TMOD (Lids/Lashes)

Dermatochalasis

Skin becomes laxative with age due to weakened orbital septum

Complaints of heavy eyelids and reduced superior VF

Deramatochalasis Treatment/Management

Blepharoplasty

Ectropion

Outward rolling of the lid (usually lower lid) due to age/involutional (lid laxity due to loss of muscle tone of orbicularis oculi), trauma, bells palsy

asymptomatic or epiphora and ocular irritation

Presents with inferior exposure keratopathy

Ectropion Treatment/Management

Sx to tighten lateral tarsal strip

Tx exposure keratopathy

If cause is bells palsy, it will resolve spontaneously

Entropion

Inward rolling of the eyelid due to involution/age

Complaints of ocular irritation, FB sensation, epiphora

Exposure keratopathy and trichiasis,

Entropion Treatment/Management

If cornea is compromised, top antibiotic ointment as a preventative measure

Abnormal position of lid can be tx with tape temporaily or botox temporarily, sx for permanent fix

Can epilate lash

Trichiasis

Misdirected eyelashes that rubs the globe due to entropion or idiopathic

Complaints of ocular irritation, FB sensation, epiphora

Presents with SPK, injection, possible corneal scarring

Trichiasis Treatment/Management

Epilation

If chronic, lashes can be permanently removed by cryotherapy, cautery or electrolysis

If cornea is compromised, top antibiotic ointment as preventative measures

Blepharospasm

Idiopathic uncontrollable eyelid closure

Spasm of orbicularis oculi, corrugator, procerus

Absent during sleep

Blepharospasm + lower facial abnormalities = Meige’s Syndrome

Blepharospasm Treatment/Management

Botox inject every 12 wks (3mths)

Bell’s Palsy

Flaccid paralysis of lower motor neuron CN 7

Usually idiopathic but also neural inflammation, herpes

Signs and symptoms develop over 24 hours

Unilateral epiphora, dry eye (affect secretion and blinking), drooling, inability to close one eye, exposure keratoconjunctivitis

Bells phenomenon is still present

Bell’s Palsy Treatment/Management

Spontaneously improve within 4 months and complete resolution within 1 yr

If due to neural inflammation, tx with oral steroid

If due to herpes, tx with oral antiviral

Tape eyelid shut while asleep but if chronic, consider gold weight implant. during the day, PF AT Q1H and AT ointment QHS

FU in 6 wks

Floppy Eyelid Syndrome

Decrease elastin within tarsal plate

Excessive lid laxity in overweight men and is a sign of sleep apnea

May present with exposure keratoconjunctivitis of inferior cornea and conjunctiva, papillae

Floppy Eyelid Syndrome Treatment/Management

Sx for definitive tx

Refer to rule out sleep apnea

Tape eyelid shut or wear eye shield while sleeping

During the day, PF AT Q1H and AT ointment QHS

If cornea is compromised, top antibiotic ointment

Xanthelasma

Seen in elderly pt with hyperlipidemia

Creamy yellow plaques found in superior nasal eyelids

Xanthelasma Treatment/Management

Not necessary

Plaques can be removed with excision or carbon dioxide laser tx but recurrence is high

Blepharitis (anterior)/Meibomian Gland Dysfunction (posterior)

Inflammation of the sebaceous glands due to staphylococcus infection

Anterior bleph afflicting glands of zeis and moll

Posteriopr bleph afflicting meibomian gland

Causes evaporative dry eye

Blepharitis (anterior)/Meibomian Gland Dysfunction (posterior) Treatment/Management

