Lids 2 - common eyelid disorders and their management

Question 1

Eyelid (palpebral alpeture) facts:

Answer 1

• Medial canthus 1mm lower than lateral canthus
• Upper eyelid skinfold
• (eye closed) Upper eyelid skin crease due to insertion of levator aponeurosis
•Insertion of levator muscle skin fold+crease
- also inserts into tarsal plate: elevating eyelid
•Mullers muscle below levator, attaches to upper border of tarsal plate: Leads to horners syndrome if dysfunctional
• Fat pad above levator: gives fullness to upper lid, it can collapse into eyelid as we get older, giving baggy eyelid
•Eyelid in east asian people inserts lower into skin + fat pad is also lower than caucasian

Question 2

Entropion types:

Answer 2

•Interning of eyelid
•Can either be congenital or acquired.
•Acquired:
- Senile
- Spastic
- Cicatricial

Question 3

Involutional entropion:

Answer 3

• Most common, two causes :
• Retractors - laxity, dehiscence, disinsertion, Horizontal eyelid laxity

• Over-riding orbicularis
- Overriding of preseptal over pretarsal orbicularis during lid closure
- Weakness of lower lid retractors

Question 4

Entropion symptoms:

Answer 4

•FB sensation
•Epiphora
•Constant irritations
•Recurrent infections
•Corneal abrasion causing marked photophobia

Question 5

Management of entropion (non surgical)

Answer 5

•Ocular lubricants
• Antibiotic ointments for infection
• Eyelid taping is an effective temporary measure
•Botox injection to the lower eyelid can temporarily correct entropion

Question 6

Surgical management of entropion

Answer 6

•Horizontal lid laxity
- Lid shortening/tendons
•Retractors muscle
- Everting sutures/plication
•Tarsus plate
- Everting sutures
•Orbicularis
- Transverse lid split

Question 7

Eyelid everting sutures :

Answer 7

Sutures eyelids tight to help entropion where there is laxity issues

Question 8

What is Cicatricial entropion?

Answer 8

•Normally caused by conjunctival contraction due to cicatrisation of conjunctiva
•Chemical injuries
•Inflammatory conditions
- Stevens-Johnsons etc

Question 9

Cicatricial entropion - Treatment

Answer 9

•More challenging to treat
•Disease process need to be arrested
•Release of scar tissue and posterior lamellar graft often required (mucous membrane)

Question 10

Spastic entropion Symptoms:

Answer 10

• Ocular irritation
• Secondary blepharospasm
• Botox may help

Question 11

Ectropion - Classification

Answer 11

•Can either be Congenital or acquired
- Involutional
- Paralytic
- Mechanical
- Cicatricial

Question 12

Involutional Ectropion

Answer 12

•Similar changes as for entropion
• Main difference is orbicularis - in entropion there is over-riding but not in ectropion.
• When lid margin begins to evert, conjunctiva begins to get exposed resulting in tarsus thickening further exacerbating ectropion.

Question 13

Ectropion - Symptoms

Answer 13

• Asymptomatic
• Epiphora
• Exposed chronically irritated conjunctiva
• Eyelid skin changes

Question 14

What laxity tests can be used for an involutional ectropion/entropion?

Answer 14

•Medial canthal tendon laxity test
- Pull the eyelid laterally and observe punctal migration
1-2mm migration - Normal
- Up to limbus - mild MCT laxity
- Limbus to pupil - mod laxity
- Beyond pupil - Severe MCT laxity
•Lateral canthal tendon laxity test
- Observe lateral canthal angle
(normally acute angle)
- Rounded canthus - LCT laxity
- Pull lid medially and observe lat canthal migration (normal <2mm)

Question 15

Mechanical ectropion

Answer 15

• Eyelid tumours/lesions causing ectropion by their weight
• Treatment - removal of lesion +/- eyelid tightening

Question 16

Paralytic ectropion

Answer 16

• VII nerve palsy
• Inadequate eyelid closure (Lagophthalmos)
• Often associated with MCT and LCT laxity
• Brow ptosis

Question 17

Management if Paralytic ectropion

Answer 17

• Aim of treatment - protect cornea, improve cosmesis
• Ocular Lubrication and
• Lower eyelid tightening
• Lower eyelid slings
• Lagophthalmos may need correction with upper lid lowering with gold weights

Question 18

Cicatricial Ectropion

Answer 18

• Eyelid scarring from previous trauma/surgery
• Some cicatrising tumours

Question 19

Medical management of ectropion

Answer 19

• Lubricants for dry eye
• Antibiotics for infection
• Skin emollients for cicatricial changes

Question 20

Surgical management of ectropion examples:

Answer 20

•Lateral tarsal strip - simple
•Sutures
• Cicatricial can be complex as needs plastic surgery to relieve scar tissue

Question 21

Ptosis definition:

Answer 21

• Abnormal low-lying upper eyelid margin with the eye in primary gaze
• Normal adult UL - about 1.5mm below superior corneal limbus
• Highest point just nasal to pupil

Question 22

Classification of Ptosis:

