1. Anaesthesia. General anaesthesia is preferred,
however, it may be performed with local infiltration
anaesthesia in adults.
2. Skin incision. Either a curved incision along the
anterior lacrimal crest or a straight incision 8 mm
medial to the medial canthus is made.
3. Exposure of medial palpebral ligament (MPL)
and Anterior lacrimal crest. MPL is exposed by
blunt dissection and cut with scissors to expose
the anterior lacrimal crest.
4. Dissection of lacrimal sac. Periosteum is separated
from the anterior lacrimal crest and along with the
lacrimal sac is reflected laterally with blunt
dissection exposing the lacrimal fossa.
5. Removal of lacrimal sac. After exposing the sac,
it is separated from the surrounding structures
by blunt dissection followed by cutting its
connections with the lacrimal canaliculi. It is then
held with artery forceps and twisted 3-4 times to
tear it away from the nasolacrimal duct (NLD).
6. Curettage of bony NLD. It is done with the help
of a lacrimal curette to remove the infected parts
of membranous NLD.
7. Closure. MPL is sutured to periosteum, orbicularis
muscle is sutured with 6-0 vicryl and skin is
closed with 6-0 silk sutures.
Showing posts with label eyelid. Show all posts
Showing posts with label eyelid. Show all posts
Thursday, December 30, 2010
DACRYOCYSTORHINOSTOMY
Dacryocystorhinostomy (DCR) operation can be
performed by two techniques:
Conventional external approach DCR, and
Endonasal DCR
Conventional external approach DCR (Fig. 15.11)
1. Anaesthesia. General anaesthesia is preferred,
however, it may be performed with local infiltration
anaesthesia in adults.
2. Skin incision. Either a curved incision along the
anterior lacrimal crest or a straight incision 8 mm
medial to the medial canthus is made.
3. Exposure of medial palpebral ligament (MPL)
and Anterior lacrimal crest. MPL is exposed by
blunt dissection and cut with scissors to expose
the anterior lacrimal crest 4. Dissection of lacrimal sac. Periosteum is separated
from the anterior lacrimal crest and along with the
lacrimal sac is reflected laterally with blunt
dissection exposing the lacrimal fossa.
5. Exposure of nasal mucosa. A 15 mm × 10 mm
bony osteum is made by removing the anterior
lacrimal crest and the bones forming lacrimal
fossa, exposing the thick pinkish white nasal
mucosa.
6. Preparation of flaps of sac. A probe is introduced
into the sac through lower canaliculus and the
sac is incised vertically. To prepare anterior and
posterior flaps, this incision is converted into H
shape.
7. Fashioning of nasal mucosal flaps. is also done
by vertical incision converted into H shape.
8. Suturing of flaps. Posterior flap of the nasal
mucosa is sutured with posterior flap of the sac
using 6-0 vicryl or chromic cat gut sutures. It is
followed by suturing of the anterior flaps.
9. Closure. MPL is sutured to periosteum, orbicularis
muscle is sutured with 6-0 vicryl and skin is
closed with 6-0 silk sutures.
Endonasal DCR
Presently many eye surgeons, alone or in
collaboration with the ENT surgeons, are pereferring
endonasal DCR over conventional external approach
DCR because of its advantages (described below).
surgical steps of endonasal DCR are (Fig. 15.12):
1. Preparation and anaesthesia. Nasal mucosa is
prepared for 15-30 minutes before operation with nasal
decongestant drops and local anaesthetic agent.
Conjunctival sac is anaesthetised with topically
instilled 2% lignocaine. Then 3 ml of lignocaine 2%
with 1 in 2 lac adrenaline is injected into the medial
parts of upper and lower eyelids and via subcaruncular
injection to the lacrimal fossa region.
2. Identification of sac area. A 20-gauge light pipe is
inserted via the upper canaliculi into the sac. With the
help of endoscope, the sac area which is
transilluminated by the light pipe is identified (Fig.
15.12A) and a further injection of lignocaine with
adrenaline is made below the nasal mucosa in this area.
3. Creation of opening in the nasal mucosa, bones
forming the lacrimal fossa and posteromedial wall
of sac can be accomplished by two techniques:
i By cutting the tissues with appropriate
instruments or
ii By ablating with Holmium YAG laser (endoscopic
laser assited DCR).
Note: The size of opening is about 12 mm × 10 mm
(Fig. 15.12B).
4. Stenting of rhinostomy opening. The outflow
system is then stented using fine silicone tubes
passed via the superior and inferior canaliculi into
the rhinostomy and secured with a process of knotting
(Fig. 15.12C). Nasal packing and dressing is done.
5. Postoperative care and removal of sialistic
lacrimal stents. After 24 hours of operation nasal
packs are removed and patient is advised to use
decongestent, antibiotic and steroid nasal drops for
3-4 weeks. The sialistic lacrimal stents are removed 8-
12 weeks after surgery and the nasal drops are
continued further for 2-3 weeks.
performed by two techniques:
Conventional external approach DCR, and
Endonasal DCR
Conventional external approach DCR (Fig. 15.11)
1. Anaesthesia. General anaesthesia is preferred,
however, it may be performed with local infiltration
anaesthesia in adults.
2. Skin incision. Either a curved incision along the
anterior lacrimal crest or a straight incision 8 mm
medial to the medial canthus is made.
3. Exposure of medial palpebral ligament (MPL)
and Anterior lacrimal crest. MPL is exposed by
blunt dissection and cut with scissors to expose
the anterior lacrimal crest 4. Dissection of lacrimal sac. Periosteum is separated
from the anterior lacrimal crest and along with the
lacrimal sac is reflected laterally with blunt
dissection exposing the lacrimal fossa.
5. Exposure of nasal mucosa. A 15 mm × 10 mm
bony osteum is made by removing the anterior
lacrimal crest and the bones forming lacrimal
fossa, exposing the thick pinkish white nasal
mucosa.
6. Preparation of flaps of sac. A probe is introduced
into the sac through lower canaliculus and the
sac is incised vertically. To prepare anterior and
posterior flaps, this incision is converted into H
shape.
7. Fashioning of nasal mucosal flaps. is also done
by vertical incision converted into H shape.
8. Suturing of flaps. Posterior flap of the nasal
mucosa is sutured with posterior flap of the sac
using 6-0 vicryl or chromic cat gut sutures. It is
followed by suturing of the anterior flaps.
9. Closure. MPL is sutured to periosteum, orbicularis
muscle is sutured with 6-0 vicryl and skin is
closed with 6-0 silk sutures.
Endonasal DCR
Presently many eye surgeons, alone or in
collaboration with the ENT surgeons, are pereferring
endonasal DCR over conventional external approach
DCR because of its advantages (described below).
surgical steps of endonasal DCR are (Fig. 15.12):
1. Preparation and anaesthesia. Nasal mucosa is
prepared for 15-30 minutes before operation with nasal
decongestant drops and local anaesthetic agent.
Conjunctival sac is anaesthetised with topically
instilled 2% lignocaine. Then 3 ml of lignocaine 2%
with 1 in 2 lac adrenaline is injected into the medial
parts of upper and lower eyelids and via subcaruncular
injection to the lacrimal fossa region.
2. Identification of sac area. A 20-gauge light pipe is
inserted via the upper canaliculi into the sac. With the
help of endoscope, the sac area which is
transilluminated by the light pipe is identified (Fig.
15.12A) and a further injection of lignocaine with
adrenaline is made below the nasal mucosa in this area.
3. Creation of opening in the nasal mucosa, bones
forming the lacrimal fossa and posteromedial wall
of sac can be accomplished by two techniques:
i By cutting the tissues with appropriate
instruments or
ii By ablating with Holmium YAG laser (endoscopic
laser assited DCR).
Note: The size of opening is about 12 mm × 10 mm
(Fig. 15.12B).
4. Stenting of rhinostomy opening. The outflow
system is then stented using fine silicone tubes
passed via the superior and inferior canaliculi into
the rhinostomy and secured with a process of knotting
(Fig. 15.12C). Nasal packing and dressing is done.
5. Postoperative care and removal of sialistic
lacrimal stents. After 24 hours of operation nasal
packs are removed and patient is advised to use
decongestent, antibiotic and steroid nasal drops for
3-4 weeks. The sialistic lacrimal stents are removed 8-
12 weeks after surgery and the nasal drops are
continued further for 2-3 weeks.
SJOGREN’S SYNDROME
It is an autoimmune chronic inflammatory disease with
multi-system involvement. It typically occurs in
women between 40 and 50 years of age. Its main
feature is an aqueous deficiency dry eye — the
keratoconjunctivitis sicca (KCS). In primary Sjogren’s
syndrome patients present with sicca complex– a
combination of KCS and xerostomia (dryness of
mouth). In secondary Sjogren’s syndrome dry eye
and/or dry mouth are associated with an autoimmune
disease, commonly rheumatoid arthritis. Its
pathological features include focal accumulation and
infiltration by lymphocytes and plasma cells with
destruction of lacrimal and salivary glandular tissue.
multi-system involvement. It typically occurs in
women between 40 and 50 years of age. Its main
feature is an aqueous deficiency dry eye — the
keratoconjunctivitis sicca (KCS). In primary Sjogren’s
syndrome patients present with sicca complex– a
combination of KCS and xerostomia (dryness of
mouth). In secondary Sjogren’s syndrome dry eye
and/or dry mouth are associated with an autoimmune
disease, commonly rheumatoid arthritis. Its
pathological features include focal accumulation and
infiltration by lymphocytes and plasma cells with
destruction of lacrimal and salivary glandular tissue.
