Anatomy of lid and ptosis with surgical aspects in short

1. ANATOMY OF EYELID
Dr. Dhwanit Khetwani
MS ophthalmology
Final year.

2. Gross Anatomy
Mobile Tissue curtain placed in front of eyeball
FUNCTION
Act as shutter- protects
the eye from injuries
and excessive light.
Perform an important
function of spreading
the tear film on the
cornea and conjunctiva.
Help in Drainage of
tears by Lacrimal Pump
Action,

3. Eyelid has two parts
• Orbital
• Tarsal
• Divided by Horizontal Palpebral
Furrow/sulcus
• Upper lid covers about 1/6th of
the cornea (2mm)
• Lower Lid just touches the
limbus
• Palpebral Fissure -Eliptical space
between upper and lower lid
• Verical extent – 10-11mm
• Horizontal extent – 28-30mm
• Lids meet at Medial and lateral
canthi
• Lateral canthi 2mm higher than
medial canthi.(Mongoloid Slant)
10-11mm
28-30mm

4. LID MARGIN- 2mm broad, divided
into two parts by punctum
Medial- LACRIMAL PORTION-
Rounded Devoid
of EyelashesLateral- CILIARY PORTION
Anterior Border -
Rounded
Posterior Border –
Sharp
INTERMARGINAL
STRIP- Between 2
borders Grey line – marks
junction of skin and
conjunctiva
Divides intermarginal strip into –
Anterior strip bearing 2-3 layers of
Eyelashes
Posterior strip-Meibomian
glands arranged in a row.
Splitting of Eyelids in
surgeries done at the grey
line.

5. STRUCTURE OF EYELID
SKIN:
Elastic, fine
texture, thinnest
in the body
Subcutaneous
tissue:
Very Loose,
contains no fat.
Readily
distended by
blood or oedema
Layer of striated muscle:
Orbicularis muscle-Forms an oval sheet
around eyelids
• Orbital, Palpebral and Lacrimal parts.
• Closes the Eyelids, supplied by
Zygomatic branch of the Facial Nerve.
In paralysis of Facial Nerve there occurs
Lagophthalmos which may be
complicated by exposure Keratitis.

6. Levator palpebrae superioris
muscle (LPS)
It arises from the apex
of the orbit and is
inserted by three parts
on the
skin of lid,
anterior surface of
the tarsal plate
conjunctiva of
superior fornix.
It raises the upper lid. It is supplied
by a branch of oculomotor nerve. Submuscular areolar
tissue.
• It is a layer of loose connective
tissue.
• The nerves and vessels lie in this
layer.
• Therefore, to anaesthetise lids,
injection is given in this plane.

7. Fibrous layer. It is the framework of the lids
and consists of two parts:
Tarsal plate. dense
connective tissue, one for
each lid,
• shape and firmness to the lids.
• The upper and lower tarsal plates
meet at medial and lateral canthi;
attached to the orbital margins
through medial and lateral
palpebral ligaments.
• In the substance of the tarsal plates
lie Meibomian glands in parallel
rows.
Septum orbitale (palpebral
fascia)
• thin membrane of connective
tissue attached centrally to the
tarsal plates and peripherally to
periosteum of the orbital margin.
• It is perforated by nerves, vessels
and levator palpebrae superioris
(LPS) muscle, which enter the lids
from the orbit.

8. Layer of non-striated muscle fibres.
consists of the palpebral muscle of Muller
which lies deep to the septum orbitale in
both the lids.
• In the upper lid it arises from the
fibres of LPS muscle and
• lower lid from prolongation of the
inferior rectus muscle; and is
inserted on the peripheral margins
of the tarsal plate.
• It is supplied by sympathetic
fibres.

9. • Meibomian glands (tarsal glands)
• present in the stroma of tarsal plate arranged
vertically.
• 30–40 in the upper lid ,20–30 in the lower lid.
• modified sebaceous glands. Ducts open at the
lid margin.
• secretion constitutes the oily layer of tear film.
• Glands of Moll.
• modified sweat glands situated near
the hair follicle.
• open into the hair follicles or the
ducts of Zeiss glands.
• Secrete sebum.
• Accessory lacrimal glands of
Wolfring.
• These are present near
the upper border of the
tarsal plate
• Glands of Zeis.
• These are also
sebaceous glands
which open into the
follicles of eyelashes.
Conjunctiva. The part which lines the lids is called palpebral
conjunctiva. It consists of three parts: marginal, tarsal and orbital.

