, is a drooping or falling of the upper eyelid.
The drooping may worsen after being awake longer when the individual's the lid -Meibomian gland dysfunction also causes evaporative dry eye (EDE), the most common form of dry eye syndrome. The Trimming of the lashes.
muscles are tired. consistency and quantity of the tears can also be examined to identify this problem. With EDE, the tears may seem thick or Topical application of yellow mercuric oxide 1% oint. 3-4 weeks (kills
This condition is sometimes called "lazy eye," but that term normally refers frothy. the lice + ova).
to the condition amblyopia. -When meibomian gland dysfunction is chronic, the glands may clog, and sometimes the glands will actually atrophy. Delousing of the patient & the family members.
If severe enough and left untreated, the drooping eyelid can cause other •Bacterial lipases break down meibomian lipids
conditions, such as amblyopia or astigmatism. This is why it is especially •Meibomian secretion becomes abnormal both chemically and physically -Lid hygiene, warm compresses to melt solidified sebum.
🔹 🔷
important for this disorder to be treated in children. •Tear film becomes unstable. - Systemic tetracyclines are the mainstay of treatment, use one of
Etiology –Classification
1-Congenital ptosis
Mixed anterior and posterior blepharitis
elements of both conditions are present 🔹
the following:
🔹 Tetracycline 250 mg b.d 6-12 weeks.
Blepharophimosis syndrome
Rare congenital disorder Dominant inheritance
Moderate to severe symmetrical ptosis
a- With normal superior rectus function
b-With superior rectus weakness 🔹🔹 Doxycycline 100mg once daily 6-12 weeks.
Minocycline 100mg once daily 6-12 weeks.
Erythromycin or azithromycin may be used when tetracyclines
c-Marcus Gunn or jaw-winking ptosis
Short horizontal palpebral aperture 2-Acquired ptosis: are contraindicated.
Telecanthus (lateral displacement a- Neurogenic due to lesion of 3rd nerve OR nucleus, Horner`s syndrome - Topical antibiotic and steroid ointment.
of medial canthus) b-Myogenic Myasthenia gravis, myotonic dystrophy
Epicanthus inversus (lower lid fold larger than upper) c-Mechanical -due to increase weight of lid –tumor
Lateral inferior ectropion d-Aponeurotic: Involutional, postoperative.
Poorly developed nasal bridge
and hypoplasia of superior orbital rims 🔷
Signs of blepharitis (lid margin disease)
🔹 Anterior blepharitis (staphylococcal)
🔹
🔹
lid margin hyperaemia
lid margin swelling
🔹
🔹
Crusting of anterior lid margin (scales at bases of lashes)
Misdirection of lashes
🔹
🔹
loss of lashes (Madarosis)
Recurrent Styes and (rarely) chalazia
Conjunctival hyperaemia
Causes of pseudoptosis Mechanical Ptosis 🔹
Secondary signs include:
🔹🔹 Punctate epithelial erosion over lower third of cornea.
Marginal keratitis.
🔹
🔹
Phlyctenulosis
Neovascularisation and pannus.
Mild papillary conjunctivitis.
🔷
🔹 Anterior blepharitis (Demodex)
🔹 lid margin hyperaemia
Cylindrical dandruff’: characteristic clear sleeve (collarette) covers
base of lash, extending further up lash than flat staphylococcal
🔹
rosettes
Persistent infestation of the lash follicles may lead to misalignment,
🔷
trichiasis or madarosis.
🔹 Anterior blepharitis (Seborrhoeic)
Symptoms of blepharitis (lid margin disease) 🔹 lid margin hyperaemia
🔹Oily or greasy deposits on lid margins
Conjunctival hyperaemia.
Blepharitis may be asymptomatic. However, when present, the symptoms of
anterior blepharitis, posterior blepharitis and mixed anterior and
Trichiasis 🔹
posterior blepharitis are similar:
🔹 ocular discomfort
🔹
an inversion of a varying number of eye lashes so that they rub against the conjunctiva or cornea soreness
🔹 Etiology 🔹
🔹
burning, itching
mild photophobia
Madarosis same as entropion, Blepharitis symptoms of dry eye including blurred vision and contact lens intolerance.
