Chapter 589

The eyelids play an important role in maintaining ocular health and good vision. The mechanical action of the eyelids sweeping over the globe brings in fresh, lubricating tears and removes debris. The edge (margin) of the two upper eyelids and two lower eyelids should be symmetric. The upper eyelid margin should rest at the superior edge of the cornea or just over the superior iris, so as not to block any visual input. The eyelid margins normally rest against the globe, and the eyelashes are directed outward.

Except for ptosis (drooping of the eyelids, blepharoptosis), which will be discussed below, congenital anomalies of the eyelids are rare. The most severe anomaly is cryptophthalmos, which presents in the newborn with complete fusion of the eyelids. The underlying eyeball is also usually malformed, and the visual prognosis is poor. Eyelid coloboma is a discrete area in which eyelid tissue is missing, most commonly on the upper eyelids, appearing as a notch or rectangular defect of the margin where there will be no lashes. Anomalies of the cartilage normally present inside the eyelid (tarsal plate) or eyelid muscles may result in congenital entropion (in-turning of the eyelid) or ectropion (out-turning of the eyelid). Congenital tarsal kink is a severe variant of ectropion, in which the upper eyelid appears to bend outward. Surgery for these conditions is indicated if they produce corneal irritation (due to eyelashes rubbing against the cornea in entropion) or exposure damage (due to inadequate corneal cover and lubrication in ectropion). A relatively minor eyelid abnormality is ankyloblepharon, which results from incomplete separation of the eyelids during embryologic development. Infants usually present with one or more fine strands of adherent tissue between the upper and lower eyelids, with secondary inability to open the eyes (eFig. 589.1). This can usually be treated successfully in the ophthalmologist’s office with simple cutting of the tissue.

###### eFigure 589.1.

Ankyloblepharon (arrow).

Epiblepharon is a relatively common congenital eyelid anomaly. It results from an extra fold of skin below the lower eyelid margin, which may cause the eyelids and lashes to rotate in toward the eye (eFig. 589.2). It is most commonly seen in Asian children. If the lashes rub against the cornea, affected infants may develop symptoms of ocular irritation, overflow tearing, and excess mucus formation. The symptoms of this disorder may be confused with those of nasolacrimal obstruction, and it is important to differentiate these two entities by inspecting the eyelid margin. Epiblepharon may spontaneously improve in the first 6 to 12 months of life, and conservative treatment with topical lubricants may provide symptomatic relief. If the condition does not improve, surgery to evert the eyelid margin is usually successful.1

###### eFigure 589.2.

Epiblepharon is an extra fold of skin ...

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