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Eyelid Disorders:

Diagnosis and Management.

arizona plastic surgeon eyelid surgery

Eyelid disorders range from benign, self-resolving processes to malignant, possibly metastatic, tumors. Inflammation, infection, benign and malignant tumors, and structural problems such as ectropion, entropion and blepharoptosis may occur. Fortunately, most eyelid disorders are not vision-threatening or life-threatening. However, many cause irritative symptoms such as burning, foreign-body sensation or pain. Harvard Eye Associates has treated practically every known eyelid condition, including some that are rarely seen.

Important to the quality of your vision.

Eyelids are crucial to the health of the underlying eye. They provide coverage of the cornea and aid in the distribution and elimination of tears. An exposed cornea will develop epithelial defects, scarring, vascularization or infection. Resulting symptoms include ocular irritation, pain and loss of vision. Eyelid closure distributes tears over the surface of the eye and pumps them through the lacrimal puncta into the tear duct. Thus, tearing or epiphora may result from various eyelid disorders.


Benign Inflammatory Eyelid Processes


Blepharitis - Inflammation of Eyelid Margin

One of the most common eyelid problems is blepharitis, or inflammation of the eyelid margin. This ocular condition is characterized by chronic inflammation of the eyelid, the severity and time course of which can vary. It may be classified as seborrhoeic, staphylococcal, mixed, posterior or meiobomitis, or parasitic. Onset can be acute, resolving without treatment within 2–4 weeks (this can be greatly reduced with lid hygiene), but more generally is a long standing inflammation varying in severity.

Patients typically experience itching, burning, mild foreign-body sensation, tearing and crusting around the eyes on awakening. On examination, the eyelid margins are red and thickened with crusts and debris within the lashes. Mild mucus discharge may be present. Blepharitis occurs with chronic bacterial lid infection, meibomian gland dysfunction, seborrhea and ocular rosacea.

Treatment of blepharitis consists initially of warm compresses, eyelid scrubs and application of antibiotic ointment. Warm compresses should be applied for 15 minutes twice a day. This step loosens irritating crusts in the eyelashes and melts the oil produced by the meibomian glands, which can occlude the gland orifices.

The eyelids should be scrubbed with baby shampoo mixed with water after the warm compress is removed, using a cotton-tipped applicator, wash cloth or finger. Antibiotic ointment should then be applied to the lid margin, but only at bedtime, as it may temporarily blur vision. Antibiotic eyedrops maybe prescribed when an obvious infection is present. If your blepharitis is more severe, your physician will discuss further treatments with you.

Chalazion - Eyelid Cyst

Chalazia, also known as a meibomian gland lipogranuloma, is a cyst in the eyelid that is caused by inflammation of a blocked meibomian gland, usually on the upper eyelid. Chalazia differ from styes (hordeola) in that they are subacute and usually painless nodules. They may become acutely inflamed but, unlike a stye, chalazia usually point inside the lid rather than on the lid margin. A chalazion or meibomian cyst could take months to fully heal with treatment and could take years to heal without any major complications.

A chalazion results from the obstruction of the meibomian gland. The blockage of the gland's duct at the eyelid margin results in release of the contents of the gland into the surrounding eyelid soft tissue. A lipogranulomatous reaction ensues. Occasionally, chalazia become secondarily infected.

Management includes warm compresses applied for 15 minutes four times a day. Blepharitis, if present, should be treated. A topical antibiotic may be used if signs of infection are present. If the lesion persists after four weeks of medical therapy, it may be incised and drained. Rarely, the chalazion is injected with steroids; however, this may result in hypopigmentation of the overlying skin.

Hordeolum - Stye

A hordeolum, also known as a stye, is an infection of the sebaceous glands of Zeis at the base of the eyelashes, or an infection of the apocrine sweat glands of Moll. External styes form on the outside of the lids and can be seen as small red bumps. Internal styes are infections of the meibomian sebaceous glands lining the inside of the eyelids. They also cause a red bump underneath the lid with only generalized redness and swelling visible on the outside. Styes are similar to chalazia, but tend to be of smaller size and are more painful and usually produce no lasting damage. Styes are characterized by an acute onset and usually short in duration (7–10 days without treatment) compared to chalazia that are chronic and usually do not resolve without intervention.


Benign Noninflammatory Eyelid Lesions


Seborrheic Keratosis

Seborrheic keratoses is a noncancerous benign skin growth that originates in keratinocytes. Like liver spots, seborrheic keratoses are seen more often as people age. In fact they are sometimes humorously referred to as the "barnacles of old age".

