4ChalazionThe meibomian glands are modified sebaceous glands located in the tarsal plates which secrete the outer lipid layer of the precorneal tear film .There are between 30 and 40 glands in the upper tarsus and fewer (20-30) in the lower tarsus (.A chalazion (meibomian cyst) is a chronic inflammatory lesion caused by blockage of meibomian gland orifices and stagnation of sebaceous secretions.Patients with acne rosacea and seborrhoeic dermatitis are at increased risk of chalazion formation.
6Examination shows a painless, roundish, firm lesion in the tarsal plate Eversion of the lid may show an associated polypoid mass (pyogenic granuloma) if the lesion has ruptured through the tarsal conjunctiva.Occasionally, a cyst of the upper lid presses on the cornea and causes blurred vision from induced astigmatism.
7Signs of chalazion (meibomian cyst) Painless, roundish, firm lesionwithin tarsal plateMay rupture through conjunctivaand cause granuloma
8Treatment is usually required for large, persistent lesions although some small chalazia may disappear spontaneously.1. Surgery is by far the most common method of treatment. The eyelid is everted with a special clamp and the cyst is incised and its contents curetted through the tarsal plate .It is very important that a meibomian gland carcinoma or a basal cell carcinoma is not mistaken for 'recurrent chalazion'.In doubtful cases the lesion should be biopsied and examined histologically.
102. Steroid injection into the lesion through the conjunctiva is a good alternative to surgery. The success rate following one injection is about 80%. In unresponsive cases a second injection can be given 2 weeks later.3. Systemic antibiotics may be required as prophylaxis in patients with recurrent chalazia who have associated acne rosacea or seborrhoeic dermatitis.
11External hordeolumThe glands of Zeis are modified sebaceous glands that are associated with the lash follicles.The glands of Moll are modified sweat glands whose ducts open either into a lash follicle or directly onto the anterior lid margin between the lashes.An external hordeolum (stye) is a small abscess caused by an acute staphylococcal infection of a lash follicle and its associated gland of Zeis or Moll.It may be associated with chronic staphylococcal blepharitis.
13External hordeolumExamination shows a tender inflamed swelling in the lid margin which points anteriorly through the skin (.More than one lesion may be present and occasionally minute abscesses may involve the entire lid margin. In severe cases there may be a preseptal cellulitis.
14External hordeolumTreatment in most cases is unnecessary because styes frequently resolve spontaneously or discharge anteriorly, close to the lash roots. Resolution may be promoted by the application of hot compresses and removal of the eyelash associated with the infected follicle. Systemic antibiotics may be necessary if there is severe preseptal cellulitis .
15Internal hordeolumAn internal hordeolum is a small abscess caused by an acute staphylococcal infection of meibomian glands.Examination shows a tender inflamed swelling within the tarsal plate which is usually more painful than a stye. The lesion may enlarge and then usually discharge either posteriorly through the conjunctiva or anteriorly through the skin .Treatment by incision may be required in some cases that do not discharge.
16Acute hordeola Staph. abscess of meibomian glands Internal hordeolum( acute chalazion )External hordeolum (stye)Staph. abscess of meibomianglandsStaph. abscess of lash follicle andassociated gland of Zeis or MollTender swelling within tarsal plateTender swelling at lid marginMay discharge through skinor conjunctivaMay discharge through skin
17Molluscum contagiosum Molluscum contagiosum is an infection caused by one of the pox viruses.Examination typically shows a pale, waxy, umblicated nodule .Ocular irritation may occur as a result of secondary chronic follicular conjunctivitis and superficial keratitis.
18Molluscum contagiosum SignsComplicationsPainless, waxy, umbilicated noduleChronic follicular conjunctivitisMay be multiple in AIDS patientsOccasionally superficial keratitis
19Treatment options include expression, shave excision, cryotherapy or cauterization.
20Strawberry naevus (Capillary haemangioma) Presentation of this rare tumour is typically within the first 6 months of birth.Examination shows a raised red lesion .The tumour usually grows until the age of about 12 months and then starts to involute spontaneously.Complete resolution occurs in 75% of patients by the age of 3 years.
21The upper eyelid is most commonly involved and the tumour may cause a mechanical ptosis. In some cases there is intraorbital extension .
22Capillary haemangioma Rare tumour which presents soon after birthMay be associated with intraorbitalextensionStarts as small, red lesion, most frequentlyon upper lidGrows quickly during first yearBegins to involute spontaneouslyduring second yearBlanches with pressure and swells on crying
23Treatment is indicated if a large tumour threatens to produce amblyopia by either obstructing the visual axis or inducing severe corneal astigmatism.The most frequently used method of treatment is steroid injection of a mixture, in equal parts, of triamcinolone 40 mg/ml and betamethasone 6mg/ml into the lesion using a 30-gauge needle.The tumour usually begins to regress within 2 weeks and, if necessary, second and third injections can be given after about 2 months.Reported but infrequent potential complications of steroid injections include: skin depigmentation, fat atrophy, eyelid necrosis and, very rarely, occlusion of the central retinal artery.
