Eyelids and Adnexal Disorders

Eyelids and AdnexalDisordersDr. Halimah Pagarra. SpMOphthalmology DepartmentMedical FacultyHasanuddin University

INTRODUCTION

Eyelids : Physical Protection to the eyes Ensuring drainage of the tear film

Major features of the normal eyelid. a. Eyelid margin with cilia b. upper eyelid crease c. medial canthus d. lateral canthus e. caruncle f. plica g. brow.

This is an abnormally low position of the upper eyelid

Ptosis of Left upper eyelids1. PTOSIS1. Mechanical factors (a) Large lid lesions (tumour) pulling down the lid. (b) Lid oedema. (c) Tethering of the lid by conjunctival scarring. (d) Structural abnormalities including a disinsertion of the aponeurosis of the levator muscle, usually in elderly patients.PATHOGENESIS of PTOSIS

Pre opPost opPATHOGENESIS OF PTOSIS2. Neurological factors (a)Third nerve palsy. (b)Horners syndrome, due to a sympathetic nerve lesion. (c)MarcusGunn jaw-winking syndrome. congenital ptosis, a mis-wiring of the nerve supply to the pterygoid muscle of the jaw and the levator of the eyelid so that the eyelid moves in conjunction with of the jaw.

Marcus Gun Jaw-wingking ptosis (synkinesi lingking cranial N V to canial N III)PATHOGENESIS OF PTOSIS 3. Myogenic factors (a)Myasthenia gravis (b)Some forms of muscular dystrophy. (c)Chronic external ophthalmoplegia.

SIGN and SYMPTOMS OF PTOSISCosmetic effectVision may be impairedReduced eye movement in a third nerve palsyDiplopiaReduced of function of M. Levator EyelidReduction in size of the interpalpebral aperture.

Management Exclude an underlying cause whose treatment could resolve the problem (e.g. myasthenia gravis, Third N. III Palsy).

Surgical correction. In very young children this is usually deferred but may be expedited if pupil cover threatens to induce amblyopia.

Management of ptosisPtosis repair is challenging oculoplastic surgical procedure that requires correct:- Diagnosis Thoughtful planning Thorough understanding of eyelid anatomy, Experience Good surgical technique Medical and surgical history whether surgical repair ptosisi is appropriate for that individual History : Dry eye syndrome, Thyroid eye disease,, previous eye or eyelid surgery and prior periorbital trauma , coagulation status 2. ENTROPION

Turning inward, usually of the lower lid and caused irritation of lashes to cornea and conjunctiva.Classification :Congenital Entropion : primary dan secondary)Acquired Entropion : spastic, senile, mechanical and cicatrical

Congenital EntropionPrimary : Overriding of M. orbicularis OculusSecondary: Anophthalmus , enophthalmus , microphthalmus

Acquired EntropionSpastic . E : - Chronical inflamation and chronic pressure Mechanical. E : - Reduced of orbital fat. - Anoftalmus - Microftalmus 3. Cicatrical E. : - Chronical inflamation ( Trachoma, Steven Johnson Syndrome - thermis/chemical trauma - radiation burn - surgical trauma4. Senile E. : ( 70-75 y.o) reduced of orbital fat, , elastisitacity of skin.

Symptoms : IrritationLacrimationPhototofobiaPainCorneal UlcerCicatrical corneaVascularitation of cornea( DD : Trichiasis)ManagementNon Surgical Entropion Spastik :1. Using prothesa ( atrophy bulbi / post enucleation)2. Eversion of palpebra with plester adhesive 3. Epilation

Entropion: inturning eyelashes may scratchand damage the cornea Temporary treatment of entropionManagementSurgical : 1. Spastic E, failed with non surgical :a. entropion suture (Gaillard arlt tehnik)c. Snellen suture d. Technic authore. AuthorModification (Wheeler orbicularis strip technique)2. Senile E. a. Kauterisasi Ziegler cicatricsb. Modification Zieglerc. Skin resection

Management of Entropion3. cicatricial Entropiona. upper eyelid: - Streatfield-Snellen- Horizontal tarsal section- Tarsal resection with mucosal graft- Von Milliagen tarsochilloplastyb. Lower eyelid :- Skin and muscle excision (graft)- Tarsal section

Turning outward of eyelids conjunctiva exposedClassification:Congenital (rare)Acquired : Spastic, mechanic, cicatricals, paralytic, senile.

3. Ectropion EtiologiSpastical spasme of m.orbicularis (young teenagers), irritation, edema of conjungtivaMechanical tumor/inflamationCicatrical post trauma Paralitik parese N.VII (morbus hansen,lues)Senile loss of tonus of Orbicularis oculi.

Types of ectropion: Involutional:Horizontal eyelid laxity(medial or lateral canthal tendons

Cicatricial

Paralytic

Mechanical

Sign and SymptomSubjektifRed eye, epiforaObjektifeyelid turning outwardIncomplete eyelid closureEpifora pungtum eversion.