Ptosis
Abnormal drooping of the upper eyelid is called ptosis.
Normally, upper lid covers about upper one-sixth of
the cornea, i.e., about 2 mm. Therefore, in ptosis it
covers more than 2 mm.
Types and etiology
I. Congenital ptosis
It is associated with congenital weakness
(maldevelopment) of the levator palpebrae superioris
(LPS). It may occur in the following forms:
1. Simple congenital ptosis (not associated with
any other anomaly) (Fig. 14.32A).
2. Congenital ptosis with associated weakness of
superior rectus muscle.
3. As a part of blepharophimosis syndrome, which
comprises congenital ptosis, blepharophimosis,
telecanthus and epicanthus inversus (Fig. 14.32B).
4. Congenital synkinetic ptosis (Marcus Gunn jawwinking
ptosis). In this condition there occurs
retraction of the ptotic lid with jaw movements
i.e., with stimulation of ipsilateral pterygoid muscle.
II. Acquired ptosis
Depending upon the cause it can be neurogenic,
myogenic, aponeurotic or mechanical.
1. Neurogenic ptosis. It is caused by innervational
defects such as third nerve palsy, Horner’s
syndrome, ophthalmoplegic migraine and multiple
sclerosis.
2. Myogenic ptosis. It occurs due to acquired
disorders of the LPS muscle or of the myoneural
junction. It may be seen in patients with
myasthenia gravis, dystrophia myotonica, ocular
myopathy, oculo-pharyngeal muscular dystrophy
and following trauma to the LPS muscle.
3. Aponeurotic ptosis. It develops due to defects of
the levator aponeurosis in the presence of a
normal functioning muscle. It includes involutional
(senile) ptosis, postoperative ptosis (which is
rarely observed after cataract and retinal
detachment surgery), ptosis due to aponeurotic
weakness associated with blepharochalasis, and
in traumatic dehiscence or disinsertion of the
aponeurosis.
4. Mechanical ptosis. It may result due to excessive
weight on the upper lid as seen in patients with
lid tumours, multiple chalazia and lid oedema. It
may also occur due to scarring (cicatricial ptosis)
as seen in patients with ocular pemphigoid and
trachoma.
Clinical evaluation
Following scheme may be adopted for work up of a
ptosis patient:
I. History. It should include age of onset, family
history, history of trauma, eye surgery and variability
in degree of the ptosis.
II. Examination
1. Exclude pseudoptosis (simulated ptosis) on
inspection. Its common causes are: microphthalmos,
anophthalmos, enophthalmos and phthisis bulbi.
2. Observe the following points in each case:
i. Whether ptosis is unilateral or bilateral.
ii. Function of orbicularis oculi muscle.
iii. Eyelid crease is present or absent.
iv. Jaw-winking phenomenon is present or not.
v. Associated weakness of any extraocular
muscle.
vi. Bell’s phenomenon (up and outrolling of the
eyeball during forceful closure) is present or
absent.
3. Measurement of amount (degree) of ptosis. In
unilateral cases, difference between the vertical height
of the palpebral fissures of the two sides indicates
the degree of ptosis (Fig. 14.33). In bilateral cases it
can be determined by measuring the amount of cornea
covered by the upper lid and then subtracting 2 mm.
Depending upon its amount the ptosis is graded as
Mild 2 mm
Moderate 3 mm
Severe 4 mm
4. Assessment of levator function. It is determined
by the lid excursion caused by LPS muscle (Burke’s
method). Patient is asked to look down, and thumb of
one hand is placed firmly against the eyebrow of the
patient (to block the action of frontalis muscle) by
the examiner. Then the patient is asked to look up and
the amount of upper lid excursion is measured with a
ruler (Fig. 14.34) held in the other hand by the examiner.
Levator function is graded as follows:
Normal 15 mm
Good 8 mm or more
Fair 5-7 mm
Poor 4 mm or less
5. Special investigations. Those required in patients
with acquired ptosis are as follows:
i. Tensilon test is performed when myasthenia is
suspected. There occurs improvement of ptosis
with intravenous injection of edrophonium
(Tensilon) in myasthenia.
ii. Phenylephrine test is carried out in patients
suspected of Horner’s syndrome.
iii. Neurological investigations may be required to
find out the cause in patient with neurogenic
ptosis.
6. Photographic record of the patient should be
maintained for comparison. Photographs should be
taken in primary position as well as in up and down
gazes.
Treatment
I. Congenital ptosis. It almost always needs surgical
correction. In severe ptosis, surgery should be
performed at the earliest to prevent stimulus
deprivation amblyopia. However, in mild and moderate
ptosis, surgery should be delayed until the age of 3-
4 years, when accurate measurements are possible.
Congenital ptosis can be treated by any of the
following operations:
1. Fasanella-Servat operation. It is performed in
cases having mild ptosis (1.5-2mm) and good levator
function. In it, upper lid is everted and the upper tarsal
border along with its attached Muller’s muscle and
conjunctiva are resected (Fig. 14.35).
2. Levator resection. It is a very commonly performed
operation for moderate and severe grades of ptosis.
It is contraindicated in patients having severe ptosis
with poor levator function.
Amount of levator resection required: Most of the
surgeons find it out by adjusting the lid margin in
relation to cornea during operation on the table in
individual case. However, a rough estimate in different
grades of ptosis is as follows:
Moderate ptosis
Level of LPS Amount of LPS to be
Function resected
Good 16-17 mm (minimal)
Fair18-22 mm (moderate)
Poor 23-24 mm (maximum)
Severe ptosis
Fair levator 23-24 mm (maximum
function LPS resected)
Techniques. Levator muscle may be resected by either
conjunctival or skin approach.
i. Conjunctival approach (Blaskowics’ operation):
This technique is comparatively easy but not
suitable for large amount of resection. In it LPS
muscle is exposed by an incision made through
the conjunctiva near the tarsal border, after the
upper lid is doubly everted over a Desmarre’s lid
retractor (Fig. 14.36).
ii. Skin approach (Everbusch’s operation): It is a
more frequently employed technique. It allows
comparatively better exposure of the LPS muscle
through a skin incision along the line of future lid
fold (Fig. 14.37).
3. Frontalis sling operation (Brow suspension):
This is performed in patients having severe ptosis
with no levator function. In this operation, lid is
anchored to the frontalis muscle via a sling (Fig.
14.38). Fascia lata or some non-absorbable material
(e.g., supramide suture) may be used as sling.
Normally, upper lid covers about upper one-sixth of
the cornea, i.e., about 2 mm. Therefore, in ptosis it
covers more than 2 mm.
Types and etiology
I. Congenital ptosis
It is associated with congenital weakness
(maldevelopment) of the levator palpebrae superioris
(LPS). It may occur in the following forms:
1. Simple congenital ptosis (not associated with
any other anomaly) (Fig. 14.32A).
2. Congenital ptosis with associated weakness of
superior rectus muscle.
3. As a part of blepharophimosis syndrome, which
comprises congenital ptosis, blepharophimosis,
telecanthus and epicanthus inversus (Fig. 14.32B).
4. Congenital synkinetic ptosis (Marcus Gunn jawwinking
ptosis). In this condition there occurs
retraction of the ptotic lid with jaw movements
i.e., with stimulation of ipsilateral pterygoid muscle.
II. Acquired ptosis
Depending upon the cause it can be neurogenic,
myogenic, aponeurotic or mechanical.
1. Neurogenic ptosis. It is caused by innervational
defects such as third nerve palsy, Horner’s
syndrome, ophthalmoplegic migraine and multiple
sclerosis.
2. Myogenic ptosis. It occurs due to acquired
disorders of the LPS muscle or of the myoneural
junction. It may be seen in patients with
myasthenia gravis, dystrophia myotonica, ocular
myopathy, oculo-pharyngeal muscular dystrophy
and following trauma to the LPS muscle.
3. Aponeurotic ptosis. It develops due to defects of
the levator aponeurosis in the presence of a
normal functioning muscle. It includes involutional
(senile) ptosis, postoperative ptosis (which is
rarely observed after cataract and retinal
detachment surgery), ptosis due to aponeurotic
weakness associated with blepharochalasis, and
in traumatic dehiscence or disinsertion of the
aponeurosis.
4. Mechanical ptosis. It may result due to excessive
weight on the upper lid as seen in patients with
lid tumours, multiple chalazia and lid oedema. It
may also occur due to scarring (cicatricial ptosis)
as seen in patients with ocular pemphigoid and
trachoma.
Clinical evaluation
Following scheme may be adopted for work up of a
ptosis patient:
I. History. It should include age of onset, family
history, history of trauma, eye surgery and variability
in degree of the ptosis.
II. Examination
1. Exclude pseudoptosis (simulated ptosis) on
inspection. Its common causes are: microphthalmos,
anophthalmos, enophthalmos and phthisis bulbi.
2. Observe the following points in each case:
i. Whether ptosis is unilateral or bilateral.
ii. Function of orbicularis oculi muscle.
iii. Eyelid crease is present or absent.
iv. Jaw-winking phenomenon is present or not.
v. Associated weakness of any extraocular
muscle.
vi. Bell’s phenomenon (up and outrolling of the
eyeball during forceful closure) is present or
absent.
