Abnormalities of eyelid position

Eyelid closure allows for the distribution of tear fluid and glandular secretions, which protect the cornea and conjunctiva from dehydration and injury by foreign bodies. Pathological changes in eyelid position (i.e., ptosis, ectropion, entropion, lagophthalmos, and blepharospasm) prevent the complete protection of the cornea and conjunctiva, predisposing affected individuals to complications such as keratitis, conjunctivitis, and corneal ulcers. Treatment such as artificial tears and eye patches, as well as surgical procedures, can be used to help prevent such complications.

For other abnormalities of the eyelids, see “Inflammation of the eyelids” and “Diseases of the lacrimal apparatus.”

• Eyelid structures
  • Skin
  • Subcutaneous tissue
  • Orbital septum
  • Orbital fat
  • Muscles
    • Orbicularis oculi muscle
    • Levator palpebrae superiors muscle
    • Superior tarsalis muscle
  • Tarsal plates
  • Conjunctiva
  • Eyelashes
  • Glands
• Innervation
  • Facial nerve: innervates the orbicularis oculi muscle
  • Oculomotor nerve: innervates the levator palpebrae superioris muscle
  • Sympathetic nervous system: innervates the superior tarsalis muscle
• Blood supply: anastomosis of the lateral and medial palpebral arteries (branches of the lacrimal artery and ophthalmic arteries)

For further information on the anatomy of the eyelid, see “Eyelid” in “Eye and orbit.”

• Definition: full or partial drooping or falling of one or both upper eyelids
• Etiology ^[1][2]
  • Congenital
    • Myogenic
      • Most common cause of congenital ptosis
      • Malformation of the levator palpebrae superioris muscle
    • Neurogenic: defective innervation of the upper eyelid (e.g., congenital third cranial nerve palsy, synkinetic ptosis, congenital Horner syndrome)
    • Aponeurotic: defective insertion of the aponeurosis into the anterior surface of the eyelids
    • Blepharophimosis syndrome
  • Acquired
    • Aponeurotic ptosis
      • Most common cause of acquired ptosis
      • Caused by dehiscence or stretching of the aponeurosis of the levator palpebrae superioris muscle
      • More frequent in elderly individuals and in contact lens users
    • Myogenic
      • Hypothyroid myopathy
      • Mitochondrial myopathies (e.g., chronic progressive external ophthalmoplegia)
      • Myotonic syndromes (e.g., myotonic dystrophy type I)
    • Mechanical
      • Excessive weight on the upper eyelid (e.g., hemangioma, hematoma, infections, tumors of the upper eyelid) prevents full opening of the eye.
      • Causes weakness of the levator palpebrae superioris muscle
    • Oculomotor nerve palsy
      • Due to neuropathy of internal neural fibers (e.g., diabetes mellitus)
      • Late manifestation of external compression (e.g., posterior communicating artery aneurysm, uncal herniation)
      • Ischemia of the oculomotor nerve
    • Neuromuscular disease (e.g., myasthenia gravis, myotonia, botulism)
    • Sympathetic nerve injury
      • Usually Horner syndrome
      • Causes palsy or weakness of the superior tarsal muscle
    • Traumatic
• Clinical features
  • Congenital ptosis
    • Unilateral
    • Lid creases are absent or lower than normal.
  • Acquired ptosis
    • Can be unilateral or bilateral
    • Associated with neurological symptoms (e.g., pupillary defects, diplopia) which vary depending on the underlying cause
• Diagnostics
  • Family and medical history
  • Clinical features (extraocular motility, pupil size, and reactivity)
• Treatment
  • Treatment of the underlying condition
  • Surgical
    • Indications ^[3]
      • Congenital ptosis
      • Impaired vision
      • Eye fatigue
      • Difficulty reading
      • Compensatory head alignment
    • Procedures: will depend on the underlying etiology
      • Blepharoplasty
      • External levator advancement surgery
• Complications
  • Congenital ptosis: amblyopia, strabismus
  • Psychosocial problems
  • Frontal headaches
  • Decreased visual field
  • Lagophthalmos (associated with corneal lesions)

For patients with untreated congenital ptosis, surgery is indicated in an early stage due to the risk of developing amblyopia.