10. Blood Supply
Arteries of Lids: 2 arcades –
• Marginal arterial arcades- Medial and lateral palpebral
arteries arise from it
• Location- sub muscular plane in front of the Tarsal Plate
• Upper lid- 2mm away from the Lid margin
• Lower lid- 4mm away from the lid margin
• Superior Arterial Arcade
• Location- in the Upper lid, near the upper border of the tarsal
plate.
Veins- Arranged in 2 plexuses
• Post-Tarsal – Draining into Ophthalmic vein,
• Pre-tarsal – Draining into Subcutaneous Veins.
Lymphatics- Arranged into Pretarsal, post tarsal
• Median half of lids : drain into Pre-auricular Lymph Nodes
• lateral Half : Drain into Submandibular Lymph nodes.

11. Nerve Supply
Motor Nerves-
• Facial- supplies Orbicularis Oculi
• Oculomotor – Levator palpebrae
supirioris
• Sympathetic Fibres – Muller’s Muscle
Sensory Supply-
• Branches of Trigeminal Nerve
• Upper lid- Lacrimal, Supraorbital,
Supratrochlear
• Lower Lid- Infraorbital, Infra trochlear.

12. PTOSIS
• Abnormal drooping of eyelids.
• The Upper eyelid covers more than 2 mm of cornea
Congenital Ptosis
Blepharophymosis
Syndrome
Marcus Gunn jaw-
winking syndrome
Acquired
Neurogenic
Third nerve palsy
Horner syndrome
Myogenic
Myasthenia gravis
Myotonic
dystrophy
Ocular myopathies
Aponeurotic Mechanical

13. Clinical Evaluation
• History -
• age of onset,
• family history,
• history of trauma,
• eye surgery
• variability in degree of
the ptosis.
Pseudoptosis- Rule out
• Ipsilateral conditions
• microphthalmos,
• phthisis bulbi,
• enophthalmos,
• prosthesis,
• brow ptosis,
• Dermatochalasis
• hypotropia.
• Contralateral conditions :
• eyelid retraction,
• high myopia
• proptosis
Examination

14. • Unilateral/Bilateral
• Function of orbicularis oculi muscle.
• Eyelid crease .
• Jaw-winking phenomenon is
present or not.
• Associated weakness of any
extraocular muscle.
• Bell’s phenomenon (up and
outrolling of the eyeball during
forceful closure) is present or
absent.

15. PTOSIS VITAL SIGNS
• PALPEBRAL FISSURE HEIGHT
• MARGIN-REFLEX DISTANCE-1
• MARGIN REFLEX DISTANCE-2
• LEVATOR FUNCTION
• SKIN CREASE HEIGHT

16. Margin Reflex Distance
• Distance between upper
lid margin and light
reflex (MRD1, 4-
4.5mm)
• Mild ptosis MRD
1(2-2.5mm)
• Moderate ptosis
(MRD1 1-1.5mm)
• Severe ptosis (MRD1
<1mm) MRD 2-Normal value is 5- 5.5mm

17. Levator Function- Upper Lid Excursion
• Reflects levator function
• Normal (15 mm or more)
• Good (12 mm or more)
• Fair (5-11 mm)
• Poor (4 mm or less)
Important to apply
pressure on the
Eyebrow to block the
action of frontalis
muscle

18. Special Investigations.
• Phenylephrine test and cocaine test is carried out in patients
suspected of Horner’s syndrome.
• Neurological investigations may be required to find out the cause in
patient with neurogenic ptosis.

19. TYPES OF PTOSIS
CONGENITAL PTOSIS
ETIOLOGY : Associated with congenital
weakness of Levator Palpabrae Superioris.
Features:
• Drooping of one/both eyelids since birth.(mild/moderate or
severe)
• Lid Crease- Diminished/Absent.
• Lid Lag on Downgaze( i.e. Ptotic Lid is higher than the
Normal),due to tethering effect of LPS, in contrast to
acquired where ptotic lid is lower in downgaze also.
• LPS function may be poor, fair or good depending upon
degree of weakness.

