Eye Lids. خروج. TEXT BOOK OF DISEASES OF THE EYE. The eye lid is made up of 4 layers. They are from without in-wards : 1) Skin – it is thin and characterized by absence of fat. 2) Muscle layer.
Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.
The eye lid is made up of 4 layers. They are from without in-wards:
1) Skin – it is thin and characterized by absence of fat.
2) Muscle layer.
a) Orbicular is oculi consists of horizontal concentric fibers it is supplied by the zygomatic branch of the facial nerve. When the orbicularis oculi contracts the lids are firmly closed.
b) Levator palpebrae superiors. The muscle fibres are arranged vertically; they end in an aponeurosis which is inserted .
i) To the skin of the upper lid.
ii) Upper border of the tarsus.
iii) Conjunctiva at the fornix.
It is supplied by the upper division of the 3rd cranial nerve.
It raises the upper lid.
c) Muller's muscle: supplied by the sympathetic nerve.
3) Tarsus : Consists of dense fibrous tissue. Embedded in it are enormously developed sebaceous glands-the meibomian (tarsal) glands.
4) Mucous layer : formed by the palpebra conjunctiva.
Oedema of lids – this is common and owing to looseness of the tissue may be so great as to close the eye.
Blepharitis: It is a chronic inflammation of the margin of the lid. The lid margin becomes thickened and red.
1) Squamous blepharitis: there is encrustration of lid margin by white scales. It is of 2 types.
b) Siccaa : Chemical irritants and cosmetics such as "surma", acne rosacea, uncorrected refractive error particularly astigmatism.
2) Ulcerative blepharitis :There is encrustation of the lid margin by yellow scales with underlying ulceration. The ulcers bleed on removing the scales. This distinguishes the condition from matting together of the lashes by conjunctival discharge in conjunctivitis; removal of the crusts in conjunctivitis reveals normal lid margin. Ulcerative blepharitis is an infective condition caused by staphylococci.
3) Mixed blepharitis:Staphylococci infection super imposed on Squamous blepharitis.
4) Margin is associated: with angular conjunctivitis – foamy discharge and excoriation of the skin of the lateral and medial canthi. It is caused by Morax – Axenfeld bacillius.
The patients are usually children debilitated from :
1) Living under poor hygienic conditions – exposure to dust, smoke.
2) DISEASES – exanthematous disease, upper respiratory infections, tuberculosis, diabetes.
3) Dietary deficiency – malnutrition. Occasionally parasite causes blepharitis, blepharitis acarica.
Itching, soreness, lacrimation, photophobia.
1) Eternal hordeolumor stye : is a circumscribed, acute inflammation at the edge of the lid, caused by staphylococcal infection of the glands of Zeis usually ending in suppuration.
Most common in children and young adults, often appear in crops. Frequently associated with blepharitis or lowered state of health – diabetes mellitus, and uncorrected refractive error.
Red swelling appears in the lash line of the margin of the lid, accompanied by pain, tenderness and often by considerable oedema of the lids. Very soon a yellowish summit will be seen orderlid indicating suppuration.
2) Hordeolum internum: this is an acute suppurative inflammation of a meibomian gland due to staphylococcus. Sometimes it may be due to secondary infection of a chalazion.
- Symptoms and Signs:
Symptoms are more violent than those of stye. Very soon pus points on the palpebral conjunctiva.
It is a condition in which there are involuntary and forcible eyelid closure (Refer Corneal ulcer for difference from photophobia).
1) Reflex sensory stimulation through branches of 5th cranial nerve – commonest.
a) Phlyctenular keratoconjunctivitis.
b) Foreign body on cornea.
c) Membranous and pseudo membranous – conjunctivitis.
d) Acte iridocyclitis.
2) Excessive stimulation of retina.
a) Bright light on sensitive eye.
b) Dilated pupil.
3) Essential Blepharospasmwithout any cause.
The margin of the lid may have a normal position, the displacement affecting only the lashes or the margins may be turned inward (Entropion ) as well as the lashes.
The misdirected lashes cause mechanical irritation and injury to cornea with ulceration – pain, lacrimation, photophobia, Blepharospasm, vascularisation and opacities of cornea.
If only a few cilia involved – epilation or electrolysis to destroy the hair follicles. If extensive – surgical treatment as for cicatricial Entropion.
