Eyelid and Conjunctival Disorder

Dr. H.E. Iskandar, SpM(K), MARS

Subdivisi Plastik Rekonstruksi Mata
Fakultas Kedokteran Unsri
Eyelid
 Embriology
The upper eyelid first develops at 45 weeks of gestation as a
proliferation of surface ectoderm in the region of the future outer
canthus.
During the second month, both the upper and lower eyelids become
discernible as undifferentiated skinfolds that surround mesenchyme of
neural crest origin
Later, mesodermal mesenchyme infiltrates the eyelids and
differentiates into the palpebral musculature. The eyelid folds grow
toward each other as well as laterally. Starting near the inner canthus,
the margins of the folds fuse at approximately 10 weeks of gestation.
As the folds adhere to each other, evolution of cilia and glands
continues.
The orbicularis muscle condenses in the fold in week 12. The eyelid
adhesions gradually break down late in the fifth month, coincident
with the secretion of sebum from the sebaceous glands and
cornification of the surface epithelium.
 Embriology

Development of the eyelids.

A, During the seventh week, the
upper and lower eyelid folds grow
over the eye.
B,Eyelids fuse during the eighth
week; fusion starts along the nasal
margin.
C, From the fifth to seventh
months, as cilia and
glandular structures develop,
eyelids gradually open.
Embriology
 Anatomy
Eyelid can be divided into:
Skin and subcutaneous tissue
Muscle of protraction
Orbital Septum
Orbital fat
Muscle of retractor
Tarsus
Palpebral conjunctiva
 Anatomy

Upper Eyelid
Anatomy
 Anatomy

Upper and lower

eyelid anatomy
 Anatomy
Skin and subcutaneous tissue
The thinnest of the body and no subcutaneous
fat layer
The pretarsal skin firmly attached to the
underlying tissues, the preseptal skin more
loosely, creating potential space for fluid
accumulation.
Attachments of the levator aponeurosis to the
skin create the upper eyelid crease
 Anatomy

Orbicularis muscle
Consist of:
1. Orbital part
2. Preseptal part
3. Pretarsal part
 Anatomy
The pretarsal and preseptal parts are more
involved in involutary eyelid movement
The orbital portion is more involved in forced
eyelid movement
Innervated by cranial nerve VII
Horner muscle encircle both canaliculi to
facilitate tear drainage
Riolani muscle to open mebomian gland
 Anatomy
The orbital septum
Is a thin multilayered sheet of fibrous tissue arises
from periosteum over the superior and inferior orbital
rims at the arcus marginalis.
In the upper eyelid, the orbital septum fuses with the
levator aponeurosis at 2 5 mm above the superior
tarsal border in non Asians, and in the lower eyelid
with the capsulopalpebral fascia at or just below the
inferior tarsal border.
With age the orbital septum may weaken, and as a
result orbital fat may herniate forwards
 Anatomy
The orbital septum
The orbital septum serves as a barrier between
the orbit and the eyelid to limit the spread of
infection and hemorrhage.
 Anatomy
Orbital fat
Normally behind the orbital septum and is
important surgical landmark in eyelid surgery.
It extends from the apex of the orbit to the orbital
septum.
Contributes to the support of the eyeball
 Anatomy

Levator muscle
 Anatomy
Levator Palpebra Muscle
Originates in the apex of the orbit just above the
annulus of Zinn
The muscular portion 40 mm long, the
aponeurosis 14 20 mm
Whitnall ligament is condensation of anterior
sheath of levator muscle as suspensory
Muller muscle is symphatetically innervated
muscle, lies posterior to the levator aponeurosis
 Anatomy
Capsulopalpebral Fascia
Analogous to the levator aponeurosis
It originates from terminal muscle fiber of the
inferior rectus muscle
Lockwood ligament is the portion of
capsulopalpebral head join to form suspensory
ligament
The inferior tarsal in the lower eyelid is analogous
to Muller muscle
 Anatomy

