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Upper Eyelid
Anatomy
Anatomy
Orbicularis muscle
Consist of:
1. Orbital part
2. Preseptal part
3. Pretarsal part
Anatomy
The pretarsal and preseptal parts are more
involved in involutary eyelid movement
The orbital portion is more involved in forced
eyelid movement
Innervated by cranial nerve VII
Horner muscle encircle both canaliculi to
facilitate tear drainage
Riolani muscle to open mebomian gland
Anatomy
The orbital septum
Is a thin multilayered sheet of fibrous tissue arises
from periosteum over the superior and inferior orbital
rims at the arcus marginalis.
In the upper eyelid, the orbital septum fuses with the
levator aponeurosis at 2 5 mm above the superior
tarsal border in non Asians, and in the lower eyelid
with the capsulopalpebral fascia at or just below the
inferior tarsal border.
With age the orbital septum may weaken, and as a
result orbital fat may herniate forwards
Anatomy
The orbital septum
The orbital septum serves as a barrier between
the orbit and the eyelid to limit the spread of
infection and hemorrhage.
Anatomy
Orbital fat
Normally behind the orbital septum and is
important surgical landmark in eyelid surgery.
It extends from the apex of the orbit to the orbital
septum.
Contributes to the support of the eyeball
Anatomy
Levator muscle
Anatomy
Levator Palpebra Muscle
Originates in the apex of the orbit just above the
annulus of Zinn
The muscular portion 40 mm long, the
aponeurosis 14 20 mm
Whitnall ligament is condensation of anterior
sheath of levator muscle as suspensory
Muller muscle is symphatetically innervated
muscle, lies posterior to the levator aponeurosis
Anatomy
Capsulopalpebral Fascia
Analogous to the levator aponeurosis
It originates from terminal muscle fiber of the
inferior rectus muscle
Lockwood ligament is the portion of
capsulopalpebral head join to form suspensory
ligament
The inferior tarsal in the lower eyelid is analogous
to Muller muscle
Anatomy
Tarsus/
Tarsal Plate
Anatomy
Tarsus
Elongated plates of dens connective tissue,
about 2.5 cm in length
The superior tarsus, the larger, is of a
semilunar form, about 10-12 mm vertically at
the center, and gradually narrowing
The inferior tarsus is smaller, thin, elliptical in
form, and has a vertical diameter of about
4 mm.
Anatomy
Tarsus
Along the inner margin of the tarsus are modified
sebaceous glands known as tarsal glands (
Mebomian glands), aligned vertically within the
tarsi: 30 to 40 glands in the upper lid, and 20 to
30 in the lower lid, which secrete a lipid-rich
product which helps keep the lacrimal secretions
or tears from evaporating too quickly, thus
keeping the eye moist.
Anatomy
Palpebral conjunctiva
Composed of nonkeratinizing squamous
epithelium
It form the posterior layer of the eyelid and
contain the mucin secreting goblet cells and
accessory lacrimal glands of Krause and Wolfring
The major component of the basic lacrimal
secretion
Main lacrimal gland is the reflex tear secretion
Anatomy
Vascular supply
A. Carotis interna
A. ophthalmica
A. supraorbita
A. lacrimal
A. Carotis externa
A. angularis
A. temporalis
Colateral
Arcade marginal
Arcade peripher
Anatomy
Nerve supply
Sensory nerve
First division of trigeminal nerve (V1)
Supraorbital nerve innervate in forehead and periocular region
Second division of trigeminal nerve (V2)
Maxillary nerve innervate lower eyelid and cheek
Lacrimal pump
Eyelid Disorders
Congenital Anomalies
Inflammation
Neoplasms
Trauma
Malposition (ectropion, entropion,
blepharoptosis)
Involutional changes (dermatochalasis,
blepharochalasis, )
Congenital Anomalies
Blepharophimosis Syndrome
-Autosomal dominantly inherited
-Telecanthus
-Epicanthus inversus
-Severe ptosis
-Additional findings:
-Lateral lower eyelid ectropion
-Poorly developed nasal bridge
-Hypoplasia of superior orbital
rims
-Lop ear, hypertelorism
Congenital Anomalies
Blepharophimosis Syndrome
-Multiple surgeries
-Repair of the ptosis
-Multiple Z plasties
-Y-V plasties
-Trans nasal wiring
-Ecktropion and hypoplasia
of orbital rims corrections
Congenital Anomalies
Congenital ectropion
Congenital Anomalies
In rare cases, congenital ectropion occurs as an
isolated finding
