1. Goal’s for Today Lagophthalmos Blepharospasm Blepharoclonus Myokymia
Trichiasis
Poliosis
Madarosis
Ingrown Cilia
Dermatochalaisis
Blepharochalaisis
Herniation of Orbital Fat
Papilloma/Verruca
Cutaneous Horn/Tag
Seborrheic Keratosis
Keratocanthoma
Dermoid
Sebaceous Gland Cysts
Sudoriferous Cysts
Nevus

2. Dear Dr. Golden Eye:
My friends say that I am super hyper and that I do not like things to pass me by. Recently, my new girlfriend took a picture of me when I was sleeping and posted the picture below. Now that I think about it, my eyes do feel a bit irritated.
What’s going on?
What are the common causes of my condition?
Clue me on your evaluation of me?
What can you do for me (treatment / management)?
Signed:
Peek-a-boo

3. Lagophthalmos
Inability to completely close the lids; remain open 2-5mm
Significance
Usually results in exposure of the globe causing epithelial dessication; c/o dry, scratchy eye, possibly secondary infection and/or corneal ulcers. Sterile ulcers can result

4. Common causes/classification
Paralytic of orbicularis
(CN VII palsy) - Bell's palsy
Orbital
Corneal apex more anterior than normal (keratoconus)
Differential diagnosis includes:
Globe displaced forward (retrobulbar mass, thyroid disease)
Larger than normal axial length
Shallow orbit (rare)

6. Neurogenic
Stimulation of retractors (Mueller's muscle)
Hyperthyroidism (Grave's disease) is most common cause
Mechanical
Scarring
Active lid disease
Physiological or nocturnal lagophthalmos

7. Signs and symptoms
During sleep lids not in apposition -> tear film evaporation - epithelial dessication
Symptoms of dry, scratchy, irritated eye upon awakening
Look for punctate epitheliopathy across inferior cornea - this may not be present or may be positioned elsewhere
Check for Bell's phenomenon (although this is probably unrelated to position of globe during sleep)

8. Check passive lid closure, may need to recline patient
Ask spouse if patient sleeps with eyes open
Check whether blink is complete. Check blink rate
Evaluate for anterior segment diseases, especially blepharitis

9. Management
Mild symptomatic lagophthalmos
Artificial tears PRN (Q1H to QID recommended)
Bland ophthalmic ointment HS if needed (Lacrilube)
Moderate
Artificial tears PRN, ophthalmic lubricants hs
Tape from cheek to brow/forehead while pulling lower lid up
Moisture chamber (Saran Wrap sealed with tape - Transpore surgical tape or Dermocel)

10. Use broad spectrum antibiotics (TABLES on pages 14 and 15) if significant corneal epithelial dessication or damage (to prevent secondary infection)
Surgery (tarsorrhaphy)
Must have regular follow up to rule out infection or serious drying; every 3 months or more frequently.

11. Blepharospasm Involuntary contraction of orbicularis
Generally bilateral and symmetric, though onset may be unilateral
Older individuals, females > males

12. Severity progresses over 6 months to 3 years
Does not occur during sleep
Fatigue and stress may increase intensity
Unknown cause, possibly due to chemical imbalance and/or misfiring of neurons of basal ganglia

13. Signs and Symptoms Involuntary lid closure
Facial muscles (jaw, tongue, lower face, mouth)
May be so severe as to cause secondary tempero-mandibular joint syndrome (TMJ)
Various sensory "tricks" may suppress the severity of the contractions
Commonest is placing a finger at the lateral margin of the orbit
Others: coughing, yawning, talking, humming, or singing

14. Differential diagnosis very complicated
Ocular disease
Myokymia
Tardive dyskinesia caused by antipsychotic medications (Prolixin, Haldol)
Various neurological disorders
Functional (hysterical)

15. Treatment Counseling since patient is quite self-conscious
Counseling for depression since many activities of daily life and work are interrupted
Medications interfering with nerve conduction are variably, but not consistently successful

