Eyelid 24/25 Notes PDF

**Eyelid** **Learning Outcomes** - To describe signs and symptoms of different eyelid problems - To make definitive diagnosis and list differential diagnoses - To appropriately manage different eyelid problems **Congenital** ***Coloboma*** A notch, gap, fissure or incomplete fusion of t...

**Eyelid** **Learning Outcomes** - To describe signs and symptoms of different eyelid problems - To make definitive diagnosis and list differential diagnoses - To appropriately manage different eyelid problems **Congenital** ***Coloboma*** A notch, gap, fissure or incomplete fusion of the eyelids Risk: exposure keratitis ⇒ scarring Treatment: surgical repair, but is usually delayed until the child is several years old, or immediately if the cornea is at risk Further reading: Goldenhar syndrome (first branchial arch syndrome) ***Trichiasis*** Primary, congenital, lashes directed posteriorly towards the eye, with normal lid margin position Secondary, acquired, abnormal lid margin position, e.g. entropion, epiblepharon Too many lashes induce irritation, pain, inflammation, infection, eventually scar Watch for corneal ulceration or erosions Tx: mechanical epilation or electrolysis or cryotherapy or laser ablation Electrolysis: each lash must be treated individually (time-consuming), inflammation will be resulted from electrolysis Cryotherapy: low cost and short duration, but may damage nearby tissue DDx: blepharitis, distichiasis, trachoma ***Distichiasis*** Rare, a second row of lashes, may affect all four lids Congenital: AD, associated with ptosis, strabismus Acquired: chronic inflammation e.g. blepharoconjunctivitis, meibomianitis; secondary to severe chemical burn, Stevens-Johnson syndrome, ocular cicatricial pemphigoid Tx: mechanical epilation, electrolysis, laser photoablation, cryotherapy, or surgically everting the lid DDx: trichiasis, entropion ***Epicanthus*** Common in Asian Bilateral, semilunar folds of skin at inner canthus covering caruncle Usually disappears during the first few years of life in Caucasian, take a bit longer in Asian DDx: strabismus, epiblepharon ***Epiblepharon*** Common in Asian A congenital disorder that occurs when the pretarsal orbicularis and the skin override the lid margin, causing the lashes to assume a vertical position The lashes occasionally rub the cornea, signs and symptoms then occur No treatment because usually resolve spontaneously with age Watch the cornea DDx: epicanthus, entropion ***Ptosis*** (abnormally low position of upper lid) [Congenital] - levator maldevelopment - usually unilateral - if affecting vision, amblyopia will be resulted - may be associated with other CIII muscles e.g. SR - head tilting backwards (chin up) [Acquired] Aponeurotic - involutional, repetitive eyelid traction (e.g. frequent eye rubbing) Mechanical - haematoma, tumour, oedema of upper lid (pseudoptosis) Myogenic - myasthenia gravis, myotonic dystrophy Neurogenic - CIII palsy (comes with other CIII EOM problems) Margin-reflex distance (MRD) MRD1: normal being 4mm to 5mm MRD2: distance from pupillary light reflex to lower eyelid margin, for identifying lower eyelid retraction or elevation; normal being 4mm to 5.5mm Levator function: normal being 13mm to 16mm, poor if 4mm or less Treatment: surgically (except myasthenia gravis) e.g. resection of levator aponeurosis or superior tarsal muscle DDx: dermatochalasis, chalazion, preseptal/orbital cellulitis **Degeneration** ***Dermatochalasis*** Redundancy and loss of elasticity of skin, an ageing problem Treatment: surgery (upper eyelid blepharoplasty) if vision affected Please state one important differential diagnosis? ***Ectropion*** Usually lower lid May cause exposure keratitis, epiphora, irritation Common in elderly -- senile ectropion Cicatricial Tx: surgery DDx: floppy eyelid syndrome (please look up!) ***Floppy eyelid syndrome*** Read the article! **Inflammation / Infection** ***Blepharitis*** McLeod A & Nau A. Anterior blepharitis: The front line of OSD. Review of Optometry. 