Eyelids and Adnexa Flashcards
macule
colour change without infiltration or elevation (ex. freckle, cafe au lait spots)
papule
small solid elevation of skin (<1cm)
ex. cherry angioma, common warts
nodule
small solid elevation of ski (>1cm)
ulcer
circumscribed area of tissue loss, extends through epidermis into dermis (ex. in basal cell carcinoma)
cyst
nodule with an epithelial lined cavity, filled with fluid or semi-solid material
Which is translucent and which is not: cyst of Zeis and cyst of Moll?
Cyst of Zeis is non-translucent, cyst of Moll is translucent (also called apocrine hidrocystoma)
pustule vs. vesicle
pustule is a small pus-filled lesion, vesicle is a small serous fluid-filled lesion (ex. in Herpes)
Herpes zoster ophthalmicus skin changes:
-viral release from the sensory nerve endings results in a macular rash, which becomes papular, then vesicular which develop (~4 days) to become pustular and eventually rupture. When acute phase subsides, the rash crusts over and dissipates.
Contact Dermatitis
common inflammatory disorder that often involves the thin skin of the eyelid, associated with hypersensitivity response or direct irritation
can caused periocular skin to be red, edematous, scaly or fissured
treating Contact Dermatitis
topical corticosteroids and removal of offending agents
rosacea dermatitis
common, chronic inflammatory eruption of the face (forehead, nose, cheeks) can involve malar flushing, telangiectasia, papules, pustules, sebaceous gland hypertrophy, rhinophyma, etc.
ocular rosacea
in about 50% rosacea cases
symptoms: burning, photophobia, FBS
blepharitis and MGD are most common findings
treating Ocular Rosacea
avoiding foods and environments that worsen flushing
oral antibiotics (tetracycline, doxy, azithromycin) topical metronidazole cream/gel on skin
topical corticosteroids
collarettes (on eyelashes)
ring-like formation around lash-shaft, mucous debris and dead epithelium
can be caused by phthirus pubis or demodex mites
trichiasis
posteriorly misdirected lashes rubbing against globe, chronic rubbing can lead to corneal problems
may be secondary to scarring - from trauma, mucous membrane pemphigoid, Stevens-Johnson syndrome
treating Trichiasis
- epilation!
- electrolysis
- cryotherapy
- argon laser ablation
- surgery
distichiasis
partial or complete second row of lashes - emerge at or behind a meibomian gland orifice (cells differentiate into a pilosebaceous unit instead of MG cell)
trichomegaly
excessive eyelash growth, may be congenital or acquired, can be induced by drugs (prostaglandins), malnutrition, AIDs, hypothyroidism
madarosis
decrease in the number of lashes, can be caused by: chronic lid margin disease, lid tumour, burns, alopecia, psoriasis, SLE, syphilis, leprosy, trichotillomania,etc.
poliosis
premature whitening of hair which can involve lashes and brows
ocular causes - chronic blepharitis, idiopathic uveitis
systemic causes - vitiligo, Vogt Koyanagi Harada syndrome, Marfans, TB
potentially malignant characteristics of anterior eyelid:
- nodular pearly consistency
- ulceration
- induration/hardening
- irregular borders
- suspicious telangiectasias
- madarosis
- loss of lid architecture
meibomian gland dysfunction
-increased lipid viscosity and opacity, needs heat (warm compresses)
congenital ptosis
unilateral or bilateral, superior VF defect
aponeurotic ptosis
most common form of ptosis, usually bilateral, associated with age (involutional), eye sx, trauma, pregnant, chronic swelling, etc. Levator aponeurosis stretching (functions fine), symptoms worse at the end of the day as Muller’s muscle fatigues after trying to compensate
treating involutional ptosis
Upneeq (oxymetazoline) a direct-acting alpha-adrenergic receptor agonist, targets Muller’s muscle to elevate the upper eyelid
mechanical ptosis
decreased elevation of the eyelid secondary to eyelid mass or scarring
myogenic ptosis
ptosis secondary to inherent levator or Muller muscle dysfunction, weakness of the actual muscle - from chronic progressive external ophthalmoplegia, myotonic dystrophy, myasthenia gravis, etc
neurogenic ptosis
caused by Horner’s syndrome or CN3 palsy -innervation defect
ICA aneurysm ocular signs
ptosis, pupil mid-dilated minimally reactive to light
pseudoptosis
false ptosis due to decreased orbital volume, contralateral lid retraction, ipsilateral hypotropia, or dermatochalasis
eyelash ptosis
downward sag of upper eyelid lashes (no turning in of the lid margin)
brow ptosis
excessive skin on the brow and forehead leading to a pseudoptosis, may be due to CNVII palsy, often accompanies dermatochalasis
Bell’s palsy
acute facial nerve palsy of unknown etiology, sudden, temporary weakness in facial muscles, typical recovery in ~6 months
involutional ectropion
outward rolling of lower lid due to horizontal lid laxity, medial/lateral canthal tendon laxity, may present gradually with tearing, redness, irritation, tear film abnormalities, dry eye, or conjunctival keratinization
cicatricial ectropion
due to scarring and contracture, trauma, burns, chronic inflammation, pulls lid away from eye
paralytic ectropion
due to ipsilateral CNVII palsy, can be temporary, may cause exposure keratopathy and epiphora
mechanical ectropion
lesion on or near lid margin, the weight causes lid eversion
involutional entropion
horizontal lower eyelid laxity, contraction of pretarsal orbicularis oculi fibres forces the lower lid margin inward
presents with more acute pain, FBS, photophobia, etc.
