The eyelids and the lacrimal
system
Eyelid layers :
1- skin: thin and loose
2- fascia: contains orbicularis oculi muscle.
3- tarsus:
-dense fibrous tissue
-Levator palpebrae superioris inserts on
superior tarsal plate.
-medial and lateral palpebral ligaments attached
to its medial and lateral border.
4-palpebral conjunctiva.
Eyelid anatomy
Innervation of Eyelids
The opthalmic and maxillary
divisions of the trigeminal
nerve provide sensory
innervation of the eyelids.
Motor control of the orbicularis
muscle is through the facial
nerve, and that of the levator
muscle is through
the oculomotor nerve.
The tarsal smooth muscles are
innervated by sympathetic fibers
from the superior cervical
ganglion
Blood supply
the eyelids are supplied with blood by two
arches on each upper and lower lid. The
arches are formed by anastomoses of
the lateral palpebral arteries and
medial palpebral arteries, branching off from
the lacrimal artery and ophthalmic artery,
respectively.
The Eyelids
Benign nodules and cyst
Inflammatory diseases of the eyelid
Benign and malignant tumors
Malposition of the eyelid and eyelashes
Benign nodules and cyst
1-chalazion
-non-infectious painless
swelling of the eyelid.
-appears as a slow
growing lump.
-due to the obstruction of
the ducts of sebaceous
glands.
Chalazion
Risk factors: Chalazia are more
common in people with
inflammatory conditions
like seborrhea, acne, rosacea,
chronic blepharitis.
Treatment:
Some chalazia can go away without
treatment.
-Home care: apply a warm compress.
-Medical treatment: abx-steroid
combination.
-Surgical: Incision and curettage.
2- hordeolum:
an infectious painful swelling of the eyelid due to obstrucion of the duct of
sebaceous gland
Hordeolum externum (stye)
-Acute suppurative infection of the
zeis gland mostly by S.Aureus
Treatment :
1-analgesic to relieve pain.
2-topical + systemic antibiotic.
3-abcess drainage and associated
eyelash should be pulled out.
4-warm compresses to improve
drainage.
Hordeolum internum
-acute suppurative infction of the
meibomien gland mosly by
S.Aureus.
- More diffuse than stye.
Treatment :
1-analgesic. 2-topical + systemic antibiotic. 3-warm compresses to
improve drainage.
Blepharitis: chronic inflammation of the
eyelid
Anterior Blepharitis:
inflammation involves the lid margin, skin, and eyelash
follicles .
Posterior blepharitis:
inflammation involves the meibomian glands.
Blepheritis
-Blepharitis is often a chronic
condition that is difficult to
treat.
- it's not contagious.
- In severe disease the corneal
epithelium is affected
(blepharokeratitis); Small
ulcers may form in the
peripheral cornea (marginal
ulceration secondary to
staphylococcal exotoxins).
Symptoms :
Watery eyes
Red eyes
Eyelids that appear greasy
Itchy eyelids
Red, swollen eyelids
Flaking of the skin around the eyes
Crusted eyelashes upon awakening
Eyelid sticking
More frequent blinking
Eyelashes that grow abnormally
(misdirected eyelashes)
Loss of eyelashes
Blepheritis
The exact cause of blepharitis
isn't clear. It may be associated
with one or more factors,
including:
-Seborrheic dermatitis
-A bacterial infection
-Clogged or malfunctioning oil
glands in your eyelids
-Rosacea
-Allergies to eye medications,
contact lens solutions or eye
makeup
-Eyelash mites or lice
Treatmet:
-treat underlying cause
-eyelid toileting
-topical steroid
-Topical antibiotic
-artificial tears
Malposition of the eyelid and eyelashes
1-Entropion
2-Ectropion
3-Ptosis
4-Blepharospasm
5-Trichiasis
6-Distichiasis
1-entropion
Entropion
-A condition in which the eyelid (usually the lower lid) inverts toward
the globe. It is very uncomfortable, as the eyelashes continuously
rub against the cornea causing irritation, redness, watery eye and
might also cause corneal abrasion.