16. Botulin A toxin injections
Interferes with neural transmission
Relief of symptoms averages 3 months
Typical side effects:
Ptosis
Subcutaneous hemorrhage at injection site
Dry eyes
Double vision
Exposure keratitis
Side effects resolve as toxin wears off

17. Onset of action after injection: 2-3 days
Full benefit: 5 days
Peak effect: 2-4 weeks
Duration of clinical benefit: 3-4 months, but can vary from few weeks to 6 months

18. Surgery
Myectomy and/or partial neurectomy
Myectomy removes squeezed muscles in upper lid, eyebrows, forehead, and base of nose
Neurectomy consists of resection and removal of small facial nerve branches innervating orbicularis
Referral to national support groups and organizations for individuals with blepharospasm

19. Blepharoclonus
Exaggerated reflex blinking characterized by increased blink rate or length of lid closure time
Causes
Often no cause found
Commonly in children 5-10 years old with no apparent cause but parents are distressed - this is most common presentation

20. Evaluation Management
Workup is the same as for blepharospasm - rule out anterior segment disease, irritation, fb, etc.; complete eye exam
Management
Reassurance - (self limited disorder)
Consult with neurologist if desired
Numerous surgical procedures to interrupt CN VII have been tried

21. Myokymia Eyelid tic or twitch
Mild to moderate fasiculations of orbicularis
Signs and symptoms
Patient aware of annoying twitch
Unilateral
More often lower lid
Examiner generally sees nothing wrong

22. Multiple causes Fatigue, lack of sleep Stress, anxiety, tension
Anterior segment irritation
Light dazzle
Anemia, nutritional deficiency
Excessive use of tobacco or alcohol
Anticholinesterases used therapeutically (physostigmine, neostigmine, echothiophate)
Rare: M.S., myasthenia gravis, trigeminal neuralgia

24. Treatment Reassurance Rule out irritation, infection, inflammation
Consultation with family MD or psychologist to evaluate stress, tension, etc.
Pharmacological treatment
Topical antihistamine eyedrops (SEE TOPICAL ANTIHISTAMINE TABLE on page 21)
QID x 1 week
BID x 1 week
Re-eval

25. Stubborn cases may warrant oral quinine, mg, QD to TID; CONTRAINDICATED in pregnant women, since increases risk of abortion
Oral antihistamine
Benadryl

26. Dirty water = tonic water with lime
Drink prn

27. Trichiasis Lashes touch globe Causes Entropion Growths on lid margin
Lid trauma
Scarring of conjunctiva (trachoma, Stevens-Johnsons syndrome)
Blepharitis is most common

28. Signs and symptoms
Discomfort or pain, foreign body sensation, injection
Chronic tearing due to foreign body sensation
May traumatize the epithelium
corneal epithelial defects - infections, ulcers
damage and scarring of conj or cornea
Can cause vision loss due to corneal scarring

29. Evaluation
Find the underlying cause of the trichiasis if possible - blepharitis is a common underlying cause
Careful slit lamp evaluation for both trichiasis and epith damage
Use fluoroscein - check for staining; epithelial damage

30. Management
Epilate in-turning lashes
Forceps or epilation tweezers
Soak tools in zephiran chloride solution (1:3OOO) with anti-rust tablets added
Can anesthetize lid
Firmly grasp lash at its base and pluck
Do not clip lashes

32. Lashes grow back
Children: 2-4 weeks
Adults: 4-8 weeks
Cauterization of follicles generally gives poor results
Electrolysis destroys lash follicles; successful but quite painful

33. If > 1/3 of lashes are turned in, surgery is warranted rather than electrolysis
Cryosurgery
Argon laser photocoagulation
Regular use of ocular lubricants Q1H to QID
Prophylactic broad spectrum antibiotic coverage

34. Poliosis Whitening of lashes Usually due to staph blepharitis
Vitiligo is not due to staph
If both poliosis and vitiligo evaluate internal ocular health (c/o uveitis), if negative get dermatology consult

35. Madarosis Lash loss Causes Very common cause is staph blepharitis
Trichotellomania (neurotic pulling of lashes)

36. Evaluation Look for any evidence of staph blepharitis
Inquire about history of infection…eg Chicken Pox
Rule out anterior segment disease of any kind (especially staph)