treating involutional entropion
temporary - lubricants, lid taping, BCL, botox
Surgical techniques - everting sutures and canthal slings
congenital entropion
mechanical effects of microphthalmos (if involving the upper lid), can involve lower lid due to improper development of inferior retractor aponeurosis
epiblepharon
congenital condition, redundant skin and muscle override the lid margin and force eyelashes against the eye
cicatricial entropion
scarring of palpebral conjunctiva - traction on upper or lower lid leading to rolling in of lid towards the globe - secondary to trauma, chemical burn, cicatrizing conjunctivitis, or trachoma
trachoma
bacterial infection, the leading cause of preventable, irreversible blindness in the world, related to poverty, overcrowding, poor hygiene
floppy eyelid syndrome
increased upper and lower eyelid laxity, typicaly affects obese middle-aged men - rubbery, floppy, easily everted tarsal plates - prominent upper palpebral conj papillary reaction
what can cause floppy eyelid syndrome?
primarily a disorder of sleeping position - face down pressing eyes against pillow
other associations - obstructive sleep apnea, hyper elastic skin, joint hypermobility, diabetes
dermatochalasis
laxity and redundancy of upper lid tissue (age related) often associated with prolapse of orbital fat - pseudoptosis, superior VF defect, heavy sensation, brow ache, tx: blepharoplasty
blepharochalasis
uncommon, recurrent episodes of painless edema of upper lids that resolve spontaneously in 1-2 days, onset at puberty
complications - redundant skin, orbital fat prolapse, ptosis (from stretching of levator and canthal tendons)
characteristics of benign eyelid neoplasms
more common than malignant, more varied, lack of induration or ulceration, uniform colour, limited/no growth, regular border, preservation of normal lid margin structure
chalazion
-meibomian cyst, due to retained sebaceous secretion, chronic, sterile (non-infectious), granulomatous, inflammatory - gradually enlarging painless nodule, MGD and rosacea are at higher risk
treating chalazion
monitor - 1/3 resolve spontaneously, surgical curettage, steroid injection (triamcinolone and lidocaine injected into lesion through conjunctiva, preferred if near punctum), doxycycline prophylaxis
what to look for in a chalazion that may suggest sebaceous gland carcinoma instead…
re-occurring, older pt, lid thickening, unilateral chronic blepharitis*, madarosis, poliosis
hordeolum
infection of an eyelid gland, can be internal (meibomian gland) or external (zeis or Moll), redness, acutely tender
epidermal inclusion cyst
slow growing, round, firm, superifcial or subcutaneous lesions, implantation of epidermal cells into dermis following trauma or surgery - tx: excision
sebaceous cyst
blocked pilosebaceous follicle, rarely seen on the eyelid, is usually on medial canthus -tx: excision
milia
small, raised, white, round, superficial cystic lesions (retained keratin), common in newborn infants, occur in crops - tx: incision of overlying skin and expression of contents
syringoma
benign proliferations, arise from eccrine sweat glands, more common in young female
pilomatricoma
benign skin tumour derived from hair follicle - most common proliferation of hair cells seen in ophthalmologic setting - seen in younger pts, pink/purple mobile, firm, irregular lesions
squamous cell papilloma (acrochordon, skin tag)
hyperkeratotic filiform projection from skin surface, very common, variable appearance, can be pedunculated or sessile, flesh coloured or raspberry-like - tx: excision
