eyelid lecture Dr. khalid al zubi
Ptosis describes a low position of the upper lid on the globe. It is not a diagnosis. Children with ptosis are at risk of amblyopia if the eyelid covers any part of the pupil, and may
require urgent brow suspension.
■ Congenital: Congenital levator dystrophy, congenital Horner’s syndrome.
■ Hereditary: Myopathic (myaesthenia gravis, ocular myopathy, systemic myopathy).
■ Acquired: Trauma, involutional (aponeurosis dehiscence), oculomotor nerve disease, ocular surface disease or orbital inflammation (e.g. chronic contact lens wear, dacryoadenitis), iatrogenic (lid/orbital surgery), mechanical (upper lid mass), and as part of the postenucleation socket syndrome.
■ Pseudoptosis: Aberrant facial nerve regeneration, blepharospasm, habit spasm, enophthalmos, hyperglobus, contralateral upper lid retraction or proptosis. Symptoms Heavy lid, restricted visual field and brow ache (frontalis overaction).
These include excess frontalis contraction, raised skin crease, deep upper sulcus, other involutional changes (e.g. dermatochalasis, lower lid ectropion), and abnormal head position.
Lid height on downgaze relative to the healthy fellow lid is low in aponeurosis dehiscence and high in congenital (myogenic) ptosis.
There is a high prevalence of strabismus and refractive errors in congenital cases.
Ask about: duration; jaw wink; variability; fatigue; diplopia; previous lid surgery; trauma; facial palsy; family history.
In addition to a full lid examination check the following: corneal sensation; Bell’s phenomenon; orbicularis power; frontalis action; eye movements (risk of postoperative
corneal exposure); pupil size/responses; exophthalmometry; peripheral fundal examination.
Arrange sympathetic chain imaging in Horner’s syndrome (head, neck and upper thorax). Check antiacetylcholine receptor antibody screen and electromyographic studies in suspected myopathy. In ocular myasthesia gravis, antibodies may be absent in 40% of patients.
Management Children at risk of amblyopia require a frontalis sling procedure within 2–4 weeks. If the upper lid obscures any part of the upper visual field, then consider early intervention, because a full visual field is required for normal visual development. Where there is a mild to moderate ptosis without risk of amblyopia, correction may be delayed until the age of awareness (4–5 years). Otherwise, surgery may reasonably be
delayed until early adult years. In adults, bilateral ptosis may cause functional blindness, and warrants early intervention. Surgical techniques depend on the cause:
■ Congenital ptosis with levator function (LF) ≥5 mm: levator muscle advancement on the tarsus (anterior or posterior approach).
■ Congenital levator dystrophy with poor LF (<5 mm): brow suspension with autogenous tissue in children >4 years of age (e.g. autogenous fascia lata). For the younger patient, use synthetic material, e.g. Nylon (Supramid) in children of a few months old, mersilene mesh in children up to 4 years old.
■ Congenital levator dystrophy associated with jaw wink: bilateral levator disinsertion and autogenous fascia lata brow suspension. Informed discussion with the parents /carers is essential. Unilateral surgery may cause asymmetry.
■ Involutional ptosis: repair/advancement of the levator aponeurosis onto the tarsus.
■ Myopathy including chronic progressive external ophthalmoplegia and myaesthenia gravis: brow suspension if LF < 8 mm (<5 mm in children) because of the risk of corneal
exposure with an aponeurosis advancement (due to orbicularis weakness, reduced Bell’s phenomenon, and reduced upgaze).
Lipogranulomatous inflammatory lid reaction to retained sebaceous secretions (meibomian glands or glands of Zeiss). Histology shows focal or diffuse involvement which may involve the whole lid. May become secondarily infected leading to
abscess formation. Associated with lid margin disease (blepharitis), acne rosacea, and seborrhoeic dermatitis.
Sebaceous gland carcinoma is notorious in masquerading as recurrent chalazion or unilateral blepharoconjunctivitis. Also consider Merkel cell tumour (rare). Other infective lesions around the eyelids include acute staphylococcal infection of the meibomian gland, and infections of a lash follicle and associated gland of Zeiss or Moll. These present as tender swellings which may resolve spontaneously or discharge. Any swelling in the region above the medial canthal ligament suggests neoplasia of the lacrimal sac and requires urgent investigation (CT and biopsy).
History : Lump in one or both eyelids. May resolve spontaneously or become intermittently inflamed.
Examination : Focal or diffuse lesion(s) within the lid often with lid margin and tear film changes. Lid eversion may reveal an exophytic inflamed conjunctival granuloma
■ Twice daily warm compresses to the lids, and lid margin hygiene to improve the fl ow of meibomian gland secretions.
■ Topical antibiotic ointment (Oc. chloramphenicol or Oc. fucithalmic b.d.).
■ Oral doxycycline if rosacea is present (50 mg o.d. for 3 months).
■ Intralesional steroid injection (0.1 mL triamcinolone with a 30- gauge needle).
Surgical management (incision and curettage)
1. Mark the skin over the lesion with a surgical pen to aid localization.
2. Apply topical conjunctival anaesthesia then inject local anaesthetic into the lid (1 mL of lidocaine 2% with 1 : 200 000 epinephrine). Injecting slowly reduces patient discomfort.
3. Position a cyst clamp over the lid and tighten firmly before everting the lid.
4. Make a vertical incision (E11 blade) into the tarsus, no closer than 2 mm to the lid margin.
5. Curette out the granuloma, which may be firm. Larger lesions may require a cruciate incision with excision of tarsus.
6. Send material to histopathology in recurrent or atypical cases.
7. Instil Oc. chloramphenicol and cover the eye with a Vaseline gauze and an eye pad for 4–6 hours. Prescribe Oc. chloramphenicol q.d.s. 1 week.
Follow-up Not required for routine cases