Answer 22

Classification
1. Congenital or acquired
2. ‘True or pseudoptosis
• Etiologic classification:
- Aponeurogenic (senile)
- Myogenic
- Neurological
- Mechanical

Question 23

Aponeurotic (sensile) ptosis:

Answer 23

• Weakness of levator aponeurosis
• Droopy upper eyelid - worse at the end of the day
• High/absent skin crease

Question 24

Myogenic Ptosis:

Answer 24

• Ptosis secondary to generalised muscular diseases that affect the eye
• Often in younger patients

• Myasthenia Gravis - variable ptosis, diplopia, other systemic disorders
• Chronic progressive external ophthalmoplegia
• Myotonic dystrophy

Question 25

Neurogenic Ptosis

Answer 25

• Oculomotor nerve palsy
• Ptosis, fixed dilated pupil, paralysis of MR, SR, IR, IO
• Horners syndrome

Question 26

Mechanical Ptosis

Answer 26

•Eyelid swelling
•Eyelid tumours

Question 27

Pseudoptosis:

Answer 27

• Loss of volume - Artificial Eye, Pthisis bulbi, Microphthalmos
• Contralateral eyelid retraction
• Ipsilateral hypotropia
• Enophthalmos
• Brow ptosis
• Dermatochalesis

Question 28

History taking during Ptosis:

Answer 28

• Onset - congenital vs acquired (looking at old photos often helpful)
• Family history
• Trauma
• Previous ocular surgery
• Contact lens wear
• Diplopia, variability

Question 29

Ptosis evaluation procedure:

Answer 29

• Rule out pseudoptosis
• Cover test/ocular motility - muscle imbalance
• Pupil evaluation - neurogenic ptosis
• Check for jaw winking
• Levator fatigue

Question 30

Ptosis correction:

Answer 30

• Depends on strength of levator palpebrae superioris
• Degree of eyelid excursion from downgaze to upgaze determines levator function
• If levator function good then levator resection surgery is appropriate
• Brow suspension procedures for patients with very poor levator function

Question 31

Malignant eyelid tumours classification (order of frequency)

Answer 31

• Basal cell carcinoma
• Squamous cell carcinoma
• Sebaceous carcinoma
• Malignant Melanoma

Question 32

Basal cell carcinoma + risk factors?

Answer 32

• Commonest malignant tumour of the eyelids
• 90% of all eyelid malignant tumours
• Lower eyelid and medial canthus most commonly involved

Risk factors:
• Sun exposure - ultraviolet light
• Caucasians, usually over 50
• AIDS patients at risk of multiple BCCs

Question 33

Basal cell carcinoma appearance:

Answer 33

• Typical appearance - nodular lesion with pearly white edges, central ulceration
• Painless, slowly growing
• Spreads locally
• Morphoeic BCC - indistinct, spread under the skin Overlying skin scarring, loss of eyelashes should alert to the possibility.

Question 34

Basal Cell Carcinoma Management:

Answer 34

• Biopsy to prove diagnosis
• Surgical excision
• Mohs micrographic surgery
• Cryotherapy
• Radiotherapy

Question 35

Squamous Cell Carcinoma

Answer 35

• Second most common eyelid malignancy
• Typically over 70 years
• Fair skinned patients with history of chronic sun exposure
• Patients with lymphoma, leukaemia, organ transplant patients on immunosuppression more at risk

Question 36

Squamous Cell Carcinoma appearance:

Answer 36

• Typically occurs at eyelid margin
• Painless slightly raised plaque or nodule with central ulceration, crusting or scaling
• More aggressive than BCC and can spread to sinuses and orbit
• Distant metastasis can occur

Question 37

Squamous Cell Carcinoma - Management

Answer 37

• If no distant spread - surgical excision with frozen section control and wide excision margins
• If distant spread - palliative

Question 38

Sebaceous Cell Carcinoma

Answer 38

• Third most common eyelid malignancy
• Arises from meibomian glands and sebaceous glands of eyelids, eyebrow and caruncle
• Typically affects eyelid margins with gradual thickening and loss of eyelashes
• Can present as persistant blepharitis, recurrent chalazia
• Distant metastasis common
• Surgical treatment involves excision of tumour with frozen section control and reconstruction
• Recurrences in upto 36% patients after excision 10 year mortality 28%

Question 39

Eyelid Malignant Melanoma

Answer 39

• 1% of eyelid malignant tumours
• Pigmented tumours
• Distant spread common
• Treatment - wide surgical excision and management of metastases

Question 40

How to differentiate between Benign and Malignant lesions?

Answer 40

•Benign eyelid lesion
- Usually well defined
- Overlying skin architecture preserved
- Surface ulceration uncommon

•Malignant eyelid lesions
- Margins often indistinct (except in nodular BCC)
- Gradual destruction of overlying skin architecture
- Surface ulceration of skin common
- Loss of eyelashes in lid margin lesions

Question 41

What are all the lumps that could be associated with the eyelid?

Answer 41

•Hordeolum
•chalazion
•Molluscum contagiosum
•Xanthelasma
•Papilloma
•Basal cell carcinoma
•Squamous cell carcinoma
•malignant melanoma
•Epidermoid cyst
•Cyst of moll