basal cell papilloma (seborrheic keratosis, seborrheic wart, senile verruca)
very common, slow-growing, in elderly pts, lesions that can appear on face or eyelids. facial lesions appear smooth and greasy; eyelid lesions appear lobulated, papillary, or pedunculated, with friable cerebriform excrescences on the surface
actinic keratosis (solar or senile keratosis)
common, slow-growing lesion, elderly pts, fair-skinned in excessive sunlight, most common on forehead and backs of hands - low risk of turning into SCC
hyperkeratotic plaque, distinct border, scaly, nodular or wart-like - tx: biopsy, excision, or cryo
freckle (ephelis)
brown macule, excessive melanin production in basal layer of epidermis, sunlight exposed areas, no malignant potential, no tx required
congenital nevus
benign melanocytic lesion, large ones may become malignant
nevocellular nevi (aquired melanocytic nevus)
can be junctional (flat), compound (raised, extends from epidermis into the dermis), or intradermal (most common, little pigment, may have lashes in it, cells confined to the dermis)
kissing nevus
very rare type of compound nevus that results from deposition of nevus cells in the eyelid fold while the lids are fused during embryogenesis
which nevi have the capacity to evolve into melanoma?
junctional and compound, the younger the patient and the larger the size of the nevus shows an increased melanoma risk
oculodermal melanocytosis (nevus of Ota)
unilateral, bluish discoloration of eyelid and skin, proliferation of dermal melanocytes, found in V1 and V2, present at birth, very small risk to become melanoma
xanthelasma
relatively common, bilateral, yellow subcutaneous plaques on the medial aspects of eyelids, older pts, associated with hyperlipidemia, can be seen with corneal arcus (deposition of lipid in the cornea) as well
pyogenic granuloma
fast-growing, vascularized, occasionally painful, polypoidal red lesion, possible bleeding, composed of granulation tissue, secondary to sx, trauma, infection - tx: excision
neurofibroma
benign nerve sheath tumour, can occur anywhere in the body, comprised of schwann cells, fibroblasts and nerve axons, plexiform neurofibromas typically affect children with NF1, typically affects upper lid and makes an S-shaped deformity
molluscom contagiosum
common self-limiting cutaneous viral infection in healthy children and young adults, caused by poxvirus
verruca vulgaris
benign epithelial hyperplasia of viral origin (HPV), common, low risk of malignancy, variable colour, can be round and flat or finger-like projection from a broad base - tx: excision
Port Wine Stain (nevus flammeus)
rare congenital, subcutaneous lesion, usually unilateral, most often on face, composed of dilated capillaries (congenital weakness of capillary walls), well-demarcated soft pink patch with no blanching, hypertrophy of overlying skin becoming nodular and friable
how can a port wine stain affect glaucoma?
when port wine stain involves upper lid, glaucoma may result from ocular vascular hamartomas causing increased episcleral pressure
sturge-weber syndrome
represented by facial nevus associated with leptomeningeal angiomatosis or ocular vascular hamartomas (such as choroidal hemangioma)
basal cell carcinoma
most common malignant eyelid tumour (90% of all eyelid malignancies) in the elderly M>F, slow-growing, locally invasive, rarely metastatic, madarosis, three main types: nodular, noduloulcerative, morpheaform/sclerosing
which are the prevalent locations for eyelid basal cell carcinoma?
