Skin of EyelidsEye Lashes

Eyelids pathologyAnatomy of Conjunctiva

1. Epidermis The outer part of the eyelid

is lined by cornified stratified squamous epidermis. 

It is made up of basal cells, melanocytes, Langerhans cells, keratinocytes and on top, the dead cell layer (also known as the stratum corneum) made up of corneocytes. The epidermal layer gives the skin its appearance, color, suppleness, texture, and health

Thickness of .05 mm

2. Dermis forms the support layer of the skin, is made up of threadlike

proteins including bundles of elastin and collagen, fibroblasts, nerves and vessels

MEIBOMIAN GLANDS (tarsal glands)- The sebaceous glands that secrete into the eyelashes

• GLANDS OF ZEIS– The sebaceous glands that do not empty into

hair follicles –  it is emptying into the space between the

conjunctiva and the cornea

• GLANDS OF MOLL – The small sweat glands in the dermis that open

in a row near the base of the eye lashes

3. Subcutaneous layer –deepest layer w/c contains a thin layer of fascia which lies on top of the orbicularis muscle, a muscle that allows the eyelid to move

Eye Lashes• The human eyes are

protected and lined by eyelashes

• Each eyelid has a single row of eyelashes.

• A single eyelash is anchored by a root hair plexus to the eyelid. This aids in the reflex action of the eyelid to close when a foreign particle enters it.

• Upper eyelid– Eyelashes are longer, and have a propensity to curve

in an upward direction. – They may grow up to ten millimeter in length.– ninety to one hundred and fifty eyelashes

• Lower eyelid− relatively shorter and tend to curve downward.− seventy to eighty eyelashes

An embryo develops it eyelashes from the seventh to eighth week inside the womb.

•  Each eyelash has a three phases of growth cycle and is similar to hair in the other parts of the body

1. Anagen phase- hair grows actively for a period of thirty to forty five days.

2. Catagen phase- eyelash stops its growth, and the follicle starts to shrink.

3. Telogen phase - eyelash rests, and stays in this phase for about a hundred days till it falls out naturally. 

– If the eyelash is pulled out or falls off, it will take as long as seven to eight weeks to grow back.

Infections & Inflammations of the Lids

1. Hordeolum

– is infection of the glands of the eyelid.

– Internal hordeolum – a large swelling involving the meibomian gland

- External hordeolum (sty)• The smaller and more superficial, infection of

Zeis's or Moll's glands.

• Pain, redness, and swelling are the principal symptoms• Most hordeola are caused by staphylococcal

infections, usually Staphylococcus aureus.

• Culture is seldom required. Treatment consists of warm compresses three or four times a day for 10–15 minutes

• If the process does not begin to resolve within 48 hours, incision and drainage of the purulent material is indicated.

• Antibiotic ointment applied to the conjunctival sac every 3 hours is beneficial. Systemic antibiotics are indicated if cellulitis develops

Chalazion• an idiopathic sterile chronic granulomatous

inflammation of a meibomian gland usually characterized by painless localized swelling that develops over a period of weeks.

•

• It may begin with mild inflammation and tenderness resembling hordeolum—differentiated from hordeolum by the absence of acute inflammatory signs.

• Most chalazia point toward the conjunctival surface, which may be slightly reddened or elevated.

• If sufficiently large, a chalazion may press on the eyeball and cause astigmatism. If large enough to distort vision or to be a cosmetic blemish, excision is indicated

• Biopsy is indicated for recurrent chalazion, since meibomian gland carcinoma may mimic the appearance of chalazion

• Intralesional steroid injections alone may be useful for small lesions, and in combination with surgery in difficult cases.

Anterior Blepharitis• Common chronic bilateral inflammation of the lid

margins

There are two main types: – 1. Staphylococcal blepharitis w/c may be due to

infection with Staphylococcus aureus, in which case it is often ulcerative, or Staphylococcus epidermidis or coagulase-negative staphylococci.

– 2. Seborrheic blepharitis (nonulcerative) is usually associated with the presence of Pityrosporum ovale,. Seborrhea of the scalp, brows, and ears is frequently associated with seborrheic blepharitis.

• Chief symptoms are irritation, burning, and itching of the lid margins. The eyes are "red-rimmed." Many scales or "granulations" can be seen clinging to the lashes of both the upper and lower lids.

• In the staphylococcal type– the scales are dry, the lids are red, tiny ulcerated

areas are found along the lid margins, and the lashes tend to fall out.

• In the seborrheic type– the scales are greasy, ulceration does not occur,

and the lid margins are less red.

• The scalp, eyebrows, and lid margins must be kept clean, particularly in the seborrheic type of blepharitis, by means of soap and water shampoo. Scales must be removed from the lid margins daily with a damp cotton applicator and baby shampoo.

