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eyelid

  1. 1. Eye Lids- Layers, Nerve Supply, Vascular Supply, Functions and Clinical Co- relations Presenter: Miss Sabina Khatun Mr Manoj Mahat
  2. 2. Presentation Layout Introduction Embryology Anatomy  Layers of Eyelids Functions Glands of Eyelids Nerve Supply Vascular Supply Drainage System Clinical Correlations
  3. 3. Introduction An eyelid is a mobile ,flexible, multilamellar structure that covers the globe anteriorly Functions  Covers the globe for protection  Contains structures that produce the tear film  Tear flow by their pumping action on the conjunctival sac and Lacrimal sac
  4. 4. Cont…  Assist in distribution of tears over the anterior surface of the eyeball  Provide protection from excessive light ,desiccation and Air born foreign matter
  5. 5. Embryology of eyelids  Derived from surface ectoderm  Reduplication of the surface ectoderm above and below the cornea In 2nd month of gestation  Folds enlarge and margins fuse with each other  Mesodermal mesenchyme-during 2nd month which forms the muscles of the lid and tarsal
  6. 6.  Eyelid adhesions break down during 5-6th months and the lids separate after 7th month of gestation
  7. 7. Congenital anomalies Cryptophthalmous lids fails to develop and skin passes continuously from the eyebrow to the cheek hiding the eye ball Congenital coloboma partial or full thickness eyelid defect
  8. 8.  Microblepharon eyelids are abnormally small Usually associated with microphthalmos or anophthalmos  EURYBLEPHARON o Unilateral or bilateral horizontal widening of palpebral fissure Usually associated with lateral canthal malposition and lateral entropion
  9. 9. Gross anatomy of eyelids  Extent  Lid folds  Position of eyelids  Canthi  Eyelids margins  Eyelashes  Palpebral aperture of fissures
  10. 10. • Extent Upper eye lid extents from the eyebrow downward to end in a free margin Lower eyelid below merge into the skin of the cheeks LID FOLDS 1. Superior lid fold - divide upper eyelid into orbital and tarsal part -lies 4mm above the edge of the eyelid formed by fibrous slips arising from the tendon of the levator
  11. 11. Continue 2.Inferior lid folds -On skin of lower eyelid -formed by fibrous slips arise from fascia surrounding the inferior rectus muscles Position of eyelids primary position of gaze Upper eyelid 1/6th of the cornea Lower eyelid just touches the cornea
  12. 12. Canthi The two eye lids meet each other at the medial and lateral canthi Medial canthus -rounded - separated from globe by lacus lacrimalis Lateral canthus -5-7mm from the lateral orbital margin Form angle 60 degree with eyes wide open and 30- 40degree with eyes open in a normal way
  13. 13. Epicanthus A fold of skin extending from the eyelid over the inner (medial ) canthus Normal facial feature in Mongolian races -
  14. 14. Eyelid margin Each eye lid margin is divided by lacrimal papillae into two part  Lacrimal portion medial portion from punctum to medial canthus  Ciliary portion lateral portion from punctum to lateral canthus -Consists of rounded anterior and sharp posterior border with inter-marginal strip in between
  15. 15. Grey line –junction of skin and conjunctiva -divide the intermarginal strip into an anterior and posterior strip (anterior contain eye lashes and posterior contain opening of meibomian gland )
  16. 16. Eye lashes Arranged in 2-3 rows Eye lashes in upper lid(100-150 in number) directed forward .Upward and down ward In lower lid (50-750 in number ) –forward ,downward and backward
  17. 17. Palpebral aperture or fissure  Elliptical space between the upper and lower lid margins At Birth Adult  Horizantally 18-21mm 28-30mm  Vertically 8mm 9-11mm
  18. 18. Trichiasis - eyelashes are misdirected and grow inwards towards the eye Distichiasis -abnormal growth of lashes from the orifices of the meibomian glands Clinical correlation of eye lashes
  19. 19. Madarosis - partial or complete loss of eye lashes Poliosis Whitening of eye lashes
  20. 20. Layers of eyelids 1. Skin 2. Subcutaneous areolar tissue 3. Layers of striated muscles 4. Submuscular areolar tissue 5. Fibrous layer 6. Non striated muscular layer 7. Conjunctiva
