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Clinical Ophthalmology > Lids > Flashcards

Lids Flashcards

1
Q

Levator muscle

A
  • elevates eyelid, weakness would lead to a droopy eyelid
  • responsible for upper eyelid skin fold and skin crease
  • inserts into the skin and the other part inserts into the anterior surface of the tarsal plate
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2
Q

Mullers muscle

A
  • small extension on the under surface of the levator
  • dysfunction leads to Horners syndrome
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3
Q

East Asian vs Caucasian

A
  • levator muscle in an East Asian eyelid usually inserts much lower on the skin
  • orbital fat also much more anteriorly placed causing the eyelid skin fold to come on top of lashes
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4
Q

Entropion

A
  • in-turning of eyelid towards eye
  • most commonly affects the lower eyelid but can affect upper eyelid as well
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5
Q

Entropion symptoms

A
  • constant irritation (lashes rubbing against ocular surface)
  • FB sensation
  • blurring of vision
  • recurrent infections?
  • red eye
  • watery eye/epiphora?
  • corneal abrasion causing marked photophobiaocula
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6
Q

Entropion (involutional)

A
  • most common
  • caused by an increase in lid laxity (age related)
  • over riding of the orbicularis muscle
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7
Q

Entropion (involutional) management

A
  • ocular lubricants (reduce FB sensation and protect ocular surface)
  • antibiotic ointment for infection
  • eyelid tapping to pull lid mechanically into normal position for a few hrs at a time
  • everting sutures temporarily correct (more permanent than lid taping)
  • Botox injection to lower eyelid can temporarily correct entropion
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8
Q

Entropion (cicatricial)

A
  • scarring and contraction of palpebral conj pulls lid margin inwards
  • e.g. Stevens-Johnson syndrome, chronic bleph, chemical burns
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9
Q

Entropion (cicatricial) management

A
  • more difficult to treat
  • disease process needs to be arrested
  • followed by complex surgery to release scar tissue in conj and having to put posterior lamellar (mucous membrane) grafts taken from inside mouth
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10
Q

Entropion (spastic)

A
  • caused by spastic contraction of orbicularis muscle triggered by ocular irritation
  • or due to secondary blepahrospasm
  • often in elderly px’s with dementia or young children who squeeze (their eye?) quite hard in response to pain in the eye, makes the ocular surface worse (sets a vicious cycle)
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11
Q

Entropion (spastic) management

A
  • usually resolves spontaneously once cause has been removed
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12
Q

Snap back test method (for lid laxity)

A
  • pull lower lid down with finger at centre of orbital rim
  • release and observe return of eye
  • normal - quickly snaps back
  • mild lid laxity - slowly snaps back
  • moderate lid laxity - returns with blink
  • severe lid laxity - incomplete return, does not go back to normal position easily
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13
Q

Ectropion

A

Outward turning of the eyelid margin

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14
Q

Ectropion symptoms

A
  • many px’s asymptomatic
  • painful, red eye
  • epiphora - tears have no access to tear duct and leak down from eye
  • eyelid skin changes - due to irritation of salty tears running down skin
  • exposed chronically irritated conjunctiva (advanced cases)
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15
Q

Ectropion (involutional)

A
  • increased lid laxity
  • main difference is orbicularis - in entropion there is overriding which makes the eyelid turn in, in ectropion orbicularis is unchanged causing eyelid to drop down with gravity?
  • when eyelid everts - exposes conjunctiva, becomes more inflamed making ectropion worse over time
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16
Q

Ectropion (cicatricial)

A
  • scarring of skin and underlying tissue
  • e.g. trauma, burns, skin tumours
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17
Q

Ectropion (cicatricial) management

A
  • allow to resolve itself if asymptomatic and no ocular surface damage
  • ocular lubricants if irritation/epiphora
  • skin emollients (Vaseline) will protect ocular surface if skin changes in the lower lid due to tears irritating it
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18
Q

Ectropion (paralytic)