3. Measurement of amount (degree) of ptosis. In
unilateral cases, difference between the vertical height
of the palpebral fissures of the two sides indicates
the degree of ptosis (Fig. 14.33). In bilateral cases it
can be determined by measuring the amount of cornea
covered by the upper lid and then subtracting 2 mm.
Depending upon its amount the ptosis is graded as
Mild 2 mm
Moderate 3 mm
Severe 4 mm
4. Assessment of levator function. It is determined
by the lid excursion caused by LPS muscle (Burke’s
method). Patient is asked to look down, and thumb of
one hand is placed firmly against the eyebrow of the
patient (to block the action of frontalis muscle) by
the examiner. Then the patient is asked to look up and
the amount of upper lid excursion is measured with a
ruler (Fig. 14.34) held in the other hand by the examiner.
Levator function is graded as follows:
Normal 15 mm
Good 8 mm or more
Fair 5-7 mm
Poor 4 mm or less
5. Special investigations. Those required in patients
with acquired ptosis are as follows:
i. Tensilon test is performed when myasthenia is
suspected. There occurs improvement of ptosis
with intravenous injection of edrophonium
(Tensilon) in myasthenia.
ii. Phenylephrine test is carried out in patients
suspected of Horner’s syndrome.
iii. Neurological investigations may be required to
find out the cause in patient with neurogenic
ptosis.
6. Photographic record of the patient should be
maintained for comparison. Photographs should be
taken in primary position as well as in up and down
gazes.
Treatment
I. Congenital ptosis. It almost always needs surgical
correction. In severe ptosis, surgery should be
performed at the earliest to prevent stimulus
deprivation amblyopia. However, in mild and moderate
ptosis, surgery should be delayed until the age of 3-
4 years, when accurate measurements are possible.
Congenital ptosis can be treated by any of the
following operations:
1. Fasanella-Servat operation. It is performed in
cases having mild ptosis (1.5-2mm) and good levator
function. In it, upper lid is everted and the upper tarsal
border along with its attached Muller’s muscle and
conjunctiva are resected (Fig. 14.35).
2. Levator resection. It is a very commonly performed
operation for moderate and severe grades of ptosis.
It is contraindicated in patients having severe ptosis
with poor levator function.
Amount of levator resection required: Most of the
surgeons find it out by adjusting the lid margin in
relation to cornea during operation on the table in
individual case. However, a rough estimate in different
grades of ptosis is as follows:
Moderate ptosis
Level of LPS Amount of LPS to be
Function resected
Good 16-17 mm (minimal)
Fair18-22 mm (moderate)
Poor 23-24 mm (maximum)
Severe ptosis
Fair levator 23-24 mm (maximum
function LPS resected)
Techniques. Levator muscle may be resected by either
conjunctival or skin approach.
i. Conjunctival approach (Blaskowics’ operation):
This technique is comparatively easy but not
suitable for large amount of resection. In it LPS
muscle is exposed by an incision made through
the conjunctiva near the tarsal border, after the
upper lid is doubly everted over a Desmarre’s lid
retractor (Fig. 14.36).
ii. Skin approach (Everbusch’s operation): It is a
more frequently employed technique. It allows
comparatively better exposure of the LPS muscle
through a skin incision along the line of future lid
fold (Fig. 14.37).
3. Frontalis sling operation (Brow suspension):
This is performed in patients having severe ptosis
with no levator function. In this operation, lid is
anchored to the frontalis muscle via a sling (Fig.
14.38). Fascia lata or some non-absorbable material
(e.g., supramide suture) may be used as sling.
BLEPHAROSPASM
It refers to the involuntary, sustained and forceful
closure of the eyelids.
Etiology. Blepharospasm occurs in two forms:
1. Essential (spontaneous) blepharospasm. It is a
rare idiopathic condition involving patients
between 45 and 65 years of age.
2. Reflex blepharospasm. It usually occurs due to
reflex sensory stimulation through branches of
fifth nerve, in conditions such as : phlyctenular
keratitis, interstitial keratitis, corneal foreign body,
corneal ulcers and iridocyclitis. It is also seen in
excessive stimulation of retina by dazzling light,
stimulation of facial nerve due to central causes
and in some hysterical patients.
Clinical features. Persistent epiphora may occur due
to spasmodic closure of the canaliculi which may lead
to eczema of the lower lid. Oedema of the lids is of
frequent occurrence. Spastic entropion (in elderly
people) and spastic ectropion (in children and young
adults) may develop in long-standing cases.
Blepharophimosis may result due to contraction of
the skin folds following eczema.
Treatment. In essential blepharospasm Botulinum
toxin, injected subcutaneously over the orbicularis
muscle, blocks the neuromuscular junction and
relieves the spasm. Facial denervation may be
required in severe cases. In reflex blepharospasm, the
causative disease should be treated to prevent
recurrences. Associated complications should also
be treated.
closure of the eyelids.
Etiology. Blepharospasm occurs in two forms:
1. Essential (spontaneous) blepharospasm. It is a
rare idiopathic condition involving patients
between 45 and 65 years of age.
2. Reflex blepharospasm. It usually occurs due to
reflex sensory stimulation through branches of
fifth nerve, in conditions such as : phlyctenular
keratitis, interstitial keratitis, corneal foreign body,
corneal ulcers and iridocyclitis. It is also seen in
excessive stimulation of retina by dazzling light,
stimulation of facial nerve due to central causes
and in some hysterical patients.
Clinical features. Persistent epiphora may occur due
to spasmodic closure of the canaliculi which may lead
to eczema of the lower lid. Oedema of the lids is of
frequent occurrence. Spastic entropion (in elderly
people) and spastic ectropion (in children and young
adults) may develop in long-standing cases.
Blepharophimosis may result due to contraction of
the skin folds following eczema.
Treatment. In essential blepharospasm Botulinum
toxin, injected subcutaneously over the orbicularis
muscle, blocks the neuromuscular junction and
relieves the spasm. Facial denervation may be
required in severe cases. In reflex blepharospasm, the
causative disease should be treated to prevent
recurrences. Associated complications should also
be treated.
TARSORRHAPHY
In this operation adhesions are created between a
part of the lid margins with the aim to narrow down or
almost close the palpebral aperture.
It is of two types: temporary and permanent.
1. Temporary tarsorrhaphy
Indications : (i) To protect the cornea when seventh
nerve palsy is expected to recover. (ii) To assist
healing of an indolent corneal ulcer. (iii) To assist in
healing of skin-grafts of the lids in the correct position.
Surgical techniques. This can be carried out as
median or paramedian tarsorrhaphy (Fig. 14.31).
1. Incision. For paramedian tarsorrhaphy, about 5
mm long incision site is marked on the
corresponding parts of the upper and lower lid
margins, 3-mm on either side of the midline. An
incision 2-mm deep is made in the grey line on the
marked site and the marginal epithelium is then
excised taking care not to damage the ciliary line
anteriorly and the sharp lid border posteriorly.
2. Suturing. The raw surfaces thus created on the
opposing parts of the lid margins are then sutured
with double-armed 6-0 silk sutures passed through
a rubber bolster.
2. Permanent tarsorrhaphy
Indications. (i) Established cases of VII nerve palsy
where there is no chance of recovery; and (ii)
established cases of neuroparalytic keratitis with
severe loss of corneal sensations.
Technique. It is performed at the lateral canthus to
create permanent adhesions. The eyelids are
overlapped after excising a triangular flap of skin and
orbicularis from the lower lid and corresponding
triangular tarso-conjunctival flap from the upper lid.
part of the lid margins with the aim to narrow down or
almost close the palpebral aperture.
It is of two types: temporary and permanent.
1. Temporary tarsorrhaphy
Indications : (i) To protect the cornea when seventh
nerve palsy is expected to recover. (ii) To assist
healing of an indolent corneal ulcer. (iii) To assist in
healing of skin-grafts of the lids in the correct position.
Surgical techniques. This can be carried out as
median or paramedian tarsorrhaphy (Fig. 14.31).
1. Incision. For paramedian tarsorrhaphy, about 5
mm long incision site is marked on the
corresponding parts of the upper and lower lid
margins, 3-mm on either side of the midline. An
incision 2-mm deep is made in the grey line on the
marked site and the marginal epithelium is then
excised taking care not to damage the ciliary line
anteriorly and the sharp lid border posteriorly.
2. Suturing. The raw surfaces thus created on the
opposing parts of the lid margins are then sutured
with double-armed 6-0 silk sutures passed through
a rubber bolster.
2. Permanent tarsorrhaphy
Indications. (i) Established cases of VII nerve palsy
where there is no chance of recovery; and (ii)
established cases of neuroparalytic keratitis with
severe loss of corneal sensations.
Technique. It is performed at the lateral canthus to
create permanent adhesions. The eyelids are
overlapped after excising a triangular flap of skin and
orbicularis from the lower lid and corresponding
triangular tarso-conjunctival flap from the upper lid.
LAGOPHTHALMOS
This condition is characterised by inability to
voluntarily close the eyelids.
Etiology. It occurs in patients with paralysis of
orbicularis oculi muscle, cicatricial contraction of the
lids, symblepharon, severe ectropion, proptosis,
following over-resection of the levator muscle for
ptosis, and in comatosed patients. Physiologically
some people sleep with their eyes open (nocturnal
lagophthalmos)
Clinical picture. It is characterised by incomplete
closure of the palpebral aperture associated with
features of the causative disease.
