DISORDERS OF THE EYELIDS 2

Dr Russell J Watkins

Entropion Types

Involutional Cicatricial Acute spastic

Involutional Entropion Affects lower lid Possible pathological mechanisms are:

Preseptal portion overrides pretarsal portion of orbicularis oculi

Horizontal lid laxity due to stretched canthal tendons, orbital fat atrophy

Weakened tarsus allowing flexure Vertical instability due to dehiscence of

retractors

Involutional Entropion Treatment of involutional entropion

Taping Botulinum toxin if unfit for surgery Surgery

Cicatricial Entropion Affects upper or lower lid Scarring shortens posterior lamella Causes include trachoma, radiation, chemical

injury, topical rx, previous surgery, trauma, SJS & mucous membrane pemphigoid

Treatment is usually surgical

Acute Spastic Entropion Orbicularis oculi spasm due to ocular irritation or

essential blepharospasm Usually associated with involutional entropion Management is by removal of irritant, treatment

of associated involutional entropion, botulinum toxin

Ectropion Types of ectropion

Involutional Cictatricial Paralytic

Involutional Ectropion Usually lower lid Tarsal stretching ± orbicularis weakness Treatment is by cicatrising cautery or surgery

Cicatricial Ectropion Upper or lower lid Causes include trauma [lacerations, burns,

surgery], tumours, infections Optometric management - refer

Pay attention to prevention of exposure keratopathy

Surgical management aimed at release of scarring including skin grafts

Paralytic Ectropion Lower lid ±lagophthalmos Causes: myopathy; CN VII disorders Optometric management – refer

Pay attention to prevention of exposure keratopathy

Botulinum toxin induced ptosis; tarsorrhaphy Various other surgical techniques including nerve

transposition

Blepharospasm Involuntary tonic, spasmodic, bilateral eyelid

closure F>M More common in older individuals (60+ yrs) Causes - idiopathic, Parkinson’s disease,

psychogenic, post-encephalitic, tetany, drugs e.g. psychotropics

Treatment - botulinum toxin injections into orbicularis oculi

Floppy Lid Syndrome Generalised laxity of eyelid tissues Can be unilateral or bilateral Symptoms - ocular irritation, redness Signs - SPK, easy distraction of lid from globe,

easy upper lid eversion, lower lid ectropion, ptosis

Treatment - wedge excision, canthal tendon repair

Orbicularis Myokymia Involuntary contraction producing an annoying

twitching sensation Related to fatigue - a very common presentation

in optometric practice Rarely due to a sinister cause

Hemifacial spasm Multiple sclerosis

Benign Eyelid Tumours Xanthelasma

Fatty plaques (foam cells in epidermis), usually medial, usually bilateral

Associated with 1° hyperlipidaemic states, DM, hypothyroidism, primary biliary cirrhosis

Optometric management - refer to GP for exclusion of underlying cause

Surgical management - excision (60% recur), laser ablation, chemical cautery

Benign Eyelid Tumours Basal cell papilloma

Also known as seborrhoeic keratosis Common Sessile

Benign Eyelid Tumours Squamous cell papilloma

Common Sessile or pedunculated Histopathology - excessive convoluted

epithelium with central fibrovascular core; may form keratin horn

Benign Eyelid Tumours Solar keratosis

Flat, multiple, scaly lesions Occasionally papillomatous with keratin horn

formation NB: premalignant Histopathology - epithelial dysplasia with

keratosis BUT no invasion

Benign Eyelid Tumours Keratoacanthoma

Rapidly enlarges (months), then regresses Volcano shaped with keratin plug Visually, often difficult to distinguish from

BCC, whereas: Histopathology - difficult to differentiate from

SCC unless whole lesion examined; no invasion, but basal inflammation

Benign Eyelid Tumours Haemangioma

Strawberry naevus: evident in neonatal period Grows then usually regresses by 5yrs May be cutaneous, orbital or mixed Histopathology - capillary proliferation, some

of which are uncanalised

Benign Eyelid Tumours Neurofibroma

Associated with neurofibromatosis Histopathology - Schwann cell & fibroblast

proliferation

Benign Eyelid Tumours Naevi

Congenital collections of naevus cells Pigmented or non-pigmented May become pigmented post-puberty

Benign Eyelid Tumours Naevi are classified according to location

Epidermal - slightly thickened epithelium with naevus cells forming cysts

Junctional - activity at epidermal/dermal junction, occuring at puberty

Dermal - collections of naevus cells within the dermis; Can be associated with choroidal melanomas

Compound - malignant

Benign Eyelid Tumours Cyst of Moll

Retention cyst Clear & fluid filled

Cyst of Zeis Retention cyst White cheesy (sebaceous) material

Miscellaneous Benign Lumps Milia Cutaneous horn Meibomian cyst Naevus flammeus Dermoid cyst

Malignant Eyelid Tumours Basal cell carcinoma

Most common malignant carcinoma Lower lid most common site Do NOT metastasise but invade locally Types

• Noduloulcerative - well defined; Ulcerated & inflamed lesion

• Sclerosing (morphoea) - tends to be multifocal Optometric management - refer for cryo, RT or surgery

Malignant Eyelid Tumours Carcinoma in situ (Bowen’s disease)

5% of eyelid tumours Upper lid most common site Histopathology - dedifferentiation of epithelial

cells; localised to epidermis; premalignant for SCC

Malignant Eyelid Tumours Squamous cell carcinoma

Arise de novo from premalignant states such as solar keratoses & xeroderma pigmentosum

Lymphatogenous spread May evoke inflammatory response Histopathology can be from well differentiated

to anaplastic Optometric management - refer (radical

excision)

Malignant Eyelid Tumours Malignant melanoma

Very rare (of the eyelid) Can arise de novo or as a malignant

transformation of a junctional naevus Signs include itching, bleeding, pigmentary

changes, increase in size

Malignant Eyelid Tumours Types of malignant melanoma

Lentigo maligna - superficial, premalignant (seen in the elderly)

Superficial spreading melanoma Nodular - occurs only on covered areas not on

face Optometric management - refer Prognosis depends on site, depth of invasion

(poor if >1.5mm) & degree of inflammation

Malignant Eyelid Tumours Meibomian gland carcinoma

Rare Localised May present as recurrent chalazion Optometric management - refer (radical

excision & RT)

Miscellaneous Malignant Lumps

Metastatic deposit Lymphomatous infiltrate Sebaceous gland carcinoma Kaposi sarcoma