Tarsus/
Tarsal Plate
 Anatomy
Tarsus
Elongated plates of dens connective tissue,
about 2.5 cm in length
The superior tarsus, the larger, is of a
semilunar form, about 10-12 mm vertically at
the center, and gradually narrowing
The inferior tarsus is smaller, thin, elliptical in
form, and has a vertical diameter of about
4 mm.
 Anatomy
Tarsus
Along the inner margin of the tarsus are modified
sebaceous glands known as tarsal glands (
Mebomian glands), aligned vertically within the
tarsi: 30 to 40 glands in the upper lid, and 20 to
30 in the lower lid, which secrete a lipid-rich
product which helps keep the lacrimal secretions
or tears from evaporating too quickly, thus
keeping the eye moist.
 Anatomy
Palpebral conjunctiva
Composed of nonkeratinizing squamous
epithelium
It form the posterior layer of the eyelid and
contain the mucin secreting goblet cells and
accessory lacrimal glands of Krause and Wolfring
The major component of the basic lacrimal
secretion
Main lacrimal gland is the reflex tear secretion
 Anatomy
Vascular supply
A. Carotis interna
A. ophthalmica
A. supraorbita
A. lacrimal
A. Carotis externa
A. angularis
A. temporalis
Colateral
Arcade marginal
Arcade peripher
 Anatomy
Nerve supply
Sensory nerve
First division of trigeminal nerve (V1)
Supraorbital nerve innervate in forehead and periocular region
Second division of trigeminal nerve (V2)
Maxillary nerve innervate lower eyelid and cheek

Motor nerve supply

Cranial nerve III
Cranial nerve VII
Sympathetic nerves
 Function
To protect the eye from strong light, dust and
foreign objects.
Closure of the lids during sleep protects the
ocular surface from drying
Blinking the eyelids lubricate the eye
Lacrimal pump
Function

Lacrimal pump
 Eyelid Disorders
Congenital Anomalies
Inflammation
Neoplasms
Trauma
Malposition (ectropion, entropion,
blepharoptosis)
Involutional changes (dermatochalasis,
blepharochalasis, )
 Congenital Anomalies
Blepharophimosis Syndrome
-Autosomal dominantly inherited
-Telecanthus
-Epicanthus inversus
-Severe ptosis
-Additional findings:
-Lateral lower eyelid ectropion
-Poorly developed nasal bridge
-Hypoplasia of superior orbital
rims
-Lop ear, hypertelorism
 Congenital Anomalies
Blepharophimosis Syndrome
-Multiple surgeries
-Repair of the ptosis
-Multiple Z plasties
-Y-V plasties
-Trans nasal wiring
-Ecktropion and hypoplasia
of orbital rims corrections
Congenital Anomalies

Congenital myogenic ptosis

 Congenital Anomalies
Results from dysgenesis of the levator muscle
Instead of normal muscle fibers, fibrous or adipose
tissue is present in the muscle belly, diminishing the
ability of the levator to contract and relax characterized
by decreased levator function, eyelid lag, and,
sometimes, lagophthalmos
The upper eyelid crease is often absent or poorly
formed
Poor Bells phenomenon or with vertical strabismus
may indicate concomitant maldevelopment of the
superior rectus muscle
 Congenital Anomalies
Congenital neurogenic ptosis is caused by
innervational defects that occur during
embryonic development
Commonly associated with congenital cranial
nerve III (CN III) palsy, congenital Horner
syndrome, or the Marcus Gunn jaw-winking
syndrome
Treatment of ptosis:
Non surgical: ptotic eye crutches
Surgical procedures to correct ptosis
Congenital Anomalies

Ptotic eye crutches

Congenital Anomalies

Congenital ectropion
 Congenital Anomalies
In rare cases, congenital ectropion occurs as an
isolated finding
More often associated with blepharophimosis
syndrome, Down syndrome. or Ichthyosis
Caused by a vertical insufficiency of the anterior
lamella
Chronic epiphora and exposure keratitis
Mild congenital ectropion usually requires no
treatment
 Congenital Anomalies
Severe and symptomatic treated like a cicatricial
ectropion, with horizontal tightening of the
lateral canthal tendon and vertical lengthening of
the anterior lamella by full -thickness skin graft
A complete eversion of the upper eyelids
occasionally occurs in newborns
Topical lubrication and short-term patching of
both eyes
Full thickness sutures or a temporary
tarsorrhaphy are used when necessary
Congenital Anomalies