Complications include conjunctival and corneal
xerosis and exposure keratitis.
Treatment. To prevent exposure keratitis artificial tear
drops should be instilled frequently and the open
palpebral fissure should be filled with an antibiotic
eye ointment during sleep and in comatosed patients.
Soft bandage contact lens may be used to prevent
exposure keratitis.
Tarsorrhaphy may be performed to cover the
exposed cornea when indicated. Measures should
be taken to treat the cause of lagophthalmos, wherever
possible.
voluntarily close the eyelids.
Etiology. It occurs in patients with paralysis of
orbicularis oculi muscle, cicatricial contraction of the
lids, symblepharon, severe ectropion, proptosis,
following over-resection of the levator muscle for
ptosis, and in comatosed patients. Physiologically
some people sleep with their eyes open (nocturnal
lagophthalmos)
Clinical picture. It is characterised by incomplete
closure of the palpebral aperture associated with
features of the causative disease.
Complications include conjunctival and corneal
xerosis and exposure keratitis.
Treatment. To prevent exposure keratitis artificial tear
drops should be instilled frequently and the open
palpebral fissure should be filled with an antibiotic
eye ointment during sleep and in comatosed patients.
Soft bandage contact lens may be used to prevent
exposure keratitis.
Tarsorrhaphy may be performed to cover the
exposed cornea when indicated. Measures should
be taken to treat the cause of lagophthalmos, wherever
possible.
SYMBLEPHARON
In this condition lids become adherent with the
eyeball as a result of adhesions between the palpebral
and bulbar conjunctiva.
Etiology
It results from healing of the kissing raw surfaces
upon the palpebral and bulbar conjunctiva. Its
common causes are thermal or chemical burns,
membranous conjunctivitis, injuries, conjunctival
ulcerations, ocular pemphigus and Stevens-Johnson
syndrome.
Clinical picture
It is characterised by difficulty in lid movements,
diplopia (due to restricted ocular motility), inability
to close the lids (lagophthalmos) and cosmetic
disfigurement.
Fibrous adhesions between palpebral conjunctiva
and the bulbar conjunctiva and/or cornea (Fig. 14.30)
may be present only in the anterior part (anterior
symblepharon), or fornix (posterior symblepharon)
or the whole lid (total symblepharon).
Complications
These include dryness, thickening and keratinisation
of conjunctiva due to prolonged exposure and corneal
ulceration (exposure keratitis).
Treatment
1. Prophylaxis. During the stage of raw surfaces,
the adhesions may be prevented by sweeping a
glass rod coated with lubricant around the
fornices several times a day. A large-sized,
therapeutic, soft contact lens also helps in
preventing the adhesions.
2. Curative treatment consists of symblepharectomy.
The raw area created may be covered by
mobilising the surrounding conjunctiva in mild
cases. Conjunctival or buccal mucosal graft is
required in severe cases.
eyeball as a result of adhesions between the palpebral
and bulbar conjunctiva.
Etiology
It results from healing of the kissing raw surfaces
upon the palpebral and bulbar conjunctiva. Its
common causes are thermal or chemical burns,
membranous conjunctivitis, injuries, conjunctival
ulcerations, ocular pemphigus and Stevens-Johnson
syndrome.
Clinical picture
It is characterised by difficulty in lid movements,
diplopia (due to restricted ocular motility), inability
to close the lids (lagophthalmos) and cosmetic
disfigurement.
Fibrous adhesions between palpebral conjunctiva
and the bulbar conjunctiva and/or cornea (Fig. 14.30)
may be present only in the anterior part (anterior
symblepharon), or fornix (posterior symblepharon)
or the whole lid (total symblepharon).
Complications
These include dryness, thickening and keratinisation
of conjunctiva due to prolonged exposure and corneal
ulceration (exposure keratitis).
Treatment
1. Prophylaxis. During the stage of raw surfaces,
the adhesions may be prevented by sweeping a
glass rod coated with lubricant around the
fornices several times a day. A large-sized,
therapeutic, soft contact lens also helps in
preventing the adhesions.
2. Curative treatment consists of symblepharectomy.
The raw area created may be covered by
mobilising the surrounding conjunctiva in mild
cases. Conjunctival or buccal mucosal graft is
required in severe cases.
ECTROPION
Out rolling or outward turning of the lid margin is
called ectropion.
Types
1. Senile ectropion. It is the commonest variety and
involves only the lower lids. It occurs due to senile
laxity of the tissues of the lids and loss of tone of the
orbicularis muscle (Fig. 14.24).
2. Cicatricial ectropion. It occurs due to scarring of
the skin and can involve both the lids (Fig. 14.25).
Common causes of skin scarring are: thermal burns,
chemical burns, lacerating injuries and skin ulcers.
3. Paralytic ectropion. It results due to paralysis of
the seventh nerve. It mainly occurs in the lower lids.
Common causes of facial nerve palsy are: Bell’s palsy,
head injury and infections of the middle ear.
4. Mechanical ectropion. It occurs in conditions
where either the lower lid is pulled down (as in
tumours) or pushed out and down (as in proptosis
and marked chemosis of the conjunctiva).
5. Spastic ectropion. It is a rare entity, seen in children
and young adults following spasm of the orbicularis,
where lids are well supported by the globe.
Clinical picture
Symptoms. Epiphora is the main symptom in
ectropion of the lower lid. Symptoms due to
associated chronic conjunctivitis include: irritation,
discomfort and mild photophobia.
Signs. Lid margin is outrolled. Depending upon the
degree of outrolling, ectropion can be divided into three
grades. In grade I ectropion only punctum is everted.
In grade II lid margin is everted and palpebral conjunctiva
is visible while in grade III the fornix is also visible.
Signs of the etiological condition such as skin scars
in cicatricial ectropion and seventh nerve palsy in
paralytic ectropion may also be seen.
Complications
Prolonged exposure may cause dryness and
thickening of the conjunctiva and corneal ulceration
(exposure keratitis). Eczema and dermatitis may occur
due to prolonged epiphora.
Treatment
1. Senile ectropion. Depending upon the severity,
following three operations are commonly performed:
i. Medial conjunctivoplasty. It is useful in mild
cases of ectropion involving punctal area. It
consists of excising a spindle-shaped piece of
conjunctiva and subconjunctival tissue from
below the punctal area (Fig. 14.26).
ii. Horizontal lid shortening. It is performed by a
full thickness pentagonal excision in patients
with moderate degree of ectropion (Fig. 14.27).
iii. Byron Smith’s modified Kuhnt-Szymanowski
operation. It is performed for severe degree of
ectropion which is more marked over the lateral
half of the lid. In it, a base up pentagonal full
thickness excision from the lateral third of the
eyelid is combined with triangular excision of the
skin from the area just lateral to lateral canthus to
elevate the lid (Fig. 14.28).
2. Paralytic ectropion. It can be corrected by a lateral
tarsorrhaphy or palpebral sling operation, in which a
fascia lata sling is passed in the subcutaneous layer
all around the lid margins.
3. Cicatricial ectropion. Depending upon the degree
it can be corrected by any of the following operations:
i. V-Y operation. It is indicated in mild degree
ectropion. In it a V-shaped incision is given,
skin is undermined and sutured in a Y-shaped
pattern (Fig. 14.29).
ii. Z-plasty (Elschnig’s operation). It is useful in
mild to moderate degree of ectropion.
iii. Excision of scar tissue and full thickness skin
grafting. It is performed in severe cases. Skin
graft may be taken from the upper lid, behind
the ear, or inner side of upper arm.
4. Mechanical ectropion. It is corrected by treating
the underlying cause.
5. Spastic ectropion. It is corrected by treating the
cause of blepharospasm.
called ectropion.
Types
1. Senile ectropion. It is the commonest variety and
involves only the lower lids. It occurs due to senile
laxity of the tissues of the lids and loss of tone of the
orbicularis muscle (Fig. 14.24).
2. Cicatricial ectropion. It occurs due to scarring of
the skin and can involve both the lids (Fig. 14.25).
Common causes of skin scarring are: thermal burns,
chemical burns, lacerating injuries and skin ulcers.
3. Paralytic ectropion. It results due to paralysis of
the seventh nerve. It mainly occurs in the lower lids.
Common causes of facial nerve palsy are: Bell’s palsy,
head injury and infections of the middle ear.
4. Mechanical ectropion. It occurs in conditions
where either the lower lid is pulled down (as in
tumours) or pushed out and down (as in proptosis
and marked chemosis of the conjunctiva).
5. Spastic ectropion. It is a rare entity, seen in children
and young adults following spasm of the orbicularis,
where lids are well supported by the globe.
Clinical picture
Symptoms. Epiphora is the main symptom in
ectropion of the lower lid. Symptoms due to
associated chronic conjunctivitis include: irritation,
discomfort and mild photophobia.
Signs. Lid margin is outrolled. Depending upon the
degree of outrolling, ectropion can be divided into three
grades. In grade I ectropion only punctum is everted.
In grade II lid margin is everted and palpebral conjunctiva
is visible while in grade III the fornix is also visible.
Signs of the etiological condition such as skin scars
in cicatricial ectropion and seventh nerve palsy in
paralytic ectropion may also be seen.