They appear in various colors, from light tan to black. They are round or oval, feel flat or slightly elevated (like the scab from a healing wound), and range in size from very small to more than 2.5 centimeters (1.0 in) across. They can resemble warts, though they have no viral origins. They can also resemble melanoma skin cancer, though they are unrelated to melanoma as well. Because only the top layers of the epidermis are involved, seborrheic keratoses are often described as having a "pasted on" appearance.

Actinic Keratosis

Actinic keratosis, also called "solar keratosis" and "senile keratosis", is a premalignant condition of thick, scaly, or crusty patches of skin. It is more common in fair-skinned people. It is associated with those who are frequently exposed to the sun, as it is usually accompanied by solar damage. Since some of these pre-cancers progress to squamous cell carcinoma, they should be treated. Untreated lesions have up to twenty percent risk of progression to squamous cell carcinoma

Nevus

Nevi is the medical term for sharply-circumscribed and chronic lesions of the skin. These lesions are commonly named birthmarks and moles. Nevi are benign by definition. Using the term nevus and nevi loosely, most physicians and dermatologists are actually referring to a variant of nevus called the "Melanocytic nevus", which are composed of melanocytes. Histologically, melanocytic nevi are differentiated from lentigines (also a type of benign pigmented macule) by the presence of nests of melanocytes, which lentigines (plural form of lentigo) lack.

Xanthelasma

Xanthelasma is a sharply demarcated yellowish collection of cholesterol underneath the skin, usually on or around the eyelids. Although not harmful or painful, these minor growths may be disfiguring and can be removed. They are common in people of Asian origin and those from the Mediterranean region.

Because of the hereditary component, they may or may not indicate high blood levels of cholesterol. Where there is no family history of xanthelasmata, they usually indicate high cholesterol and may correlate with a risk of atheromatous disease.

Molluscum Contagiosum

Molluscum contagiosum is a viral infection of the skin or occasionally of the mucous membranes. It is caused by a DNA poxvirus called the molluscum contagiosum virus (MCV). MCV has no animal reservoir, infecting only humans. There are four types of MCV, MCV-1 to -4; MCV-1 is the most prevalent and MCV-2 is seen usually in adults and often sexually transmitted. This common viral disease has a higher incidence in children, sexually active adults, and those who are immunodeficient, and the infection is most common in children aged one to ten years old. MC can affect any area of the skin but is most common on the trunk of the body, arms, and legs. It is spread through direct contact or shared items such as clothing or towels.

The virus commonly spreads through skin-to-skin contact. This includes sexual contact or touching or scratching the bumps and then touching the skin. Handling objects that have the virus on them (fomites), such as a towel, can also result in infection. The virus can spread from one part of the body to another or to other people. The virus can be spread among children at day care or at school. Molluscum contagiosum is contagious until the bumps are gone-which, if untreated, may be up to 6 months or longer.

Hydrocystoma

Hydrocystoma are cysts of sweat ducts, usually on the eyelids. Histrocystomas are not tumors. (A similar sounding lesion called hidroadenoma is a benign tumour.)

There are three types of "sweat" glands: True sweat glands or eccrine glands, sebaceous glands which have an oily secretion around hair follicles and apocrine glands which have more oily product than eccrine glands and are found on the face, armpit and groin. Hidrocystomas usually arise from apocrine glands. The are also called Cysts of Moll or sudoriferous cysts. There may be a type of hidroadenoma that arises from eccrine glands but these are uncommon.


Malignant Eyelid Lesions


Basal Cell Carcinoma

Basal cell carcinoma, the most common eyelid malignancy, usually appears in the lower lid and medial canthal region as a firm, pearly nodule. It rarely metastasizes or kills. However, because it can cause significant destruction and disfigurement, it is still considered malignant by invading surrounding tissues. Statistically, approximately 3 out of 10 Caucasians may develop a basal-cell cancer somewhere on their bodies within their lifetime.

Treatment is complete surgical resection with histologic control of margins. Radiation and cryotherapy, which have higher recurrence rates than surgical resection, are used when surgery is not appropriate or possible.

Squamous Cell Carcinoma

Squamous cell carcinoma, although much less common than basal cell carcinoma, behaves more aggressively. It is a malignant tumor of squamous epithelium (epithelium showing squamous-cell differentiation). Despite the common name, these are unique cancers with large differences in manifestation and prognosis. Treatment is similar to that for basal cell carcinoma.

Sebaceous Carcinoma

Sebaceous carcinoma occurs in middle-aged to elderly patients and may mimic a chalazion or chronic unilateral or bilateral blepharitis. It is an uncommon and aggressive malignant cutaneous tumor. This neoplasm is thought to arise from sebaceous glands in the skin and, therefore, may originate anywhere in the body where these glands are found. Because the periocular region is rich in this type of gland, this region is a common site of origin.