🔹
Is a decrease in number or complete loss of lashes secondry to chronic blepharitis,
🔹
Causes:
1-local
Signs and symptoms
The misdirection lashes cause mechanical irritation and injury to cornea with ulceration- pain,
-chronic anterior lid margin disease Lacrimation, photophobia-blepharospasm, vascularisation and opacities of cornea
🔷Posterior blepharitis (MGD is the most common cause)
-infiltrating tumors
🔷 🔹 Thick and/or opaque secretion at meibomian gland orifices, making it
🔹
-burns Treatment Options for Trichiasis
🔹
-radiotherapy or cryotherapy of lid tumors
2.Skin disorders:
Medical treatment:
Tear substitutions: drops, ointment
🔹
difficult or impossible to express oil by finger pressure
🔹 Foam in the lower tear film meniscus (due to excess tear film lipid)
Plugging of duct orifices with abnormal lipid leading to dilatation of
🔹
Generalized alopecia, psoriasis
3.Systemic disorders: 🔹
Soft contact lens
Non medical treatment:
🔹
glands and formation of microliths and chalazia
myxoedeama, lepatomatous leprosy, SLE, acquired 1.Epilation - but recurrences within few weeks
🔹🔹Conjunctival hyperaemia
Evaporative tear deficiency
🔹
syphilis.
4. Following removal:
2.Electrolysis - but frequently repeated treatments require
3.Cryotherapy - for many lashes
Unstable pre-corneal tear film
iatrogenic for trichiasis, trichotillomania. 4. Laser ablation - for few scattered lashes
5.Surgery - for localized crop resistant to other methods
🔹
Secondary signs include:
🔹 Punctate epithelial erosion over lower third of cornea.
Distichiasis
6. Releasing follicle roots to treat trichiasis:
Plastic surgeons have tested a newer technique for treating trichiasis that involves surgery to remove and
🔹 Marginal keratitis.
🔹Scarring; neovascularisation and pannus.
Mild papillary conjunctivitis.
Distichiasis is an uncommon condition that reposition the hair follicles. The incision is glued back together.
results in two rows of eyelashes. The rows One advantage of this treatment is that your eyelashes remain in place, so your eyelashes are fuller. Some
may be complete rows, a few extra lashes or people don’t like the way they look with fewer eyelashes. The follicle release procedure lets you keep the
a single lash growing next to another. eyelashes you have.
🔹
🔹 Congenital:
Eye lid
Acquired distichiasis: (Metaplastic
eyelashes):
Metaplasia of the meibomian glands to >>>
hair follicles..
- Mostly occurs after cicatrisation (chemical 🔹
a. Non pharmacological
Management of Dry Eye Disease, Full blinks and artificial tears are important for managing dry eye if it
🔹
burn, cicatricial pemphigoid).
Treatment: As trichiasis. 🔹
develops with blepharitis.
Patients should be made aware of the importance of the chronic nature of the condition and the need of on-
🔹
going treatment.
Lid hygiene, consisting of lid cleansing using a variety of measures, is the first line of management regardless
🔹
of type of blepharitis.
Lid cleansing measures wipe away bacteria and deposits from lid margins and lead to improved signs and
symptoms in the majority of individuals.
🔹
🔹Wet warm compresses loosen collarettes and crusts in anterior blepharitis.
Entropion: The mainstay of blepharitis treatment is to apply warm compresses, several times a day followed by eyelid
Is a rolling in of the margin of the lid and with the lashes. scrubs once or twice per day. Eyelid scrubs can be as simple as applying lathered baby shampoo onto a warm
🔹
Etiology and varieties washcloth. When doing this, close your eye and scrub gently with a washcloth, using a gentle back and forth
Ectropion
1-Cicatricial :
due to cicatricial changes in the conjunctiva and distortion of the tarsal 🔹
motion. Baby shampoo is recommended because it does not sting your eyes.
Dry warm compresses melt meibum in posterior blepharitis (compress applied to lid skin twice daily for not
Lagophthalmos
It is a rolling out of the margin of the lid.
🔹
Etiology and varieties:
plate, most commonly affects the upper lid
a-Old case of trachoma 🔹
less than 5 minutes at 40°C.
Commercial products and electronic heating devices are available that are able to maintain temperatures in
This is the incomplete closure
of the palpebral aperture
🔹
lid-
1-Cicatrical: due to cicatrical changes in the skin of the b-Blepharitis
c-Burns 🔹
this region)
Intense Pulsed Light (IPL) therapy has been recommended for the management of meibomian gland
when an attempt is made to
🔹 2-Involutinal
3-Paralytic -it occurs as a result of weakness of the 🔹
d-Operation upon the lids
🔹
dysfunction (MGD).