• Definition: outward folding of the eyelid (usually the lower eyelid)
• Etiology ^[4][5]
  • Congenital ectropion
    • Down syndrome
    • Microphthalmia
    • Blepharophimosis syndrome
  • Acquired ectropion
    • Involutional: due to age-related laxity of the tarsal plates and canthal tendons
    • Cicatricial ectropion: due to trauma, inflammation, burns, surgery, cancer
    • Paralytic ectropion: paresis of the orbicularis oculi muscle due to facial nerve palsy
    • Mechanical ectropion
      • Mass
      • Conjunctival edema
• Clinical features
  • Conjunctival hyperemia
  • Blurry vision
  • Photophobia
  • Lagophthalmos
  • Epiphora
• Diagnostics
  • Ectropion is mainly a clinical diagnosis.
  • Routine eye examination
• Treatment ^[6]
  • Treatment of the underlying condition
  • Symptomatic treatment
    • Artificial tears and ointments: lubricate the conjunctiva
    • Eye patch: prevents eye desiccation
  • Surgery for definitive treatment
• Complications
  • Conjunctivitis
  • Keratitis (ulcer formation)
  • Vision loss

• Definition: inward folding of the eyelid margin
• Etiology
  • Congenital entropion
    • Lower eyelid
      • Most common type of congenital entropion
      • Due to increased direct mechanical pressure in utero or intrauterine tarsal deformity
    • Upper eyelid: due to horizontal laxity of the medial or lateral canthal tendons or facial nerve palsy
  • Involutional entropion
    • Most common type of entropion
    • Frequency increases with age.
    • Due to laxity of the tarsal plates, canthal tendons, and eyelid retractors
  • Spastic entropion
    • Usually accompanies involutional entropion
    • An exaggerated contraction of the orbicularis muscle, leading to the preseptal part of the muscle to override the tarsal plate
    • Due to preexisting lower eyelid laxity or ocular irritation (e.g., due to infection, inflammation, trauma)
  • Cicatricial entropion
    • Vertical tarsoconjunctival contracture and internal rotation of the eyelid margin
    • Due to scarring (e.g., due to trachoma, ocular pemphigoid, infection, trauma) ^[7]
• Clinical features
  • Congenital entropion: usually asymptomatic
    • Can manifest with photosensitivity, blepharospasm, and/or infrequent eye opening
    • Manifestation depends on the clinical malposition of the eyelids
  • Acquired entropion
    • Trichiasis
    • Recurrent blepharospasm
    • Ocular pruritus
    • Ciliary injection or conjunctival injection
    • Foreign body sensation in the eye
    • Epiphora
    • Hemifacial spasms (seen in spastic entropion)
• Diagnostics
  • Clinical features
  • Complete eye examination
  • Exophthalmopathy: in cases of involutional entropion to rule out exophthalmos
• Treatment ^[8]
  • Treatment of the underlying condition
  • Congenital entropion typically does not require treatment and often involutes spontaneously.
  • Palliative
    • Artificial tears and ointments
    • Soft contact lenses: protect the cornea from external injury
    • Skin tape: used to hold the lid in place
    • Cyanoacrylate liquid bandage: used to evert the lid
    • Botulinum toxin application on the orbicularis muscle: in case of spastic entropion
    • Removal of the eyelashes: in case of trichiasis
  • Surgical
    • Definitive treatment
    • Indications ^[8]
      • Recurrent erosions
      • Recurrent infections
      • Uncontrolled eye inflammation
    • Procedure: Suture eversion of the lid.
• Complications
  • Trichiasis
  • Amblyopia with possible vision loss
  • Conjunctival and corneal lesions (e.g., corneal thinning, scarring, ulcers)