-It is seen most commonly in elderly patients where the orbicularis
muscle becomes weakened.
Other causes: scars, infection, inflammation
-Complication: corneal erosion and ulcer.
-Treatment:
Short-term treatment includes the application of lubricants to the eye
or taping the lid to overcome the lid inversion.
Permanent treatment requires surgery, in which excess skin of the
outer lids is removed or tendons and muscles are shortened
2-Ectropion
Ectropion
Abnormal eversion of the lid away from the globe.
Presentation: Irritation and redness with tearing due to corneal
exposure
Causes:-age related orbicularis muscle laxity.
-facial nerve palsy.
-scarring of periorbital skin.
the initial complaint is watery eye, because the malposition of the lids
everts the Puncta and prevents drainage of the tears leading to
epiphora, excessive dryness, irritation, light sensitivity.
treatment: lubrication, taping the inferolateral canthal skin, surgery.
3-Ptosis
Ptosis
Ptosis is an abnormal low position of the upper eyelid.
PATHOGENESIS
It may be caused by:
1.Mechanical factors:
- Large lid lesions pulling down the lid as in
dermatocalesis , tumor
-Lid edema.
-Tethering of the lid by conjunctival scarring.
-Structural abnormalities including dehiscence or
disinsertion of the aponeurosis of the Levator muscle,
usually in elderly patients.
Ptosis
2.Neurological factors:
-Third nerve palsy
-Horner’s syndrome results from the an interruption of the sympathetic
nerve supply to the eye
Characterized by classic triad of ( miosis, loss of hemifacial sweating –
hemianhidrosis , enophthalmos , mild-to-moderate ptosis due to
denevation of the sympathatically controlled Muller muscle )
-Marcus–Gunn jaw-winking syndrome; the patient has ptosis but when he/she
moves their jaw the whole eyelid elevates. The cause of congenital ptosis in 5%
of cases.
3.Myogenic factors:
-Myasthenia gravis
-Some forms of muscular dystrophy.
-Chronic external ophthalmoplegia.
Ptosis
Patients are usually present because:
-they came for cosmetic purposes
-vision may be impaired
-there are symptoms and signs associated with the underlying
cause(e.g. asymmetric pupils in Horner’s syndrome, diplopia and
reduced eye movements in a third nerve palsy).
Management:
It is important to exclude any underlying cause whose treatment could
resolve the problem (e.g. myasthenia gravis).
In most cases : surgery
4-Blepharospasm
Blepharospasm
It is a type of dystonia, a condition defined by sudden, irregular, involuntary
muscle spasms.
The problem can be caused or aggravated by a range of factors, including:
Stress , Eye strain, Certain drugs and medications, including caffeine, Dry
or irritated eye, Insufficient sleep
Other conditions that sometimes include eyelid twitching as a sign include:
Blepharitis
Dry eyes
Entropion
Glaucoma
Light sensitivity
Trichiasis
Uveitis
5-Trichiasis
Trichiasis
Trichiasis is a common eyelid abnormality in which the eyelashes are
misdirected and grow inwards toward the eye.
Trichiasis can be idiopathic or secondary to chronic inflammatory conditions.
Causes:
Infectious: trachoma, herpes zoster, autoimmune disease
Traumatic: postsurgical > as after ectropion repair
Chemical: alkaine burns to eye, medical drops(glucoma drops)
Those inward-turning lashes rub against the conjunctiva and cornea, irritating
the eye.
Symptoms : redness and irritation , foreign body sensation, watery eye ,
sensitivity and sometimes pain when exposed to light
Trichiasis
Treatment :
1- Lubricants ( artificial
tears and ointment)
2- Epilation of the affected eyelashes with forceps,
electrolysis, cryotherapy .