🔹 Advise the avoidance of cosmetics, especially eye liner and mascara.
🔹
shut the eyes. 2.Spastic:
Causes
1. Exophthalmos as in Graves 🔹
orbicularis muscle due to facial nerve paralysis.
4. Mechanical: large lower lid tumor
5.Congenital: very rare
Due to spasm of the palpebral portion of the orbicularis muscle
a-Atrophy or absence of eye ball
Complete eradication of the blepharitis may not be possible, but long-term compliance with these measures
should reduce symptoms and minimize the number and severity of relapses
disease ,proptosis due to
orbital tumour. Symptoms:
b-Old persons
c-After surgical operation Disorder of
🔹 🔹
Epiphora due to eversion of lacrimal puncta.
2- Facial nerve paralysis d-Blepharospasm.
lashes b. Pharmacological:
3-Cicatrical ectropion of
upper lid 🔹 3. Congenital: mostly in the lower lid with absence of the lid crease.
4. Involutional: in the lower lid due to laxity of tissue with aging.
Staphylococcal and Seborrhoeic blepharitis may benefit from topical antibiotics if not controlled by
🔹Short
first line management
🔹
4-Symblepharon
Complications
S&S: same as for trichiasis
Continuous rubbing of the cornea by the lashes may lead to corneal
Treatment 🔹
🔹
Antibiotic ointment (e.g. chloramphenicol) twice daily; place in eyes or rub into lid margin with fingertip
course of topical azithromycin.
Consider Demodex blepharitis if characteristic ‘cylindrical dandruff’ is present at roots of eyelashes or if
1-Xerosis of conjunctiva. ulceration followed by corneal opacity.
2-Chronic conjunctivitis and
exposure keratitis
Treatment : Surgical.
🔹
blepharitis is refractory to treatment.
Although Demodex blepharitis is commonly treated with tea tree oil (TTO),. However, if used, lower
🔹
concentrations are recommended to avoid ocular toxicity.
Preparations containing 4-terpineol (the proposed active ingredient of TTO) are commercially available for
patient use.
🔹
🔹 In patients with posterior blepharitis, systemic antibiotics may be effective as a second line treatment
Consider prescribing a systemic tetracycline, such as doxycycline or minocycline (contraindicated in
pregnancy, lactation and in children under 12 year) for several weeks or months and the dosage may need to
Hypertrichosis:
trichomegaly
polytrichiosis,
🔹
be varied from time to time
🔹 Where tetracyclines are contraindicated, consider prescribing oral erythromycin or azithromycin
Poliosis: Premature localized
whitening of hair
🔹Tear substitution.
Omega 3 fatty acid.
🔹
Causes:
Ocular:
Chronic anterior blepharitis,
♦️ In patients who do not respond to therapy the possibility of carcinoma or immune mediated
diseases should be considered, particularly if the blepharitis is associated with loss of eyelashes
🔹
sympathetic ophthalmitis
Systemic:
Vogt- Koyangi-Harada syndrome,
🔺In unilateral cases, meibomian gland carcinoma is suspected
and/or cicatricial changes.
Waardenburg syndrome.
Symblepharon 1-External hordeolum or stye
by fatema okoff Is a cicatrical attachment between the Acute inflammation at the edge of the lid,caused by staphylococcal
conjuctiva of the lid and the eye ball.
It may affect both lids, 🔹
infection of the glands of zies,usually ending in suppuration.
Symptoms and signs
Red swelling appears in the lash line of the margin of the lid , pain,
but usually the lower, sometimes it includes
🔹
part of the cornea tenderness and edema of the lids ,very soon a yellowish summit will be
🔹
Types seen indicating suppuration.
1-Anterior =when extending bridge like from Treatment
lid to globe,leaving a free portion of the 1-Hot fomentation to hasten suppuration, the pus should be evacuated
conjunctiva corresponding to the fornix. by epilating of the eye lash , horizontal incision.
2-posterior When involves only the fornix 2-Antibiotics
3-Total when the lids are adherent to the
🔹
globe throughout.
ETIOLOGY:
1-injuries especially burns from lime, acid ,
2-Hordeolum Internum
This is an acute suppurative inflammation of a miebomian gland
molten metal
2-operation
🔹
due to staphylococcus.
Symptoms and signs
Symptoms are more violent than those of stye , very soon pus
3-trachoma
INFLAMMATION OF THE
GLANDS OF THE LID 🔹
points on the palpebral conjunctiva.
