Disorders of the Eyelids Dr.Mazen Khwaira

Disorders of the Eyelids   Benign eyelid lesions       Malignant eyelid tumours       Disorders of eyelashes       Entropion       Ectropion       Ptosis

Benign Eyelid Lesions Chalazion� External hordeolum � Internal hordeolum  �    Molluscum contagiosum  �    Strawberry naevus  �    Port wine stain �    Keratoacathoma  �    Pigmented naevi  �    Miscellaneous lesions

Chalazion The 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.

Examination 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.

Signs of chalazion (meibomian cyst) Painless, roundish, firm lesion within tarsal plate May rupture through conjunctiva and cause granuloma

Treatment 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.

2. 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.

External hordeolum The 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.

External hordeolum Examination 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.

External hordeolum Treatment 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 .

Internal hordeolum An 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.

Acute hordeola Staph. abscess of meibomian glands Internal hordeolum ( acute chalazion ) External hordeolum (stye) Staph. abscess of meibomian glands Staph. abscess of lash follicle and associated gland of Zeis or Moll Tender swelling within tarsal plate Tender swelling at lid margin May discharge through skin or conjunctiva May discharge through skin

Molluscum 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.

Molluscum contagiosum Signs Complications Painless, waxy, umbilicated nodule Chronic follicular conjunctivitis May be multiple in AIDS patients Occasionally superficial keratitis

Treatment options include expression, shave excision, cryotherapy or cauterization.  

Strawberry 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.

The upper eyelid is most commonly involved and the tumour may cause a mechanical ptosis. In some cases there is intraorbital extension .

Capillary haemangioma Rare tumour which presents soon after birth May be associated with intraorbital extension Starts as small, red lesion, most frequently on upper lid Grows quickly during first year Begins to involute spontaneously during second year Blanches with pressure and swells on crying

Treatment 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.

Port wine stain Presentation 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.

Treatment with an argon or yellow dye laser can reduce the amount of skin discoloration.

Port-wine stain (naevus flammeus) Rare, congenital subcutaneous lesion Segmental and usually unilateral Does not blanch with pressure Associations Ipsilateral glaucoma in 30% Sturge-Weber or Klippel-Trenaunay-Weber syndrome in 5%

Keratoacanthoma Presentation 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.

Treatment 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.

Keratoacanthoma Lesion above surface epithelium Uncommon, fast growing nodule Acquires rolled edges and keratin-filled crater Central keratin-filled crater Involutes spontaneously within 1 year Chronic inflammatory cellular infiltration of dermis

Pigmented naevi Naevi (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.

Intradermal naevus Junctional naevus

Naevi Appearance and classification determined by location within skin Tend to become more pigmented at puberty Intradermal Junctional Compound Elevated Flat, well-circumscribed Has both intradermal and junctional components May be non-pigmented Pigmented No malignant potential Low malignant potential

Miscellaneous lesions A cyst of Moll is a small, round, non-tender, translucent fluid-filled lesion on the anterior lid margin A 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 .

Eyelid cysts Eccrine sweat gland hidrocystoma Cyst of Moll Translucent On anterior lid margin Similar to cyst of Moll Not confined to lid margin Cyst of Zeis Sebaceous cyst Opaque On anterior lid margin Cheesy contents Frequently at inner canthus

Milia 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 .

Keratoses Common in elderly Affects elderly, fair-skinned individuals Seborrhoeic Actinic Common in elderly Affects elderly, fair-skinned individuals Discrete, greasy, brown lesion Most common pre-malignant skin lesion Friable verrucous surface Rare on eyelids Flat ‘stuck-on’ appearance Flat, scaly, hyperkeratotic lesion

Xanthelasma Common in elderly or those with hypercholesterolaemia Yellowish, subcutaneous plaques containing cholesterol and lipid Usually bilateral and located medially

Viral wart (squamous cell papilloma) Most common benign lid tumour Raspberry-like surface Pedunculated Sessile

Actinic 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.