• Staphylococcal blepharitis is treated with antistaphylococcal antibiotic or sulfonamide eye ointment applied on a cotton applicator once daily to the lid margins.

Posterior Blepharitis• inflammation of the eyelids secondary to dysfunction

of the meibomian glands. • Like anterior blepharitis, it is a bilateral, chronic

condition.• Posterior blepharitis is manifested by a broad spectrum

of symptoms involving the lids, tears, conjunctiva, and cornea.

• There is Inflammation of the meibomian orifices (meibomianitis), plugging of the orifices with inspissated secretions, dilatation of the meibomian glands in the tarsal plates, and production of abnormal soft, cheesy secretion upon pressure over the glands

• The lid margin shows hyperemia and telangiectasia

• The tears may be frothy or abnormally greasy. Hypersensitivity to staphylococci may produce epithelial keratitis. The cornea may also develop peripheral vascularization and thinning, particularly inferiorly, sometimes with frank marginal infiltrates.

• Treatment of posterior blepharitis is determined by the associated conjunctival and corneal changes.

• Frank inflammation of these structures calls for active treatment, including long-term low-dose systemic antibiotic therapy—usually with doxycycline (100 mg twice daily) or

erythromycin (250 mg three times daily), but guided by results of bacterial cultures from the lid margins

—and (preferably short-term) treatment with weak topical steroids, eg, prednisolone, 0.125% twice daily.

• Topical therapy with antibiotics or tear substitutes is usually unnecessary and may lead to further disruption of the tear film or toxic reactions to their preservatives.

• Periodic meibomian gland expression may be helpful, particularly in patients with mild disease that does not warrant long-term therapy with oral antibiotics or topical steroids.

Anatomic Deformities of the Lids1. Entropion

– turning inward of the lid – may be involutional (spastic, senile)

• most common and by definition occurs as a result of aging. It always affects the lower lid and is the result of a combination of laxity of the lower lid retractors, upward migration of the preseptal orbicularis muscle, and buckling of the upper tarsal border

– Cicatricial• may involve the upper or lower lid and is the result of

conjunctival and tarsal scar formation. It is most often found with chronic inflammatory diseases such as trachoma.

• Congenital entropion – rare and should not be confused with congenital

epiblepharon, which usually afflicts Asians. In congenital entropion, the lid margin is rotated toward the cornea, whereas in epiblepharon, the pretarsal skin and muscle cause the lashes to rotate around the tarsal border.

• Trichiasis – is impingement of eyelashes on the cornea and may be due to

entropion, epiblepharon, or simply misdirected growth. It causes corneal irritation and encourages ulceration. Chronic inflammatory lid diseases such as blepharitis may cause scarring of the lash follicles and subsequent misdirected growth.

• Distichiasis – is a condition manifested by accessory eyelashes, often

growing from the orifices of the meibomian glands. It may be congenital or the result of inflammatory metaplastic changes in the glands of the eyelid margin.

• Surgery to evert the lid is effective in all kinds of entropion.

• Useful temporary measures in involutional entropion are to tape the lower lid to the cheek, with tension exerted temporally and inferiorly, or to inject botulinum toxin.

• Trichiasis without entropion can be temporarily relieved by plucking the offending eyelashes.

• Permanent relief may be achieved with electrolysis, laser or knife surgery, or cryosurgery.

Ectropion• Ectropion (sagging and eversion of the lower

lid) – is usually bilateral and is a frequent finding in older

persons. – It may be caused by relaxation of the orbicularis

oculi muscle, either as part of the aging process or following seventh nerve palsy.

– The symptoms are tearing and irritation. Exposure keratitis may occur.

• Involutional ectropion is treated surgically by horizontal shortening of the lid.

• Cicatricial ectropion is caused by contracture of the anterior lamella of the lid. – Treatment requires surgical revision of the scar and often

skin grafting.

• Minor degrees of ectropion can be treated by several fairly deep electrocautery penetrations through the conjunctiva 4–5 mm from the lid margins at the inferior aspect of the tarsal plate.

• The fibrotic reaction that follows will often draw the lid up to its normal position.

Tumors of the Eyelids

1. Benign Lid Tumors– Benign tumors of the lids are very common and

increase in frequency with age. – Most are readily distinguished clinically, and

excision is done for cosmetic reasons. However, it is often impossible to recognize malignant lesions clinically, and biopsy should always be performed if there is any doubt about the diagnosis.

A. Nevus– Melanocytic nevi of the eyelids are common benign tumors

with the same pathologic structure as nevi found elsewhere.

– They initially may be relatively nonpigmented and show enlargement and increased pigmentation during adolescence. Many never acquire visible pigment, and many resemble benign papillomas.