Treatment :
is the same as for stye,the pus should be evacuated by a vertical
🔷 Benign essential blepharospasm:
is part of a group of movement disorders called dystonia. Dystonia is characterized by
incision.
involuntary muscle contractions. 3-Chalazion
Experts do not fully understand the cause of benign essential blepharospasm. Blepharospasm: This is a chronic lipo- granulomatous inflammation of one of the
Gene mutations may play a role, given that about 20% to 30%Trusted Source of people
🔹
with benign essential blepharospasm have a family history of people with the condition.
Other factors that may play a role include:
is any abnormal contraction of the orbicularis oculi muscle. The condition should be
distinguished from the more common, and milder, involuntary quivering of an eyelid, 🔹
meibomian glands
Etiology , Pathology:
The miebomian duct becomes obstructed through proliferation of its
known as myokymia, or fasciculation. In most cases, blepharospasm symptoms last
neurotransmitter dysregulation for a few days and then disappear without treatment, but in some cases the epithelium and consequently the gland enlarges. The fatty secretion
structural damage
face trauma
previous eye disorders
🔹
twitching is chronic and persistent, causing life-long challenge.
1-Reflex sensory stimulation through branches of 5th cranial nerve – 🔹
escapes into the surrounding tissue and excites a foreign body reaction.
Symptoms
1-Cosmetic disfigurement-lid swelling
commonest.
other neurological movement conditions such as Parkinson’s disease a-phlyctenular keratoconjunctivitis 2-conjuctival irritation
b-foreign body on cornea Blepharospasm Signs
🔷 Drug-induced blepharospasm
c-Membranous and pseudomembranous conjunctivitis
🔹
A circumscribed swelling which feel hard
🔹
d-Acute iridocyclitis Treatment
Some medications can cause eyelid twitching. It’s a form of secondary 2-Excessive stimulation of retina -Warm compresses & digital massage.
blepharospasm, but it isn’t directly due to another health condition. Medications a-Bright light on sensitive eye -Topical steroid ointment.
linked to drug-induced blepharospasm include: b-Dilated pupil - Surgical incision & curettage.
🔹
dopamine agonists, which often treat Parkinson’s c- Albinism - Intra-lesional steroid injection (triamcinolone acetate).
🔹
benzodiazepines, which treat anxiety and insomnia 3-Hysteria
antihistamines, which treat allergies 4-Essential blepharospasm : with out any cause
calcium channel blockers, which lower blood pressure and treat arrhythmia
atypical antipsychotics, which treat schizophrenia and bipolar disorder
1. Skin
2. Subcutaneous tissue
3. Orbicularis oculi muscle
4. Sub-muscular areolar tissue
4. The fibrous layer consisting of
the tarsi and the orbital septum, lid
retractors of the upper and lower
eyelids "levator palpebrae ",
5. Retro-septal fat pad
6. Conjunctiva
🔹 Lid coloboma:
🔹
Is a congenital absence of a part of the eyelid.
Epicanthic folds: Are bilateral vertical folds of
skin that extend from the upper or lower lid towards
🔷 Edema of lids:
This is common and owing to looseness of the tissue may be so
the medial canthus >>> give rise to pseudo- great as to close the eye.
🔹
esotropia.
Epiblepharon:A congenital extra horizontal fold
of skin below the lower lid margin, and the lashes
🔹
Causes
a-Inflammatory edema
1-Inflammation of the lids –allergic dermatitis due to atropine,
are directed vertically. cosmetics, insect bite.
- When we pull the lower lid, every part turns to its 2-Acute conjunctivitis
normal location. DISEASES OF THE LIDS 3-Acute dacryocystitis
- Spontaneous resolution with age. 4-Acute iridocyclitis
5-panophthalmaitis
Simple congenital Ptosis 🔹
6-Obital cellulites]
b-Passive edema due to circulatory obstruction.
1-Nephrotic syndrome
Developmental dystrophy of levator muscle
2-cardiac failure
Occasionally associated with weakness of superior rectus 3-Cavernous sinus thrombosis
Drooping of upper eye lid.
Absent eye lid crease. Blepharitis: is a chronic inflammation of the eyelids that primarily affects the eyelid margins.
🔷
Other less common forms of anterior blepharitis:
Compensatory mechanisms:
-Corrugations of the forehead 🔷
Blepharitis is classified as:
🔹 Anterior blepharitis (also known as Anterior Lid Margin Disease)
Bacterial
Angular blepharitis:
- Is a form of anterior blepharitis.