More often associated with blepharophimosis
syndrome, Down syndrome. or Ichthyosis
Caused by a vertical insufficiency of the anterior
lamella
Chronic epiphora and exposure keratitis
Mild congenital ectropion usually requires no
treatment
Congenital Anomalies
Severe and symptomatic treated like a cicatricial
ectropion, with horizontal tightening of the
lateral canthal tendon and vertical lengthening of
the anterior lamella by full -thickness skin graft
A complete eversion of the upper eyelids
occasionally occurs in newborns
Topical lubrication and short-term patching of
both eyes
Full thickness sutures or a temporary
tarsorrhaphy are used when necessary
Congenital Anomalies
Euryblepharon
Congenital Anomalies
Is a unilateral or bilateral horizontal widening of
the palpebral fissure
Sometimes associated with blepharophimosis
syndrome
Usually involves the lateral portion of the lower
eyelids and is associated with both vertical
shortening and horizontal lengthening
The palpebral fissure often has a downward (anti
mongoloid) slant because of the inferiorly
displaced lateral canthal tendon
Congenital Anomalies
Impaired blinking, poor closure, and
lagophthalmos may result in exposure keratitis
If the condition is symptomatic,reconstruction
may include lateral canthal repositioning along
with suspension of the suborbicularis oculi fat to
the lateral orbital rim so that the lower eyelid is
supported
If excess horizontal length is still apparent, a
lateral tarsal strip or eyelid margin resection may
be added
Skin grafts may occasionally be necessary
Congenital Anomalies
Ankyloblepharon
Congenital Anomalies
Partial or complete fusion of the eyelids by
webs of skin
These webs can usually be opened with
scissors after being clamped for a few seconds
with a hemostat.
Congenital Anomalies
Epicanthus
Congenital Anomalies
Medial canthal fold that may result from
immature midfacial bones or a fold of skin and
subcutaneous tissue
Usually bilateral
Child may appear esotropic because of
decreased scleral exposure nasally
(pseudostrabismus)
Congenital Anomalies
4 types of epicanthus are
epicanthus tarsalis if the fold is most prominent in
the upper eyelid
epicanthus inversus if the fold is most prominent
in the lower eyelid
epicanthus palpebralis if the fold is equally
distributed in the upper and lower eyelids
epicanthus supraciliaris if the fold arises from the
eyebrow region running to the lacrimal sac
Congenital Anomalies
Epicanthus tarsa lis can be a normal variation
of the Asian eyelid
Epicanthus inversus is frequently associated
with blepharophimosis syndrome
Most forms of epicanthus resolve with normal
growth of the facial bones
observation is recommended until the face
achieves maturity
Congenital Anomalies
Epicanthus inversus, rarely resolves with facial
growth
Most cases of epicanthus requiring revisions
such as Z-plasty or Y-V-plasty with or without
construction of an upper eyelid crease
Congenital Anomalies
Epiblepharon
Congenital Anomalies
The lower eyelid pretarsal muscle and skin ride
above the lower eyelid margin to form a
horizontal fold of tissue that causes the cilia to
assume a vertical position
The eyelid margin is in normal position with
respect to the globe
The cilia often do not touch the cornea except in
down gaze
Epiblepharon is most common in Asian children
Congenital Anomalies
Epiblepharon may not require surgical
treatment because it tends to diminish with
the maturation of the facial bones
In case of keratitis, the excess skin and muscle
fold should be excised just inferior to the
eyelid margin and the skin edges
approximated
Congenital Anomalies
Congenital Entropion
Congenital Anomalies
In contrast to epiblepharon, eyelid margin
inversion is present in congenital entropion
Lower eyelid retractor dysgenesis, structural
defects in the tarsal plate, and relative
shortening of the posterior lamella
Congenital entropion often does not improve
spontaneously
Congenital Anomalies
Repaired through removal of a small amount
of the skin and orbicularis along the subciliary
portion of the eyelid, in conjunction with a
suture that advances the lower eyelid
retractors onto the tarsus
Tarsal kink of the upper eyelid is an unusual
