Eyelid

BLEPHAROSPASM
It refers to the involuntary, sustained and forceful closure of the eyelids.
Etiology. Blepharospasm occurs in two forms:
1. 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

Like
1. Corneal foreign body, corneal ulcers and iridocyclitis.
2. It is also seen in excessive stimulation of retina by dazzling light,
3. stimulation of facial nerve due to central causes
A- BLEPHAROSPASM, B-Normal
Clinical features.
Persistent epiphora
Oedema of the lids
Blepharophimosis
Spastic entropion (in elderly people) and spastic ectropion (in children and young adults)
may develop in long-standing cases.

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.
SYMBLEPHARON
In this condition lids become adherent with the eyeball as a result of
adhesions between the palpebral and bulbar conjunctiva.

Etiology
Congenital- Due to undevlopment of eye or idiopathic
Aquired- It results from healing of the kissing raw surfaces upon the
palpebral and bulbar conjunctiva.
like- thermal or chemical burns, membranous conjunctivitis, injuries,
conjunctival ulcerations, ocular pemphigus and Stevens-Johnson
syndrome.
Clinical picture
Difficulty in lid movements
diplopia
restricted ocular motility
inability to close the lids
cosmetic disfigurement.

Symblepharon is 3 types
Anterior symblepharon
Posterior symblepharon(fornix)
Total symblepharon
Anterior
SYMBLEPHARON
Posterior symblepharon
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.
LAGOPHTHALMOS
This condition is characterised by inability to voluntarily close the eyelids

Etiology.

Paralysis of orbicularis oculi muscle

Cicatricial contraction of the lids
Symblepharon
Severe ectropion
Proptosis
Following over-resection of the levator muscle for ptosis
Comatosed patients
Physiologically some people sleep with their eyes open (nocturnal lagophthalmos)
Clinical picture.
Incomplete closure of the palpebral aperture
conjunctival and corneal xerosis
Dryeye
Watering
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.
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
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
(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.
EXTERNAL HORDEOLUM (STYE)
It is an acute suppurative inflammation of gland of the Zeis or Moll.
Etiology
1. Predisposing factors.
• Children and young adults (though no age is bar)
• 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
• Metabolic factors
• Alcohol
2. Causative organism commonly involved is Staphylococcus aureus.
Symptoms
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
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.
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
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.
Symptom
Painless swelling in the lid and a feeling of mild heaviness, small, firm to hard,
non-tender swelling
Sign
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.
Treatment
• 1. Small, soft and recent chalazion, 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. 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.
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).
Symptoms
• Acute pain associated with swelling of lid, mild watering and photophobia. pain is more
intense, due to the swelling being embedded deeply in the dense fibrous tissue
Sign
• 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.
TRICHIASIS
It refers to inward misdirection of cilia (which rub against the eyeball) with
normal position of the lid margin. 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.F
• 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
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: 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. 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.
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
• 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.
• 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.
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
• 2. Cicatricial ectropion. It occurs due to scarring of the skin and can involve both the lids.
Common causes of skin scarring are: thermal burns, chemical burns, lacerating injuries and
skin ulcers Signs of the etiological condition such as skin scars in cicatricial ectropion and
seventh nerve palsy in paralytic ectropion may also be seen.
• 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.
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. 1. ectropion only punctum is everted. 2. lid margin is everted
and palpebral conjunctiva is visible. 3. the fornix is also visible.
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. ii. Horizontal lid shortening. It is
performed by a full thickness pentagonal excision in patients with moderate degree of
ectropion. 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 toe
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:
1. Seborrhoeic or squamous blepharitis,
2. Staphylococcal or ulcerative blepharitis,
3. Mixed staphylococcal with seborrhoeic blepharitis,
4. Posterior blepharitis or meibomitis,
5. Parasitic blepharitis.
1. 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. 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.
2. 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. 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).
Ulcerative Blepharitis
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.
4. Posterior blepharitis (Meibomitis)
1. Chronic meibomitis is a meibomian glanddysfunction, 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.
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.
5. Parasitic blepharitis
Blepharitis acarica 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.

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.
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).
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.
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.
Marcus Gunn Jaw-Winking syndrome
• Also called Trigemino-oculomotor Synkineses
• Autosomal dominant
• In this congenital ptosis there is miswiring of the nerve supply to the
pterygoid muscle of the jaw and the levator of the eye so that the eyelid
moves in conjugation with movements of the jaw.