Euryblepharon
 Congenital Anomalies
Is a unilateral or bilateral horizontal widening of
the palpebral fissure
Sometimes associated with blepharophimosis
syndrome
Usually involves the lateral portion of the lower
eyelids and is associated with both vertical
shortening and horizontal lengthening
The palpebral fissure often has a downward (anti
mongoloid) slant because of the inferiorly
displaced lateral canthal tendon
 Congenital Anomalies
Impaired blinking, poor closure, and
lagophthalmos may result in exposure keratitis
If the condition is symptomatic,reconstruction
may include lateral canthal repositioning along
with suspension of the suborbicularis oculi fat to
the lateral orbital rim so that the lower eyelid is
supported
If excess horizontal length is still apparent, a
lateral tarsal strip or eyelid margin resection may
be added
Skin grafts may occasionally be necessary
Congenital Anomalies

Ankyloblepharon
 Congenital Anomalies
Partial or complete fusion of the eyelids by
webs of skin
These webs can usually be opened with
scissors after being clamped for a few seconds
with a hemostat.
Congenital Anomalies

Epicanthus
 Congenital Anomalies
Medial canthal fold that may result from
immature midfacial bones or a fold of skin and
subcutaneous tissue
Usually bilateral
Child may appear esotropic because of
decreased scleral exposure nasally
(pseudostrabismus)
 Congenital Anomalies
4 types of epicanthus are
epicanthus tarsalis if the fold is most prominent in
the upper eyelid
epicanthus inversus if the fold is most prominent
in the lower eyelid
epicanthus palpebralis if the fold is equally
distributed in the upper and lower eyelids
epicanthus supraciliaris if the fold arises from the
eyebrow region running to the lacrimal sac
 Congenital Anomalies
Epicanthus tarsa lis can be a normal variation
of the Asian eyelid
Epicanthus inversus is frequently associated
with blepharophimosis syndrome
Most forms of epicanthus resolve with normal
growth of the facial bones
observation is recommended until the face
achieves maturity
 Congenital Anomalies
Epicanthus inversus, rarely resolves with facial
growth
Most cases of epicanthus requiring revisions
such as Z-plasty or Y-V-plasty with or without
construction of an upper eyelid crease
Congenital Anomalies

Epiblepharon
 Congenital Anomalies
The lower eyelid pretarsal muscle and skin ride
above the lower eyelid margin to form a
horizontal fold of tissue that causes the cilia to
assume a vertical position
The eyelid margin is in normal position with
respect to the globe
The cilia often do not touch the cornea except in
down gaze
Epiblepharon is most common in Asian children
 Congenital Anomalies
Epiblepharon may not require surgical
treatment because it tends to diminish with
the maturation of the facial bones
In case of keratitis, the excess skin and muscle
fold should be excised just inferior to the
eyelid margin and the skin edges
approximated
Congenital Anomalies

Congenital Entropion
 Congenital Anomalies
In contrast to epiblepharon, eyelid margin
inversion is present in congenital entropion
Lower eyelid retractor dysgenesis, structural
defects in the tarsal plate, and relative
shortening of the posterior lamella
Congenital entropion often does not improve
spontaneously
 Congenital Anomalies
Repaired through removal of a small amount
of the skin and orbicularis along the subciliary
portion of the eyelid, in conjunction with a
suture that advances the lower eyelid
retractors onto the tarsus
Tarsal kink of the upper eyelid is an unusual
form of congenital entropion. It may be
repaired by incision of the kink combined with
a marginal rotation
Congenital Anomalies

Congenital Distichiasis
 Congenital Anomalies
Is a rare condition, sometimes hereditary in
which an extra row of eyelashes is present in
place of the orifices of the meibomian glands
Embryonic pilosebaceous units improperly
differentiate into hair follicles
Treatment is indicated if the patient is
symptomatic or if evidence of corneal
irritation is present
 Congenital Anomalies
Lubricants and soft contact lenses may be
sufficient
Electrolysis, radiofrequency epilation, or
cryoepilation as alternatives
Congenital Anomalies

Congenital Coloboma
 Congenital Anomalies
An embryologic cleft that is usually an isolated
anomaly when it occurs in the medial upper
eyelid
When found in the lower eyelid, the coloboma
is frequently associated with other congenital
conditions such as facial clefts (Goldenhar
syndrome) and lacrimal deformities
A true coloboma includes a defect in the
eyelid margin
 Congenital Anomalies
Surgical repaired:
One third defects: the creation of a rectangular
surgical wound between the eyelid crease line and
the eyelid margin
Large defects: variation of the lateral canthal
semicircular flap
Congenital Anomalies