  21. 21. 1. Skin -Highly elastic ,thinnest and folds easily Microscopic structure  Epidermis 6-7 layers of stratified squamous epithelium contain sebaceous gland and eccentric sweat gland  Dermis thin layer of dense connective tissue Rich network of elastic fibres ,blood vessels ,lymphatics and Blood vessel
  22. 22. Applied anatomy Xanthelasma Sharply demarcated yellowish deposits of cholesterol underneath the Skin Mostly on nasal side due to more unicellular sebaceous gland
  23. 23. 2.Subcutaneous areolar tissue -Layer of loose areolar connective tissue -contain no fat -readily distended by oedema or blood -absent near ciliary margin ,at lid folds at medial and lateral angles
  24. 24. 3.Layer of striated muscles Orbicularis muscle which forms a thin oval sheet around the eyelids (supplied by branches of 7th cranial nerve ) Levator muscle (upper eyelids )  The orbicularis oculi muscle -divided into 2 parts 1.orbital part 2.palpebral
  25. 25. 1.Orbital part Forms the most peripheral part of the orbicularis arise from the anterior part of the medial palpebral ligament and adjacent bones upper orbital margin medial to supra orbital notch maxillary process of frontal bone frontal process of maxilla Lower orbital margin medial to the infraorbital foramen
  26. 26. Cont… Muscles fibres sweeps superiorly & inferiorly, covering the orbital margins in the form of ellipse & meet at the lateral palpebral raphe  Superior fibres called musculus superciliaris get inserted into the skin of eyebrows  Inferior fibres called musculus malaris attached to skin of cheeks
  27. 27. Palpebral part Overlies the mobile eyelid from the orbital rims to the eyelid margins Subdivided into: - preseptal -Pretarsal
  28. 28. Preseptal fibres: Arise from Lacrimal fascia Posterior lacrimal crest Anterior part of medial palpebral ligament  Fibers pass superiorly & inferiorly in front of the orbital septum and unite at the lateral palpebral raphe
  29. 29. Pretarsal fibers: Arise from Deep head (lacrimal fascia & posterior lacrimal crest) And superficial head (medial palpebral ligament)  Fibers pass laterally above & below, overlying the upper & lower tarsus respectively and join at lateral canthal tendon which is inserted over lateral orbital tubercule of whitnall.
  30. 30. Function of orbicularis oculi muscle Closure of eyelids Orbital portions -Forced closure of eyelids -reflex blinking Palpebral portion -helps in gentle closure during blinking and sleep
  31. 31. Horner muscle (pars lacrimalis ) Prominent bundle of fibers, formed by fusion of the deep heads of the pretarsal orbicularis Insertion - posterior lacrimal crest Functions - helps to maintain the posterior position of the canthal angle -Tightens the eyelids against the globe during eyelid closure -Aids in the lacrimal pump mechanism
  32. 32. Applied aspects Horners syndrome Due to interruption of the sympathetics nerve Supply to the eye Characterised by classical triad  miosis  partial ptosis  loss of hemifacial sweating anhidrosis
  33. 33. Muscle of riolan (pars ciliaris) • Small bundle of striated muscle fibers • At the eyelid margin • Extension of pretarsal portion of orbicularis oculi fibers • Function: • Keep the lids in close apposition to the globe
  34. 34. The lid Retractors  Upper lid i. Levator Palpebrae Superioris ii. Muller’s Muscle  Lower lid i. Capsulopalpebral fascia
  35. 35. Levator palpebral superior muscle (LpS) Major eye lid retractor Origin: At the apex of orbit from the under surface of lesser wing of the sphenoid above annulus of zinn Course & attachment oPasses forward below the roof of the orbit, above the superior rectus oAt septum orbitale, it fans out into white tendon called aponeurosis of LPS and forms medial and lateral horns
  36. 36. o Lateral horn divides the lacrimal gland into orbital and palpebral parts inserts into superior edge of lateral canthal tendon Medial horn • Passes over the reflected portion of superior oblique And fuses with medial canthal tendon • Together the two horns serve to distribute the forces of the levator muscles along the aponeurosis and tarsal plate
  37. 37. Applied aspects of LPS Ptosis Droppping of upper eye lid usually Due to paralysis or defective development Of the levator palpebral superioris