3- Surgical
6-Distichiasis
Distichiasis
is a rare disorder defined
as the abnormal growth
of lashes from the
orifices of the
Meibomian glands on
the posterior lamella of
the tarsal plate
Two types : acquired
and congenital.
Benign and Malignant Tumours
1- Capillary Hemangioma
2-Port Wine Stain
3-Xanthelasma
4- Basal Cell Carcinoma
5-Squamous Cell Carcinoma.
1- Capillary Haemangioma
Capillary hamangioma
Cutaneous hemangioma
red, raised lesion
Treatment :
- Simple observation since most lesions regress
on their own
- Beta blockers ( as propanolol)
- Steroids
- Surgery in rare cases
Subcutaneous hemangioma
Dark blue lesion.
2-Port-wine stains (nevus flammus)
-Congenital malformation of the
superficial dermal blood vessels.
-Presents at birth, grows
commensurate to the child
-No tendency for regression
-More prone to bleeding than
normal skin
-Appears flat and wellcircumscribed patch but over
time it becomes thicker.
Laser Tx for cosmotic needs
Capillary hemangioma VS Port-wine stains
On examination :
1-Capillary hemangioma becomes
white when pressed this is
called BLANCHING.
Port-wine stain stays as it is
2-Capillary hemangiomas can be
found anywhere
Port-wine stain is usually found at
the site of the trigeminal
dermatomes, especially V1
and V2.
3-Xanthelasma
-Bilateral lipid-containing
lesions which may be
associated with
Hypercholesterolaemia.
-They are removed for
cosmetic reasons.
4-Basal cell carcinoma
-Most common form of malignant tumors
-accounts for 90% of eyelid malignancies
-characteristics :
slow growing
locally invasive
non-metastasizing
-Patients are present with a painless lesion
on the eyelid which may be nodular,
sclerosing or ulcerative (called rodent
ulcer). It may have a typical, pale,
pearly margin.
-The prognosis is usually very good but
deep invasion of the tumor can be
difficult to treat.
Basal cell carcinoma
Treatment:
-Excisional biopsy with a
margin of normal tissue
surrounding the lesion
-Cryotherapy
-Radiotherapy
5-Squamous cell carcinoma
-This is a less common but more
malignant tumor which can
metastasize to the lymph nodes.
-It can arise de novo or from premalignant lesions.
-It may present as a hard nodule or a
scaly patch.
-Treatment is by excisional biopsy
with a margin of healthy tissue.
-UV exposure is an important risk
factor for both basal cell and
squamous cell carcinoma
Lacrimal
System
/Apparatus
Anatomy of Lacrimal system
 The lacrimal apparatus :
set of connected
anatomical structures
located within the orbit
that are responsible for the
production and drainage of
tears.
Contains :
 The lacrimal gland
 The lacrimal puncta
 The lacrimal canaliculi
 the lacrimal sac
 the nasolacrimal duct
Anatomy of Lacrimal system
Lacrimal gland
-serous gland ,Yellowish soft lobulated
-almond shaped and approximately 2 cm long
-lies in the fossa of the lacrimal gland in the superalateral part of each orbit
-The gland is divided into a superior orbital and inferior palpebral part by the
lateral expansion of the tendon of the Levator palpebrae superioris
-secretes lacrimal fluid
Accessory lacrimal glands may also be present, sometimes in the middle
part of the eyelid, or along the superior or inferior fornices of the conjunctival
sac. They are more numerous in the superior eyelid than in the inferior eyelid
Anatomy of Lacrimal system
Lacrimal fluid
-a watery physiological saline containing the bactericidal enzyme
lysozyme.
-moistens and lubricates the surfaces of the conjunctiva and cornea and
provides some nutrients and dissolved oxygen to the cornea
-when produced in excess, the overflowing fluid constitutes tears.