Melanoma

Melanoma is a rare pigmented eyelid tumor that must be differentiated from nevi and basal cell carcinoma. During examination of the eye, the physician should always evert the eyelid to look for conjunctival involvement. Change in the appearance of a pigmented lesion warrants excisional biopsy of the lesion. Systemic evaluation for regional or distant metastasis is necessary with the diagnosis of melanoma.


Mechanical Eyelid Disorders


Entropion

Entropionis a medical condition in which the eyelid (usually the lower lid) folds inward. It is very uncomfortable, as the eyelashes constantly rub against the cornea. Entropion is usually caused by genetic factors and may be congenital. Trachoma infection may cause scarring of the inner eyelid, which may cause entropion. In human cases, this condition is most common to people over 60 years of age.

Ectropion

Ectropion is a medical condition in which the lower eyelid turns outwards. It is one of the notable aspects of newborns exhibiting congenital Harlequin type ichthyosis, but ectropion can occur due to any weakening of tissue of the lower eyelid. The condition can be repaired surgically. Ectropion is also found in dogs as a genetic disorder in certain breeds.

Trichiasis

Trichiasis is a condition of misdirected eyelashes that rub on the cornea or conjunctiva. This can be caused by infection, inflammation, autoimmune conditions, congenital defects, eyelid agenesis and trauma such as burns or eyelid injury.

Standard treatment involves removal or destruction of the affected eyelashes with electrology, specialized laser, or surgery. In many cases, removal of the affected eyelashes with forceps resolves the symptoms, although the problem often recurs in a few weeks when the eyelashes regrow. Severe cases may cause scarring of the cornea and lead to vision loss if untreated. Mild cases may not require treatment.

Dermatochalasis

Dermatochalasis is defined as an excess of skin in the upper or lower eyelid. It may be either an acquired or a congenital condition. It is generally treated with blepharoplasty.

Blepharoptosis

Blepharoptosis is a (drooping) of the upper or lower eyelid. The drooping may be worse after being awake longer, when the individual's muscles are tired. This condition is sometimes called "lazy eye", but that term normally refers to amblyopia. If severe enough and left untreated, the drooping eyelid can cause other conditions, such as amblyopia or astigmatism. This is why it is especially important for this disorder to be treated in children at a young age, before it can interfere with vision development.

Eyelid Retraction

The normal resting position of the upper lid is 2 mm below the junction of the superior cornea with the sclera, and that of the lower lid is at the junction of the inferior cornea with the sclera. Because the most common cause of eyelid retraction is thyroid ophthalmopathy), the thyroid status of the patient should be evaluated. Other causes include midbrain disease, such as tumors or infarcts, or blepharoptosis with compensatory contralateral eyelid retraction. Treatment depends on the underlying etiology.

Facial Palsy

Facial palsy results in an inability to close the upper lid and laxity of the lower lid. A frank paralytic ectropion may occur as well. A thorough work-up for the etiology of the facial palsy must be performed.

Treatment of the eyelid problems includes vigorous lubrication of the eye with artificial tear drops and lubricating ointment. Plastic wrap, fixed to the skin with ointment, may be placed over the orbital region during the night to create a moisture chamber for the eye. For temporary facial palsies such as Bell's palsy, small external tantalum eyelid weights may be easily fixed to the skin with double-sided tape. The weight passively closes the upper lid, protecting the cornea. Surgical procedures are performed in patients with permanent palsies.

Blepharospasm

Blepharospasm is an abnormal contraction or twitch of the eyelid. It normally refers to benign essential blepharospasm, a focal dystonia - a neurological movement disorder involving involuntary and sustained contractions of the muscles around the eyes. Benign means the condition is not life threatening. Essential indicates that the cause is unknown, but fatigue, stress, or an irritant are possible contributing factors.

Symptoms sometimes last for a few days then disappear without treatment, but in most cases the twitching is chronic and persistent, causing lifelong challenges. The symptoms are often severe enough to result in functional blindness. The person's eyelids feel like they are clamping shut and will not open without great effort. Patients have normal eyes, but for periods of time are effectively blind due to their inability to open their eyelids. Although strides have recently been made in early diagnosis, blepharospasm is often initially misdiagnosed as allergies or "dry eye syndrome". It is a fairly rare disease, affecting only one in every 20,000 people in the United States.

Bilateral blepharospasm is most commonly the result of dry eyes, corneal irritation or benign essential blepharospasm. Initial treatment is artificial tear drops and injections of botulinum toxin to weaken the affected muscles.


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