form of congenital entropion. It may be
repaired by incision of the kink combined with
a marginal rotation
Congenital Anomalies
Congenital Distichiasis
Congenital Anomalies
Is a rare condition, sometimes hereditary in
which an extra row of eyelashes is present in
place of the orifices of the meibomian glands
Embryonic pilosebaceous units improperly
differentiate into hair follicles
Treatment is indicated if the patient is
symptomatic or if evidence of corneal
irritation is present
Congenital Anomalies
Lubricants and soft contact lenses may be
sufficient
Electrolysis, radiofrequency epilation, or
cryoepilation as alternatives
Congenital Anomalies
Congenital Coloboma
Congenital Anomalies
An embryologic cleft that is usually an isolated
anomaly when it occurs in the medial upper
eyelid
When found in the lower eyelid, the coloboma
is frequently associated with other congenital
conditions such as facial clefts (Goldenhar
syndrome) and lacrimal deformities
A true coloboma includes a defect in the
eyelid margin
Congenital Anomalies
Surgical repaired:
One third defects: the creation of a rectangular
surgical wound between the eyelid crease line and
the eyelid margin
Large defects: variation of the lateral canthal
semicircular flap
Congenital Anomalies
Capillary Hemangioma
Congenital Anomalies
Sometimes occur as congenital eyelid lesions
Most are not apparent at birth
Appear over the first weeks or months of life
May also involve the orbit
Treatment is recommended for occlusion of
the visual axis, anisometropia, strabismus, or
lesions causing significant disfigurement
Congenital Anomalies
Increases in size until the patient is 1 year old,
and then decreases over the next 4-5 years
Treatment:
Intralesional corticosteroid injection.
If there is more widespread involvement, systemic
steroids may be given
Clobetasol propionate has also been reported
Congenital Anomalies
Treatment:
Interferon for life-threatening or sight-threatening
lesions (serious adverse effects)
Surgical excision may be used on circumscribed
lesions
Carbon-dioxide laser as an incisional device
Topical lasers may be used on the superficial (1-2
mm) layers of the skin to diminish the redness of a
lesion
Congenital Anomalies
Cryptophthalmos
Congenital Anomalies
Is a rare condition that presents with partial or
complete absence of the eyebrow, palpebral
fissure, eyelashes, and conjunctiva
The partially developed adnexa are fused to the
anterior segment of the globe
May be unilateral or bilateral
Histologically, the levator, orbicularis, tarsus,
conjunctiva, and meibomian glands are
attenuated or absent
Reconstruction are difficult
Eyelid Inflammation
Chalazion
Eyelid Inflammation
Characterized by chronic lipogranulomatous
inflammation.
Obstruction of the Meibomian gland
Often associated with rosacea and chronic
blepharitis
Treatment
warm compresses and appropriate eyelid hygiene
Topical anti biotic or anti-inflammatory (Doxycycline
or tetracycline)
Occasionally, requiring surgical management
Eyelid Inflammation
Treatment
Combining excision with steroid injection into the
excision bed results in a 95% resolution rate
Eyelid Inflammation
Hordeolum
Eyelid Inflammation
An acute infection (usually staphylococcal) can
involve the glands of Zeis (external
hordeolum, or stye) or the meibomian glands
(internal hordeolum)
In external hordeolum, the infection often
appears to center around an eyelash follicle,
and the eyelash can be plucked to promote
drainage
Eyelid Inflammation
Spontaneous resolution often occurs
Curative: Warm compresses and topical
antibiotic ointrnent
Rarely complication: cellulitis, or abscesses of
the eyelid. In such cases, systemic antibiotic
therapy and possible surgical Incision and
drainage may be required
Eyelid Inflammation
Eyelid Edema
Eyelid Inflammation
Caused by local conditions such as insect bites or
allergy or by systemic conditions such as
cardiovascular disease, renal disease, certain
collagen vascular diseases, or thyroid eye disease
Cerebrospinal fluid leakage into the orbit or
eyelids following trauma may mimic eyelid
edema
Lymphedema may be present if the lymphatic
drainage system from the eyelid is interrupted.