Capillary Hemangioma
 Congenital Anomalies
Sometimes occur as congenital eyelid lesions
Most are not apparent at birth
Appear over the first weeks or months of life
May also involve the orbit
Treatment is recommended for occlusion of
the visual axis, anisometropia, strabismus, or
lesions causing significant disfigurement
 Congenital Anomalies
Increases in size until the patient is 1 year old,
and then decreases over the next 4-5 years
Treatment:
Intralesional corticosteroid injection.
If there is more widespread involvement, systemic
steroids may be given
Clobetasol propionate has also been reported
 Congenital Anomalies
Treatment:
Interferon for life-threatening or sight-threatening
lesions (serious adverse effects)
Surgical excision may be used on circumscribed
lesions
Carbon-dioxide laser as an incisional device
Topical lasers may be used on the superficial (1-2
mm) layers of the skin to diminish the redness of a
lesion
Congenital Anomalies

Cryptophthalmos
 Congenital Anomalies
Is a rare condition that presents with partial or
complete absence of the eyebrow, palpebral
fissure, eyelashes, and conjunctiva
The partially developed adnexa are fused to the
anterior segment of the globe
May be unilateral or bilateral
Histologically, the levator, orbicularis, tarsus,
conjunctiva, and meibomian glands are
attenuated or absent
Reconstruction are difficult
Eyelid Inflammation

Chalazion
 Eyelid Inflammation
Characterized by chronic lipogranulomatous
inflammation.
Obstruction of the Meibomian gland
Often associated with rosacea and chronic
blepharitis
Treatment
warm compresses and appropriate eyelid hygiene
Topical anti biotic or anti-inflammatory (Doxycycline
or tetracycline)
Occasionally, requiring surgical management
 Eyelid Inflammation
Treatment
Combining excision with steroid injection into the
excision bed results in a 95% resolution rate
Eyelid Inflammation

Hordeolum
 Eyelid Inflammation
An acute infection (usually staphylococcal) can
involve the glands of Zeis (external
hordeolum, or stye) or the meibomian glands
(internal hordeolum)
In external hordeolum, the infection often
appears to center around an eyelash follicle,
and the eyelash can be plucked to promote
drainage
 Eyelid Inflammation
Spontaneous resolution often occurs
Curative: Warm compresses and topical
antibiotic ointrnent
Rarely complication: cellulitis, or abscesses of
the eyelid. In such cases, systemic antibiotic
therapy and possible surgical Incision and
drainage may be required
Eyelid Inflammation

Eyelid Edema
 Eyelid Inflammation
Caused by local conditions such as insect bites or
allergy or by systemic conditions such as
cardiovascular disease, renal disease, certain
collagen vascular diseases, or thyroid eye disease
Cerebrospinal fluid leakage into the orbit or
eyelids following trauma may mimic eyelid
edema
Lymphedema may be present if the lymphatic
drainage system from the eyelid is interrupted.
Eyelid Inflammation

Floppy Eyelid Syndrome

 Eyelid Inflammation
Characterized by ocular irritation and mild
mucus discharge that is frequently worse on
awakening
Chronic papillary conjunctivitis
The superior tarsal plate is soft, rubbery,
flaccid, and easily everted
The upper eyelid will evert spontaneously,
especially in the temporal area
 Eyelid Inflammation
Associations have been reported with obesity,
keratoconus, eyelid rubbing, mechanical
pressure, hyperglycemia, and sleep apnea
Decrease in the number of elastin fibers in the
tarsus plate from histologic examination
Have a history of sleeping prone: palpebral
conjunctiva to rub against the pillow or
bedding
 Eyelid Inflammation
Conservative treatment using viscous
lubrication and a patch or eyelid shield at
night.
Surgical correction by horizontal tightening of
the eyelid.
 Eyelid Neoplasms

Seborrheic Keratosis(Benign Eyelid Neoplasm)

 Eyelid Neoplasms
Acquired benign eyelid papillomas
It tends to affect middle-aged and elderly
patients
Clinical appearance varies: sessile or
pedunculated and have varying degrees of
pigmentation and hyperkeratosis
On facial skin seborrheic keratosis typically
appears as a smooth, greasy, stuck on lesion
 Eyelid Neoplasms
On the thinner eyelid skin, this lesion can be
more lobulated, papillary, or pedunculated
with visible excrescences on its surface
They can be managed by shave excision at the
dermal-epidermal junction.
 Eyelid Neoplasms