– Nevi rarely become malignant– Nevi may be removed by shave excision if desired for

cosmetic reasons.

Papillomas• Papillomas are the most common benign eyelid

tumors. Two types occur: – squamous cell papillomas – seborrheic keratoses- occur in middle-aged and older

individuals. They have a friable, verrucous surface and are often pigmented because melanin accumulates in the keratocytes.

• In both, fibrovascular cores permeate thickened (acanthotic and hyperkeratotic) surface epithelium, giving it a papillomatous appearance.

Xanthelasma• common disorder that occurs on the anterior surface of the

eyelid, usually bilaterally near the inner angle of the eye.• The lesions appear as yellow plaques within the eyelid

skin and occur most commonly in elderly people. • Xanthelasma represents collections of lipid-containing

histiocytes in the dermis of the lid.

• While they may occur in patients with hereditary hyperlipidemia or with secondary hyperlipidemia, approximately two-thirds of patients with xanthelasma have normal serum lipids

Treatment is indicated for cosmetic reasons. Lesions can be excised, cauterized, or treated with laser surgery. Recurrence following removal is not unusual.

Cysts • Cysts in the eyelids are common.

• Keratinous cysts, lined by epithelium and filled with cheesy-looking keratin and debris, are the result of obstruction of pilosebaceous structures (milia and pilar cysts) or congenital and traumatic subepithelial implantation of surface epithelium (epidermal inclusion cysts).

• Dermoid cysts, with adnexal structures such as hair follicles and sebaceous glands in the walls and with hair as well as keratin in the lumen, are congenital but may not become apparent until later in life, when they increase in size or rupture, eliciting a granulomatous inflammatory response.

• Most are located near the orbital rim superotemporally, and many are associated with a defect in the bone that may communicate with the intracranial cavity.

• Hidrocystomas (sudoriferous cysts, ductal cysts) arise from the eccrine or apocrine sweat ducts and are filled with a watery material.

Hemangioma • 1. Capillary hemangioma (strawberry nevus)

– The most common congenital vascular tumor of the eyelids– composed of proliferating capillaries and endothelial cells. – They arise at or shortly after birth, often grow rapidly, and

usually involute spontaneously by age 7 years. – If superficial, they may be bright red (strawberry nevus);

deeper lesions may be bluish or violet.

• Treatment of the tumor is indicated if it blocks the visual axis or induces a significant astigmatism. Intralesional injection of steroids or interferon alpha may produce rapid resolution; if this fails, partial surgical excision is indicated.

2. Nevus flammeus (port wine stain)– more purple in hue than the bright red of capillary hemangiomas.

Composed of dilated, cavernous vascular channels. It is always present at birth, does not grow or regress as does a capillary hemangioma, and is often associated with Sturge-Weber syndrome. The cosmetic defect can be treated with laser surgery.

3. Cavernous hemangioma

- A third type of angioma composed of large, endothelium-lined vascular channels with smooth muscle in their walls. They are developmental rather than congenital and tend to arise after the first decade. Unlike capillary hemangiomas, they do not usually regress.

Primary Malignant Tumors of the Lids1. Carcinoma• Basal cell and squamous cell carcinomas of the lids are

the most common malignant ocular tumors. – These tumors occur most frequently in fair-

complexioned individuals who have had chronic exposure to the sun.

– Ninety-five percent of lid carcinomas are of the basal cell type.

– The remaining 5% consist of squamous cell carcinomas, meibomian gland carcinomas, and other rare tumors such as Merkel cell carcinomas and carcinomas of the sweat glands.

• Treatment of all these carcinomas is by complete excision, which is best achieved by controlling the surgical margins with frozen sections.

• Many of these malignant tumors and many benign ones as well can have the same appearance; biopsy is usually required to establish the correct diagnosis.

Basal Cell Carcinoma• Usually grows slowly and painlessly as a nodule that

may become ulcerated. • While it may slowly invade adjacent tissues, basal

cell carcinoma rarely metastasizes.• A less common type—sclerosing or morphea basal

cell carcinoma—tends to extend insidiously and therefore may be more difficult to completely extirpate.

• Depending on their location, basal cell carcino mas may produce ectropion, entropion, lid notching or retraction, dimpling of the overlying skin, or loss of eyelashes.

• Frozen section study of the surgical margins is particularly important for sclerosing basal cell carcinomas, since the tumor margins are seldom clinically apparent.

• Microscopically controlled excision (a modified Mohs technique) is used by some dermatologists to achieve complete excision.

• Selected cases may be treated by other methods such as radiotherapy or cryotherapy with liquid nitrogen.

Squamous Cell Carcinoma• Squamous cell carcinomas also grow slowly and

painlessly, often starting as a hyperkeratotic nodule that may become ulcerated.