-Production is stimulated by the parasympathetic impulses from CN VII
(Facial)
-It is secreted through 8–12 excretory ducts, which open into the lateral
part of the superior conjunctival fornix of the conjunctival sac
Excretory ducts of lacrimal gland: convey lacrimal fluid from the
lacrimal glands to the conjunctival sac
Anatomy of Lacrimal system
Lacrimal canaliculi : begins at the
lacrimal punctum (opening) on
the lacrimal papilla near the medial
angle of the eye and drain lacrimal
fluid from the lacrimal lake ( a
triangular space at the medial angle
of the eye where the tears collect)
to the lacrimal sac (dilated superior
part of the nasolacrimal duct)
Nasolacrimal duct: conveys the
lacrimal fluid to the inferior nasal
meatus
Watery Eyes (Epiphora)
Watery Eyes (Epiphora or tearing) , is a condition in which there is
an overflow of tears onto the face, often without a clear
explanation.
-Epiphora can develop at any age, but it is more common in those
aged under 12 months or over 60 years. It may affect one or both
eyes.
-Watering eye can usually be treated effectively.
Causes :
1- Blocked tear ducts
2- Over-production of tears
3- Other causes
Watery Eyes (Epiphora)
Blocked tear ducts
1.Conginital causes
-Babies are sometimes born with under-developed tear ducts. The tear
ducts can be completely or partially closed (congenital nasolacrimal
duct obstruction/ dacryostenosis) and can cause the baby's eyes to
water. Most blocked tear ducts in babies get better on their own before
the baby is one year old.
dacryocystocele
Watery Eyes (Epiphora)
Blocked tear ducts
2.Acquired causes
.
-Involutional stenosis is the most common cause of nasolacrimal
duct obstruction in older people , compression of the lumen is
caused by inflammation and edema or related to an autoimmune
diseases like sarcoidosis
-Dacryolithiasis or cast formation, within the lacrimal sac
-Sinus disease
-Naso-orbital fractures may involve the nasolacrimal duct
-dislodged punctual and canalicular plugs can migrate to and
occlude the nasolacrimal duct.
-Neoplasm should be considered in any patient presenting with
nasolacrimal duct obstruction.
- Cancer treatments, A blocked tear duct is a possible side effect of
chemotherapy medication and radiation treatment for cancer.
Watery Eyes (Epiphora)
some chemicals,
such as fumes,
and even onion
Irritated eyes may
produce more tears
than normal as the
body tries to rinse
the irritant away.
Injury to the eye,
such as a scratch or
a bit of grit (tiny
pebble or piece of
dirt)
Infective
conjunctivitis
Overproduction of
tears
Trichiasis, where
eyelashes grow
inward
allergic
conjunctivitis
Ectropion, when
the lower eyelid
turns outward
Watery Eyes (Epiphora)
One of the most prevalent
reasons for watery eyes
is dry eye syndrome.
Extremely dry eyes can
cause you to produce excess
tears. Because your eyes are
not receiving proper
lubrication, you continually
produce an abundance of
tears, which continues the
cycle. In simpler words: the
eye stays dry for quite a
while and then it suddenly
produces an excessive
amount of tears. This is
called reflex tearing.
keratiti
s
corneal
ulcer
styes
or
lumps
use of
certain
medicati
ons
Bell's
palsy
Other
causes
dry eye
syndrome
allergies
problem
with the
Meibomi
an glands
Watery Eyes (Epiphora)
Evaluation
Not every case of watery eyes requires
evaluation by a doctor.
Warning signs
1)Repeated, unexplained episodes of
red watery eyes
2) A hard mass in or near the tear duct
Had injuries,
infections, burns,
radiation therapy, or
surgical procedures
involving the eyes,
nose, or sinuses
Taken a drug that
may cause watery
eyes (such as
chemotherapy / eye
drops
The physical examination
focuses on the face,
particularly the eyes and
nose.
small probe into the
punctum and
sometimes the
canaliculus to try to
detect blockage
Doctors look for tears
running down the cheek.
They examine the eyelids,
the puncta, and the area
at the inner corners of the
eyes
They also examine the
surface of the eye with
a slit lamp to examine the
eye under high
magnification.