Verruca Vulgaris (Benign Eyelid Neoplasm)

 Eyelid Neoplasms
Caused by epidermal infection with the
human papillomavirus (type 6 or II )
Rarely occurs in thin eyelid skin
Cryotherapy may eradicate the lesion and
minimizes the risk of viral spread
 Eyelid Neoplasms

Xanthelasma (Benign Eyelid Neoplasm)

 Eyelid Neoplasms
Yellowish plaques that occur commonly in the
medial canthal areas of the upper and lower
eyelids
Although xanthelasmas usually occur
inpatients with normal serum cholesterol
levels, they are sometimes associated with
hypercholesterolemia or congenital disorders
of lipid metabolism
 Eyelid Neoplasms
Deep extension into the orbicularis muscle
Xanthelasmas may recur
Treatment options: serial excision, CO2 laser
ablation, or topical 100% trichloroacetic acid
 Eyelid Neoplasms

Molluscum Contagiosum (Benign Eyelid Neoplasm)

 Eyelid Neoplasms
Viral infection of the epidermis that often
involves the eyelid in children
Occasionally, multiple exuberant lesions appear
in adult patients with acquired immunodeficiency
syndrome (AIDS)
The lesions are characteristically waxy and
nodular, with a central umbilication
They may produce an associated follicular
conjunctivitis
Treatment is observation, excision, controlled
cryotherapy, or curettage
 Eyelid Neoplasms

Squamous cell carcinoma (Malignant Eyelid Tumors)

 Eyelid Neoplasms
Squamous cell carcinoma of the eyelid is 40 times
less common than basal cell carcinoma
Biologically more aggressive
Tumors can arise spontaneously or from areas of
solar injury and actinic keratosis
May be potentiated by immunodeficiency
Treatment: Mohs micrographic resection or
surgical excision with wide margins and frozen
sections
 Eyelid Neoplasms
May metastasize through:
Lymphatic transmission,
Blood borne transmission
Direct extension along nerves
Recurrences: wide surgical resection, possibly
including orbital exenteration, and may
require collaboration with a head and neck
cancer surgeon
 Eyelid Neoplasms

Kaposi sarcoma (Malignant Eyelid Tumors)

 Eyelid Neoplasms
This previously rare tumor
Chronic reddish dermal mass
Is a frequent manifestation of AIDS
The conjunctival lesions can be mistaken for
foreign body granuloma or cavernous
hemangioma
The lesion is composed of spindle cells of
probable endothelial origin
 Eyelid Neoplasms
Treatment: cryotherapy, excision, radiation, or
intralesional chemotherapeutic agents
Kaposi sarcoma may regress with adequate
antiviral treatment of the HIV infection
Periocular Malpositions

Involutional Ectropion
 Periocular Malpositions
Results from horizontal eye lid laxity either in the
medial or lateral canthal tendons.
Horizontal laxity of the eyelid caused by
disinsertion or stretching of the inferior limbs of
the lateral canthal tendons
Usually occurs in the lower eyelid because of the
effects of gravity
Treatment:
Thermal cautery for medial ectropion with punctal
malposition
 Periocular Malpositions
Treatment:
Medial spindle procedure for punctal
malposition
Horizontal eyelid shortening + reinsertion of
lower eyelid retractor for more severe cases
Periocular Malpositions

Involutional Entropion
 Periocular Malpositions
Usually occurs in the lower eyelids
Role play factors:
Tissue atrophy with horizontal laxity of the eyelid
Attenuation or disinsertion of eyelid retractors
Overriding by the preseptal orbicularis
Ancillary test for horizontal laxity
Snap back test
Distraction test
 Periocular Malpositions
Ancillary test for disinsertion of retractors
A white subconjunctival line several millimeters
below the inferior tarsal border caused by the
leading edge of the detached retractors
Deeper than normal in ferior fornix
Reverse ptosis of the lower eyelid (lower eyelid
margin sits higher than normal)
Little or no inferior movement of the lower eyelid
on downgaze (diminished lower eyelid excursion)
 Periocular Malpositions
Ancillary test to detect superior override of the
preseptal orbicularis
The patient squeezes his or her eyes closed after the
entropic eyelid has been placed in its normal position
Procedures to repair:
Temporizing measures(lubrications and bandage CL)
Horizontal tightening procedures
Repair of the retractors
Often, a combination of procedures is necessary
Periocular Malpositions