• Definition: inability to close the eyelids completely
• Etiology ^[9]
  • Congenital: due to congenital facial nerve palsy
  • Acquired
    • Paralytic lagophthalmos: due to any CN VII dysfunction
      • Bell palsy (most common cause)
      • Stroke (due to the facial nerve's irrigation supplied by the anterior inferior cerebellar artery)
      • Infections (due to herpes zoster, HIV, Lyme disease, measles, diphtheria, leprosy)
      • Traumatic paralysis: e.g., bone fractures (due to temporal bone fracture, orbital fracture), iatrogenic injury following surgery (due to blepharoplasty, parotid gland resection, acoustic neuroma excision)
      • Tumors (due to acoustic neuromas, parotid lesions, schwannoma)
      • Ectropion (due to facial nerve palsy)
      • Exophthalmos (due to Graves disease)
      • Enophthalmos (due to orbital fat atrophy, aging)
    • Cicatricial lagophthalmos: due to upper eyelid edema, orbital septal elevation (e.g., secondary to surgery, trauma, burns, chronic skin conditions)
    • Nocturnal lagophthalmos
      • Incomplete closure of the eyelids during sleep
      • Common in the general population
    • Iatrogenic: medication (due to sedatives, lidocaine, procaine)
• Clinical features
  • Abnormal blinking
  • Desiccation of the conjunctiva and cornea
  • Keratitis
  • Corneal ulcers
• Diagnostics ^[10]
  • Lagophthalmos is mainly a clinical diagnosis.
  • Slit lamp examination: Assess conjunctiva and cornea for lesions.
• Treatment ^[10]
  • Treatment of the underlying condition
  • Palliative: to prevent desiccation of the conjunctiva
    • Artificial tears and ointments
    • Eye patch
  • Surgical
    • Indicated for severe cases of lagophthalmos (e.g., corneal exposure)
    • Procedures
      • Tarsorrhaphy
      • Gold or platinum weight implantation on the upper eyelid
      • Upper eyelid retraction
      • Lower eyelid tightening

• Definition: involuntary closure of the eyelids
• Types
  • Benign essential blepharospasm (BEB): a type of focal dystonia that causes the orbicularis oculi muscle and other periocular muscles to contract, which leads to increased bilateral eyelid closure
  • Idiopathic blepharospasm
  • Secondary blepharospasm
    • Typically due to brain lesions, systemic diseases, medications
    • Reflex blepharospasm: a type of secondary blepharospasm triggered by severely dry eyes, photosensitivity, and/or inflammatory processes (i.e., blepharitis, intraocular inflammation)
• Etiology
  • BEB
    • Inherited (positive family history of BEB)
    • Noninherited risk factors
      • Environmental factors (high socioeconomic status, chronic stressful environments)
      • Increased reading or screen time
      • Psychiatric conditions (e.g., depression, anxiety, obsessive compulsive disorder)
  • Idiopathic (most commonly seen in elderly women)
  • Secondary blepharospasm
    • Severe irritation of the eyes (e.g., due to a foreign body, burns)
    • Corneal or ocular diseases (e.g., conjunctivitis, keratitis, uveitis)
    • Neurological disorders (e.g., trigeminal neuralgia, supranuclear lesion, extrapyramidal disorders)
    • Medication-induced (e.g., neuroleptics, calcium channel blockers, serotonin reuptake inhibitors)
    • Dystonic syndromes (e.g., Meige syndrome)
    • Tardive dyskinesia
• Clinical features ^[11]
  • Synchronous bilateral spasms
  • Brief repetitive blinking
  • Inability to reopen eyes in the absence of spasms
  • Dry eyes
  • Photophobia
  • Sensory tricks like touching of the face
• Diagnostics
  • Medical history
  • Blepharospasm is mainly a clinical diagnosis.
  • Complete eye examination
• Differential diagnoses
  • Myokymia
  • Hemifacial spasm: unilateral facial muscular fasciculations that include the eyelids
• Treatment ^[11]
  • Treatment of the underlying condition
  • Medical
    • Periodic injections of botulinus toxin
    • Muscle relaxants (rarely effective)
  • Surgical: eyelid myectomy (removal of the superior part of the orbicularis oculi muscle) ^[12]