Lids 2 - common eyelid disorders and their management Flashcards
Eyelid (palpebral alpeture) facts:
• 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
Entropion types:
•Interning of eyelid
•Can either be congenital or acquired.
•Acquired:
- Senile
- Spastic
- Cicatricial
Involutional entropion:
• 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
Entropion symptoms:
•FB sensation
•Epiphora
•Constant irritations
•Recurrent infections
•Corneal abrasion causing marked photophobia
Management of entropion (non surgical)
•Ocular lubricants
• Antibiotic ointments for infection
• Eyelid taping is an effective temporary measure
•Botox injection to the lower eyelid can temporarily correct entropion
Surgical management of entropion
•Horizontal lid laxity
- Lid shortening/tendons
•Retractors muscle
- Everting sutures/plication
•Tarsus plate
- Everting sutures
•Orbicularis
- Transverse lid split
Eyelid everting sutures :
Sutures eyelids tight to help entropion where there is laxity issues
What is Cicatricial entropion?
•Normally caused by conjunctival contraction due to cicatrisation of conjunctiva
•Chemical injuries
•Inflammatory conditions
- Stevens-Johnsons etc
Cicatricial entropion - Treatment
•More challenging to treat
•Disease process need to be arrested
•Release of scar tissue and posterior lamellar graft often required (mucous membrane)
Spastic entropion Symptoms:
• Ocular irritation
• Secondary blepharospasm
• Botox may help
Ectropion - Classification
•Can either be Congenital or acquired
- Involutional
- Paralytic
- Mechanical
- Cicatricial
Involutional Ectropion
•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.
Ectropion - Symptoms
• Asymptomatic
• Epiphora
• Exposed chronically irritated conjunctiva
• Eyelid skin changes
What laxity tests can be used for an involutional ectropion/entropion?
•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)
Mechanical ectropion
• Eyelid tumours/lesions causing ectropion by their weight
• Treatment - removal of lesion +/- eyelid tightening
Paralytic ectropion
• VII nerve palsy
• Inadequate eyelid closure (Lagophthalmos)
• Often associated with MCT and LCT laxity
• Brow ptosis
Management if Paralytic ectropion
• 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
Cicatricial Ectropion
• Eyelid scarring from previous trauma/surgery
• Some cicatrising tumours
Medical management of ectropion
• Lubricants for dry eye
• Antibiotics for infection
• Skin emollients for cicatricial changes
Surgical management of ectropion examples:
•Lateral tarsal strip - simple
•Sutures
• Cicatricial can be complex as needs plastic surgery to relieve scar tissue
Ptosis definition:
• 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
Classification of Ptosis:
Classification
1. Congenital or acquired
2. ‘True or pseudoptosis
• Etiologic classification:
- Aponeurogenic (senile)
- Myogenic
- Neurological
- Mechanical
Aponeurotic (sensile) ptosis:
• Weakness of levator aponeurosis
• Droopy upper eyelid - worse at the end of the day
• High/absent skin crease
Myogenic Ptosis:
• 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
Neurogenic Ptosis
• Oculomotor nerve palsy
• Ptosis, fixed dilated pupil, paralysis of MR, SR, IR, IO
• Horners syndrome
Mechanical Ptosis
•Eyelid swelling
•Eyelid tumours
Pseudoptosis:
• Loss of volume - Artificial Eye, Pthisis bulbi, Microphthalmos
• Contralateral eyelid retraction
• Ipsilateral hypotropia
• Enophthalmos
• Brow ptosis
• Dermatochalesis
History taking during Ptosis:
• Onset - congenital vs acquired (looking at old photos often helpful)
• Family history
• Trauma
• Previous ocular surgery
• Contact lens wear
• Diplopia, variability
Ptosis evaluation procedure:
• Rule out pseudoptosis
• Cover test/ocular motility - muscle imbalance
• Pupil evaluation - neurogenic ptosis
• Check for jaw winking
• Levator fatigue
Ptosis correction:
• 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
Malignant eyelid tumours classification (order of frequency)
• Basal cell carcinoma
• Squamous cell carcinoma
• Sebaceous carcinoma
• Malignant Melanoma
Basal cell carcinoma + risk factors?
• 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
Basal cell carcinoma appearance:
• 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.
Basal Cell Carcinoma Management:
• Biopsy to prove diagnosis
• Surgical excision
• Mohs micrographic surgery
• Cryotherapy
• Radiotherapy
Squamous Cell Carcinoma
• 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
Squamous Cell Carcinoma appearance:
• 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
Squamous Cell Carcinoma - Management
• If no distant spread - surgical excision with frozen section control and wide excision margins
• If distant spread - palliative
Sebaceous Cell Carcinoma
• 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%
Eyelid Malignant Melanoma
• 1% of eyelid malignant tumours
• Pigmented tumours
• Distant spread common
• Treatment - wide surgical excision and management of metastases
How to differentiate between Benign and Malignant lesions?
•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
What are all the lumps that could be associated with the eyelid?
•Hordeolum
•chalazion
•Molluscum contagiosum
•Xanthelasma
•Papilloma
•Basal cell carcinoma
•Squamous cell carcinoma
•malignant melanoma
•Epidermoid cyst
•Cyst of moll