-Arching of eye brow ( astonished look). -Staphylococcal (usually) : - Affecting the skin of the outer & the inner canthi.
-Chin elevation: in bilateral cases, head is throw backwards & caused by: - Caused by Moraxella species or staphylococcal
(1) direct infection. species.
eyes roll downwards CONGENITAL (2) reaction to staphylococcal exotoxin. -Proteolytic enzymes elaborated by these bacteria can
-Face turn: in unilateral cases, head is tilted to one side. produce maceration, and crusting of the skin.
ABNORMALITIES (3) allergic response to staphylococcal antigen.
🔹
Complications: Demodex folliculorum: Demodex mites are a natural part of the human microbiome Treatment:
Of THE LIDS 🔹 Seborrhoeic (disorder of the ciliary sebaceous glands of Zeis). - Lid hygiene.
Amblyopia in severe cases.
Less common type of Anterior blepharitis : - Topical Antibiotics ointment. & Zinc sulphate oint.
Lumber lordosis. Angular blepharitis (neutralizes the offending enzymes).
Torticollis and contracture sternomastiod ms. Parasitic blepharitis
🔷 Posterior blepharitis (also known as Posterior Lid Margin Disease)
The -meibomian glands inside the eyelid have an opening on the eyelid margin, and they normally contribute oils to 🔷 Parasitic blepharitis (pthiriasis palpebrarum):
Myotonic dystrophy the tears that protect the eyes. Typically, posterior blepharitis develops due to meibomian gland dysfunction, which is - Is an infestation of the eye lashes with the crab louse (pthirus
irregular oil production in the glands of the eyelids (meibomian blepharitis). The oil can create a favorable environment for pubis).
bacterial growth. - Typically affecting children living in poor hygienic conditions
-Meibomian gland dysfunction is very common, and mild cases often go undiagnosed. causing severe itching.
-Full, complete blinks are important to meibomian gland secretion. - The eye lashes are covered with nits (brownish pearly) adherent to
Ptosis: -Decreased blink rates can contribute to blepharitis by decreasing the excretion of meibomian gland content. Additionally, the base of the cilia, a single louse could be seen occasionally.
when the eye remains open and exposed for longer, increased evaporation of tears can contribute to eyelid margin disease. Treatment:
also known as blepharoptosis, is a drooping or falling of the upper eyelid.
The drooping may worsen after being awake longer when the individual's the lid -Meibomian gland dysfunction also causes evaporative dry eye (EDE), the most common form of dry eye syndrome. The Trimming of the lashes.
muscles are tired. consistency and quantity of the tears can also be examined to identify this problem. With EDE, the tears may seem thick or Topical application of yellow mercuric oxide 1% oint. 3-4 weeks (kills
This condition is sometimes called "lazy eye," but that term normally refers frothy. the lice + ova).
to the condition amblyopia. -When meibomian gland dysfunction is chronic, the glands may clog, and sometimes the glands will actually atrophy. Delousing of the patient & the family members.
If severe enough and left untreated, the drooping eyelid can cause other •Bacterial lipases break down meibomian lipids
conditions, such as amblyopia or astigmatism. This is why it is especially •Meibomian secretion becomes abnormal both chemically and physically -Lid hygiene, warm compresses to melt solidified sebum.
🔹 🔷
important for this disorder to be treated in children. •Tear film becomes unstable. - Systemic tetracyclines are the mainstay of treatment, use one of
Etiology –Classification
1-Congenital ptosis
Mixed anterior and posterior blepharitis
elements of both conditions are present 🔹
the following:
🔹 Tetracycline 250 mg b.d 6-12 weeks.
Blepharophimosis syndrome
Rare congenital disorder Dominant inheritance
Moderate to severe symmetrical ptosis
a- With normal superior rectus function
b-With superior rectus weakness 🔹🔹 Doxycycline 100mg once daily 6-12 weeks.
Minocycline 100mg once daily 6-12 weeks.
Erythromycin or azithromycin may be used when tetracyclines
c-Marcus Gunn or jaw-winking ptosis
Short horizontal palpebral aperture 2-Acquired ptosis: are contraindicated.
Telecanthus (lateral displacement a- Neurogenic due to lesion of 3rd nerve OR nucleus, Horner`s syndrome - Topical antibiotic and steroid ointment.
of medial canthus) b-Myogenic Myasthenia gravis, myotonic dystrophy
Epicanthus inversus (lower lid fold larger than upper) c-Mechanical -due to increase weight of lid –tumor
Lateral inferior ectropion d-Aponeurotic: Involutional, postoperative.