Treatment
Treatment is usually unnecessary but in severe cases, surgery with a bilateral
levator excision and frontalis brow suspension may be used.
Clinical evaluation
I. History.
• Age of onset,
• Family history,
• History of trauma,
• Eye surgery
• 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. 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 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
Normal MRD 4–5 mm. Grading of ptosis is mild when the reflex is + 1.5 mm,
moderate when + 0.5 mm, and severe for measurements below - 0.5 mm
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
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
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
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
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
Fascia lata or some non-absorbable material (e.g., supramide suture) may be used as sling.
II. Acquired ptosis. Efforts should be made to find out the underlying cause and if possible
treat it. In neurogenic ptosis conservative treatment should be carried out and surgery
deferred at least for 6 months. Surgical procedures (when required) are essentially the same
as described for congenital ptosis. However, the amount of levator resection required is
always less than the congenital ptosis of the same degree. Further, in most cases the simple
Fasanella-Servat procedure is adequate.
 Eyelid lesions

Almost all types of tumours arising from the skin, connective tissue, glandular tissue, blood
vessels, nerves and muscles can involve the lids. A few common tumours are listed

Classification
1. Benign tumours. These include; simple papilloma, naevus, angioma, haemangioma,
neurofibroma and sebaceous adenoma.

2. Pre-cancerous conditions. These are solar keratosis, carcinoma-in-situ and xeroderma

pigmentosa.

3. Malignant tumours. Commonly observed tumours include squamous cell carcinoma, basal
cell carcinoma, malignant melanoma and sebaceous gland adenocarcinoma.
 Cyst of Moll Eyelid cysts Eccrine sweat
gland
hidrocystoma

• Translucent • Similar to cyst of moll

• On anterior lid margin • Not confined to lid
margin
Cyst of Zeis Sebaceous cyst

• Opaque • Cheesy contents

• On anterior lid • Frequently at
margin inner canthus
1. Papillomas
These are the most common benign tumours arising from the surface
epithelium. These occur in two forms: squamous papillomas and seborrhoeic
keratosis (basal cell papillomas, senile verrucae)

i. Squamous papillomas occur in adults, as very slow growing or stationary,

raspberry-like growths, Its treatment consists of simple excision.

ii. Seborrhoeic keratosis occurs in middle-aged and older persons. Their surface
is friable, verrucous and slightly pigmented.

2. Xanthelasma
These are creamy-yellow plaque-like lesions which frequently involve the skin of
upper and lower lids near the inner canthus. Xanthelasma occurs more
commonly in middle-aged women. Xanthelasma represents lipid deposits in
histiocytes in the dermis of the lid. These may be associated with diabetes
mellitus or high cholesterol levels.

Treatment: Excision may be advised for cosmetic reasons; but recurrences are
common.
3. Haemangioma
Haemangiomas of the lids are common tumours.
These occur in three forms:
i. Capillary haemangioma is the most common variety which occurs at or shortly after birth,
often grows rapidly and in many cases resolves spontaneously by the age of 7 years. These
may be superficial and bright red in colour (strawberry naevus) or deep and bluish or violet
in colour. They consist of proliferating capillaries and endothelial cells.
Treatment. Unless the tumour is very large it may be left untouched until the age of 7 years
(as in many cases it resolves spontaneously).
The treatment modalities include:
Excision: It is performed in small tumours.
Intralesional steroid (triamcinolone) injection is effective in small to medium size tumours.
Alternate day high dose steroid therapy regime is recommended for large diffuse tumours.
Superficial radiotherapy may also be given for large tumours.
ii. Naevus flammeus (port wine stain). It may occur side by side or more commonly as
a part of SturgeWeber syndrome. It consists of dilated vascular channels and does not
grow like the capillary haemangioma.
This is having 3 types
• Junctional
• Compound
• Dermal
iii. Cavernous haemangiomas are developmental and usually occur after first
decade of life. It consists of large endothelium-lined vascular channels and
usually does not show any regression.
Treatment is similar to capillary haemangiomas.
4. Neurofibroma Lids and orbits are commonly affected in
neurofibromatosis (von Recklinghausen’s disease). The tumour is
usually of plexiform type
 Malignant eyelid
tumors

• Basal cell carcinoma

• Squamous cell
carcinoma
• Meibomian gland
carcinoma
• Melanoma
1. Basal-cell carcinoma
It is the commonest malignant tumour of the lids (90%) usually seen in elderly
people. It is locally malignant and involves most commonly lower lid and medial
canthus

Clinical features. It starts as a small nodule which undergoes central ulceration with
pearly rolled margins. The tumour grows by burrowing and destroying the tissues
locally like a rodent, Other rare presentations include: non-ulcerated nodular form,
sclerosing or morphea type and pigmented basal cell carcinoma.

Treatment
Surgery. Local surgical excision of the tumour along with a 3 mm surrounding area of
normal skin with primary repair is the treatment of choice.
Radiotherapy and cryotherapy should be given only in inoperable cases for palliation.
2. Squamous cell carcinoma
It forms the second commonest malignant tumour of the lid. Its incidence (5%) is much less
than the basal cell carcinoma. It commonly arises from the lid margin (mucocutaneous
junction) in elderly patients. Affects upper and lower lids equally.

Clinial features. It may present in two forms: An ulcerated growth with elevated and
indurated margins is the common presentation.The second form, fungating or polypoid
verrucous lesion without ulceration, is a rare presentation.