The nose is examined for
congestion, blockages,
pus, discharge, and
bleeding.
Testing
History
Other symptoms (for
example, headache,
shortness of breath,
cough, fever, or rash)
Physical Examination
Watery Eyes (Epiphora)
Doctors may insert a
Itching, a runny nose,
or sneezing ,Eye
irritation, redness, or
pain or discomfort
with swelling or
redness near the
inner corner of the
eye
They may also gently
flush fluid through
the canaliculus to see
whether the fluid
drains into the nose
as it should.
Imaging tests and
procedures (imaging
of the tear ducts, CT,
or examination of the
inside of the nose
with nasal endoscopy
Watery Eyes (Epiphora)
Watery Eyes (Epiphora)
Treatment
-Treatment of other causes (a nasal corticosteroid if allergic
rhinitis is the cause /antibiotics if conjunctivitis )
-Sometimes artificial tears (to decrease watery eyes when
dry eyes or eye surface irritation is the cause)
-Measures to open blocked tear ducts
*In infants with blocked tear ducts, resolves without
treatment as the infant grows
* If the blockage is not relieved by the time the infant is
about 1 year old, , The infant is given a general
anesthetic, and the doctor inserts a small probe into
the tear duct to break through the blockage. If
blockage persists, doctors may need to insert a small
plastic tube through the tear duct for a few months
to keep a drainage pathway open.
Watery
Eyes
(Epiphora)
Treatment
Measures to open blocked tear ducts
*In adults with blocked tear ducts, doctors first try
different methods to treat the underlying
disorder. If these methods do not work, doctors
may have to do surgery to make a new drainage
pathway for tears
*Dacryocystorhinostomy (DCR for short) is a
common surgical procedure that is used to treat
blocked tear ducts. It involves creating a new
channel from the tear sac to the inside of your
nose.
removing a very small piece of bone from the side of
your nose
using a balloon to expand the blocked tear duct
using a laser to create a similar but smaller hole in
the sac and bone between the sac and the nose;
Dacryocystitis
is an infection of the lacrimal sac, secondary to obstruction of
the nasolacrimal duct at the junction of lacrimal sac.
Pathophysiology :
-stasis of the nasolacrimal fluid
-stones
-Staphylococcus aureus is a common bacterial pathogen causing
infectious Dacrocystitis.
-pneumococcus, infection due to surrounding structure such as
paranasal sinuses
Signs and Symptoms :
-Sudden Pain, swelling, redness over the lacrimal sac ,
-Tearing, crusting, fever , Pus, purulent discharge from the puncta .
Dacryocystitis
Complications and Prognosis :
-The most common complication is corneal
ulceration frequently in association
with S. pneumonia
-Immunocompromised patients might
develop orbital cellulitis, which may lead
to optic neuritis, proptosis motility
abnormalities, or blindness
Treatment
-The mainstays of treatment are
oral antibiotics, warm compresses
-Relief of nasolacrimal duct obstruction
by dacryocystorhinostomy
Canalculitis
an infection of the lacrimal canaliculus, typically occurs
in individuals over 40.
Pathophysiology :
usually caused by infection ( Actinomyces israelii is the
most common pathogen)
Signs and Symptoms:
-symptoms are usually unilateral
-swollen, red ,watering discharge, a pouting punctum, or
a medial canthal swelling
-expression of yellowish granules
Canalculitis
Diagnosis :
-The diagnosis of canaliculitis is clinical
-The differential diagnosis includes chronic
conjunctivitis, dacryocystitis, migrated punctal
plug, and rarely carcinoma of the lacrimal
canaliculus.
Laboratory test
Histopathology examination of the discharge and
concretions with different stains (gram stain,
GMS and PAS) and culture are important to know
the pathogen
Treatment
-warm compresses, digital massage, and topical
antibiotics (rarely curative alone.)
-canaliculotomy is still the mainstay of treatment
and is more effective than conservative
management.