Complications
Prolonged exposure may cause dryness and
thickening of the conjunctiva and corneal ulceration
(exposure keratitis). Eczema and dermatitis may occur
due to prolonged epiphora.
Treatment
1. Senile ectropion. Depending upon the severity,
following three operations are commonly performed:
i. Medial conjunctivoplasty. It is useful in mild
cases of ectropion involving punctal area. It
consists of excising a spindle-shaped piece of
conjunctiva and subconjunctival tissue from
below the punctal area (Fig. 14.26).
ii. Horizontal lid shortening. It is performed by a
full thickness pentagonal excision in patients
with moderate degree of ectropion (Fig. 14.27).
iii. Byron Smith’s modified Kuhnt-Szymanowski
operation. It is performed for severe degree of
ectropion which is more marked over the lateral
half of the lid. In it, a base up pentagonal full
thickness excision from the lateral third of the
eyelid is combined with triangular excision of the
skin from the area just lateral to lateral canthus to
elevate the lid (Fig. 14.28).
2. Paralytic ectropion. It can be corrected by a lateral
tarsorrhaphy or palpebral sling operation, in which a
fascia lata sling is passed in the subcutaneous layer
all around the lid margins.
3. Cicatricial ectropion. Depending upon the degree
it can be corrected by any of the following operations:
i. V-Y operation. It is indicated in mild degree
ectropion. In it a V-shaped incision is given,
skin is undermined and sutured in a Y-shaped
pattern (Fig. 14.29).
ii. Z-plasty (Elschnig’s operation). It is useful in
mild to moderate degree of ectropion.
iii. Excision of scar tissue and full thickness skin
grafting. It is performed in severe cases. Skin
graft may be taken from the upper lid, behind
the ear, or inner side of upper arm.
4. Mechanical ectropion. It is corrected by treating
the underlying cause.
5. Spastic ectropion. It is corrected by treating the
cause of blepharospasm.
ENTROPION
It is inturning of the lid margin.
Types
1. Congenital entropion. It is a rare condition seen
since birth. It may be associated with microphthalmos.
2. Cicatricial entropion (Fig. 14.17). It is a common
variety usually involving the upper lid. It is caused
by cicatricial contraction of the palpebral conjunctiva,
with or without associated distortion of the tarsal
plate.
Common causes are trachoma, membranous
conjunctivitis, chemical burns, pemphigus and
Stevens-Johnson syndrome.
3. Spastic entropion. It occurs due to spasm of the
orbicularis muscle in patients with chronic irritative
corneal conditions or after tight ocular bandaging. It
commonly occurs in old people and usually involves
the lower lid.
4. Senile (involutional) entropion. It is a common
variety and only affects the lower lid in elderly people
(Fig. 14.18). The etiological factors which contribute
for its development are : (i) weakening or dehiscence
of capsulopalpebral fascia (lower lid retractor);
(ii) degeneration of palpebral connective tissue
separating the orbicularis muscle fibres and thus
allowing pre-septal fibres to override the pretarsal
fibres; and (iii) horizontal laxity of the lid.
5. Mechanical entropion. It occurs due to lack of
support provided by the globe to the lids. Therefore,
it may occur in patients with phthisis bulbi,
enophthalmos and after enucleation or evisceration
operation.
Clinical picture
Symptoms occur due to rubbing of cilia against the
cornea and conjunctiva and are thus similar to
trichiasis. These include foreign body sensation,
irritation, lacrimation and photophobia.
Signs. On examination, lid margin is found inturned.
Depending upon the degree of inturning it can be
divided into three grades. In grade I, only the
posterior lid border is inrolled. Grade II entropion,
includes inturning up to the inter-marginal strip while
in grade III the whole lid margin including the anterior
border is inturned.
Complications. These are similar to trichiasis.
Treatment
1. Congenital entropion requires plastic reconstruction
of the lid crease.
2. Spastic entropion. (i) Treat the cause of blepharospasm
e.g. remove the bandage (if applied) or treat
the associated condition of cornea. (ii) Adhesive
plaster pull on the lower lid may help during acute
spasm. (iii) Injection of botulinum toxins in the
orbicularis muscle is advocated to relieve the spasm.
(iv) Surgical treatment similar to involutional (senile)
entropion may be undertaken if the spasm is not
relieved by above methods.
3. Cicatricial entropion. It is treated by a plastic
operation, which is based on any of the following
basic principles : (i) Altering the direction of lashes,
(ii) Transplanting the lashes, (iii) Straightening the
distorted tarsus.
Surgical techniques employed for correcting
cicatricial entropion are as follows:
i. Resection of skin and muscle. It is the simplest
operation employed to correct mild degree of
entropion. In this operation an elliptical strip of
skin and orbicularis muscle is resected 3 mm
away from the lid margin.
ii. Resection of skin, muscle and tarsus: It corrects
moderate degree of entropion associated with
atrophic tarsus. In this operation, in addition to
the elliptical resection of skin and muscle, a
wedge of tarsal plate is also removed (Fig. 14.19A).
iii. Modified Burrow’s operation. It is performed
from the conjunctival side after everting the lid.
A horizontal incision is made along the whole
length of the eyelid, involving conjunctiva and
tarsal plate (but not the skin), in the region of
sulcus subtarsalis (2-3 mm above the lid margin).
The temporal end of the strip is incised by a full
thickness vertical incision. Pad and bandage is
applied in such a way that the edge of lid is kept
everted till healing occurs. After healing, the
lashes are directed away from the eye.
iv. Jaesche-Arlt’s operation (Fig. 14.19B): The lid is
split along the grey line up to a depth of
3-4 mm, from outer canthus to just lateral to the
punctum. Then a 4 mm wide crescentric strip of
skin is removed from 3 mm above the lid margin.
After suturing the skin incision, the lash line will
be transplanted high. The gap created at the level
of grey line may be filled by a mucosal graft taken
from the lip.
v. Modified Ketssey’s operation (Transposition of
tarsoconjunctival wedge) (Fig.14.20): A horizontal
incision is made along the whole length of sulcus
subtarsalis (2-3 mm above the lid margin)
involving conjunctiva and tarsal plate. The lower
piece of tarsal plate is undermined up to lid
Fig. 14.19. Operations for cicatricial entropion: A, skin,
muscle and tarsal wedge resection; B, Jaesche-Arlt’s
operation. Fig. 14.20. Modified Ketssey’s operation.
margin. Mattress sutures are then passed from
the upper cut end of the tarsal plate to emerge on
the skin 1 mm above the lid margin. When sutures
are tied the entropion is corrected by transposition
of tarsoconjunctival wedge.
4. Senile entropion. Commonly used surgical
techniques are as follows:
i. Modified Wheeler’s operation: A base down
triangular piece of tarsal plate and conjunctiva is
resected along with double breasting of the
orbicularis oculi muscle (Fig. 14.21).
ii. Bick’s procedure with Reeh’s modification: It is
useful in patients with associated horizontal lid
laxity. In it a pentagonal full thickness resection
of the lid tissue is performed.
iii. Weiss operation. An incision involving skin,
orbicularis and tarsal plate is given 3 mm below
the lid margin, along the whole length of the
eyelid. Mattress sutures are then passed through
the lower cut end of the tarsus to emerge on the
skin, 1 mm below the lid margin. On tying the
sutures, the entropion is corrected by
transpositioning of the tarsus.
iv. Tucking of inferior lid retractors (Jones, Reeh
and Wobig operation): It is performed in severe
cases or when recurrence occurs after the above
described operations. In this operation the
inferior lid retractors are strengthened by
tucking or plication procedure
Types
1. Congenital entropion. It is a rare condition seen
since birth. It may be associated with microphthalmos.
2. Cicatricial entropion (Fig. 14.17). It is a common
variety usually involving the upper lid. It is caused
by cicatricial contraction of the palpebral conjunctiva,
with or without associated distortion of the tarsal
plate.
Common causes are trachoma, membranous
conjunctivitis, chemical burns, pemphigus and
Stevens-Johnson syndrome.
3. Spastic entropion. It occurs due to spasm of the
orbicularis muscle in patients with chronic irritative
corneal conditions or after tight ocular bandaging. It
commonly occurs in old people and usually involves
the lower lid.
4. Senile (involutional) entropion. It is a common
variety and only affects the lower lid in elderly people
(Fig. 14.18). The etiological factors which contribute
for its development are : (i) weakening or dehiscence
of capsulopalpebral fascia (lower lid retractor);
(ii) degeneration of palpebral connective tissue
separating the orbicularis muscle fibres and thus
allowing pre-septal fibres to override the pretarsal
fibres; and (iii) horizontal laxity of the lid.
5. Mechanical entropion. It occurs due to lack of
support provided by the globe to the lids. Therefore,
it may occur in patients with phthisis bulbi,
enophthalmos and after enucleation or evisceration
operation.
Clinical picture
Symptoms occur due to rubbing of cilia against the
cornea and conjunctiva and are thus similar to
trichiasis. These include foreign body sensation,
irritation, lacrimation and photophobia.
Signs. On examination, lid margin is found inturned.
Depending upon the degree of inturning it can be
divided into three grades. In grade I, only the
posterior lid border is inrolled. Grade II entropion,
includes inturning up to the inter-marginal strip while
in grade III the whole lid margin including the anterior
border is inturned.