Poorly developed nasal bridge
and hypoplasia of superior orbital rims 🔷
Signs of blepharitis (lid margin disease)
🔹 Anterior blepharitis (staphylococcal)
🔹
🔹
lid margin hyperaemia
lid margin swelling
🔹
🔹
Crusting of anterior lid margin (scales at bases of lashes)
Misdirection of lashes
🔹
🔹
loss of lashes (Madarosis)
Recurrent Styes and (rarely) chalazia
Conjunctival hyperaemia
Causes of pseudoptosis Mechanical Ptosis 🔹
Secondary signs include:
🔹🔹 Punctate epithelial erosion over lower third of cornea.
Marginal keratitis.
🔹
🔹
Phlyctenulosis
Neovascularisation and pannus.
Mild papillary conjunctivitis.
🔷
🔹 Anterior blepharitis (Demodex)
🔹 lid margin hyperaemia
Cylindrical dandruff’: characteristic clear sleeve (collarette) covers
base of lash, extending further up lash than flat staphylococcal
🔹
rosettes
Persistent infestation of the lash follicles may lead to misalignment,
🔷
trichiasis or madarosis.
🔹 Anterior blepharitis (Seborrhoeic)
Symptoms of blepharitis (lid margin disease) 🔹 lid margin hyperaemia
🔹Oily or greasy deposits on lid margins
Conjunctival hyperaemia.
Blepharitis may be asymptomatic. However, when present, the symptoms of
anterior blepharitis, posterior blepharitis and mixed anterior and
Trichiasis 🔹
posterior blepharitis are similar:
🔹 ocular discomfort
🔹
an inversion of a varying number of eye lashes so that they rub against the conjunctiva or cornea soreness
🔹 Etiology 🔹
🔹
burning, itching
mild photophobia
Madarosis same as entropion, Blepharitis symptoms of dry eye including blurred vision and contact lens intolerance.
🔹
Is a decrease in number or complete loss of lashes secondry to chronic blepharitis,
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Causes:
1-local
Signs and symptoms
The misdirection lashes cause mechanical irritation and injury to cornea with ulceration- pain,
-chronic anterior lid margin disease Lacrimation, photophobia-blepharospasm, vascularisation and opacities of cornea
🔷Posterior blepharitis (MGD is the most common cause)
-infiltrating tumors
🔷 🔹 Thick and/or opaque secretion at meibomian gland orifices, making it
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-burns Treatment Options for Trichiasis
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-radiotherapy or cryotherapy of lid tumors
2.Skin disorders:
Medical treatment:
Tear substitutions: drops, ointment
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difficult or impossible to express oil by finger pressure
🔹 Foam in the lower tear film meniscus (due to excess tear film lipid)
Plugging of duct orifices with abnormal lipid leading to dilatation of
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Generalized alopecia, psoriasis
3.Systemic disorders: 🔹
Soft contact lens
Non medical treatment:
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glands and formation of microliths and chalazia
myxoedeama, lepatomatous leprosy, SLE, acquired 1.Epilation - but recurrences within few weeks
🔹🔹Conjunctival hyperaemia
Evaporative tear deficiency
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syphilis.
4. Following removal:
2.Electrolysis - but frequently repeated treatments require
3.Cryotherapy - for many lashes
Unstable pre-corneal tear film
iatrogenic for trichiasis, trichotillomania. 4. Laser ablation - for few scattered lashes
5.Surgery - for localized crop resistant to other methods
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Secondary signs include:
🔹 Punctate epithelial erosion over lower third of cornea.
Distichiasis
6. Releasing follicle roots to treat trichiasis:
Plastic surgeons have tested a newer technique for treating trichiasis that involves surgery to remove and
🔹 Marginal keratitis.
🔹Scarring; neovascularisation and pannus.
Mild papillary conjunctivitis.
Distichiasis is an uncommon condition that reposition the hair follicles. The incision is glued back together.
results in two rows of eyelashes. The rows One advantage of this treatment is that your eyelashes remain in place, so your eyelashes are fuller. Some
may be complete rows, a few extra lashes or people don’t like the way they look with fewer eyelashes. The follicle release procedure lets you keep the
a single lash growing next to another. eyelashes you have.
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🔹 Congenital:
Eye lid
Acquired distichiasis: (Metaplastic
eyelashes):
Metaplasia of the meibomian glands to >>>
hair follicles..