Trichiasis
 Periocular Malpositions
Acquired misdirection of the eyelashes
Inturned lashes usually associated with
posterior lamellar scarring (marginal cicatricial
entropion)
If the eyelid margin is misdirected, treatment
should be directed at correcting the entropion
Management:
Mechanical epilation
 Periocular Malpositions
Management:
Electrolysis
Radiofrequency
Cryotherapy
Argon laser
Full-thickness pentagonal resection with primary
closure
Periocular Malpositions

Dermatochalasis
 Periocular Malpositions
Redundancy of eyelid skin and is often
associated with orbital fat protrusion or
prolapse
More common in older patients
Occurs in middle aged people, particularly if
there is a familial predisposition
Patient complaints: heavy feeling around the
eyes, brow ache, eyelashes in the visual axis,
and reduction in the superior visual field
Periocular Malpositions

Acquired aponeurotic blepharoptosis

 Periocular Malpositions
Results from stretching or dehiscence of the
levator aponeurosis or disinsertion from its
normal position
Common causes:
Involutional attenuation
Repetitive traction on the eyelid (frequent eye
rubbing)
Prolonged use of rigid contact lenses
Intraocular surgery or eyelid surgery
 Periocular Malpositions
Characteristically have a high or an absent
upper eyelid crease
Levator function is usually normal ( 12- 15
mm)
Ptosis may worsen in downgaze and therefore
interfere with the patient's ability to read as
well as limiting the superior visual field
 Periocular Malpositions
Clinical measurements
Margin-reflex distance 1 4
Palpebral fissure height 9 - 10
Upper eyelid crease 5-9
Levator function 12 - 15
Lagophthalmos 0
 Eyelid Trauma
Take a careful history.
Record the best visual acuity for each eye.
Thoroughly evaluate the globe and orbit.
Obtain appropriate radiologic studies.
Have a detailed knowledge of eyelid and
orbital anatomy.
Ensure the best possible primary repair
Eyelid Trauma

Blunt Trauma
 Eyelid Trauma
Ecchymosis and edema
Evaluated for intraocular injury with
biomicroscopic evaluation and dilated fundus
examination
Computed tomography: determine whether
an orbital fracture is present
Eyelid Trauma

Penetrating Trauma
 Eyelid Trauma
Penetrating Trauma
Lacerations not involving the eyelid margin
Lacerations involving the eyelid margin
Trauma involving the canthal soft tissue
 Eyelid Trauma
Lacerations not involving the eyelid margin
Skin and orbicularis muscle lacerations usually
require only skin sutures
The basic principles of plastic repair: Unnecessary
scarring can be avoided
Copious irrigation washes away contaminated
material and foreign bodies
Orbital fat prolapse: indication for levator
exploration
Orbital septum lacerations should not be sutured
 Eyelid Trauma
Lacerations involving the eyelid margin
Skin and orbicularis muscle lacerations usually
require only skin sutures
Repair of eyelid margin: requires precise suture
placement and critical suture tension to minimize
notching of the eyelid margin
by placing 2 or 3 sutures for alignment through
the lash line, the meibomian gland plane, and
(optionally) the gray line
 Eyelid Trauma
Lacerations involving the eyelid margin
Precise anatomical alignment of the margin and
secure tarsal closure are the goals
To avoid corneal epithelial disruption, the tarsal
sutures should not extend through the
conjunctival surface
Resorbable buried sutures may be used in the
margin as an alternative to the permanent
externally tied sutures
CONJUNGTIVA
 Embryology
At 10 weeks, the conjunctiva epithelium
diffrentiates from the eyelid skin and cornea
when goblet cells and glandular ducts become
visible.
By 12 weeks, caruncular development from the
nasal aspect of the lower lid fold and further
epithelial invagination to form the accessory
gland of Krause and Wolfring are seen. A soft
moveable fold (plica semilunaris) is also seen
between the caruncle and the globe.
 Anatomy
Divided into:
Bulbar conjungtiva
Fornix conjungtiva
Palpebral conjungtiva
The tarsal conjunctiva is tightly adherent to
the underlying tarsus
The bulbar conjunctiva is loosely adherent to
Tenon capsule
 Anatomy
The conjunctival epithelium varies from
stratified cuboidal over the tarsus to columnar
in the fornices to squamous on the globe
The substantia propria of the conjunctiva
consists of loose connective tissue.
 Anatomy
Vascular supply
The bulbar conjunctiva is supplied by the
anterior ciliary arteries branching of the
ophthalmic artery
The palpebral conjunctiva shares its blood
supply with the eyelids
Branch of peripheral arcade supply superior
and inferior fornix conjungtiva
 Anatomy
Lymph drainage
Lymphatic vessels serving the medial portion of
the eyelids drain into the submandibular lymph
nodes.
Lymph channels serving the lateral portions of the
eyelids drain first into the superficial preauricular
nodes and then into the deeper cervical nodes.
 Anatomy
Nerve supply
Sensory innervation is controlled by the lacrimal.
supraorbital, supratrochlear, and infraorbital
branches of the ophthalmic division of cranial nerve
V
 Function
Serve as a barrier to foreign particles and
inhibits the invasion of exogenous bacteria
The conjunctival secretion is important in
corneal nourishment and the transportation
of secretion to the nasal lacrimal outflow
system
Conjungtiva
 Conjunctival disorder
Degenerative changes
Conjunctival inflammation
Immune mediated disordeor of the
conjunctiva
Conjunctival Trauma
Neoplastic disorder
Degenerative changes