Complications. These are similar to trichiasis.
Treatment
1. Congenital entropion requires plastic reconstruction
of the lid crease.
2. Spastic entropion. (i) Treat the cause of blepharospasm
e.g. remove the bandage (if applied) or treat
the associated condition of cornea. (ii) Adhesive
plaster pull on the lower lid may help during acute
spasm. (iii) Injection of botulinum toxins in the
orbicularis muscle is advocated to relieve the spasm.
(iv) Surgical treatment similar to involutional (senile)
entropion may be undertaken if the spasm is not
relieved by above methods.
3. Cicatricial entropion. It is treated by a plastic
operation, which is based on any of the following
basic principles : (i) Altering the direction of lashes,
(ii) Transplanting the lashes, (iii) Straightening the
distorted tarsus.
Surgical techniques employed for correcting
cicatricial entropion are as follows:
i. Resection of skin and muscle. It is the simplest
operation employed to correct mild degree of
entropion. In this operation an elliptical strip of
skin and orbicularis muscle is resected 3 mm
away from the lid margin.
ii. Resection of skin, muscle and tarsus: It corrects
moderate degree of entropion associated with
atrophic tarsus. In this operation, in addition to
the elliptical resection of skin and muscle, a
wedge of tarsal plate is also removed (Fig. 14.19A).
iii. Modified Burrow’s operation. It is performed
from the conjunctival side after everting the lid.
A horizontal incision is made along the whole
length of the eyelid, involving conjunctiva and
tarsal plate (but not the skin), in the region of
sulcus subtarsalis (2-3 mm above the lid margin).
The temporal end of the strip is incised by a full
thickness vertical incision. Pad and bandage is
applied in such a way that the edge of lid is kept
everted till healing occurs. After healing, the
lashes are directed away from the eye.
iv. Jaesche-Arlt’s operation (Fig. 14.19B): The lid is
split along the grey line up to a depth of
3-4 mm, from outer canthus to just lateral to the
punctum. Then a 4 mm wide crescentric strip of
skin is removed from 3 mm above the lid margin.
After suturing the skin incision, the lash line will
be transplanted high. The gap created at the level
of grey line may be filled by a mucosal graft taken
from the lip.
v. Modified Ketssey’s operation (Transposition of
tarsoconjunctival wedge) (Fig.14.20): A horizontal
incision is made along the whole length of sulcus
subtarsalis (2-3 mm above the lid margin)
involving conjunctiva and tarsal plate. The lower
piece of tarsal plate is undermined up to lid
Fig. 14.19. Operations for cicatricial entropion: A, skin,
muscle and tarsal wedge resection; B, Jaesche-Arlt’s
operation. Fig. 14.20. Modified Ketssey’s operation.
margin. Mattress sutures are then passed from
the upper cut end of the tarsal plate to emerge on
the skin 1 mm above the lid margin. When sutures
are tied the entropion is corrected by transposition
of tarsoconjunctival wedge.
4. Senile entropion. Commonly used surgical
techniques are as follows:
i. Modified Wheeler’s operation: A base down
triangular piece of tarsal plate and conjunctiva is
resected along with double breasting of the
orbicularis oculi muscle (Fig. 14.21).
ii. Bick’s procedure with Reeh’s modification: It is
useful in patients with associated horizontal lid
laxity. In it a pentagonal full thickness resection
of the lid tissue is performed.
iii. Weiss operation. An incision involving skin,
orbicularis and tarsal plate is given 3 mm below
the lid margin, along the whole length of the
eyelid. Mattress sutures are then passed through
the lower cut end of the tarsus to emerge on the
skin, 1 mm below the lid margin. On tying the
sutures, the entropion is corrected by
transpositioning of the tarsus.
iv. Tucking of inferior lid retractors (Jones, Reeh
and Wobig operation): It is performed in severe
cases or when recurrence occurs after the above
described operations. In this operation the
inferior lid retractors are strengthened by
tucking or plication procedure
TRICHIASIS
It refers to inward misdirection of cilia (which rub
against the eyeball) with normal position of the lid
margin (Fig. 14.16A). The inward turning of lashes
along with the lid margin (seen in entropion) is called
pseudotrichiasis.
Etiology. Common causes of trichiasis are : cicatrising
trachoma, ulcerative blepharitis, healed membranous
conjunctivitis, hordeolum externum, mechanical
injuries, burns, and operative scar on the lid margin.
Symptoms. These include foreign body sensation
and photophobia. Patient may feel troublesome
irritation, pain and lacrimation.
Signs. Examination reveals one or more misdirected
cilia touching the cornea. Reflex blepharospasm and
photophobia occur when cornea is abraded.
Conjunctiva may be congested. Signs of causative
disease viz. trachoma, blepharitis etc. may be present.
Complications. These include recurrent corneal
abrasions, superficial corneal opacities, corneal
vascularisation (Fig. 14.16B) and non-healing corneal
ulcer.
Treatment. A few misdirected cilia may be treated by
any of the following methods:
1. Epilation (mechanical removal with forceps): It is
a temporary method, as recurrence occurs within
3-4 weeks.
2. Electrolysis: It is a method of destroying the lash
follicle by electric current. In this technique,
infiltration anaesthesia is given to the lid and a
current of 2 mA is passed for 10 seconds through
a fine needle inserted into the lash root. The
loosened cilia with destroyed follicles are then
removed with epilation forceps.
3. Cryoepilation: It is also an effective method of
treating trichiasis. After infiltration anaesthesia, the
cryoprobe (–20 °C) is applied for 20-25 seconds to
the external lid margin. Its main disadvantage is
depigmentation of the skin.
4. Surgical correction: When many cilia are
misdirected operative treatment similar to cicatricial
entropion should be employed.
against the eyeball) with normal position of the lid
margin (Fig. 14.16A). The inward turning of lashes
along with the lid margin (seen in entropion) is called
pseudotrichiasis.
Etiology. Common causes of trichiasis are : cicatrising
trachoma, ulcerative blepharitis, healed membranous
conjunctivitis, hordeolum externum, mechanical
injuries, burns, and operative scar on the lid margin.
Symptoms. These include foreign body sensation
and photophobia. Patient may feel troublesome
irritation, pain and lacrimation.
Signs. Examination reveals one or more misdirected
cilia touching the cornea. Reflex blepharospasm and
photophobia occur when cornea is abraded.
Conjunctiva may be congested. Signs of causative
disease viz. trachoma, blepharitis etc. may be present.
Complications. These include recurrent corneal
abrasions, superficial corneal opacities, corneal
vascularisation (Fig. 14.16B) and non-healing corneal
ulcer.
Treatment. A few misdirected cilia may be treated by
any of the following methods:
1. Epilation (mechanical removal with forceps): It is
a temporary method, as recurrence occurs within
3-4 weeks.
2. Electrolysis: It is a method of destroying the lash
follicle by electric current. In this technique,
infiltration anaesthesia is given to the lid and a
current of 2 mA is passed for 10 seconds through
a fine needle inserted into the lash root. The
loosened cilia with destroyed follicles are then
removed with epilation forceps.
3. Cryoepilation: It is also an effective method of
treating trichiasis. After infiltration anaesthesia, the
cryoprobe (–20 °C) is applied for 20-25 seconds to
the external lid margin. Its main disadvantage is
depigmentation of the skin.
4. Surgical correction: When many cilia are
misdirected operative treatment similar to cicatricial
entropion should be employed.
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.
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 (Fig. 14.12).
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.
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.
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 (Fig. 14.13) is the
conventional and effective treatment for chalazion.
Surface anaesthesia is obtained by instillation of
xylocaine drops in the eye and the lid in the
region of the chalazion is infiltrated with 2 percent
xylocaine solution. An incision is made with
a sharp blade, which should be vertical on the
conjunctival side (to avoid injury to other
meibomian ducts) and horizontal on skin side (to
have an invisible scar). The contents are curetted
out with the help of a chalazion scoop. To avoid
recurrence, its cavity should be cauterised with
carbolic acid. An antibiotic ointment is instilled
and eye padded for about 12 hours. To decrease
postoperative discomfort and prevent infection,
antibiotic eyedrops, hot fomentation and oral
anti-inflammatory and analgesics may be given
for 3-4 days.
4. Diathermy. A marginal chalazion is better treated
by diathermy.
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.
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 (Fig. 14.12).
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.
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.
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 (Fig. 14.13) is the
conventional and effective treatment for chalazion.
Surface anaesthesia is obtained by instillation of
xylocaine drops in the eye and the lid in the
region of the chalazion is infiltrated with 2 percent
xylocaine solution. An incision is made with
a sharp blade, which should be vertical on the
conjunctival side (to avoid injury to other
meibomian ducts) and horizontal on skin side (to
have an invisible scar). The contents are curetted
out with the help of a chalazion scoop. To avoid
recurrence, its cavity should be cauterised with
carbolic acid. An antibiotic ointment is instilled
and eye padded for about 12 hours. To decrease
postoperative discomfort and prevent infection,
antibiotic eyedrops, hot fomentation and oral
anti-inflammatory and analgesics may be given
for 3-4 days.
4. Diathermy. A marginal chalazion is better treated
by diathermy.