  38. 38. Fibrous sheet in the lower eyelid ,that arises from the lockwoods ligament Fuses with fibres of the septum orbital Forms a common fascial sheet And inserts onto the lower border Of the tarsal plates CAPSULOPALPEBRAL FASCIA
  39. 39. Fine fibrous slips pass forwad from this fascial sheet to the inferior conjunctival fornix,so forming the lower eye lid crease Applied anatomy  Spastic entropion Due to disinsertion of the lower eyelid retractors from the tarsus
  40. 40. 4.Submuscular areolar tissue o layer of loose connective tissue o nerves and vessel of the lid lies in this layer Splits the eye lid into two parts i.e anterior lamina and posterior lamila applied aspects –to anaesthetise the lid injection is made in this plane
  41. 41. 5.Fibrous layers • form the framework of the lids • Consists of two parts ie • tarsal plate –central thick part • septum orbital –peripheral thin part • Includes the medial and palpebral ligaments
  42. 42. Tarsal plates Firm plates of dense fibrous tissue Form the skeletal of the eyelids 29 mm long and 1mm thick Septum orbital and mullers muscles are attached at the superior border of the upper tarsus Capsulopalpebral fascia and inferior palpebral Muscle are attached to inferior border of tarsus
  43. 43. Contd.. Anterior surface -convex -Separated from orbicularis muscles by loose areolar tissue Posterior surface-concave -lined by conjunctiva which is firmly adherent to the Tarsal plates Meibomian gland are embedded in the substances of the Tarsal plates
  44. 44. Septum orbital (palpebral fascia) Thin floating membrane of connective tissue which takes part in all movements of the eyelids Structure passing through septum orbital
  45. 45. Applied anatomy Barrier to extravasation of blood /spread of infection With age orbial septum weakens orbital fat herniats the condition manifest as DERMATOCHALASIS
  46. 46. Medial palpebral ligament -Triangular band of connective tissue -attached to the frontal process of the maxilla from anterior lacrimal crest to the suture line of frontal process with nasal bone Lateral palpebral ligament -thin band of connective tissue -laterally attached to the whitnalls tubercule -medially to lateral end of tarsal plates
  47. 47. 5.Muller muscles Sympathetics accessory retractor of upper eyelid Modulates the position of the upper and lower eyelids when the eye is open Origin –under surface of the levator muscle just anterior to whitnall’ligament Insertion –anterior edge of the superior tarsal border
  48. 48. 7.CONJUNCTIVA o Transparent vascularized membrane covered by a non keratinized epithelium that lines the posterior surface of the eyelids (palpebral conjunctiva)and the anterior surface of the globe (bulbar conjunctiva) o Firmly adherent to the tarsus o Small accessory lacrimal glands (glands of krause & wolfring) are located within the sub
  49. 49. Glands Of Eyelids: Tarsal / Meibomian Glands Gland of Zeis Gland of Moll Accessory lacrimal glands.
  50. 50. Tarsal / Meibomian Glands Modified sweat gland Present on the posterior part of stroma of tarsal plate 30 -40 no. in upper eyelid & 20- 30 no. in lower eyelid Oily secretion
  51. 51. Structure : Consists of a central duct which runs straight perpendicular to the lid margin 10-15 acini from the sides open into central canal Acini are lined by glandular epithelium Opening of Meibomian glands arranged in single row on lid margin between grey-line and posterior border of lid
  52. 52. Functions: o Forms hydrophobic barrier at the margin of the eyelid, preventing overflow of tears at the lid margin o Forms oily layer of tear film over cornea &bulbar conjunctiva o Retards evaporation of tears. o Ensure the air-tight closure of the eyelids
  53. 53. Cont…. Gland of Zeis Modified sebaceous glands Attached to eyelash follicles (usually two glands with each cilium) Sebum secretion Microscopically consists of epithelium placed on basement membrane Cuboidal cells lining the acini are actively dividing
  54. 54. Cont… Functions: Prevents eyelashes from being dry & brittle Contribution in the oily nature of tear film  Note:  If eyelashes are not kept clean, conditions like Folliculitis may take place.