Pinguecula
 Degenerative changes
The appearance of yellow-white amorphous
subepithelial deposits with occasionally
calcification that occurs at the nasal and
temporal anterior bulbar conjunctiva more
often nasally
As a result of the effects of ultraviolet
Enlarge gradually over long periods of time
 Degenerative changes
Lubricant therapy is the mainstay of treatment
Excision: for cosmetic problems
Topical corticosteroids: chronic inflammation
Degenerative changes

Pterygeum
 Degenerative changes
A pterygium is a wing-shaped fold of conjunctiva
and fibrovascular tissue that has invaded the
superficial cornea
The pathogenesis of a pterygium is strongly
correlated with UV exposure although dryness,
inflammation, and exposure to wind and dust or
other irritants may also be factors
The histopathology of pterygium shows elastotic
degeneration of the stromal collagen with
subepithelial fibrovascular tissue.
 Degenerative changes
Pterygia are nearly always preceded and
accompanied by pingueculae
The prevalence of pterygia increases steadily
to the equator
Regular and irregular astigmatism occurs in
proportion to pterygium size
A pigmented iron line (Stocker line) may be
seen at the central anterior edge of the
pterygium on the cornea
 Degenerative changes
Excision is indicated:
The pterygium approaches the visual axis,causing
loss of vision from irregular astigmatism
In cases of considerable irritation
Degenerative changes

Conjunctival Concretion
 Degenerative changes
Yellow-white deposits
In the palpebral conjunctiva of older patients
or patients who have had chronic
conjunctivitis.
Secondary calcification occurs occasionally
Sometimes referred to as conjunctival lithiasis.
The subconjunctival deposition of oral
tetracyclines mimics concretions.
 Degenerative changes
Concretions are almost always asymptomatic
but may erode the overlying epithelium to
cause foreign-body sensation
If symptomatic, concretions can be easily
removed under topical anesthesia
 Conjungtival Inflammation
Conjunctivitis
1. Dapat disebabkan
bakteri, virus
2. Dapat akut dan kronis
3. Tanda radang umum:
merah, papil, folikel,
sekret
4. Tanda radang khusus:
pseudomembran.
5. Pengobatan:
1. kausatif
Immune disorder of the conjunctiva