37. Management Treat blepharitis if present
Could photodocument to monitor therapy
If caused by trichotellomania
seek psychological counseling
mascara use to minimize pulling

38. Ingrown Cilia Eyelash grown into the epidermis of the lid
Can be directed against globe (trichiasis)
may have foreign body sensation
Look for more than a single ingrown cilia
Look for cause, lid trauma and scarring

39. Management Cut lash near follicle Remove distal portion of lash
Epilate remainder of lash
Prophylaxis with antibiotic *

40. Dermatochalaisis
Redundancy of skin of the upper lid such that it drapes downward over lid margin. May look like ptosis - hold the redundant skin flap up
Middle aged to elderly patient; bilateral
May be familial tendency
May have herniation of orbital fat through the orbital septum causing puffy, "swollen“ appearance

41. Evaluation
Usually quite easy to notice and diagnose (just "baggy" eyelids)
Watch for true ptosis and for lid edema
Management
If no trichiasis and no field loss the problem is cosmetic only - reassure the patient
If trichiasis, treat it. (Consider surgery - cryo, electrolysis, etc.) *

42. If field loss and desire to obtain cosmetic improvement, do a careful formal visual field evaluation with and without lids held to document functional vision defect (10˚ difference in VF loss). Insurance needs this in most cases to allow a claim for blepharoplasty
Surgery - blepharoplasty remember VF necessary with and without lid held to obtain insurance funding
Referral to oculoplastic specialist or cosmetic surgeon

44. Blepharochalaisis
Younger to middle aged patient with baggy lids secondary to recurrent swelling of lids due to recurrent inflammation or edema
These recurrences of edema result in stretching of periorbital skin, loss of elasticity

45. Superior lid drapes over lid margin in many cases
May mimic ptosis. Be sure to rule out true ptosis. Note that a ptosis (not of neurogenic origin) can result from damage to the levator aponeurosis. May be some cases with familial tendency

47. Evaluation
Rule out active cause, i.e. lid mass, edema, inflammation
Rule out ptosis
Look for underlying cause - recurrent edema due to allergy, high BP, kidney disease

48. Management
Treat any active cause
Cool compressed during swelling may help to decrease
Steroids usually not helpful
Consult with physician may help to rule out allergic disease, cardiac or renal diseases if suspected

49. If cosmetically displeasing to patient - VF's and referral to plastic surgeon particularly oculoplastics specialist for blepharoplasty
May need medical consult to determine cause of recurrent edema, i.e., rule out cardiac, renal causes and angioneurotic edema

50. Herniation of Orbital Fat
As orbital septum atrophies with age orbital fat herniates through small dehistences resulting in a soft mass usually located in upper lid medially
May get referrals to evaluate "tumor“
Occurs in elderly (secondary to weakening of orbital septum involutional change)
Presents as localized (inner canthus) soft, spongy mass within lid, anterior to tarsal plate

52. Evaluation
Generally easily differentiated from lid or orbital growth (or lid edema)
Pressure to globe results in further herniation of orbital fat in front of the septum
Management
Reassure patient
Cosmetic surgery, if desired
Excision of orbital fat plus blepharoplasty for dermatochalaisis if present

53. Papilloma Benign Epithelial Tumor
A common benign overgrowth of the epidermal portion of the skin of the eyelid (mainly the squamous epith)
Can have vascular core
Benign growths but varied appearance
Malignancies may look like these but are generally clinically differentiated on appearance
May be caused by virus (if so called verruca); more common in young
Can have numerous presentations; can be pigmented, variety of colors

54. Types
Non-viral
Usually in elderly
Viral
Verruca
Verruca is a form of papilloma
Verruca plana - flat top
Verruca vulgaris - angular, raised, broad stalk
Verruca digitala - narrow stalk, cauliflower-like

56. Signs/symptoms
Usually asymptomatic
Growth
Viral - fairly quick
Non-viral-slow
Color
Various colors
Surface usually rough (keratinized epithelium) but may be smooth, not eroded, ulcerated