It occurs most frequently in adults. The meibomian duct becomes obstructed through proliferation of its epithelium and consequently the gland enlarges. The fatty secretion escapes into the surrounding tissue and excites a foreign body reaction (lipogranuloma) which consists of lymphocytes, epitheloid cells and giant cells. The blood supply is cut off by the surrounding fibrous tissue leading to degeneration of contents – jelly like mass.
1) Cosmetic disfigurement – lid swelling.
2) Conjunctiva irrition.
The process develops slowly. After weeks or months it presents a circumscribed swelling which feels hard, not adherent to skin. On everting the lid, its situation is usually shown by a purple discolouration of the conjunctiva.
Etiology and Varieties :
I) Cicatricial entopion – due to cicatricial changes in the conjunctiva and distortion of the tarsal plate, most commonly affects the upper lid .
a) Old case of trachoma .
c) Burns and other injuies to the lids
d) Operation upon the lids
e) Diphtheritic conjunetivitis
II) Spastic entropion:
Due to spasm of the palpebral portion of the orbicularis muscle, most commonly affecting lower lid, strong contraction of the circularly arranged fibers tends not only to approximate the lid margins but also to turn them inwards of outwards according to the degree of mechanical support afforded by the globe and orbital contents. If the support is insufficient intropion is produced:
i) Atrophy or absence of eye ball
ii) Old persons ( senile entropion) owing to absence of orbital fat.
iii) Tight bandaging after surgical operation of the eye.
Symptoms and signs – same as for trichiasis .
I) Cicatricial entrpion : The principles governing various operation are:
i) Altering the direction of eyelashes
a) Snellen,s operation
b) Jaesch Arlt operation
ii) Straightening of the distorted tarsus.
II) Spastic entropion
i) Pull the lower lid down and out and apply leucoplast which should extend below the mandible.
ii) Injection of alcohol is made close to the lateral 3rd of the lid margin .
Ectropion : It is a rolling out of the margin of the lid
Etiology and varieties :
Cicartical Ectropion : due to cicatricial changes in the skin of the lids- Blepharitis, burns, operations on the lids, leprosy.
Both upper and lower lids may be affected.
2) Senile ectropion – the lower lid is affected in old age due to laxity of the tissue of the lid and due to loss of tone of the orbicularis muscle.
3) Paralytic ectropion – it occurs as a result of weakness of the orbicularis muscle due to facial nerve paralysis . The lower lid is affected.
Symptoms – Epiphora due to eversion of lacrimal punta.
1) Xerosis of conjunctiva
2) Chronic conjunctivitis and exposure keratitis particularly in Ectropion of upper lid.
1) In mild cases row of heat cautery applied to the palpebral conjunctiva below the lek margin . As a result of fibrosis of conjunctiva ectropion is corrected .
2) Lateral tarsorrhaphy
3) In severe case, platstic surgery – Kuhnt Szymanowski operation.
is a cicatricial attachment between the conjunctiva of the lid and the eye ball, it may affect both lids, but usually the lower, sometimes it includes part of the cornea.
1) Anterior- when extending bridge like from lid to globe, leaving a free portion of the conjunctiva corresponding to the fornix .
2) Posterior- When it involves only the fornix.
3) Total – When the lids are adherent to the globe throughout.
It is caused by the junction of 2 opposing granulating surfaces raw surfaces hence it occurs after.
1) injuries especially burns from lime, acids, and molten metal.
3) Trachoma, rarely diphtheritic conjunctigitis.
1) It often interferes with movement of eye ball producing diplopia.
2) Traction upon the adherent parts causes irrition
3) In extensive cases the cornea is involved and vision is affected.
4) If there is inability to close , lagoph thalmos.
5) Cosmetic disfigurement.
1) Prophylactic - use of contact shell in fresh cases of alkali burns, after operations on lids.
a) If anterior and not extensive, the band is divided and the 2 raw surfaces kept from uniting by separating them daily with a glass rod smeared with antibiotic ointment .
b) In more sever cases of anterior symblepharon, in posterior and total symblepharon the separated raw surfaces must be cobered with conjunctiva or with grafts of mucous membrane from the lip to keep them from uniting .
This is the condition of incomplete closure of the palpebral aperture when an attempt is made to shut the eyes.
1) Exophthalomos as in Graves' disease, proptosis due to orbital tumour.
2) Facial never paralysis .
