By Riad Ma'luf, MD
Department of Ophthalmology, Oculoplastics
American University of Beirut Medical Center
The eyelids protect the eye by preventing contact with
foreign materials and by preventing
excessive drying of
the cornea and conjunctiva.
1) The eyelids are
lamellar structures covered on their outer surface by thin skin and
on their inner surface by conjunctiva. Between the skin and
conjunctiva are the tarsal plates, the orbital septum, the upper lid
elevators (Levator & Mullerís muscle) , the lower lid
retractors, and the orbicularis muscle.The levator muscle is the
major elevator and originates from the orbital apex just above the
annulus of zinn to insert over the anterior tarsal border. It is
innervated by the upper division of the third cranial nerve. Fibers
from the levator aponeurosis to the skin form the lid crease.
Mullerís muscle originates from the undersurface of the levator
muscle and inserts on the upper tarsal border. It is innervated by
the sympathetic nervous system. Interruption of these sympathetic
fibers results in Hornerís syndrome (ptosis, miosis, anhidrosis).
The orbicularis muscle is innervated by the seventh cranial nerve
and is divided into three subdivisions: preorbital (forceful closure
of the eyelids), preseptal, and pretarsal (fine blinking).
Malposition of the upper eyelid in which the lid margin is
abnormally low. Ptosis can be congenital or acquired. The type of
ptosis should be carefully established by history, since the
treatment of congenital ptosis is usually different from that of
acquired ptosis. Ptosis must be distinguished from pseudoptosis, a
condition in which the upper eyelid appears to be low without true
insufficiency of the lid retractors.
2)can be bilateral but more commonly
unilateral. Associated abnormalities include:
inversus-ptosis syndrome (fig.3 )
Gunn ďjaw winkingĒ syndrome. Synkinesis
in which the ptotic eyelid
elevates with movement of mandible.( fig.
muscle palsies. Mainly the
superior rectus muscle.
Treatment : Usually not before three or
four years of age. Levator resection should be done in cases with
acceptable levator function. Otherwise a frontalis sling is
Levator function is usually good. May
be categorized as follows:
(fig. 5) Most common form of acquired ptosis. Usually is bilateral and
involves elderly patients. It results from disinsertion of the
Associated with Myasthenia gravis, muscular dystrophy, and
progressive external ophthalmoplegia.
Deficient innervation 3rd CN to levator muscle or
deficient sympathetic innervation to Mullerís muscle (Hornerís
Direct trauma to levator muscle or aponeurosis
Can be associated with lid tumors. (eg. Neurofibromatosis fig.
6 ). Contact lens induced ptosis can be
disinsertional or mechanical (cobblestone papillae), and can improve
upon discontinuation of the lens ( fig.
Involves correcting the cause when possible. If not possible,
then a levator resection is to be done (in cases of acceptable
levator function). In cases of poor levator function, frontalis
suspension is advised.
Pseudoptosis: Abnormally low upper lid with no
insufficiency of the retractors.
a: Excessive upper lid skin-
b: Contralateral lid retraction.
c: Enophthalmos or contralateral
Lid margin is turned away from the globe. Lower lid is more
involved. Tearing may result from
eversion of punctum. The congenital
form is rare.
The acquired form is categorized as
ectropion is a frequent cause of tearing (epiphora) (Fig.
10 ) .
a. Is caused by attenuation of canthal tendons and
lower lid retractors.
b. Treatment involves lid tightening procedures.
2 . Paralytic
, mainly from seventh nerve injury.
caused by scarring and secondary skin traction
and Fig. 12)
Entropion: Lid margin is turned toward the globe. Inturned lid margin may damage the
cornea and cause keratitis or
ulceration. The acquired form
is categorized as follows:
entropion usually involves the lower lid. (Fig.
attenuation of lid
structures(retractors & canthal tendons).
Cicatricial entropion is usually the result of
tarsoconjunctival shrinkage. May be
caused by trachoma, Stevens -Johnson syndrome, ocular pemphigoid,
1. Distichiasis : extra row of lashes arise from the
lid margin, frequently from
Trichiasis: Lashes are directed posteriorly toward the surface of
Loss of lashes
Basal cell carcinomas;
-Most common malignant tumors of the eyelids
-Most frequently arise on sun exposed lower lids
-More commonly nodular with pearly surface
-Invade adjacent areas, however rarely metastasize to distant
-Less common than basal cell carcinomas
-Potential of metastasis
-Metastasis is common
- May evolve from preexisting nevi
cell carcinomas : (fig.
from meibomian glands
may mimic chalazion (
caution in cases of recurrent chalazia)
inflammation & degeneration:
Very common condition
Associated with conjunctivitis
May be associated with Staphylococcus infection
a. Mechanical debridement of lid margin
b. Topical antibiotics
c. Warm compresses
of a meibomian gland
a. Warm compresses
b. Incision & curettage may be necessary in
Results from repeated idiopathic episodes of eyelid
edema and inflammation---ŗ
wrinkling of skin & ptosis
-More common in young females
Redundancy of the skin of the eyelids
change among old people
predisposition is common