ManagementNonSurgical :Mild CaseSpastical ( Tapping eyelids, sweep tear film from down to up)Senile & ParaliticSnellen sutureElektrocauter (Galvanocauter Ziegler)4.BlepharitiesChronic eyelid inflammation Staphylococcal infection. The condition causes squamous debris, inflammation of the lid margin, skin and eyelash follicles (anterior blepharitis). The meibomian glands may be affected independently (meibomian gland disease or posterior blepharitis).Sign and SymptomsTired, sore eyes, worse in the morningCrusting and scalling of the lid margin.debris in the form of a rosette around the eyelash, ulcerated, a sign of staphylococcal infectionreduction in the number of eyelashesobstruction and plugging of the meibomian ductsinjection of the lid margin;tear film abnormalities.

Fig. A diagram showing the signs of blepharitis. (b) The clinical appearance of the lid margin. Note (1) the scales on the lashes, (2) dilated blood vessels on the lid margin and (3) plugging of the meibomian glands.

Fig. Chronic staphyloccal blepharitis, (a) Collarettes, (b) Papillari conjunctivitis Scarring of the lid margin, (d) Madarosis and trichiasis

Fig. Chronic Seborrhoic blepharitis, (a) Grasy lid margin with sticky lashes(b) Soft scales

Fig. Posterior blepharitis, (a) Capping of Meibomian gland orifices by oil globules,(b) Plugging og MG orifices and teleangiectasis, expressed toothpaste-like plaques(d) Froth on the lid marginTreatmentDifficult and must be long term.A cotton bud wetted with bicarbonate solution or diluted baby shampoo removed squamous debris .Abnormal meibomian gland secretions (hot bathing) Lid massage . Topical (fusidic acid gel) and, occasionally, with systemic antibiotics (oral tetracyclin).Steroids may improve an anterior blepharitis but frequent use is best avoided. Posterior blepharitis can be associated with a dry eye which requires treatment with artificial tears.

The term adnexa refers to skin appendages that are located within the dermis but communicate through the epidermis to the surface. Oil glands, (Meybom) The lash follicle have a sweat glands (apocrine) gland of Moll modified sebaceus gland (of Zeis)3Figure 4. Anatomic section of eyelid skinshowing major dermal adnexal structures.

Hordeolum

An abscess (internal hordeolum) may also form within the meibomian gland

A stye (external hordeolum) is a painful abscess of an eyelash follicle

It is painfull ( Unlike chalazion, painless )

Fig. Internal hordeolum. An acute infection of a meibom gland produces a swelling directed internally toward the conjunctiva. The figure demonstrates a discret, circumscribed area of inflammation highlighted by a hyperemic conjunctivaIt is an acute suppurative inflammation of gland of the Zeis or Moll.EXTERNAL HORDEOLUM (STYE)Etiology1. 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. Metabolicfactors, chronic debility, excessive intake ofcarbohydrates and alcohol also act as predisposingfactors.2. Causative organism commonly involved isStaphylococcus aureus.Fig. External hordeolum. This large, acute swelling, wich is red and painful, involves the haie follicle or associated glands of Zeis or Moll and points toward the skin

ChalazionObstructed meibomian gland within the tarsal plate

It is painless.

Symptoms are of an unsightly lid swelling which usually resolves within 6 months.

If the lesion persists it can be incised and curetted from the conjunctival surface.

Eyelids Lumps

Molluscum ContangiosumThis umbilicated lesion found on the lid margin is caused by the pox virus.

It causes irritation of the eye. The eye is red and small elevations of lymphoid tissue (follicles) are found on the tarsal conjunctiva.

Treatmentrequires excision of the lesion.Trichiasis Aberrant eyelashes are directed slow growing; locally invasive; non-metastasizing. The lashes rub against the cornea and cause irritation and abrasion. It may result from any cicatricial process. In developing countries trachoma is an important cause.

Treatment Epilation of the offending lashes Cryotherapy or electrolysis recurranceSurgical Underlying abnormality of lid position

5. Congenital Anomalies Isolated or associated with other eyelid, facial, or systemic anomalies.

Blepharophimosis syndrome

Congenital eyelid eversion

Congenital eyelid deformities; A, Ankyloblepharon. B, Epiblepharon. C, Epicanthus. D, Euryblepharon.

Ankyloblepharon. Epiblepharon.

Epicanthal foldEuryblepharon

True coloboma of upper eyelid.

CryptophthalmosThank youThe term adnexa refers to skin appendages that are located within the dermis but communicate through the epidermis to the surface. They include oil glands, sweat glands, and hair foll icles.

The eyelids contain both the speC ialized eyelashes and the normal vellus hairs found on skin throughout the body.

Periocular adnexal oil glands include the meibomian glalnds within the tarsal plate, the glalnds of Zeis associated with eyelash follicles, and normal sebaceous glands that are present as part of the pilosebaceous units in the skin hair.

Sweat glands in the periocular region include the eccrine sweat glands, which have a general distribution throughout the body and are responsible for thermal regulation, and the eccrine glands with apocrine secretion (the glands of Moll) associated with the eyelid margin.Figure 2 Anatomic section of eyelid skinshowing major dermal adnexal structures.