Eyelid Inflammation
Involutional Ectropion
Periocular Malpositions
Results from horizontal eye lid laxity either in the
medial or lateral canthal tendons.
Horizontal laxity of the eyelid caused by
disinsertion or stretching of the inferior limbs of
the lateral canthal tendons
Usually occurs in the lower eyelid because of the
effects of gravity
Treatment:
Thermal cautery for medial ectropion with punctal
malposition
Periocular Malpositions
Treatment:
Medial spindle procedure for punctal
malposition
Horizontal eyelid shortening + reinsertion of
lower eyelid retractor for more severe cases
Periocular Malpositions
Involutional Entropion
Periocular Malpositions
Usually occurs in the lower eyelids
Role play factors:
Tissue atrophy with horizontal laxity of the eyelid
Attenuation or disinsertion of eyelid retractors
Overriding by the preseptal orbicularis
Ancillary test for horizontal laxity
Snap back test
Distraction test
Periocular Malpositions
Ancillary test for disinsertion of retractors
A white subconjunctival line several millimeters
below the inferior tarsal border caused by the
leading edge of the detached retractors
Deeper than normal in ferior fornix
Reverse ptosis of the lower eyelid (lower eyelid
margin sits higher than normal)
Little or no inferior movement of the lower eyelid
on downgaze (diminished lower eyelid excursion)
Periocular Malpositions
Ancillary test to detect superior override of the
preseptal orbicularis
The patient squeezes his or her eyes closed after the
entropic eyelid has been placed in its normal position
Procedures to repair:
Temporizing measures(lubrications and bandage CL)
Horizontal tightening procedures
Repair of the retractors
Often, a combination of procedures is necessary
Periocular Malpositions
Trichiasis
Periocular Malpositions
Acquired misdirection of the eyelashes
Inturned lashes usually associated with
posterior lamellar scarring (marginal cicatricial
entropion)
If the eyelid margin is misdirected, treatment
should be directed at correcting the entropion
Management:
Mechanical epilation
Periocular Malpositions
Management:
Electrolysis
Radiofrequency
Cryotherapy
Argon laser
Full-thickness pentagonal resection with primary
closure
Periocular Malpositions
Dermatochalasis
Periocular Malpositions
Redundancy of eyelid skin and is often
associated with orbital fat protrusion or
prolapse
More common in older patients
Occurs in middle aged people, particularly if
there is a familial predisposition
Patient complaints: heavy feeling around the
eyes, brow ache, eyelashes in the visual axis,
and reduction in the superior visual field
Periocular Malpositions
Blunt Trauma
Eyelid Trauma
Ecchymosis and edema
Evaluated for intraocular injury with
biomicroscopic evaluation and dilated fundus
examination
Computed tomography: determine whether
an orbital fracture is present
Eyelid Trauma
Penetrating Trauma
Eyelid Trauma
Penetrating Trauma
Lacerations not involving the eyelid margin
Lacerations involving the eyelid margin
Trauma involving the canthal soft tissue
Eyelid Trauma
Lacerations not involving the eyelid margin
Skin and orbicularis muscle lacerations usually
require only skin sutures
The basic principles of plastic repair: Unnecessary
scarring can be avoided
Copious irrigation washes away contaminated
material and foreign bodies
Orbital fat prolapse: indication for levator
exploration
Orbital septum lacerations should not be sutured
Eyelid Trauma
Lacerations involving the eyelid margin
Skin and orbicularis muscle lacerations usually
require only skin sutures
Repair of eyelid margin: requires precise suture
placement and critical suture tension to minimize
notching of the eyelid margin
by placing 2 or 3 sutures for alignment through
the lash line, the meibomian gland plane, and
(optionally) the gray line
Eyelid Trauma
Lacerations involving the eyelid margin
Precise anatomical alignment of the margin and
secure tarsal closure are the goals
To avoid corneal epithelial disruption, the tarsal
sutures should not extend through the
conjunctival surface
Resorbable buried sutures may be used in the
margin as an alternative to the permanent
externally tied sutures
CONJUNGTIVA
Embryology
At 10 weeks, the conjunctiva epithelium
diffrentiates from the eyelid skin and cornea
when goblet cells and glandular ducts become
visible.