Vernal Conjunctivitis
 Immune disorder of the conjunctiva
Usually a seasonally recurring
Bilateral inflammation of the cornea and
conjunctiva, vernal (springtime)
keratoconjunctivitis (VKC)
Predominantly in male children
Have a personal or family history of atopy
May persist year round in tropical climates
Involve both types I and IV hypersensitivity
reactions
 Immune disorder of the conjunctiva
Infiltrate in VKC consists of eosinophils,
lymphocytes, plasma cells, and monocytes
Symptoms consist of itching, blepharospasm,
photophobia, blurred vision, and copious
mucoid discharge.
Clinically, 2 forms of VKC may be seen:
palpebral and Iimbal.
 Immune disorder of the conjunctiva
The palpebral conjunctiva: papillary
hypertrophy develops, usually more
prominently on the upper rather than the
lower region.
Bulbar conjunctival hyperemia and chemosis
may also occur.
In more severe cases, giant papillae
resembling cobblestones on the upper tarsus
 Immune disorder of the conjunctiva
Horner- Trantas dots, whitish dots that
represent macroaggregates of degenerated
eosinophils and epithelial cells, in the
hypertrophied limbus
Mild cases: topical antihistamines.
Mild to moderate: topical mast-cell stabilizers
Climatotherapy: air condition or relocation to
a cooler environment
 Immune disorder of the conjunctiva
Severe cases: topical corticosteroids every 2
hours for 5- 7 days and then rapidly tapered or
topical immunomodulatory agents such as
cyclosporine applied 2-4 times daily
Immune disorder of the conjunctiva

Horner trantas dot

Conjunctival Trauma

Conjunctival Laseration
 Conjunctival Trauma
1. Eksplorasi dilakukan untuk melihat struktur
dalam mengalami kerusakan (menggunakan
pinset dan cotton bud steril)
2. Bila disertai subconjunctival hemorrhage
masif, eksplorasi dilakukan dgn peritomi di
kamar operasi
3. Pengobatan: pada umumnya tidak
memerlukan penjahitan
Conjunctival Trauma

Subconjunctival hemorrhage
 Conjunctival Trauma
Blood under the conjunctiva
Most frequently, without a history of
antecedent trauma
Occasionally, a history of vomiting, coughing,
or other forms of the Valsalva maneuver.
Repeated episodes of spontaneous
subconjunctival hemorrhage or indicates the
presence of bleeding diathesis
 Conjunctival Trauma
Recurrent subconjunctival hemorrhages:
association with uncontrolled hypertension,
diabetes mellitus, or a bleeding diathesis.
No therapy for the hemorrhage, usually
resolves in 7-12 days
 Neoplastic disorder

Inclusion Cysts of the Epithelium

 Neoplastic disorder
Inclusion cysts of the conjunctival epithelium
are typically asymptomatic
Can be congenital or acquired
Most acquired cysts of the conjunctiva are
derived from an inclusion of conjunctival
epithelium into the substantia propria
Stimuli for cyst formation include chronic
inflammation, trauma, and surgery
 Neoplastic disorder
Conjunctival inclusion cysts typically appear
clear and most commonly occur in either the
bulbar conjunctiva or the conjunctival fornix
Cysts will usually reform after simple drainage
because the inner epithelial cell wall remains.
Complete excision is necessary to prevent
recurrence.
Neoplastic disorder

Conjunctival Melanoma
 Neoplastic disorder
Conjunctival melanomas make up less than 1
% of ocular malignanciesConjunctival
Conjunctival melanomas are rare in black and
Asian populations
Although malignant conjunctival melanoma
has a better prognosis than cutaneous
melanoma, the overall mortality rate is 25%.
 Neoplastic disorder
Conjunctival melanomas may arise from PAM
(70%) or nevi (2%), or be de novo (10%)%.
Metastasis: intralymphatic spread to regional
lymph nodes of the brain, lungs, liver, and bone.
Ciliary body melanoma can extend through the
sclera (rare) or full thickness intraepithelial
spread
Most commonly found in bulbar conjunctiva or at
the limbus
25% of conjunctival melanomas are amelanotic
 Neoplastic disorder
May bleed easily
Grow in a nodular fashion
Can invade the globe or orbit
Poor prognostic:
palpebral conjunctiva, caruncle, or fornix, the
eyelid margin
invasion into deeper tissues
thickness> 1.8 mm
 Neoplastic disorder
Management:
Excisional biopsy seems not to increase the risk of
metastasis
Excision of conjunctiva 4 mm beyond the clinically
apparent margins of the tumor
Treatment of the remaining sclera with absolute
alcohol
Cryotherapy applied to the conjunctival margins and
residual disease
Conjunctival or amniotic membrane grafts are
necessary for large excisions
 Neoplastic disorder
Management:
Topical mitomycin C has been used after excision
Orbital exenteration is performed for advanced
disease
Adjunctive radiotherapy and chemotherapies has
not been determined