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)
and in patients with eye strain due to muscle
imbalance or refractive errors. Habitual rubbing
of the eyes or fingering of the lids and nose,
chronic blepharitis and diabetes mellitus are
usually associated with recurrent styes. Metabolic
factors, chronic debility, excessive intake of
carbohydrates and alcohol also act as predisposing
factors.
2. Causative organism commonly involved is
Staphylococcus aureus.
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 associated
with marked oedema (Fig. 14.11).
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, these
may be multiple.
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.
the Zeis or Moll.
Etiology
1. Predisposing factors. It is more common in
children and young adults (though no age is bar)
and in patients with eye strain due to muscle
imbalance or refractive errors. Habitual rubbing
of the eyes or fingering of the lids and nose,
chronic blepharitis and diabetes mellitus are
usually associated with recurrent styes. Metabolic
factors, chronic debility, excessive intake of
carbohydrates and alcohol also act as predisposing
factors.
2. Causative organism commonly involved is
Staphylococcus aureus.
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 associated
with marked oedema (Fig. 14.11).
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, these
may be multiple.
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.
Blepharitis & Meibomitis
BLEPHARITIS
It is a subacute or chronic inflammation of the lid
margins. It is an extremely common disease which
can be divided into following clinical types:
Seborrhoeic or squamous blepharitis,
Staphylococcal or ulcerative blepharitis,
Mixed staphylococcal with seborrhoeic blepharitis,
Posterior blepharitis or meibomitis, and
Parasitic blepharitis.
Seborrhoeic or squamous blepharitis
Etiology. It is usually associated with seborrhoea of
scalp (dandruff). Some constitutional and metabolic
factors play a part in its etiology. In it, glands of Zeis
secrete abnormal excessive neutral lipids which are
split by Corynebacterium acne into irritating free fatty
acids.
Symptoms. Patients usually complain of deposition
of whitish material at the lid margin associated with
mild discomfort, irritation, occasional watering and a
history of falling of eyelashes.
Signs. Accumulation of white dandruff-like scales are
seen on the lid margin, among the lashes (Fig. 14.7).
On removing these scales underlying surface is found
to be hyperaemic (no ulcers). The lashes fall out
easily but are usually replaced quickly without
distortion. In long-standing cases lid margin is
thickened and the sharp posterior border tends to be
rounded leading to epiphora.
Treatment. General measures include improvement
of health and balanced diet. Associated seborrhoea
of the scalp should be adequately treated. Local
measures include removal of scales from the lid margin
with the help of lukewarm solution of 3 percent soda
bicarb or baby shampoo and frequent application of
combined antibiotic and steroid eye ointment at the
lid margin.
Ulcerative blepharitis
Etiology. It is a chronic staphylococcal infection of
the lid margin usually caused by coagulase positive
strains. The disorder usually starts in childhood and
may continue throughout life. Chronic conjunctivitis
and dacryocystitis may act as predisposing factors.
Symptoms. These include chronic irritation, itching,
mild lacrimation, gluing of cilia, and photophobia. The
symptoms are characteristically worse in the morning.
Signs (Fig. 14.8). Yellow crusts are seen at the root of
cilia which glue them together. Small ulcers, which
bleed easily, are seen on removing the crusts. In
between the crusts, the anterior lid margin may show
dilated blood vessels (rosettes).
Complications and sequelae. These are seen in longstanding
(non-treated) cases and include chronic
conjunctivitis, madarosis (sparseness or absence of
lashes), trichiasis, poliosis (greying of lashes), tylosis
(thickening of lid margin) and eversion of the punctum
leading to epiphora. Eczema of the skin and ectropion
may develop due to prolonged watering. Recurrent
styes is a very common complication.
Treatment. It should be treated promptly to avoid
complication and sequelae. Crusts should be removed
after softening and hot compresses with solution of
3 percent soda bicarb. Antibiotic ointment should be
applied at the lid margin, immediately after removal of
crusts, at least twice daily. Antibiotic eyedrops should
be instilled 3-4 times in a day. Avoid rubbing of the
eyes or fingering of the lids. Oral antibiotics such as
erythromycin or tetracyclines may be useful. Oral
anti-inflammatory drugs like ibuprofen help in
reducing the inflammation.
Posterior blepharitis (Meibomitis)
1. Chronic meibomitis is a meibomian gland
dysfunction, seen more commonly in middle-aged
persons with acne rosacea and seborrhoeic dermatitis.
It is characterized by white frothy (foam-like) secretion
on the eyelid margins and canthi (meibomian
seborrhoea). On eversion of the eyelids, vertical
yellowish streaks shining through the conjunctiva
are seen. At the lid margin, openings of the meibomian
glands become prominent with thick secretions
(Fig. 14.9).
2. Acute meibomitis occurs mostly due to
staphylococcal infection.
Treatment of meibomitis consists of expression of
the glands by repeated vertical lid massage, followed
by rubbing of antibiotic-steroid ointment at the lid
margin. Antibiotic eyedrops should be instilled 3-4
times. Systemic tetracyclines for 6-12 weeks remain
the mainstay of treatment of posterior blepharitis.
Erythromycin may be used where tetracyclines are
contraindicated.
Parasitic blepharitis
Blepharitis acrica refers to a chronic blepharitis
associated with Demodex folliculorum infection and
Phthiriasis palpebram to that due to crab-louse, very
rarely to the head-louse. In addition to features of
chronic blepharitis, it is characterized by presence of
nits at the lid margin and at roots of eyelashes
(Fig. 14.10).
Treatment consists of mechanical removal of the nits
with forceps followed by rubbing of antibiotic
ointment on lid margins, and delousing of the patient,
other family members, clothing and bedding.
It is a subacute or chronic inflammation of the lid
margins. It is an extremely common disease which
can be divided into following clinical types:
Seborrhoeic or squamous blepharitis,
Staphylococcal or ulcerative blepharitis,
Mixed staphylococcal with seborrhoeic blepharitis,
Posterior blepharitis or meibomitis, and
Parasitic blepharitis.
Seborrhoeic or squamous blepharitis
Etiology. It is usually associated with seborrhoea of
scalp (dandruff). Some constitutional and metabolic
factors play a part in its etiology. In it, glands of Zeis
secrete abnormal excessive neutral lipids which are
split by Corynebacterium acne into irritating free fatty
acids.
Symptoms. Patients usually complain of deposition
of whitish material at the lid margin associated with
mild discomfort, irritation, occasional watering and a
history of falling of eyelashes.
Signs. Accumulation of white dandruff-like scales are
seen on the lid margin, among the lashes (Fig. 14.7).
On removing these scales underlying surface is found
to be hyperaemic (no ulcers). The lashes fall out
easily but are usually replaced quickly without
distortion. In long-standing cases lid margin is
thickened and the sharp posterior border tends to be
rounded leading to epiphora.
Treatment. General measures include improvement
of health and balanced diet. Associated seborrhoea
of the scalp should be adequately treated. Local
measures include removal of scales from the lid margin
with the help of lukewarm solution of 3 percent soda
bicarb or baby shampoo and frequent application of
combined antibiotic and steroid eye ointment at the
lid margin.
Ulcerative blepharitis
Etiology. It is a chronic staphylococcal infection of
the lid margin usually caused by coagulase positive
strains. The disorder usually starts in childhood and
may continue throughout life. Chronic conjunctivitis
and dacryocystitis may act as predisposing factors.
Symptoms. These include chronic irritation, itching,
mild lacrimation, gluing of cilia, and photophobia. The
symptoms are characteristically worse in the morning.
Signs (Fig. 14.8). Yellow crusts are seen at the root of
cilia which glue them together. Small ulcers, which
bleed easily, are seen on removing the crusts. In
between the crusts, the anterior lid margin may show
dilated blood vessels (rosettes).
Complications and sequelae. These are seen in longstanding
(non-treated) cases and include chronic
conjunctivitis, madarosis (sparseness or absence of
lashes), trichiasis, poliosis (greying of lashes), tylosis
(thickening of lid margin) and eversion of the punctum
leading to epiphora. Eczema of the skin and ectropion
may develop due to prolonged watering. Recurrent
styes is a very common complication.
Treatment. It should be treated promptly to avoid
complication and sequelae. Crusts should be removed
after softening and hot compresses with solution of
3 percent soda bicarb. Antibiotic ointment should be
applied at the lid margin, immediately after removal of
crusts, at least twice daily. Antibiotic eyedrops should
be instilled 3-4 times in a day. Avoid rubbing of the
eyes or fingering of the lids. Oral antibiotics such as
erythromycin or tetracyclines may be useful. Oral
anti-inflammatory drugs like ibuprofen help in
reducing the inflammation.
Posterior blepharitis (Meibomitis)
1. Chronic meibomitis is a meibomian gland
dysfunction, seen more commonly in middle-aged
persons with acne rosacea and seborrhoeic dermatitis.
It is characterized by white frothy (foam-like) secretion
on the eyelid margins and canthi (meibomian
seborrhoea). On eversion of the eyelids, vertical
yellowish streaks shining through the conjunctiva
are seen. At the lid margin, openings of the meibomian
glands become prominent with thick secretions
(Fig. 14.9).
2. Acute meibomitis occurs mostly due to
staphylococcal infection.
Treatment of meibomitis consists of expression of
the glands by repeated vertical lid massage, followed
by rubbing of antibiotic-steroid ointment at the lid
margin. Antibiotic eyedrops should be instilled 3-4
times. Systemic tetracyclines for 6-12 weeks remain
the mainstay of treatment of posterior blepharitis.