By 12 weeks, caruncular development from the
nasal aspect of the lower lid fold and further
epithelial invagination to form the accessory
gland of Krause and Wolfring are seen. A soft
moveable fold (plica semilunaris) is also seen
between the caruncle and the globe.
Anatomy
Divided into:
Bulbar conjungtiva
Fornix conjungtiva
Palpebral conjungtiva
The tarsal conjunctiva is tightly adherent to
the underlying tarsus
The bulbar conjunctiva is loosely adherent to
Tenon capsule
Anatomy
The conjunctival epithelium varies from
stratified cuboidal over the tarsus to columnar
in the fornices to squamous on the globe
The substantia propria of the conjunctiva
consists of loose connective tissue.
Anatomy
Vascular supply
The bulbar conjunctiva is supplied by the
anterior ciliary arteries branching of the
ophthalmic artery
The palpebral conjunctiva shares its blood
supply with the eyelids
Branch of peripheral arcade supply superior
and inferior fornix conjungtiva
Anatomy
Lymph drainage
Lymphatic vessels serving the medial portion of
the eyelids drain into the submandibular lymph
nodes.
Lymph channels serving the lateral portions of the
eyelids drain first into the superficial preauricular
nodes and then into the deeper cervical nodes.
Anatomy
Nerve supply
Sensory innervation is controlled by the lacrimal.
supraorbital, supratrochlear, and infraorbital
branches of the ophthalmic division of cranial nerve
V
Function
Serve as a barrier to foreign particles and
inhibits the invasion of exogenous bacteria
The conjunctival secretion is important in
corneal nourishment and the transportation
of secretion to the nasal lacrimal outflow
system
Conjungtiva
Conjunctival disorder
Degenerative changes
Conjunctival inflammation
Immune mediated disordeor of the
conjunctiva
Conjunctival Trauma
Neoplastic disorder
Degenerative changes
Pinguecula
Degenerative changes
The appearance of yellow-white amorphous
subepithelial deposits with occasionally
calcification that occurs at the nasal and
temporal anterior bulbar conjunctiva more
often nasally
As a result of the effects of ultraviolet
Enlarge gradually over long periods of time
Degenerative changes
Lubricant therapy is the mainstay of treatment
Excision: for cosmetic problems
Topical corticosteroids: chronic inflammation
Degenerative changes
Pterygeum
Degenerative changes
A pterygium is a wing-shaped fold of conjunctiva
and fibrovascular tissue that has invaded the
superficial cornea
The pathogenesis of a pterygium is strongly
correlated with UV exposure although dryness,
inflammation, and exposure to wind and dust or
other irritants may also be factors
The histopathology of pterygium shows elastotic
degeneration of the stromal collagen with
subepithelial fibrovascular tissue.
Degenerative changes
Pterygia are nearly always preceded and
accompanied by pingueculae
The prevalence of pterygia increases steadily
to the equator
Regular and irregular astigmatism occurs in
proportion to pterygium size
A pigmented iron line (Stocker line) may be
seen at the central anterior edge of the
pterygium on the cornea
Degenerative changes
Excision is indicated:
The pterygium approaches the visual axis,causing
loss of vision from irregular astigmatism
In cases of considerable irritation
Degenerative changes
Conjunctival Concretion
Degenerative changes
Yellow-white deposits
In the palpebral conjunctiva of older patients
or patients who have had chronic
conjunctivitis.
Secondary calcification occurs occasionally
Sometimes referred to as conjunctival lithiasis.
The subconjunctival deposition of oral
tetracyclines mimics concretions.
Degenerative changes
Concretions are almost always asymptomatic
but may erode the overlying epithelium to
cause foreign-body sensation
If symptomatic, concretions can be easily
removed under topical anesthesia
Conjungtival Inflammation
Conjunctivitis
1. Dapat disebabkan
bakteri, virus
2. Dapat akut dan kronis
3. Tanda radang umum:
merah, papil, folikel,
sekret
4. Tanda radang khusus:
pseudomembran.