Metastasis. It metastatises in preauricular and submandibular lymph nodes.

Histological features. It is characterised by an irregular downward proliferation of epidermal

cells into the dermis. In well-differentiated form, the malignant cells have a whorled
arrangement forming epithelial pearls which may contain laminated keratin material in the
centre.

Treatment on the lines of basal cell carcinoma.

 Squamous cell carcinoma
•
•

•
3. Sebaceous gland carcinoma or Meibomian gland carcinoa
It is a rare tumour arising from the meibomian glands.

Clinically, it usually presents initially as a nodule (which may be

mistaken for a chalazion). Which then grows to form a big growth
Rarely, a diffuse tumour along the lid margin may be mistaken as
chronic blepharitis.

Surgical excision with reconstruction of the lids is the treatment of

choice. Recurrences are common.
4. Malignant melanoma (melanocarcinoma)
It is a rare tumour of the lid (less than 1% of all eyelid lesions). It may arise
from a pre-existing naevus, but usually arises a new from the melanocytes
present in the skin.

Clinically, it often appears as a flat or slightly elevated naevus which has

variegated pigmentation and irregular borders. It may ulcerate and bleed.

Metastasis. The tumour spreads locally as well as to distant sites by

lymphatics and blood stream.

Treatment. It is a radio-resistant tumour. Therefore, surgical excision with

reconstruction of the lid is the treatment of choice.
Benign eyelid lesions
BENIGN EYELID LESIONS
1. Nodules
• Chalazion
• Acute hordeola
• Molluscum contagiosum
• Xanthelasma
2.. Cysts
• Cyst of Moll
• Cyst of Zeiss
• Sebaceous cyst
• Hidrocystoma
3. Tumours
• Viral wart
• Keratoacanthoma
• Cappilary haemangioma
• Port-wine stain
• Pyogenic granuloma
• Cutaneous horn
Signs of chalazion (meibomian cy

Painless, roundish, firm lesion May rupture through conjunctiva

within tarsal plate and cause granuloma
 Treatment of chalazion

Injection of local anaesthe tIincsertion of clamp Incision and curettag

 Acute
Internal hordeolum
hordeola
External hordeolum (stye)
( acute chalazion )

• Staph. abscess of meibomian• Staph. abscess of lash follicle and

glands associated gland of Zeis or Moll
• Tender swelling within tarsal•pTlaetneder swelling at lid margin
• May discharge through skin • May discharge through skin
Viral wart (squamous cell papilloma
• Most common benign lid tumour
• Raspberry-like surface

Pedunculat Sess
ed ile
 Keratoses
Seborrhoeic Actinic

• Common in elderly
•Affects elderly, fair-skinned indiv idual
• Discrete, greasy, brown le n
• Friable verrucous surface si•oMnost common pre-malignant
lesi
• Flat ‘stuck-on’ ski
appearance • Rare on eyelids
 Keratoacanthoma

• Uncommon, fast growing nodul • Lesion above surface epithelium

e
• Acquires rolled edges and
kera crater tin-filled
• Central keratin-filled crater
• Involutes spontaneously within tr
1 •yCeahrronic inflammatory cellular
infil of dermis
 Naevi
• Appearance and classification determined by location withi
• Tend to become more pigmented at puberty
Intradermal Junctional Compound

• Elevated • Flat, well-circumscribe d• Has both

• May be non-pigment intradermal and
e•d Pigmented junctional
• No malignant components
potenti a•l Low malignant potenti al
 Capillary haemangioma

• Rare tumour which presents soon a tf•e rb rti h rb

M ay b e associated with
quintrao
ently extension
• Starts as small, red lesion, most fre •
on upper lid Grows quickly during first yea r
• Blanches with pressure and swells on•Bcreygiinngsto involute s
spontaneou during second
year
Periocular haemangioma
Treatment options
• Steroid injection
in most cases
• Surgical resection in
selected cases
Occasional systemic
associations

• High-out heart
failure
• Kasabach-Merritt syndro
thrombocytopenia, anaem
and reduced coagulant fa
• Maffuci syndrome - skin
haemangiomas,
endrochondromas and
bowing of long bones
Port-wine stain (naevus flammeus)

• Rare, congenital subcutaneous l

• Segmental and usually unilateral

• Does not blanch with pressure

Associations

• Ipsilateral glaucoma in 30%

• Sturge-Weber or
Klippel-Trenaunay-Weber
syndrome in 5%
 Progression of port-wine stain

Initially red and flat Subsequent darkenin g Skin becomes coarse,

and hypertrophy of kin odular and friable
s
 Pyogenic granuloma Cutaneous horn

• Usually antedated by surgery or tr a•uUmnacommon, horn-like lesion

• Fast-growing pinkish, protred rough skin
pedunculated sessile mass • May be associated with
• Bleeds easily underlying keratosis or
squamous cell carcin