57. Can be slowly growing, have vascular core, do not usually erode in center. Usually near lid margins at mucocutaneous junction
Vascular core

58. Evaluation
Rule out neoplastic growth, if possible, by looking for the following:
Look for rapid growth, color change
If on lid margin, no cilia at the location
Bleeding highly unlikely unless papilloma is traumatized
Vascularization - not present on surface of papilloma

59. Surface is often rough but not eroded or ulcerated
Surface is often rough but not eroded or ulcerated. Papilloma can occasionally outgrow blood supply resulting in keratinization or necrosis -> erosion, ulceration

60. Management
Generally no treatment indicated, reassure
Cosmetic treatment only if desired (excision)
Can produce local lash misdirection and resultant trichiasis
Easily excised with scissors if pedunculated. If large or flat, refer for surgical excision

61. Refer to dermatologist or ophthalmologist if highly suspicious or take photos and follow up in one month
If new lesion, carefully evaluate for evidence of malignant characteristics; photograph and follow-up in one to three months
If old, follow up yearly

62. Excision techniques
Scissors/scalpal technique
i) Scissors or scalpal
ii) If base is small, clean area with alcohol wipe
iii) Anesthetize with topical proparacaine for > 1 minute

63. iv) Grasp top with forceps and lift
v) Cut base with scalpal or scissors
vi) Curved scissors are best
vii) Apply pressure for bleeding
viii) Cover with antibiotic ointment (TABLE page 14)
ix) Follow up in one day

64. Chemical technique
i) Clean area with alcohol wipe
ii) Topical anesthetic
iii) Surround papilloma with petroleum jelly
iv) Apply bichloroacetic acid to wooden tip of cotton swab - apply to lesion
v) Should turn lesion white immediately, later darkens, scab falls off in about one week

68. Verruca (Wart)
A papilloma in which papilloma inclusion bodies have been seen in the epith cells. Possibly all papillomas are viral in origin - caused by the human papilloma (wart) virus
Viral papillomas tend to occur in children and young adults
Transmission by direct or indirect contact and autoinoculation

69. Management
Spontaneous regression is likely - reassure and wait
Treat any associated conjunctivitis or keratitis with goal to prevent secondary bacterial infection
Excisional biopsy can be performed but can be followed by the spontaneous appearance of multiple viral papilloma
Cryotherapy should accompany excision if viral etiology suspected

70. Cutaneous horn or tag
Form of papilloma probably, although may be keratinized
Management
Easily excised (see management of papilloma)

71. Seborrheic keratosis (not actinic keratosis)
Benign, epithelial growth common in middle aged to older (some in children)
Common on trunk and head
Can occur on eyebrow and lids
Sharply defined, slightly elevated, brown, plastered on lesions, brownish color - like a "brown plaque" on the skin

72. Important point looks like it is tacked on or stuck onto surface of skin. Little invasion into epidermis, none into dermis
Significance
Not pre-malignant (actinic keratosis is)
Management
Excision if desired
Easily removed for cosmetic reasons

73. Keratoacanthoma Pseudocarcinomatous hyperplasia - benign growth
Exposed usually hairy regions (such as head, face) of skin
Middle aged or older, usually 50-70
Usually Caucasian
Grows rapidly x 2-6 weeks then involutes in a few months or year
Maximal size usually 1-2 cm

75. Appearance
Raised lesion initially - dome-shaped nodule with central core like molluscum contagiosum
Has central umbilicated apical region (composed of keratin) in a crater-like excavation
Has elevated rolled borders. Mimics sq. cell ca and molluscum contagiosum

76. Grows rapidly to 1-2 cm with pore expanded to display keratin filled crater
Growth stops, keratin plug is discharged leaving a pit. Mimics squamous cell carcinoma
Significance
Spontaneously regresses by involution but very often mistaken for squamous cell. Because of this appearance, usually excised during phase of involutional regression

77. Management
Reassure
Photograph if unsure and close follow-up
Excision if cosmetically desired
Excision should be strongly considered because:
Most patients prefer not to wait for regression because of the poor cosmesis of these growths
BCC and SCC can (rarely) occur along the edges

