1
Q
Levator muscle
A
- elevates eyelid, weakness would lead to a droopy eyelid
- responsible for upper eyelid skin fold and skin crease
- inserts into the skin and the other part inserts into the anterior surface of the tarsal plate
2
Q
Mullers muscle
A
- small extension on the under surface of the levator
- dysfunction leads to Horners syndrome
3
Q
East Asian vs Caucasian
A
- levator muscle in an East Asian eyelid usually inserts much lower on the skin
- orbital fat also much more anteriorly placed causing the eyelid skin fold to come on top of lashes
4
Q
Entropion
A
- in-turning of eyelid towards eye
- most commonly affects the lower eyelid but can affect upper eyelid as well
5
Q
Entropion symptoms
A
- constant irritation (lashes rubbing against ocular surface)
- FB sensation
- blurring of vision
- recurrent infections?
- red eye
- watery eye/epiphora?
- corneal abrasion causing marked photophobiaocula
6
Q
Entropion (involutional)
A
- most common
- caused by an increase in lid laxity (age related)
- over riding of the orbicularis muscle
7
Q
Entropion (involutional) management
A
- ocular lubricants (reduce FB sensation and protect ocular surface)
- antibiotic ointment for infection
- eyelid tapping to pull lid mechanically into normal position for a few hrs at a time
- everting sutures temporarily correct (more permanent than lid taping)
- Botox injection to lower eyelid can temporarily correct entropion
8
Q
Entropion (cicatricial)
A
- scarring and contraction of palpebral conj pulls lid margin inwards
- e.g. Stevens-Johnson syndrome, chronic bleph, chemical burns
9
Q
Entropion (cicatricial) management
A
- more difficult to treat
- disease process needs to be arrested
- followed by complex surgery to release scar tissue in conj and having to put posterior lamellar (mucous membrane) grafts taken from inside mouth
10
Q
Entropion (spastic)
A
- caused by spastic contraction of orbicularis muscle triggered by ocular irritation
- or due to secondary blepahrospasm
- often in elderly px’s with dementia or young children who squeeze (their eye?) quite hard in response to pain in the eye, makes the ocular surface worse (sets a vicious cycle)
11
Q
Entropion (spastic) management
A
- usually resolves spontaneously once cause has been removed
12
Q
Snap back test method (for lid laxity)
A
- pull lower lid down with finger at centre of orbital rim
- release and observe return of eye
- normal - quickly snaps back
- mild lid laxity - slowly snaps back
- moderate lid laxity - returns with blink
- severe lid laxity - incomplete return, does not go back to normal position easily
13
Q
Ectropion
A
Outward turning of the eyelid margin
14
Q
Ectropion symptoms
A
- many px’s asymptomatic
- painful, red eye
- epiphora - tears have no access to tear duct and leak down from eye
- eyelid skin changes - due to irritation of salty tears running down skin
- exposed chronically irritated conjunctiva (advanced cases)
15
Q
Ectropion (involutional)
A
- increased lid laxity
- main difference is orbicularis - in entropion there is overriding which makes the eyelid turn in, in ectropion orbicularis is unchanged causing eyelid to drop down with gravity?
- when eyelid everts - exposes conjunctiva, becomes more inflamed making ectropion worse over time
16
Q
Ectropion (cicatricial)
A
- scarring of skin and underlying tissue
- e.g. trauma, burns, skin tumours
17
Q
Ectropion (cicatricial) management
A
- allow to resolve itself if asymptomatic and no ocular surface damage
- ocular lubricants if irritation/epiphora
- skin emollients (Vaseline) will protect ocular surface if skin changes in the lower lid due to tears irritating it
18
Q
Ectropion (paralytic)
A
- caused by 7th CN palsy
- paralysis of ortbicularis muscle, support to lower lid lost and so hangs down
- lagophthalmos - unable to close eyes
- often associated with MCT and LCT laxity
- brow ptosis often seen due to loss of function of frontaleis muscle of brow
19
Q
Ectropion (paralytic) management
A
- aim - protect cornea (as eye can’t close) to avoid corneal infection and vision loss
- some px’s recover spontaneously as 7th CN palsy’s often recover in 3-6 months
- some px’s only need ocular lubricants
- others may need a temporary tarsorrhaphy - stitch between upper and lower tarsal plate to close eyelid permanently until it closes itself
- if no recovery in 3-6 months, surgical procedures can tighten lower eyelid either by stitches or using eyelid slings
- lagophthalmos may need correction with upper lid lowering with gold weighs (to cause a small ptosis) which helps close the eye mechanically
20
Q
Ectropion (mechanical)
A
- eyelid tumours/lesions causing ectropion due to their weight
- lid swelling due to inflammation from an infection or allergies
21
Q
Ectropion (mechanical) management
A
- treating the lesion and removing it will cause the eyelid to snap back into position
- often accompanied by eyelid tightening (may have hung down for multiple months)
22
Q
Lid laxity - medial canthal tendon method
A
- pull eyelid down laterally and observe position of lacrimal punctum
- 1-2mm migration = normal
- up to limbus = mild MCT laxity
- limbus to pupil = moderate MCT laxity
- beyond pupil = severe MCT laxity
23
Q
Lid laxity - lateral canthal tendon method
A
- observe lateral canthal angle (normally acute angle)
- pull lid medially and observe LCT migration
- rounded canthus - LCT laxity
24
Q
Chalazion
A
- painless swelling/lump on the eyelid due to a blocked MG
25
Chalazion management
- reassure benign and self-limiting
- advise may take months or weeks
- often settles down with a hot compress (5 mins, 2 x daily)
- recommend lid massage (after compress, TOWARDS lid margin)