3) Cicatricial ectropion of upper lid .
5) Laxity of the tissue and absence of reflex blinking in people who are extremely ill – coma, keratomalacia etc.
1) Parenchymatous xerosis of conjunctiva.
2) Chronic conjunctivitis and exposure keratitis
1) Of the cause whenever possible.
2) Application of a bland or antibiotic ointment to protect cornea.
3) Lateral or median tarsorrhaphy to protect the cornea.
1) Distichiasis: It is a condition in which there is an extra posterior row of eye lashes. The posterior row occupies the position of the opening of Meibomian glands, these lashes may irritate the cornea.
2) Coloboma of the lid: It is a triangular gap in the lid magin, generally affecting the upper lid. It may form part of Golden Har's syndrome- accessory auricles, dermolipoma at the limbus, hypoplasia of the maxilla and anomalies of the vertebral column.
All degrees o ptosis occur- partial or complete. When severe it interferes with vision by covering the pupil.
1) Patients attempt to raise the lid by forced action of the occipito frontalis muscle, wrinkling the skin of the forehead and raising the brow.
2) When condition is severe and bilateral they favour exposure of the pupil by throwing the head backwards.
Etiology & Classification:
1) Congenital ptosis:
a) With normal superior rectus funtction.
b) With superior rectus weakness- developmentally superior rectus is closely related to L.P.S.
2) Acquired ptosis:
- Horner's syndrome due to affection of sympathetic nerves.
b) Myogenic – Myasthenia gravis.
c) Mechanical ptosis - due to increased weight of lid as in trachomatous ptosis, tylosis , tumours of upper lid or lack of support of upper lid as phthisis bulbi etc.
d) Traumatic ptosis.
1) Medical : in the acquired form cause is determined and treated – Syphilis – Inj. Penicillin I.M. – Myashthenia gravis _ Physostigmine
2) Surgical – usually necessary for Congenital ptosis.
C) If both levator and superior rectus are paralysed, the action of the frontalis muscle may be utilized in raising the lid: frontalis suspension – the frontalis muscle is sutured to the tarsal plate using strips of fascia lata or 4.O supramid suture . As a result contraction of frontalis muscle elevates the lid.
TUMOURS OF the eye lids :
1) Benign tumouts of the lids are
Excision of these nodules
d) Xanthelasma or Xanthoma – this is a raised yellow plague, most commonly found in the upper and lower lids near the inner canthus and often symmetrical in the 2lids on both sides. They are most common in :
1) Elderly women
2) Diabetes mellitus
3) Excessive levels of blood cholesterol
Treatment : They may be excised if causing cosmetic disfigurement .
e)Haemangioma – may occur in 2 forms.
__ cavernous haemangioma
It is seen usually in children and often follows the distribution of the 1st and 2nd division of 5th cranial nerve. In Sturge – Weber syndrome it is associated with haemangioma of the choroid , buphthalmos and also with haemangioma of the leptomeninges, causing homonymous hemianopia or epilepsy. The intracranial causing lesion may be diagnosed on x-ray skull since there are often calcareous deposits underlying the cerebral cortex.
f) Neurofibromatosis – Von Reckinghausen's disease.
The hypertrophied nerves can be felt through the skin as hard cords. It may be associated with café au lait spots elsewhere in the body , buphthalmos, proptosis in some cases and enophthalmos in others.
2) Malignant tumours of the lids are:
a) Rodent ulcer or basal cell carcinoma. It originates either from the basal layer of the epidermis or from the epithelium of the hair follicles and glands of the skin . It shows a predilection for the inner canthus. It starts as a small pimple which ulcerates and if the scab is removed it is found that the edges are raised and indurated. The ulcer spreads very slowly destroying the lids, orbital structures. It is locally malignant and the regional lymph nodes are not involved.
b) Squamous cell carcinoma: It originates at the lid margin which is the transition zone of the epithelium. It starts as a small nodule which ulcerates. The regional lymph nodes preauricular or submandibular become enlarged. Histologically it shows epitheliai pearls'
C) Meibomian gland carcinoma: it is an adenocarcinoma of the Meibormian gland. The upper lid is more commonly affected than the lower lid. In old people it may start as a recurrent chalazion. Therefore in this group of patients it is advisable to send the curettings of a chalazion for histopathological examination.
دعوني الان اترككم مع