  55. 55. Gland of Moll Modified sweat gland Lies between cilia Numerous in lower lid than upper lid Secretory portion is lined by cylindrical cells which contain secretory granules and fatty granules
  56. 56. Acessory lacrimal glands A/k as Ciaccio’s glands or wolfring’s glands Found in lacrimal caruncle of eyelids Located in upper border of superior tarsus and lower border of inferior tarsus Functions: Production of tear which are secreted onto the surface of conjunctiva
  57. 57. Another type of accessory lacrimal glands are ”Krause’s glands” which are similar and more numerous than ciaccio’s glands located on superior and inferior fornices of conjunctival sac.
  58. 58. Nerve Supply to Eyelids 1.Motor Nerve Supply  Motor Nerves to the Orbicularis oculi muscle - Facial nerve(7th CN) (temporal & zygomatic branches)  Motor Nerve to the Levator Palpebrae Superioris (LPS) - superior division of oculomotor nerve(3rd CN)  Motor Nerve to the Müller muscle - sympathetic nervous system
  59. 59. Sensory Nerve Supply: Ophthalmic & Maxillary divisions of the trigeminal nerve( 5th CN)  Upper eyelid - supraorbital, supratrochlear & lacrimal nerves (ophthalmic division)  lateral portion of upper eyelid - zygomaticotemporal branch of the maxillary nerve  extreme medial portion of both upper & lower eyelid - infratrochlear nerve
  60. 60. Contd… Sensory Nerve Supply:  lower eyelid - infraorbital nerve (maxillary division)  lateral portion of lower eyelid - zygomaticofacial branch of the maxillary nerve
  61. 61. Vascular supply of Eyelids Arterial Supply Upper eyelid Marginal Arcade – 2-3 mm from the eyelid margin; either between the tarsal plate & the orbicularis or within the tarsus Peripheral Arcade - along the upper border of tarsal between the levator aponeurosis & Müller muscle supplied by superior medial palpebral vessel (the terminal ophthalmic artery and superior lateral palprebal Vessel from lacrimal artery)
  62. 62. Lower eyelid: By medial and lateral palpebral arteries
  63. 63. Venous Drainage System: not well defined can be divided into two portions: a superficial, or pretarsal system & a deep, or posttarsal system mainly into several large vessels of the facial system
  64. 64. Lymphatic Drainage Through lymapthetic plexuses and lympathic vessels  Lympathetic plexuses  Superficial or pretarsal plexus • Drains from skin and orbicularis muscle  Deep or post tarsal plexus • Drains from tarsal plate region and conjunctiva  Lympathetic vessels  Medial group • 2 Superficial drain the medial half of lower lid,medial ¼ of upperlid and medial commissure into superficial submandibular lymph nodes
  65. 65. Contd… • 2 deep medial channels drain conjunctiva of medial 2/3rd of lower lid and caruncle into deep sub mandibular lymph nodes  Lateral group • Superficial lateral trunk drains the lateral 3/4th of upper lid and lateral part of lower lid into superficial parotid lymph nodes and pre-auricular lymph nodes • Deep lateral trunk drains the entire conjunctiva of upper lid and conjunctiva of lateral third of lower lid into deep parotid lymph nodes
  66. 66. Clinical Co-relations  External Hordeolum (Common Stye)  Localized suppurative inflammation of gland of Zeis and glands of Moll’s at lid margin at ciliary follicle.
  67. 67. Lesions are often associated with fatigue, poor diet and stress and can be recurrent Pain on manipulation of eyelid With skin abscess , nodule is usually red and warm to touch.
  68. 68.  Internal Hordeolum( Meibomian stye)  Internum Hordeolum is a suppurative inflammation of meibomian gland associated with the blockage of the duct.
  69. 69. Cont… A specific change in the Meibomian gland secretion is seen during internal hordeolum formation. Painful swelling and erythema in conjunction with acute or chronic blepharitis. Reccurrence is common if any underlying conjunctivitis or blepharitis is not adequately treated.