A
  • caused by 7th CN palsy
  • paralysis of ortbicularis muscle, support to lower lid lost and so hangs down
  • lagophthalmos - unable to close eyes
  • often associated with MCT and LCT laxity
  • brow ptosis often seen due to loss of function of frontaleis muscle of brow
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19
Q

Ectropion (paralytic) management

A
  • aim - protect cornea (as eye can’t close) to avoid corneal infection and vision loss
  • some px’s recover spontaneously as 7th CN palsy’s often recover in 3-6 months
  • some px’s only need ocular lubricants
  • others may need a temporary tarsorrhaphy - stitch between upper and lower tarsal plate to close eyelid permanently until it closes itself
  • if no recovery in 3-6 months, surgical procedures can tighten lower eyelid either by stitches or using eyelid slings
  • lagophthalmos may need correction with upper lid lowering with gold weighs (to cause a small ptosis) which helps close the eye mechanically
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20
Q

Ectropion (mechanical)

A
  • eyelid tumours/lesions causing ectropion due to their weight
  • lid swelling due to inflammation from an infection or allergies
21
Q

Ectropion (mechanical) management

A
  • treating the lesion and removing it will cause the eyelid to snap back into position
  • often accompanied by eyelid tightening (may have hung down for multiple months)
22
Q

Lid laxity - medial canthal tendon method

A
  • pull eyelid down laterally and observe position of lacrimal punctum
  • 1-2mm migration = normal
  • up to limbus = mild MCT laxity
  • limbus to pupil = moderate MCT laxity
  • beyond pupil = severe MCT laxity
23
Q

Lid laxity - lateral canthal tendon method

A
  • observe lateral canthal angle (normally acute angle)
  • pull lid medially and observe LCT migration
  • rounded canthus - LCT laxity
24
Q

Chalazion

A
  • painless swelling/lump on the eyelid due to a blocked MG
25
Q

Chalazion management

A
  • reassure benign and self-limiting
  • advise may take months or weeks
  • often settles down with a hot compress (5 mins, 2 x daily)
  • recommend lid massage (after compress, TOWARDS lid margin)
  • consider routine referral if: persistent (>2 months), recurrent, large or affects vision
  • ophth may consider incision and curettage or steroid injection
26
Q

Hordeolum

A
  • acute staphylococcal infection which presents in base of eyelash follicle
  • localised eyelid swelling with a central pus point, will spontaneously burst at some point with small pus discharge
  • often self-limiting
  • external - glands of moll & zeiss infection
  • internal - MG infection
27
Q

Hordeolum management

A
  • reassure benign, will settle over time
  • consider eyelash epilators to encourage discharge
  • warm compress (5 mins, 2 x daily)
  • lid massage (after compress, TOWARDS lid margin)
  • consider antibiotic drops (chloramphenicol) if significant discharge
  • ophth may consider possible incision, oral antibiotic (amoxicillin) for severe and recurrent cases
28
Q

Moluscum Kontagiosum

A
  • low grade viral infection
  • typical pres - raised, well defined, slightly pearly edges, umbilicated centre
  • same pres can also be in a BCC
  • doesn’t cause problems unless on eyelid as can cause chronic low grade follicular conjunctivitis
29
Q

Moluscum Kontagiosum management

A
  • self-limiting (weeks/months)
  • excision if causing problems or can be left to resolve over time
30
Q

Benign Epidermoid Cyst

A
  • smooth, well defined, white lesion with normal skin architecture over it
  • sometimes a few dilated BV’s due to stretching of skin
  • completely harmless
  • only reason to remove would be cosmetic
31
Q

Cysts of Moll/Hydrocystoma

A
  • clear fluid filled translucent lesions typically seen on the lid margin
  • painless and entirely benign
  • only reason to remove would be cosmetic
32
Q

Dermoid Cyst

A
  • benign lesion
  • typically occurs in our upper corner or inner inner upper corner of orbit
  • smooth, well defined lesion often attached to orbital rim
33
Q

Benign Naevus

A
  • similar to moles
  • difference in diagnosis here would be from a melanoma (malignant condition, any change in size or shape if this lesion should raise concern of being malignant)
34
Q