24Port wine stainPresentation is at birth.Examination shows a sharply demarcated pink patch which darkens with age from red to purple (naevus flammeus).The tumour is soft and subcutaneous, and composed of large thin- walled vessels and capillaries.Occasionally the involved skin is also swollen and coarse.The vast majority of lesions occur in isolation, although more extensive lesions involving the first and second divisions of the trigeminal nerve are associated with a 45% incidence of glaucoma, and about 5% are associated with multisystem disorders such as the Sturge-Weber syndrome.
25Treatment with an argon or yellow dye laser can reduce the amount of skin discoloration.
26Port-wine stain (naevus flammeus) Rare, congenital subcutaneous lesionSegmental and usually unilateralDoes not blanch with pressureAssociationsIpsilateral glaucoma in 30%Sturge-Weber orKlippel-Trenaunay-Webersyndrome in 5%
27KeratoacanthomaPresentation is typically in adult life with a fast-growing skin lesion.Examination shows an erythematous papule which turns into a firm, pinkish, indurated nodule with a keratin-filled crater Spontaneous resolution is common but it may take up to a year and leave a scar.
28Treatment involves excision and histological examination because squamous cell carcinoma may have a similar clinical appearance; rarely, a keratoacanthoma may reveal histological evidence of invasive squamous cell carcinoma at deeper levels of sectioning.
29Keratoacanthoma Lesion above surface epithelium Uncommon, fast growing noduleAcquires rolled edges and keratin-filledcraterCentral keratin-filled craterInvolutes spontaneously within 1 yearChronic inflammatory cellular infiltrationof dermis
30Pigmented naeviNaevi (moles) tend to become more pigmented at puberty. Their appearance and classification are determined by their location within the skin as indicated below.An intradermal naevus is usually elevated and may be pigmented or non-pigmented. It is the most common type and, when located on the eyelid margin, lashes may be seen growing through the lesion. It has no malignant potential.A junctional naevus is usually flat and well circum-scribed with a uniform brown colour .The naevus cells contained within the lesion are located at the junction of the epidermis and dermis. It has a low potential for malignant transformation.A compound naevus is characterized by both intradermal and junctional components.
32Naevi Appearance and classification determined by location within skin Tend to become more pigmented at pubertyIntradermalJunctionalCompoundElevatedFlat, well-circumscribedHas both intradermaland junctionalcomponentsMay be non-pigmentedPigmentedNo malignant potentialLow malignant potential
33Miscellaneous lesions A cyst of Moll is a small, round, non-tender, translucent fluid-filled lesion on the anterior lid marginA cyst of Zeis is similar but, because it contains oily secretions, it is less translucent .A sebaceous cyst arises from an ordinary sebaceous gland and is characterized by a central punctum with retained cheesy secretions. It is rarely found on the eyelid although it may occur at the inner canthus .
34Eyelid cysts Eccrine sweat gland hidrocystoma Cyst of Moll TranslucentOn anterior lidmarginSimilar to cyst of MollNot confined to lidmarginCyst of ZeisSebaceous cystOpaqueOn anterior lidmarginCheesy contentsFrequently atinner canthus
35Milia are small, white, round, superficial cysts which tend to occur in crops. They are derived from hair follicles or sebaceous glands .Squamous cell papilloma is the most common benign tumour of the eyelids. It may be broad based (sessile) or pedunculated .Seborrhoeic keratosis (basal cell papilloma) is a slow-growing, discrete, greasy, brown, round or oval lesion with a friable verrucous surface .
36Keratoses Common in elderly Affects elderly, fair-skinned individuals SeborrhoeicActinicCommon in elderlyAffects elderly, fair-skinned individualsDiscrete, greasy, brown lesionMost common pre-malignant skin lesionFriable verrucous surfaceRare on eyelidsFlat ‘stuck-on’ appearanceFlat, scaly, hyperkeratotic lesion
37Xanthelasma Common in elderly or those with hypercholesterolaemia Yellowish, subcutaneous plaquescontaining cholesterol and lipidUsually bilateral and located medially
38Viral wart (squamous cell papilloma) Most common benign lid tumourRaspberry-like surfacePedunculatedSessile
39Actinic keratosis is characterized by a rough, dry, scaly lesion on an erythematous base . It typically affects elderly fair-skinned individuals who have been exposed to excessive sunlight. It is a pre-malignant lesion because it may occasionally undergo transformation into a squamous cell carcinoma.Xanthelasmata are yellowish subcutaneous plaques of cholesterol and lipid which typically occur at the medial aspects of the eyelids in elderly individuals .A cutaneous horn is frequently associated with an underlying dysplastic (e.g. actinic keratosis) or neoplastic (e.g. squamous cell carcinoma) lesion. The lesion should therefore be biopsied and a portion of the base excised to determine the underlying pathology.