15 November 2021. pp. 74-83. Ayres et al. Clinical diagnosis and management of Demodex blepharitis: the Demodex expert panel on treatment and eyelid health (DEPTH). Eye. 2023 Mar 24. **Posterior blepharitis** - meibomitis or meibomianitis Meibomian gland dysfunction (MGD) - blockage of gland orifices (sign) - changes in glandular secretion Blepharitis could cause tear film disturbance (S. epidermidis and S. aureus release lipases that hydrolyze sebaceous gland lipids. These enzymes produce free fatty acids and other byproducts that irritate the eyes and cause tear film instability.) Symptoms: dry eye LipiFlow Thermal Pulsation System for MGD **Hordeolum** Infection ([staphylococcal]) of lid glands, may occur with blepharitis Internal: meibomian glands External (stye): eyelash follicles, or glands of Zeis (sebaceous) or Moll (apocrine) Symptom: acute pain Tx: warm compression, epilation of the lash, topical antibiotic systemic antibiotic if preseptal cellulitis **Chalazion** Chronic lipogranulomatous inflammatory of sebaceous glands (Meibomian) Signs: immobile, hard, nodular swelling within 5mm from lid margin, elevated area seen with everted eyelid Symptoms: painless (slightly tender), vision can be reduced, why? Tx: resolved spontaneously, enhanced by warm compression, may also require intralesional injection of steroid Excision is indicated if size is large and with distorted vision Watch for sebaceous gland carcinoma ***Contact dermatitis*** Common eyelid dermatitis (70%) Eyelid is thin, small amount of fat and high vascularity Usually female Sources: BAK from ophthalmic solutions, eye cosmetics, artificial nails, hair dye Tx: cessation and avoidance of the offending agents, cool compresses ***Entropion*** Lid margin turns towards the globe Usually lower lid Foreign body sensation to irritation, epiphora Senile Spastic - remove underlying cause e.g. f.b. Cicatricial - trachoma, thermal / chemical injury Tx: surgery DDx: trachoma, trichiasis, distichiasis, dermatochalasis ***Lagophthalmos*** Anomaly of eyelid? Facial nerve problem? Nocturnal lagophthalmos Take care of the cornea ***Molluscum Contagiosum*** Look up yourselves! **Tumours** ***Benign*** Naevus: melanocytes Haemangioma ***Papillomas*** - basal cell papilloma (seborrheic keratosis): common in middle-aged and older, flatly elevated, usually brown but can also be black - squamous cell papilloma: most common benign eyelid tumour, is caused by HPV infection, raspberry shape, can be flat or finger-like projections (pedunculated), usually lid margin Tx: surgical excision DDx: chalazion, hordeolum, molluscum contagiosum, xanthelasma, lid carcinoma ***Xanthelasma*** Anterior surface of eyelid Usually bilateral, near inner angle of the eye Yellow, wrinkled patches on the skin, usually in elderly Lipid deposits No treatment, but should refer especially occurring at young patients, one-third of them will have systemic hyperlipidemia ***Actinic keratosis*** Also called solar keratosis Associated with chronic sun exposure, precursor of squamous cell carcinoma Common in patients with fair skin, over 50 years of age A reddish-brown scaly patches Tx: cryotherapy or curettage ***Malignant (Carcinoma)*** [Basal cell carcinoma] - covering 90% malignant eyelid tumour - usually lower lid margin, may have orbital and sinus involvements if at medial canthus - ulcerative presentation at center, volcano appearance - painless - grow slowly, not metastasise but invades adjacent tissues [Squamous cell carcinoma] - grow slowly, usually lower eyelid - can spread to regional lymph nodes via the lymphatic system - painless [Sebaceous gland carcinoma] - from Meibomian glands and glands of Zeis - more aggressive than squamous cell carcinoma - metastasising to lymph nodes, lung tissue and the liver ***Malignant melanoma*** Like elsewhere in the skin Most pigmented lesions on the eyelid skin are not melanomas ***Kaposi's sarcoma of the eyelid*** - red-to-purple elevations on skin surface - usually in immunocompromised patients All tumours are treated by excision **Injuries** Blunt trauma Rupture Laceration **Reference** Ch. 2. Eyelids. In: Kanski's Clinical Ophthalmology. A Systematic Approach. 9th. ed. 2020. Elsevier. Crusting: dried exudate on skin surface Ulceration: loss of epithelial tissue Cyst: nodule filled with fluid and lined with epithelial tissue Vesicles: small fluid-filled cysts Bullae: large fluid-filled cysts Papule: small lump Nodules: large papules **Eyelid myokymia** - twitching of eyelid - spontaneous, fine fascicular contractions of eyelid muscle - stress? - fatigue?