- consider routine referral if: persistent (>2 months), recurrent, large or affects vision
- ophth may consider incision and curettage or steroid injection
26
Hordeolum
- acute staphylococcal infection which presents in base of eyelash follicle
- localised eyelid swelling with a central pus point, will spontaneously burst at some point with small pus discharge
- often self-limiting
- external - glands of moll & zeiss infection
- internal - MG infection
27
Hordeolum management
- reassure benign, will settle over time
- consider eyelash epilators to encourage discharge
- warm compress (5 mins, 2 x daily)
- lid massage (after compress, TOWARDS lid margin)
- consider antibiotic drops (chloramphenicol) if significant discharge
- ophth may consider possible incision, oral antibiotic (amoxicillin) for severe and recurrent cases
28
Moluscum Kontagiosum
- low grade viral infection
- typical pres - raised, well defined, slightly pearly edges, umbilicated centre
- same pres can also be in a BCC
- doesn’t cause problems unless on eyelid as can cause chronic low grade follicular conjunctivitis
29
Moluscum Kontagiosum management
- self-limiting (weeks/months)
- excision if causing problems or can be left to resolve over time
30
Benign Epidermoid Cyst
- smooth, well defined, white lesion with normal skin architecture over it
- sometimes a few dilated BV’s due to stretching of skin
- completely harmless
- only reason to remove would be cosmetic
31
Cysts of Moll/Hydrocystoma
- clear fluid filled translucent lesions typically seen on the lid margin
- painless and entirely benign
- only reason to remove would be cosmetic
32
Dermoid Cyst
- benign lesion
- typically occurs in our upper corner or inner inner upper corner of orbit
- smooth, well defined lesion often attached to orbital rim
33
Benign Naevus
- similar to moles
- difference in diagnosis here would be from a melanoma (malignant condition, any change in size or shape if this lesion should raise concern of being malignant)
34
Squamous Papilloma
- multiple eyelid skin tags
- usually in the eyelids, neck or armpits
- benign
- treatment - surgical incision
35
Xanthelasma
- deposition of cholesterol just under skin
- typically happens on upper and lower eyelids
- more common in those with raised cholesterol but can happen in anybody
- treatment is laser or surgical excision
- can often reappear after treatment
36
Malignant Eyelid Tumours
- basal cell carcinoma
- squamous cell carcinoma
- sebaceous carcinoma
- malignant melanoma
37
Basal Cell Carcinoma Risk factors
- due to chronic sun exposure and UV light
- caucasian more prone
- can also happen in area exposed to sunlight (scalp, neck, face etc)
- px’s with low immunity at risk of multiple
38
Basal cell carcinoma (typical appearance)
- nodular lesion with pearly edges with a central ulceration
- painless and grows slowly
- spreads locally and doesn’t spread to other parts of the body, once removed results in complete cure
- morphoeic BCC - indistinct edges and can spread under the skin, can become quite extensive locally
- changes to skin overlying lesion, loss of lashes, loss of normal skin hair should alert to malignant eyelid tumour
39
Basal cell carcinoma vs Moluscum kontagiosum
- moluscum typically in younger px’s
- NO LOSS OF LASHES in moluscum
40
Basal cell carcinoma (management)
- biopsy to prove diagnosis
- surgical excision - as long as whole lesion is removed
- mohs micrographic surgery (when edges not well defined)
- cryotherapy or radiotherapy (for those with extensive disease or unfit for surgery)
41
Squamous Cell Carcinoma risk factors
- typically affects px over 70
- fair skinned px’s with history of chronic sun exposure more commonly affected
- px’s with lymphoma, leukaemia, HIV etc more at risk
42
Squamous cell carcinoma (typical presentation)
- typically at eyelid margin
- not as well defined as BCC
- painless, slightly raised plaque or nodule with a central ulceration, crusting or scaling
- more aggressive than BCC (can enlarge more rapidly and spread to orbit and sinuses)
43
Squamous cell carcinoma (management)
- if no distant spread - surgical excision with wide margin is preferred
- prognosis excellent as long as not spread
- if spread, often palliative treatment, risk of death over 5 yrs significant
44
Sebaceous Cell Carcinoma
- arises from MG and sebaceous glands of eyelids, eyebrow and caruncle
- typically affects eyelid margin with gradual loss thickening and LOSS OF LASHES
- can present as recurrent chalazia or persistent blepharitis
45
Sebaceous cell carcinoma (management)
- distant metastasis to other body parts common
- surgical treatment involves excision of tumour with frozen section control and reconstruction
- recurrence rates of these tumours very high (almost 1/3 of px’s after excision)
- 1/4 of these px’s will die within 10 yrs of diagnosis
46
Eyelid Malignant Melanoma
- pigmented tumours that enlarge rapidly
- spread to other body parts often resulting in death over time
- treatment - wide surgical incision, and then manage metastasis
- regular and variable pigmentation with distortion of surrounding architecture should raise suspicion of MM
47
Malignant melanoma vs Benign naevus
- variability in colour of the lesion at different parts is classic presentation of MM
- naevus is uniformly pigmented
48
Benign vs Malignant
- benign usually well defined
- malignant often indistinct (except in nodular BCC)
- benign - overlying skin architecture
- malignant - gradual destruction of overlying skin architecture
- benign - surface ulceration uncommon
- malignant - surface ulceration of skin common
MALIGNANT - LOSS OF EYELASHES IN LID MARGIN LESIONS
Clinical Ophthalmology
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