78. Excision and biopsy (all excised material should be biopsied) is recommended because of resemblance to SCC and BCC
BCC and SCC can (rarely) occur along the edges
Recurrence
Recurrence after excision is rare so if recurrence occurs, it was almost definitely BCC or SCC, not keratoacanthoma

79. Dermoid Benign Cystic Lesion
Choriostomas, not neoplasms
Choriostoma arises during development from location of the lesion
Dermoids are congenital, developmental anomalies
Probably groups of surface ectodermal cells entrapped during development along lines of embryonic closure

80. Appearance
Tend to be cystic in nature - "dermoid cyst“
Usually superior temporal in location; usually adherent to periosteum of orbit
Skin slides over surface easily

81. Evaluation
If dermoid is noted look for other congenital anomalies
Goldenhar's syndrome-dermoids on surface of globe often accompanied by lid coloboma and appendages on ears
Management
Can be removed if desired for cosmetic reasons

83. Sebaceous gland cysts
Cysts in the glands of Zeiss (along lid margin) and/or in larger sebaceous glands (near eyebrows)
Very common
Many possible locations: scalp, face, ears, back, axillary regions

84. Types
Comedo (blackhead)
Keratin plaque in follicle
Milia (whitehead)
Small whitish, slight elevated, cyst of the pilosebaceous gland
On skin of lid, usually in groups

85. Appearance
Painless, benign, slow progression
Firm, rubbery, rounded, often moveable, yellowish or whitish color
Depth:
Superficial (epithelial) - tend to be smaller < 10 mm
Subcutaneous (epidermal) - tend to be large < 20 mm

86. Management
Reassure, benign but can be removed for cosmetic reasons
Excision of superficial cysts – technique
a) Clean area with alcohol wipe
b) Apply topical anesthetic for ~ 1 minute
c) Incise with 18 to 27 gauge needle

87. d) Express contents
e) Apply pressure for bleeding
f) Cover with Polysporin ung
g) Follow-up in 1 day
Surgical excision for larger, deeper cysts

88. Sudoriferous cysts
Elevated rounded lesions caused by blockage of the gland of Moll
Common
Appearance
May be < 2 mm in diameter
Localized at lid margin
Usually painless
Usually cause no problems
Cystic nature apparent in indirect/proximal illumination

89. Management
Reassurance, benign
Can be excised easily - technique
a) Clean area with alcohol wipe
b) Anesthetize surface for minute
c) Lance with 18 to 27 gauge needle
d) Express material
e) Cover with Polysporin ung
f) Follow up in 1 day

91. Nevus (freckle) Benign melanotic lesions
Overgrowth of melanin-containing cells in skin
Can change with time and remain benign, however change ALWAYS suggests malignancy
Flat, brownish, well defined borders

92. Types
Junctional nevi
a) FLAT or only slightly elevated
b) Smooth surface
c) Uniform light to medium brown
d) Symmetrical borders
e) Rarely become malignant

93. Compound nevi
a) Somewhat elevated, more so with age
b) Flesh colored or brown
c) Smooth or warty surface
d) Symmetric, uniformly round or oval

94. Dermal nevi
a) Raised, dome-shaped
b) Brown or black, lighter with age
c) Smooth or warty surface
d) May have telangiectatic vessels on surface
e) Exposed and prone to trauma from clothing

95. Guidelines for recognition of normal nevi
a) (A)symmetrical: symmetric, matching halves if "folded" together; round or oval
b) Borders: regular, usually quite distinct
c) Color: uniform within lesion, varies from very light brown to black

96. d) Diameter: < 6 mm
e) Elevation: fairly flat
f) Remain uniform in size, shape, and color
ABCDEF

97. Evaluation
Careful history to document onset and progression
Size it!!!
If any doubt photodocument and follow very closely or better yet dermatology consult
Management
Photograph carefully
Re-evaluate based on degree of suspicion
Only biopsy can definitely rule out melanoma. Any change demands a biopsy.