- Mostly occurs after cicatrisation (chemical 🔹
a. Non pharmacological
Management of Dry Eye Disease, Full blinks and artificial tears are important for managing dry eye if it
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burn, cicatricial pemphigoid).
Treatment: As trichiasis. 🔹
develops with blepharitis.
Patients should be made aware of the importance of the chronic nature of the condition and the need of on-
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going treatment.
Lid hygiene, consisting of lid cleansing using a variety of measures, is the first line of management regardless
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of type of blepharitis.
Lid cleansing measures wipe away bacteria and deposits from lid margins and lead to improved signs and
symptoms in the majority of individuals.
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🔹Wet warm compresses loosen collarettes and crusts in anterior blepharitis.
Entropion: The mainstay of blepharitis treatment is to apply warm compresses, several times a day followed by eyelid
Is a rolling in of the margin of the lid and with the lashes. scrubs once or twice per day. Eyelid scrubs can be as simple as applying lathered baby shampoo onto a warm
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Etiology and varieties washcloth. When doing this, close your eye and scrub gently with a washcloth, using a gentle back and forth
Ectropion
1-Cicatricial :
due to cicatricial changes in the conjunctiva and distortion of the tarsal 🔹
motion. Baby shampoo is recommended because it does not sting your eyes.
Dry warm compresses melt meibum in posterior blepharitis (compress applied to lid skin twice daily for not
Lagophthalmos
It is a rolling out of the margin of the lid.
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Etiology and varieties:
plate, most commonly affects the upper lid
a-Old case of trachoma 🔹
less than 5 minutes at 40°C.
Commercial products and electronic heating devices are available that are able to maintain temperatures in
This is the incomplete closure
of the palpebral aperture
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lid-
1-Cicatrical: due to cicatrical changes in the skin of the b-Blepharitis
c-Burns 🔹
this region)
Intense Pulsed Light (IPL) therapy has been recommended for the management of meibomian gland
when an attempt is made to
🔹 2-Involutinal
3-Paralytic -it occurs as a result of weakness of the 🔹
d-Operation upon the lids
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dysfunction (MGD).
🔹 Advise the avoidance of cosmetics, especially eye liner and mascara.
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shut the eyes. 2.Spastic:
Causes
1. Exophthalmos as in Graves 🔹
orbicularis muscle due to facial nerve paralysis.
4. Mechanical: large lower lid tumor
5.Congenital: very rare
Due to spasm of the palpebral portion of the orbicularis muscle
a-Atrophy or absence of eye ball
Complete eradication of the blepharitis may not be possible, but long-term compliance with these measures
should reduce symptoms and minimize the number and severity of relapses
disease ,proptosis due to
orbital tumour. Symptoms:
b-Old persons
c-After surgical operation Disorder of
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Epiphora due to eversion of lacrimal puncta.
2- Facial nerve paralysis d-Blepharospasm.
lashes b. Pharmacological:
3-Cicatrical ectropion of
upper lid 🔹 3. Congenital: mostly in the lower lid with absence of the lid crease.
4. Involutional: in the lower lid due to laxity of tissue with aging.
Staphylococcal and Seborrhoeic blepharitis may benefit from topical antibiotics if not controlled by
🔹Short
first line management
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4-Symblepharon
Complications
S&S: same as for trichiasis
Continuous rubbing of the cornea by the lashes may lead to corneal
Treatment 🔹
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Antibiotic ointment (e.g. chloramphenicol) twice daily; place in eyes or rub into lid margin with fingertip
course of topical azithromycin.
Consider Demodex blepharitis if characteristic ‘cylindrical dandruff’ is present at roots of eyelashes or if
1-Xerosis of conjunctiva. ulceration followed by corneal opacity.
2-Chronic conjunctivitis and
exposure keratitis
Treatment : Surgical.
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blepharitis is refractory to treatment.
Although Demodex blepharitis is commonly treated with tea tree oil (TTO),. However, if used, lower
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concentrations are recommended to avoid ocular toxicity.
Preparations containing 4-terpineol (the proposed active ingredient of TTO) are commercially available for
patient use.
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🔹 In patients with posterior blepharitis, systemic antibiotics may be effective as a second line treatment
Consider prescribing a systemic tetracycline, such as doxycycline or minocycline (contraindicated in
pregnancy, lactation and in children under 12 year) for several weeks or months and the dosage may need to
Hypertrichosis:
trichomegaly
polytrichiosis,
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be varied from time to time
🔹 Where tetracyclines are contraindicated, consider prescribing oral erythromycin or azithromycin
Poliosis: Premature localized
whitening of hair
🔹Tear substitution.