Erythromycin may be used where tetracyclines are
contraindicated.
Parasitic blepharitis
Blepharitis acrica refers to a chronic blepharitis
associated with Demodex folliculorum infection and
Phthiriasis palpebram to that due to crab-louse, very
rarely to the head-louse. In addition to features of
chronic blepharitis, it is characterized by presence of
nits at the lid margin and at roots of eyelashes
(Fig. 14.10).
Treatment consists of mechanical removal of the nits
with forceps followed by rubbing of antibiotic
ointment on lid margins, and delousing of the patient,
other family members, clothing and bedding.
Eyelids anatomy
The eyelids are mobile tissue curtains placed in front
of the eyeballs (Fig. 14.1). 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.
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). The medial
canthus is about 2 mm higher than the lateral canthus.
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.
The lid margin. It is about 2-mm broad and is divided
into two parts by the punctum. The medial, lacrimal
portion is rounded and devoid of lashes or glands.
The lateral, ciliary portion consists of a rounded
anterior border, a sharp posterior border (placed
against the globe) and an intermarginal strip (between
the two borders). The grey line (which marks junction
of skin and conjunctiva) divides the intermarginal strip
into an anterior strip bearing 2-3 rows of lashes and a
posterior strip on which openings of meibomian
glands are arranged in a row. The splitting of the
eyelids when required in operations is done at the
level of grey line.
STRUCTURE
Each eyelid consists (from anterior to posterior) of
the following layers (Fig. 14.2):
1. The skin. It is elastic having a fine texture and is
the thinnest in the body.
2. The subcutaneous areolar tissue. It is very loose
and contains no fat. It is thus readily distended by
oedema or blood.
3. The layer of striated muscle. It consists of
orbicularis muscle which forms an oval sheet across
the eyelids. It comprises three portions: the orbital,
palpebral and lacrimal. It closes the eyelids and is
supplied by zygomatic branch of the facial nerve.
Therefore, in paralysis of facial nerve there occurs
lagophthalmos which may be complicated by
exposure keratitis.
In addition, the upper lid also contains levator
palpebrae superioris muscle (LPS). It arises from
the apex of the orbit and is inserted by three parts
on the skin of lid, anterior surface of the tarsal plate
and conjunctiva of superior fornix. It raises the
upper lid. It is supplied by a branch of oculomotor
nerve.
4. Submuscular areolar tissue. It is a layer of loose
connective tissue. The nerves and vessels lie in this
layer. Therefore, to anaesthetise lids, injection is
given in this plane.
5. Fibrous layer. It is the framework of the lids and
consists of two parts: the central tarsal plate and the
peripheral septum orbitale (Fig. 14.3).
i. Tarsal plate. There are two plates of dense
connective tissue, one for each lid, which give
shape and firmness to the lids. The upper and
lower tarsal plates join with each other at medial
and lateral canthi; and are attached to the orbital
margins through medial and lateral palpebral
ligaments. In the substance of the tarsal plates lie
meibomian glands in parallel rows.
ii. Septum orbitale (palpebral fascia). It is a thin
membrane of connective tissue attached centrally
to the tarsal plates and peripherally to periosteum
of the orbital margin. It is perforated by nerves,
vessels and levator palpebrae superioris (LPS)
muscle, which enter the lids from the orbit.
6. Layer of non-striated muscle fibres. It consists
of the palpebral muscle of Muller which lies deep to
the septum orbitale in both the lids. In the upper lid
it arises from the fibres of LPS muscle and in the
lower lid from prolongation of the inferior rectus
muscle; and is inserted on the peripheral margins of
the tarsal plate. It is supplied by sympathetic fibres.
7. Conjunctiva. The part which lines the lids is
called palpebral conjunctiva. It consists of three
parts: marginal, tarsal and orbital.
GLANDS OF EYELIDS (Fig. 14.4)
1. Meibomian glands. These are also known as
tarsal glands and are present in the stroma of
tarsal plate arranged vertically. They are about
30-40 in the upper lid and about 20-30 in the
lower lid. 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.
BLOOD SUPPLY
The arteries of the lids (medial and lateral palpebral)
form marginal arterial arcades which lie in the
submuscular plane in front of the tarsal plate, 2 mm
away from the lid margin, in each lid. In the upper lid
another arcade (superior arterial arcade) is formed
which lies near the upper border of the tarsal plate.
Branches go forward and backward from these arches
to supply various structures.
Veins. These are arranged in two plexuses: a posttarsal
which drains into ophthalmic veins and a pretarsal
opening into subcutaneous veins.
Lymphatics. These are also arranged in two sets: the
pre-tarsal and the post-tarsal. Those from lateral half
of the lids drain into preauricular lymph nodes and
those from the medial half of the eyelids drain into
submandibular lymph nodes.
NERVES OF LIDS
Motor nerves are facial (which supplies orbicularis
muscle), oculomotor (which supplies LPS muscle) and
sympathetic fibres (which supply the Muller’s
muscle). Sensory nerve supply is derived from
branches of the trigeminal nerve
of the eyeballs (Fig. 14.1). 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.
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). The medial
canthus is about 2 mm higher than the lateral canthus.
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.
The lid margin. It is about 2-mm broad and is divided
into two parts by the punctum. The medial, lacrimal
portion is rounded and devoid of lashes or glands.
The lateral, ciliary portion consists of a rounded
anterior border, a sharp posterior border (placed
against the globe) and an intermarginal strip (between
the two borders). The grey line (which marks junction
of skin and conjunctiva) divides the intermarginal strip
into an anterior strip bearing 2-3 rows of lashes and a
posterior strip on which openings of meibomian
glands are arranged in a row. The splitting of the
eyelids when required in operations is done at the
level of grey line.
STRUCTURE
Each eyelid consists (from anterior to posterior) of
the following layers (Fig. 14.2):
1. The skin. It is elastic having a fine texture and is
the thinnest in the body.
2. The subcutaneous areolar tissue. It is very loose
and contains no fat. It is thus readily distended by
oedema or blood.
3. The layer of striated muscle. It consists of
orbicularis muscle which forms an oval sheet across
the eyelids. It comprises three portions: the orbital,
palpebral and lacrimal. It closes the eyelids and is
supplied by zygomatic branch of the facial nerve.
Therefore, in paralysis of facial nerve there occurs
lagophthalmos which may be complicated by
exposure keratitis.
In addition, the upper lid also contains levator
palpebrae superioris muscle (LPS). It arises from
the apex of the orbit and is inserted by three parts
on the skin of lid, anterior surface of the tarsal plate
and conjunctiva of superior fornix. It raises the
upper lid. It is supplied by a branch of oculomotor
nerve.
4. Submuscular areolar tissue. It is a layer of loose
connective tissue. The nerves and vessels lie in this
layer. Therefore, to anaesthetise lids, injection is
given in this plane.
5. Fibrous layer. It is the framework of the lids and
consists of two parts: the central tarsal plate and the
peripheral septum orbitale (Fig. 14.3).
i. Tarsal plate. There are two plates of dense
connective tissue, one for each lid, which give
shape and firmness to the lids. The upper and
lower tarsal plates join with each other at medial
and lateral canthi; and are attached to the orbital
margins through medial and lateral palpebral
ligaments. In the substance of the tarsal plates lie
meibomian glands in parallel rows.
ii. Septum orbitale (palpebral fascia). It is a thin
membrane of connective tissue attached centrally
to the tarsal plates and peripherally to periosteum
of the orbital margin. It is perforated by nerves,
vessels and levator palpebrae superioris (LPS)
muscle, which enter the lids from the orbit.
6. Layer of non-striated muscle fibres. It consists
of the palpebral muscle of Muller which lies deep to
the septum orbitale in both the lids. In the upper lid
it arises from the fibres of LPS muscle and in the
lower lid from prolongation of the inferior rectus
muscle; and is inserted on the peripheral margins of
the tarsal plate. It is supplied by sympathetic fibres.
7. Conjunctiva. The part which lines the lids is
called palpebral conjunctiva. It consists of three
parts: marginal, tarsal and orbital.
GLANDS OF EYELIDS (Fig. 14.4)
1. Meibomian glands. These are also known as
tarsal glands and are present in the stroma of
tarsal plate arranged vertically. They are about
30-40 in the upper lid and about 20-30 in the
lower lid. 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.
BLOOD SUPPLY
The arteries of the lids (medial and lateral palpebral)
form marginal arterial arcades which lie in the
submuscular plane in front of the tarsal plate, 2 mm
away from the lid margin, in each lid. In the upper lid
another arcade (superior arterial arcade) is formed
which lies near the upper border of the tarsal plate.
Branches go forward and backward from these arches
to supply various structures.
Veins. These are arranged in two plexuses: a posttarsal
which drains into ophthalmic veins and a pretarsal
opening into subcutaneous veins.
Lymphatics. These are also arranged in two sets: the
pre-tarsal and the post-tarsal. Those from lateral half
of the lids drain into preauricular lymph nodes and
those from the medial half of the eyelids drain into
submandibular lymph nodes.
NERVES OF LIDS
Motor nerves are facial (which supplies orbicularis
muscle), oculomotor (which supplies LPS muscle) and
sympathetic fibres (which supply the Muller’s
muscle). Sensory nerve supply is derived from
branches of the trigeminal nerve
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