20. Associations
Blepharophymosis Syndrome
• Congenital Ptosis with Poor levator function
• Blepharophymisis
• Telecanthus(lateral displacement of medial
canthus)
• Epicanthus Inversus (lower lid fold larger than
upper)
Marcus Gunn Jaw Winking Ptosis
• Retraction of Ptotic lid with Jaw Movements.
• With stimulation of ipsilateral Pterygoid muscle
• Caused by abberent innervation

21. ACQUIRED PTOSIS
PTOSIS
MIOSIS
ANHYDROSIS
Rare entity, occurs due to interruption in
the sympathetic innervation to the eye.
Pre-Ganglionic
Post-Ganglionic
Central
•Cocaine Test
•Hydroamphetamine test
Conjunctivomullerectomy

22. OCULOMOTOR NERVE PALSY

23. MYSTHENIA GRAVIS
• Ptosis and diplopia
• Levator function-decreased
• Eyelid twitches-falls on prolonged gaze
• CAUSE-AUTOIMMUNE,ANTIBODIES TO
ach RECEPTORS
• Treatment-Medical,
Thymectomy(selected Patients)

24. Before injection Positive result
Edrophonium/
anticholinesterases prevents
breakdown of neurotransmitter
Acetylcholine

25. Chronic Progressive
External
Ophthalmoplegia
• Progressive Bilateral
mitochondrial
myopathy affecting
Extra ocular muscles.
• Gradually increasing
ptosis with lost
ocular motility
• Associated with
pigmentary
retinopathy and
heart block
• Treatment- Frontalis
Sling
Oculopharyngeal
Dystrophy
• Autosomal dominant
• Bilateral progressive
ptosis with facial
weakness.
Myotonic Dystrophy
• Characterised by
failure to relax
muscles after
sustained
contraction
• Associated with
Christmas Tree
cataract, frontal
balding, testicular
atrophy
MYOGENIC PTOSIS

27. APONEUROTIC PTOSIS
• Develops due to defects of Levator
aponeurosis.
• Involution Ptosis(senile)
• Aponeurotic Weakness(Blepharochalasis)
• Traumatic Dehiscence/Disinsertion.
• Levator Function- Good.
• Rx Levator Resection

28. Mechanical Ptosis:
• It results from impaired mobility
of upper lid.
• Causes include dermatochalasis,
large tumours such as
neurofibromas, heavy scar tissue,
severe oedema and anterior orbital
leisions.

29. TREATMENT

30. MILD PTOSIS + GOOD LF
+ Phenylephrine Test - Phenylephrine Test
Fasanella-Servat operation. Levator Advancement
with Resection
POOR LF -<5mm – FRONTALIS SLING
LF> 5MM – LEVATOR RESECTION
LF> 6mm – LEVATOR Advancement/
Fasanella Servat

31. Congenital Ptosis
Tarso-conjunctivo-Mullerectomy (Fasanella-
Servat operation).
• mild ptosis (1.5–2 mm) and good levator function.
• upper everted,and the upper tarsal border along
with its attached Muller’s muscle and conjunctiva
are resected.
• Almost always needs
surgical correction.
• SEVERE PTOSIS surgery
performed - earliest to
prevent stimulus
deprivation amblyopia
• MILD AND MODERATE
PTOSIS, surgery delayed
until the age of 3-4
years, when accurate
measurements are
possible.

32. Levator Resection
■Moderate ptosis.
•Depending on the level of LPS function the amount of LPS to be resected is as below:
•Good function : 16–17 mm (minimal)
•Fair function : 18–22 mm (moderate)
•Poor function : 23–24 mm (maximum)
■Severe ptosis.
•Fair levator function: 23–24
mm (maximum LPS
resection).
Conjunctival approach (Blaskowics’ operation):Skin approach (Everbusch’s operation):

33. Frontalis sling operation (Brow suspension).
• severe ptosis, no levator function.
• In this operation, lid is anchored to the frontalis muscle via a
sling. Fascia lata (best material) or some non-absorbable
material (e.g., supramide suture, silicon rod) may be used as
sling.

34. Treatment of acquired ptosis
• Treat the underlying cause wherever possible.
• Conservative treatment should be carried out and surgery deferred
at least for 6 months in neurogenic ptosis.
• Surgical procedures (when required) for acquired ptosis are
essentially the same as described for congenital ptosis. However, the
amount of levator resection required is always less than the
congenital ptosis of the same degree. Further, in most cases the
simple Fasanella-Servat procedure is adequate.

35. BLEPHARITIS
Bacterial Blepharitis Seborrhoeic/squamous
Posterior Blepharitis/Meibomitis

36. STYE
HORDEOLUM INTERNUM

37. Chalazion