• Benign inflammatory tumors such as keratoacanthomas may closely resemble carcinomas.

• Establishing the correct diagnosis usually requires a biopsy.

• Like basal cell carcinomas, these tumors can invade and erode through adjacent tissue; they can also spread to regional lymph nodes via the lymphatic system.

Sebaceous Gland Carcinoma• Most often arise from the meibomian glands and the

glands of Zeis but can also occur in the sebaceous glands of the eyebrow or caruncle.

• About half resemble benign inflammatory lesions and disorders such as chalazia and chronic blepharitis.

• They are more aggressive than squamous cell carcinomas, often extending into the orbit, invading lymphatics, and metastasizing.

• There may be a role for sentinal node biopsy as part of the evaluation of patients with malignant adnexal tumors.

CONJUNCTIVA

CONJUNCTIVA

• Is a thin translucent mucous membrane that lines the inner surface of the eyelids and covers the anterior portion of the sclera.

• It’s epithelium is continuous with that of the cornea and with the lacrimal drainage system through the puncta.

– 1. Palpebral Conjunctiva• lines the posterior surface of the lids and is firmly

adherent to the tarsus. At the superior and inferior margins of the tarsus, the conjunctiva is reflected posteriorly (at the superior and inferior fornices) and covers the episcleral tissue to become the bulbar conjunctiva.

– divided into• marginal tarsal – closely adherent to the tarsal plate• orbital portion- thrown into many folds

2. Conjunctiva of superior and Inferior fornices– Forms transitional area bet. Palpebral and bulbar

conjunctiva.– Loosely attached to the underlying tissue and may

become markedly swollen

• 3. Bulbar conjunctiva– is loosely attached to the orbital septum in the

fornices and is folded many times. This allows the eye to move and enlarges the secretory conjunctival surface

– Adjacent to the sclera, w/c can be seen as the white of the eye through the translucent conjunctiva tissue

• Semilunar fold ( Plica Semilunaris)– Consist of a delicate vertical cresent of conjunctiva, the free

edge of w/c is concave and concentric with the corneal margin

– A soft, movable, thickened fold of bulbar conjunctiva (is located at the inner canthus

– Separated from bulbar conjunctiva by a 2 mm deep cul de sac• Lacrimal Curuncle• small, fleshy, epidermoid structure attached superficially to

the inner portion of the semilunar fold Covered by stratifies epithelium that is not keratinized

• Contains large sebaceous gland similar to meibomian gland and has delicate hairs with sebaceous gland similar to the gland of Zeis

Structure• Composed of two layer

– 1. Stratified Columnar Epithelium• Varies in thickness from two cell layers in its

upper tarsal portion to 5-7 layers at the corneoscleral junction

• Never keratinized in healthy individual

2. Lamina Propia Composed of connective tissue that contain

blooed vessel, nerves, glands, mast celss, macrophages, and Poplymorphonuclear leukocyte

• Conjunctival epithelium near the limbus, over the caruncle, and near the mucocutaneous junctions at the lid margins consists of stratified squamous epithelial cells

• superficial epithelial cells contain round or oval mucus-secreting goblet cells. The mucus, as it forms, pushes aside the goblet cell nucleus and is necessary for proper dispersion of the precorneal tear film.

• basal epithelial cells stain more deeply than the superficial cells and near the limbus may contain pigment.

Conjunctival stroma• Divided into:

1. Adenoid layer (superficial)− contains lymphoid tissue and in some areas may

contain "follicle-like" structures without germinal centers. The adenoid layer does not develop until after the first 2 or 3 months of life

This explains why inclusion conjunctivitis of the newborn is papillary in nature rather than follicular and why it later becomes follicular

2. Fibrous layer ( Deep) • is composed of connective tissue that attaches to the

tarsal plate. This explains the appearance of the papillary reaction in inflammations of the conjunctiva. The fibrous layer is loosely arranged over the globe.

• The accessory lacrimal glands (glands of Krause and Wolfring), which resemble the lacrimal gland in structure and function, are located in the stroma.

• Most of the glands of Krause are in the upper fornix, and the remaining few are in the lower fornix.

• The glands of Wolfring lie at the superior margin of the upper tarsus.

• Blood Supply, Lymphatics, & Nerve Supply

– The conjunctival arteries are derived from the anterior ciliary and palpebral arteries.

– The two arteries anastomose freely and along with the numerous conjunctival veins that generally follow the arterial pattern”form a considerable conjunctival vascular network.

– The conjunctival lymphatics are arranged in superficial and deep layers and join with the lymphatics of the eyelids to form a rich lymphatic plexus.

• The conjunctiva receives its nerve supply from the first (ophthalmic) division of the fifth nerve. It possesses a relatively small number of pain fibers

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