Omega 3 fatty acid.
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Causes:
Ocular:
Chronic anterior blepharitis,
♦️ In patients who do not respond to therapy the possibility of carcinoma or immune mediated
diseases should be considered, particularly if the blepharitis is associated with loss of eyelashes
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sympathetic ophthalmitis
Systemic:
Vogt- Koyangi-Harada syndrome,
🔺In unilateral cases, meibomian gland carcinoma is suspected
and/or cicatricial changes.
Waardenburg syndrome.
Symblepharon 1-External hordeolum or stye
by fatema okoff Is a cicatrical attachment between the Acute inflammation at the edge of the lid,caused by staphylococcal
conjuctiva of the lid and the eye ball.
It may affect both lids, 🔹
infection of the glands of zies,usually ending in suppuration.
Symptoms and signs
Red swelling appears in the lash line of the margin of the lid , pain,
but usually the lower, sometimes it includes
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part of the cornea tenderness and edema of the lids ,very soon a yellowish summit will be
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Types seen indicating suppuration.
1-Anterior =when extending bridge like from Treatment
lid to globe,leaving a free portion of the 1-Hot fomentation to hasten suppuration, the pus should be evacuated
conjunctiva corresponding to the fornix. by epilating of the eye lash , horizontal incision.
2-posterior When involves only the fornix 2-Antibiotics
3-Total when the lids are adherent to the
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globe throughout.
ETIOLOGY:
1-injuries especially burns from lime, acid ,
2-Hordeolum Internum
This is an acute suppurative inflammation of a miebomian gland
molten metal
2-operation
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due to staphylococcus.
Symptoms and signs
Symptoms are more violent than those of stye , very soon pus
3-trachoma
INFLAMMATION OF THE
GLANDS OF THE LID 🔹
points on the palpebral conjunctiva.
Treatment :
is the same as for stye,the pus should be evacuated by a vertical
🔷 Benign essential blepharospasm:
is part of a group of movement disorders called dystonia. Dystonia is characterized by
incision.
involuntary muscle contractions. 3-Chalazion
Experts do not fully understand the cause of benign essential blepharospasm. Blepharospasm: This is a chronic lipo- granulomatous inflammation of one of the
Gene mutations may play a role, given that about 20% to 30%Trusted Source of people
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with benign essential blepharospasm have a family history of people with the condition.
Other factors that may play a role include:
is any abnormal contraction of the orbicularis oculi muscle. The condition should be
distinguished from the more common, and milder, involuntary quivering of an eyelid, 🔹
meibomian glands
Etiology , Pathology:
The miebomian duct becomes obstructed through proliferation of its
known as myokymia, or fasciculation. In most cases, blepharospasm symptoms last
neurotransmitter dysregulation for a few days and then disappear without treatment, but in some cases the epithelium and consequently the gland enlarges. The fatty secretion
structural damage
face trauma
previous eye disorders
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twitching is chronic and persistent, causing life-long challenge.
1-Reflex sensory stimulation through branches of 5th cranial nerve – 🔹
escapes into the surrounding tissue and excites a foreign body reaction.
Symptoms
1-Cosmetic disfigurement-lid swelling
commonest.
other neurological movement conditions such as Parkinson’s disease a-phlyctenular keratoconjunctivitis 2-conjuctival irritation
b-foreign body on cornea Blepharospasm Signs
🔷 Drug-induced blepharospasm
c-Membranous and pseudomembranous conjunctivitis
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A circumscribed swelling which feel hard
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d-Acute iridocyclitis Treatment
Some medications can cause eyelid twitching. It’s a form of secondary 2-Excessive stimulation of retina -Warm compresses & digital massage.
blepharospasm, but it isn’t directly due to another health condition. Medications a-Bright light on sensitive eye -Topical steroid ointment.
linked to drug-induced blepharospasm include: b-Dilated pupil - Surgical incision & curettage.
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dopamine agonists, which often treat Parkinson’s c- Albinism - Intra-lesional steroid injection (triamcinolone acetate).
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benzodiazepines, which treat anxiety and insomnia 3-Hysteria
antihistamines, which treat allergies 4-Essential blepharospasm : with out any cause
calcium channel blockers, which lower blood pressure and treat arrhythmia
atypical antipsychotics, which treat schizophrenia and bipolar disorder
