DISEASES OF THE

EYELIDS
MSHANGILA Barnabas MD, M.MED
APPLIED ANATOMY
• GROSS ANATOMY
• The eyelids are mobile tissue curtains placed in front of the eyeballs.
These act as shutters protecting the eyes from injuries and excessive
light.
• These also perform an important function of spreading the tear film
over the cornea and conjunctiva and also help in drainage of tears by
lacrimal pump system.
• Parts of eyelid. Each eyelid is divided by a horizontal furrow (sulcus)
into an orbital and tarsal part.
GROSS ANATOMY
• Position of lids.
When the eye is open, the upper lid covers
about one-sixth of the cornea and the lower
lid just touches the limbus.
• Canthi.
The two lids meet each other at medial and
lateral angles (or outer and inner canthi).
. Palpebral aperture.
It is the elliptical space between the upper
and the lower lid. When the eyes are open it
measures about 10-11 mm vertically in the
centre and about 28-30 mm horizontally.
GROSS ANATOMY
Structure of the upper eyelid
Each eyelid consists (from anterior to posterior) of
the following layers:

1. The skin. Elastic, the thinnest in the body.

2. The subcutaneous areolar tissue.
3. The layer of striated muscle. orbicularis muscle. It
closes the eyelids and is supplied by zygomatic branch
of the facial nerve.
4. Submuscular areolar tissue.
5. Fibrous layer. It is the framework of the lids: the
central tarsal plate and the peripheral septum orbitale.
6.Layer of non-striated muscle fibres. It consists
of the palpebral muscle of Muller
7. Conjunctiva. The part which lines the lids is
called palpebral conjunctiva.
GROSS ANATOMY
• GLANDS OF EYELIDS
1. Meibomian glands.
These are also known as tarsal glands arranged
vertically. They are modified sebaceous glands. Their
ducts open at the lid margin. Their secretion
constitutes the oily layer of tear film.
2. Glands of Zeis.
These are also sebaceous glands which open into the
follicles of eyelashes.
3. Glands of Moll.
These are modified sweat glands situated near the
hair follicle. They open into the hair follicles or into the
ducts of Zeis glands. They do not open directly onto the
skin surface as elsewhere.
4. Accessory lacrimal glands of Wolfring.
These are present near the upper border of the tarsal
plate.
CONGENITAL ANOMALIES
1. Congenital ptosis. It is a common
congenital anomaly.
2. Congenital coloboma.
It is a rare condition characterised
by a full thickness triangular gap in
the tissues of the lids.
The anomaly usually occurs near the
nasal side and involves the upper lid
more frequently than the lower lid.
Treatment consists of plastic repair
of the defect.
CONGENITAL ANOMALIES(Cont)
3. Epicanthus.
It is a semicircular fold of skin which covers the
medial canthus.
It is a bilateral condition and may disappear with
the development of nose.
It is a normal facial feature in Mongolian races.
It is the most common congenital anomaly of
the lids.
• Treatment consists of plastic repair of the
deformity.
CONGENITAL ANOMALIES(Cont)
4. Telecanthus
An uncommon condition that may occur in
isolation or in association with blepharophimosis
syndrome.
Signs. Increased distance between the medial
canthi as a result of abnormally long medial
canthal tendons.
It should not be confused with hypertelorism in
which there is wide separation of the orbits.
Treatment involves shortening and refixation of
the medial canthal tendons to the anterior
lacrimal crest, or insertion of a transnasal suture.
CONGENITAL ANOMALIES(Cont)