Squamous Papilloma

A
  • multiple eyelid skin tags
  • usually in the eyelids, neck or armpits
  • benign
  • treatment - surgical incision
35
Q

Xanthelasma

A
  • deposition of cholesterol just under skin
  • typically happens on upper and lower eyelids
  • more common in those with raised cholesterol but can happen in anybody
  • treatment is laser or surgical excision
  • can often reappear after treatment
36
Q

Malignant Eyelid Tumours

A
  • basal cell carcinoma
  • squamous cell carcinoma
  • sebaceous carcinoma
  • malignant melanoma
37
Q

Basal Cell Carcinoma Risk factors

A
  • due to chronic sun exposure and UV light
  • caucasian more prone
  • can also happen in area exposed to sunlight (scalp, neck, face etc)
  • px’s with low immunity at risk of multiple
38
Q

Basal cell carcinoma (typical appearance)

A
  • nodular lesion with pearly edges with a central ulceration
  • painless and grows slowly
  • spreads locally and doesn’t spread to other parts of the body, once removed results in complete cure
  • morphoeic BCC - indistinct edges and can spread under the skin, can become quite extensive locally
  • changes to skin overlying lesion, loss of lashes, loss of normal skin hair should alert to malignant eyelid tumour
39
Q

Basal cell carcinoma vs Moluscum kontagiosum

A
  • moluscum typically in younger px’s
  • NO LOSS OF LASHES in moluscum
40
Q

Basal cell carcinoma (management)

A
  • biopsy to prove diagnosis
  • surgical excision - as long as whole lesion is removed
  • mohs micrographic surgery (when edges not well defined)
  • cryotherapy or radiotherapy (for those with extensive disease or unfit for surgery)
41
Q

Squamous Cell Carcinoma risk factors

A
  • typically affects px over 70
  • fair skinned px’s with history of chronic sun exposure more commonly affected
  • px’s with lymphoma, leukaemia, HIV etc more at risk
42
Q

Squamous cell carcinoma (typical presentation)

A
  • typically at eyelid margin
  • not as well defined as BCC
  • painless, slightly raised plaque or nodule with a central ulceration, crusting or scaling
  • more aggressive than BCC (can enlarge more rapidly and spread to orbit and sinuses)
43
Q

Squamous cell carcinoma (management)

A
  • if no distant spread - surgical excision with wide margin is preferred
  • prognosis excellent as long as not spread
  • if spread, often palliative treatment, risk of death over 5 yrs significant
44
Q

Sebaceous Cell Carcinoma

A
  • arises from MG and sebaceous glands of eyelids, eyebrow and caruncle
  • typically affects eyelid margin with gradual loss thickening and LOSS OF LASHES
  • can present as recurrent chalazia or persistent blepharitis
45
Q

Sebaceous cell carcinoma (management)

A
  • distant metastasis to other body parts common
  • surgical treatment involves excision of tumour with frozen section control and reconstruction
  • recurrence rates of these tumours very high (almost 1/3 of px’s after excision)
  • 1/4 of these px’s will die within 10 yrs of diagnosis
46
Q

Eyelid Malignant Melanoma

A
  • pigmented tumours that enlarge rapidly
  • spread to other body parts often resulting in death over time
  • treatment - wide surgical incision, and then manage metastasis
  • regular and variable pigmentation with distortion of surrounding architecture should raise suspicion of MM
47
Q

Malignant melanoma vs Benign naevus

A
  • variability in colour of the lesion at different parts is classic presentation of MM
  • naevus is uniformly pigmented
48
Q

Benign vs Malignant

A
  • benign usually well defined
  • malignant often indistinct (except in nodular BCC)
  • benign - overlying skin architecture
  • malignant - gradual destruction of overlying skin architecture
  • benign - surface ulceration uncommon
  • malignant - surface ulceration of skin common

MALIGNANT - LOSS OF EYELASHES IN LID MARGIN LESIONS

Clinical Ophthalmology (10 decks)

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