in order: lower lid, medial canthus, upper lid, lateral canthus
nodular BCC
shiny, firm pearly nodule, small dilated surface vessels (telangiectatic), initially very slow growing but can develop an ulcer and become noduloulcerative BCC
noduloulcerative BCC
increased radial growth, the interior of the tumor may outgrow its blood supply, leading to central ulceration. border becomes indurated and seem to roll over, dilated vessels at margins, (rodent ulcer)
morpheaform (sclerosing) BCC
less common, lateral infiltration beneath the epidermis, indurated plaque, margins difficult to delineate, looks like chronic blepharitis
typical presentation of basal cell carcinoma
lump that doesn’t go away, up to 4 years history, very slow growing, like a wound that won’t heal, usually only locally invasive, metastasis is <0.1%
treating BCC:
complete excision and biopsy, referral to oncology for systemic workup and follow-ups with dermatology, avoid further sun damage
actinic keratosis
proliferations of transformed keratinocytes, premalignant, induced by UV exposure, risk of malignancy is <0.24% but if several spots over 10 years risk is 16.9%
Bowen’s disease (carcinoma in situ)
isolated, slightly elevated, red lesion with well-demarcated borders that fail to heal, scaly patch or plaque, can appear in non-sun exposed areas of the body
5% of Bowen’s disease lesions may progress to invasive SCC
Squamous cell carcinoma
less common (<10% of eyelid malignancies), more aggressive than BCC, metastatic in 20% of cases, most common on lower lid and lid margin, possible link to HPV
painless plaques or nodules, may be scaly, crusty or ulcerated
treating SCC:
biopsy to confirm dx, surgical excision with microscopic monitoring of tissue margins (Moh’s sx), radiation or cryo as alternative to sx, refer for oncology workup, avoid further sun damage
observing differences bw eyelid malignancies on slit lamp:
malignancies: loss of lashes, distortion or destruction of Meibomian orifices
BCC - more likely to be translucent, white, or flesh-coloured lesion stretching the skin
SCC - more likely to look flakey on surface, diameter of 1 cm attained in <3mo, grows fast
keratoacanthoma
rare, possibly a spectrum of SCC, higher incidence in immune comprised pts, pink, rapidly growing, hyperkeratotic lesions, lower lid frequently
2x/3x in size in a few weeks, growth cessation for 2-3mos, spontaneous involution - keratin filled crater, significant scar
treating keratoacanthoma:
complete surgical excision, hard to differentiate from SCC
sebaceous (cell/gland) carcinoma
very rare, slow-growing, generally hard yellowish lesion due to presence of lipid, can be misdiagnosed as recurrent chalazion, arises from MGs more common on upper lid
major difference bw sebaceous cell carcinoma and chalazion
sebaceous carcinoma is rock hard and immobile whereas chalazion is more rubbery and not adherent to the skin
what is pagetoid spread?
sebaceous cell carcinoma nodule enlarges, erupts toward eyelid skin and spreads, may look like blepharitis - mistaken for unilateral chronic blepharoconjunctivitis
treating Sebaceous cell carcinoma:
full thickness biopsy, map biopsies, total resection, exenteration may be necessary, palliative radiation
What is the most common cutaneous malignancy?
Basal cell carcinoma (86%)
others are Squamous cell (7%) and Sebaceous (3%)
malignant melanoma
most lethal primary skin tumor, pigmented or not, plaque or lesion, highly metastatic
3 main types: lentigo maligna, superficial spreading, or nodular
suspicious findings for melanoma (ABCDE)
asymmetry, irregular border, inconsistent colour, diameter >6mm, evolving and elevated
scaliness, itching, oozing, pain
lentigo maligna melanoma
10% of melanoma cases, flat tan-brown plaque with irregular borders, occurs on sun-exposed skin, enlarges radially
can form from premalignant Hutchinson’s melanotic freckle (lentigo maligna)
superficial spreading melanoma
most common form of melanoma (70%), plaque with irregular border, pigment variable and inconsistent, quickly develops into a raised nodule
*primarily involves non-exposed skin surfaces (upper back, anterior tibia)
nodular melanoma
bluish black nodule, surrounded by normal skin, aggressive, rare on eyelids, worst prognosis :(
Merkel cell carcinoma
very rare, highly malignant (50% already have metastatic spread at dx) common to lymph nodes, poor prognosis >65% mortality
firm, non-tender, red nodule, smooth surface and shiny
AEIOU signs of Merkel cell carcinoma
common features: AEIOU: asymptomatic, expansion-rapid, immunosuppression, older than 50yrs, UV exposed skin as location
treating Merkel cell carcinoma:
complete excision, lymph node resection, chemo/radiation therapy likely
Kaposi sarcoma
vascular tumor typically assoc. w/ AIDS (occurring in approx. 24-35% of AIDS pts), very malignant, pink/red/violet lesion on face or eyelids, tx-excision or chemo/immunotherapy