5. Pengobatan:
1. kausatif
Immune disorder of the conjunctiva
Vernal Conjunctivitis
Immune disorder of the conjunctiva
Usually a seasonally recurring
Bilateral inflammation of the cornea and
conjunctiva, vernal (springtime)
keratoconjunctivitis (VKC)
Predominantly in male children
Have a personal or family history of atopy
May persist year round in tropical climates
Involve both types I and IV hypersensitivity
reactions
Immune disorder of the conjunctiva
Infiltrate in VKC consists of eosinophils,
lymphocytes, plasma cells, and monocytes
Symptoms consist of itching, blepharospasm,
photophobia, blurred vision, and copious
mucoid discharge.
Clinically, 2 forms of VKC may be seen:
palpebral and Iimbal.
Immune disorder of the conjunctiva
The palpebral conjunctiva: papillary
hypertrophy develops, usually more
prominently on the upper rather than the
lower region.
Bulbar conjunctival hyperemia and chemosis
may also occur.
In more severe cases, giant papillae
resembling cobblestones on the upper tarsus
Immune disorder of the conjunctiva
Horner- Trantas dots, whitish dots that
represent macroaggregates of degenerated
eosinophils and epithelial cells, in the
hypertrophied limbus
Mild cases: topical antihistamines.
Mild to moderate: topical mast-cell stabilizers
Climatotherapy: air condition or relocation to
a cooler environment
Immune disorder of the conjunctiva
Severe cases: topical corticosteroids every 2
hours for 5- 7 days and then rapidly tapered or
topical immunomodulatory agents such as
cyclosporine applied 2-4 times daily
Immune disorder of the conjunctiva
Conjunctival Laseration
Conjunctival Trauma
1. Eksplorasi dilakukan untuk melihat struktur
dalam mengalami kerusakan (menggunakan
pinset dan cotton bud steril)
2. Bila disertai subconjunctival hemorrhage
masif, eksplorasi dilakukan dgn peritomi di
kamar operasi
3. Pengobatan: pada umumnya tidak
memerlukan penjahitan
Conjunctival Trauma
Subconjunctival hemorrhage
Conjunctival Trauma
Blood under the conjunctiva
Most frequently, without a history of
antecedent trauma
Occasionally, a history of vomiting, coughing,
or other forms of the Valsalva maneuver.
Repeated episodes of spontaneous
subconjunctival hemorrhage or indicates the
presence of bleeding diathesis
Conjunctival Trauma
Recurrent subconjunctival hemorrhages:
association with uncontrolled hypertension,
diabetes mellitus, or a bleeding diathesis.
No therapy for the hemorrhage, usually
resolves in 7-12 days
Neoplastic disorder
Conjunctival Melanoma
Neoplastic disorder
Conjunctival melanomas make up less than 1
% of ocular malignanciesConjunctival
Conjunctival melanomas are rare in black and
Asian populations
Although malignant conjunctival melanoma
has a better prognosis than cutaneous
melanoma, the overall mortality rate is 25%.
Neoplastic disorder
Conjunctival melanomas may arise from PAM
(70%) or nevi (2%), or be de novo (10%)%.
Metastasis: intralymphatic spread to regional
lymph nodes of the brain, lungs, liver, and bone.
Ciliary body melanoma can extend through the
sclera (rare) or full thickness intraepithelial
spread
Most commonly found in bulbar conjunctiva or at
the limbus
25% of conjunctival melanomas are amelanotic
Neoplastic disorder
May bleed easily
Grow in a nodular fashion
Can invade the globe or orbit
Poor prognostic:
palpebral conjunctiva, caruncle, or fornix, the
eyelid margin
invasion into deeper tissues
thickness> 1.8 mm
Neoplastic disorder
Management:
Excisional biopsy seems not to increase the risk of
metastasis
Excision of conjunctiva 4 mm beyond the clinically
apparent margins of the tumor
Treatment of the remaining sclera with absolute
alcohol
Cryotherapy applied to the conjunctival margins and
residual disease
Conjunctival or amniotic membrane grafts are
necessary for large excisions
Neoplastic disorder
Management:
Topical mitomycin C has been used after excision
Orbital exenteration is performed for advanced
disease
Adjunctive radiotherapy and chemotherapies has
not been determined