5. Distichiasis.
Congenital distichiasis is a rare anomaly in
which an extra row of cilia occupies the
position of Meibomian glands which open into
their follicles as ordinary sebaceous glands.
These cilia are usually directed backwards and
when rubbing the cornea, should be
electroepilated or cryoepilated.
CONGENITAL ANOMALIES(Cont)
6. Cryptophthalmos. It is a very rare
anomaly in which lids fail to develop and
the skin passes continuously from the
eyebrow to the cheek hiding the eyeball
7. Microblepharon. In this condition,
eyelids are abnormally small. It is usually
associated with microphthalmos or
anophthalmos. Occasionally the lids may
be very small or virtually absent and the
condition is called ablepharon
INFLAMMATORY DISORDERS OF
THE EYELIDS
• BLEPHARITIS
• It is a subacute or chronic inflammation of the lid margins.
• Involvement is usually bilateral and symmetrical
• It is an extremely common disease
• subdivided into anterior and posterior although there is considerable
overlap and both are often present
Chronic anterior blepharitis
Affects the area surrounding the bases of the eyelashes and may be
staphylococcal or seborrhoeic
The former is thought to be the result of an abnormal cell mediated response
to components of the cell wall of S. aureus which may also be responsible for
the red eyes and the peripheral corneal infiltrates seen in some patients.
Seborrhoeic blepharitis is often associated with generalized seborrhoeic
dermatitis that may involve the scalp, nasolabial folds, behind the ears, and
the sternum.
Because of the intimate relationship between the lids and ocular surface,
chronic blepharitis may cause secondary inflammatory and mechanical
changes in the conjunctiva and cornea.
Chronic anterior blepharitis(cont)
• Symptoms
• Do not provide a reliable clue to the type of blepharitis and are caused by
disruption of normal ocular surface function and reduction in tear
stability.
• Because of poor correlation between the severity of symptoms and clinical
signs it can be difficult to objectively assess the benefit of treatment.
• Burning, grittiness, mild photophobia, and crusting and redness of the
lid margins with remissions and exacerbations are characteristic.
• Symptoms are usually worse in the mornings although in patients with
associated dry eye they may increase during the day
Chronic anterior blepharitis(cont)
• Signs
a) Staphylococcal blepharitis
Hard scales and crusting mainly located around the bases of the lashes
Mild papillary conjunctivitis and chronic conjunctival hyperaemia are
common.
Long-standing cases may develop scarring and notching (tylosis) of the
lid margin, madarosis, trichiasis and poliosis.
Secondary changes include stye formation, marginal keratitis and
occasionally phlyctenulosis.
Associated tear film instability and dry eye syndrome are common.
b) Seborrhoeic blepharitis
Hyperaemic and greasy anterior lid margins with sticking together of
lashes.
The scales are soft and located anywhere on the lid margin and lashes.
Chronic anterior blepharitis(cont)
• Treatment
There is little evidence to support any particular treatment protocol for anterior blepharitis. Patients should be advised
that a permanent cure is unlikely, but control of symptoms is usually possible.
1. Lid hygiene
• A warm compress applied for several minutes to soften crusts at the bases of the lashes.
• Lid cleaning to mechanically remove crusts involves scrubbing the lid margins once or twice daily with a cotton
bud dipped in a dilute solution of baby shampoo or sodium bicarbonate.
Gradually, lid hygiene can be performed less frequently as the condition is brought under control but blepharitis often
recurs if it is stopped completely.
2. Antibiotic
a ) Topical chloramphenicol is used to treat acute folliculitis but is of limited value in long-standing cases. Following lid
hygiene the ointment should be rubbed onto the anterior lid margin with a cotton bud or clean finger.
b) Oral azithromycin (500 mg daily for three days) may be helpful to control ulcerative lid margin disease.
3. Weak topical steroid such as fluorometholone 0.1% q.i.d. for one week is useful in patients with severe papillary
conjunctivitis, marginal keratitis and phlyctenulosis although repeated courses may be required.
4. Tear substitutes are required for associated tear film instability and dry eye.
Chronic posterior blepharitis
• Pathogenesis
• Posterior blepharitis is caused by meibomian gland dysfunction and
alterations in meibomian gland secretions.
• Bacterial lipases may result in the formation of free fatty acids. This
increases the melting point of the meibum preventing its expression
from the glands, contributing to ocular surface irritation and possibly
enabling growth of S. aureus.
• Loss of the tear film phospholipids that act as surfactants results in
increased tear evaporation and osmolarity, and an unstable tear
film.
Chronic posterior blepharitis(cont)
• Diagnosis
There is poor correlation between the severity of symptoms and the clinical signs.
1 Symptoms are similar to anterior blepharitis.
2 Signs
• Excessive and abnormal meibomian gland secretion manifest as capping of
meibomian gland orifices with oil globules.
• Pouting, recession, or plugging of the meibomian gland orifices.
• Hyperaemia and telangiectasis of the posterior lid margin.
• Pressure on the lid margin results in expression of meibomian fluid that may be
turbid or toothpaste-like; in severe cases the secretions become so inspissated that
expression is impossible.
• The tear film is oily and foamy, and froth may accumulate on the lid margins or
inner canthi.
• Secondary changes include papillary conjunctivitis and inferior corneal
punctate epithelial erosions.
Chronic posterior blepharitis(cont)
• Treatment
• It is very important to inform the patient that a cure is unlikely. Although remission may be achieved recurrence is usual,
particularly when treatment is stopped prematurely.
1. Lid hygiene
• Warm compresses and hygiene are performed as for anterior blepharitis except the emphasis is on massaging the lid to
express accumulated meibum.
• Massaging toward the lid margin edge to ‘milk’ meibum and physical expression of the glands
2 Systemic tetracyclines are the mainstay of treatment but should not be used in children under the age of 12 years or in
pregnant or breast-feeding women because they are deposited in growing bone and teeth, and may cause staining of teeth
and dental hypoplasia (erythromycin is an alternative). • The rationale for the use of tetracyclines is their ability to block
staphylococcal lipase production at well below the minimum inhibitory antibacterial concentration.
a Oxytetracycline 250 mg b.d. for 6–12 weeks.
b Doxycycline 100 mg b.d. for one week and then daily for 6–12 weeks.
c Erythromycin 250 mg daily or b.d. may be used in children.
3 Topical therapy involves antibiotics, steroids and tear substitutes for evaporative dry eye.
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).
Habitual rubbing of the eyes or fingering of
the lids and nose, chronic blepharitis and
diabetes mellitus are usually associated with
recurrent styes.
2. Causative organism commonly involved is
Staphylococcus aureus.
 EXTERNAL HORDEOLUM (STYE)

Symptoms
These include;
acute pain associated with swelling of lid, mild watering
and photophobia.