  70. 70.  Chalazion  Chronic granulomatous inflammation of meibomian gland or sometimes Zeis glands caused by retained sebaceous secretions  Ocurrs secondary to obstruction of the gland duct.  More common in upper eyelid appearing as hard, immobile, painless, roundish lump.
  71. 71.  Blepharitis  Blepharitis is chronic inflammation of lid margin occurring as true inflammation.  Bilateral and often misdiagnosed as conjunctivitis  Types  Anterior Blepharitis  Affects the base of eyelashes and may be Staphylococcal , Seborrhoeic or parasitic.  Staphylococcal:  In case of Staphylococcal – Red eyes and peripheral corneal infiltrates (more common in atopic dermatitis)  Common cause of ocular discomfort and irritation
  72. 72.  Cont…  Yellow crusts are seen at the root of cilia  Small ulcers which bleed easily on removal of clusters  Mild papillary conjunctivitis or conjunctival hyperemia are common associations  Seborrheic Blepharitis  Primary anterior blepharitis with some posterior spill over  Usually associated with seborrhea of scalp(dandruff)
  73. 73. Cont…  Accumulation of white dandruff like scales on lid margin  Parasitic Blepharitis  Due to crab louse very rarely to head louse  Presence of nits at the lid margin and at roots of eyelashes  Conjunctival congestion may be seen on long standing
  74. 74.  Meibomitis ( Posterior Blepharitis)  Inflammation and obstruction of meibomian glands. Characterized by diffuse thickening of posterior border of lid margin which becomes rounded.
  75. 75. Entropion  Involutional entropion: Age related inward rolling of eyelashes mainly affecting lower lid Constant rubbing on the cornea cause irritation, corneal punctate epithelial erosions and sometimes ulceration
  76. 76. Cont…..  Cicatricial entropion Scarring of the palpebral conjunctiva can rotate the upper or lower lid margin towards the globe Causes include cicatricial conjunctivitis, trachoma, trauma and chemical injuries
  77. 77. Ectropion  Involutional ectropion Age related outward rolling of eyelid margin mainly affecting lower lid Causes epiphora and on long standing become chronically inflamed and keratinized
  78. 78. Cont…  Cicatricial ectropion Caused by scarring or contracture of the skin and underlying tissues which pulls the eyelids away from the globe.  Paralytic ectropion Caused by ipsilateral facial nerve palsy Associated with retraction of upper and lower lids an brow ptosis  Mechanical ectropion Caused by tumors on or near lid margin that mechanically evert the lid
  79. 79.  Lagopthalmos  Incomplete closure of the palpabral aperture when attempt is made to close the eyes.
  80. 80.  Blepharospasm  It is the involuntary, sustained and forceful closure of the eyelids.
  81. 81.  Symblepharon  It is a partial or complete adhesion of the palpebral conjunctiva of the eyelid to the bulbar conjunctiva of the eyeball.
  82. 82.  Ankyloblepharon  It is an adhesion of the ciliary edges of the eyelid to each other
  83. 83. Pyogenic Granuloma Seen after trauma or surgery or may form over inflammatory lesions such as chalazion. Occurs rarely in the anopthalmic socket following enucleation of the eye and the margin of corneal transplants. Lesions are fleshy red, usually sessile with non tender or moderately tender presentation. Composed of granulation tissue with chronic inflammatory cells, fibroblasts and endothelial cells of budding capillaries.
  84. 84. Refrences Previous Presentations
  85. 85. Wish You All Happy Holi In Advance

Notizen

  • M-chronic blepharitis ,complication of cryotherapy ,radiotherapy and hypothyroidism
  • Most of the nerves of the eyelids are present in submuscular plane ie between orbicularis and tarsal plate. Therefore to anaesthetize the lid injection should be made in this compartment.
  • Note: But the chalazion may produce pain if it grows very large and cause distention of sensory nerve endings.
    An upper lid chalazion may press on the cornea and cause blurred vision from induced astigmatism11.

  • Upper lid has wider tarsus and more stable
  • Unilateral cicatricial ectropion due to traumatic scarring
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