Signs
Stage of cellulitis is characterised by;
localised, hard, red, tender swelling at the lid margin
usually with a lash at the apex associated with marked
oedema
Stage of abscess formation is characterised by a visible pus
point on the lid margin in relation to the affected cilia.
Usually there is one stye, but occasionally, there may be
multiple.
EXTERNAL HORDEOLUM (STYE)

Treatment
• Hot compresses 2-3 times a day are very useful in cellulitis stage. When the
pus point is formed it may be evacuated by epilating the involved cilia.
• Surgical incision is required rarely for a large abscess.
• Antibiotic eyedrops (3-4 times a day) and eye ointment (at bed time)
should be applied to control infection.
• Anti-inflammatory and analgesics relieve pain and reduce oedema.
Systemic antibiotics may be used for early control of infection.
• In recurrent styes, try to find out and treat the associated predisposing
condition.
CHALAZION

• It is also called a tarsal or meibomian cyst. It is a chronic non-infective

granulomatous inflammation of the meibomian gland.
• Etiology
1. Predisposing factors are similar to hordeolum externum.
2. Pathogenesis. Usually, first there occurs mild grade infection of the
meibomian gland by organisms of very low virulence. As a result, there
occurs proliferation of the epithelium and infiltration of the walls of the
ducts, which are blocked. Consequently, there occurs retention of
secretions (sebum) in the gland, causing its enlargement. The pent-up
secretions (fatty in nature) act like an irritant and excite non-infective
granulomatous inflammation of the meibomian gland.
CHALAZION(cont)
• Clinical picture
• Patients usually present with a painless swelling in the lid
and a feeling of mild heaviness.
• Examination usually reveals small, firm to hard, non-tender
swelling present slightly away from the lid margin.
• It usually points on the conjunctival side, as a red,purple or
grey area, seen on everting the lid. Rarely, the main bulk of
the swelling project on the skin side.
• Occasionally, it may present as a reddish-grey nodule on the
intermarginal strip (marginal chalazion).
• Frequently, multiple chalazia may be seen involving one or
more eyelids.
CHALAZION
• Clinical course and complications
• Complete spontaneous resolution may occur rarely.
• Often it slowly increases in size and becomes very large. A large chalazion of the upper
lid may press on the cornea and cause blurred vision from induced astigmatism. A large
chalazion of the lower lid may rarely cause eversion of the punctum or even ectropion
and epiphora.
• Occasionally, it may burst on the conjunctival side, forming a fungating mass of
granulation tissue.
• Secondary infection leads to formation of hordeolum internum.
• Calcification may occur, though very rarely.
• Malignant change into meibomian gland carcinoma may be seen occasionally in elderly
people.
CHALAZION
• Treatment
1. Conservative treatment.
In a small, soft and recent chalazion, self-resolution may be helped by conservative
treatment in the form of hot fomentation, topical antibiotic eyedrops and oral
anti-inflammatory drugs.
2. Intralesional injection of long-acting steroid (triamcinolone) is reported to
cause resolution in about 50 percent cases, especially in small and soft chalazia. So,
such a trial is worthwhile before the surgical intervention.
3. Incision and curettage is the conventional and effective treatment for chalazion.
INTERNAL HORDEOLUM

• It is a suppurative inflammation of the meibomian gland associated with blockage of the duct.
• Etiology.
It may occur as primary staphylococcal infection of the meibomian gland or due to secondary
infection in a chalazion (infected chalazion).
• Clinical picture. Symptoms are similar to hordeolum externum, except that pain is more intense,
due to the swelling being embedded deeply in the dense fibrous tissue.
• On examination, it can be differentiated from hordeolum externum by the fact that in it, the
point of maximum tenderness and swelling is away from the lid margin and that pus usually
points on the tarsal conjunctiva (seen as yellowish area on everting the lid) and not on the root of
cilia. Sometimes, pus point may be seen at the opening of involved meibomian gland or rarely on
the skin.
• Treatment. It is similar to hordeolum externum, except that, when the pus is formed, it should be
drained by a vertical incision from the tarsal conjunctiva.
INTERNAL HORDEOLUM
MOLLUSCUM CONTAGIOSUM

• It is a viral infection of the lids, commonly affecting children. It is

caused by a large poxvirus.
• Its typical lesions are multiple, pale, waxy, umbilicated swellings
scattered over the skin near the lid margin.
• These may be complicated by chronic follicular conjunctivitis and
superficial keratitis.
• Treatment. The skin lesions should be incised and the interior
cauterised with tincture of iodine or pure carbolic acid.
MOLLUSCUM CONTAGIOSUM
THANKS