Anterior bleph

• Warm compress

• lid scrubs

• erythromycin or bacitracin ung QHS

• tobradex for severe cases

Posterior bleph

• warm compress and digital massage

• eyelid scrub

• tobradex for short term

• oral azithromycin or oral doxy or minocycline for pts with ocular rosacea

Inflammation can be controlled with Xiidra or Restasis

AT and omegag-3 fatty acids

Hordeolum

“Stye” pimple of the eyelid or infection of sebaceous gland

Complaint of pain and eyelid tenderness

Internal hordeolum: meibomian gland

External hordeolum: zeis or moll

Hordeolum Treatment/Management

Ask about rosacea

Hot compress as much as possible with digital massage

Rx anitbiotic ointment or top steroid-antibiotic ointment (tobradex) if persisten

Chalazion

Sterile inflmmation of sebaceous gland

Painless, nontender bump and lid does not appear red, hard and immobile

Chalazion Treatment/Management

Hot compress

If persists for a month, remove via biopsy

If recurrent and in the same location, suspect sebaceous gland carcinoma dn refer for biopsy

Steroid injection is also an option but CI in AA due to high risk of hypopigmentation

Pediculosis/Phthiriasis

Eyelash infection of lice

If in children, suspect sexual abuse

Presnts with burrowing lice, spots fo dried blood, tiny brown deposits (feces), white/translucent nits (eggs), +PAN

Pediculosis/Phthiriasis Treatment/Management

Remove lce with jeweler’s forceps

Antibiotic ointment (erythromycin or bacitracin) for 2 wks

Can recommended kwell (for genitals)

Instruct pt to thoroughly wash towels and linens

If child, optometrists are mandated reporters and must notify authroities of child abuse

Demodicosis

Caused by parasite Demodex folliculorum

Demodicosis Treatment/Management

Lid hygeine + tea tree oil

Sebaceous Gland Carcinoma

Remember suspect SGC if chalazion is recurrent

Usually in women between 50-70

Risk factor for mortality:

• tumors >2cm

• superior and inferior involvement

• duration >6mths

Presents with yellow, hard tumor (usually superior lid), madarosis, poliosis, possible lymphadenopathy (which indicates malignancy)

Sebaceous Gland Carcinoma Treatment/Management

Full thickness excision with biopsy

Basal Cell Carcinoma

Mostly on the inferior eyelid/sun exposed areas of the skin

Older white pts

Most common malignant eyelid tumor (rarely metastasizes

Layers of the epidermis from superficial to deep: corneum → lucidum → granulosum → spinosum → basale

Pearly umbilicated nodule that can progress to include central ulcerative telangiectasia (“rodent ulcer”)

Basal Cell Carcinoma Treatment/Management

Full thickness excision with biopsy

Advise to use sun protection

Actinic Keratosis → Squamous Cell Carcinoma

Usually on the inferior eyelid/sun exposed area

Usually older white pts who also smokes

Actinic keratosis is the most common precancerous skin lesion

SCC is the 2nd most common malignant eyelid tumor

SCC is more invasive than BCC

Metastasis to lymph nodes (submandibular or preauricular)

Actinic keratosis: scaly, round erythematous lesion

SCC: scaly, erythematous, ulcerated plaque (flat or elevated) rarely contains surface vascularization

Actinic Keratosis → Squamous Cell Carcinoma Treatment/Management

Full thickness excision with biopsy

Cryotherapy can be used as further tx once dx has been confirmed

Advise to use sun protection

Malignant Melanoma

Rare but most lethal primary skin tumor

Presents with pigmented, elevate, lesions with irregular borders

Due to abnormal proliferation of melanocytes

ABCDE: asymmetry, boarders, color, diameter, enlargement

Malignant Melanoma Treatment/Management

Full thickness excision with biopsy

Severe cases require orbital exenteration with neck dissection

Advise pt on sun protection and refer to dermatology for an evaluation

Malignant Melanoma prognosis

Based on thickness and depth of lesion

Capillary Hemangioma

Most common benign orbital tumors in children (in adults is cavernous hemangiomas)

Presents within the first month of life

Superficial vascular lesion (strawberry nevus) with rapid growth

May cause amblyopia if they block visual axis or press against the cornea and induce astigmatism

Capillary Hemangioma Treatment/Management

Spontaneously resolve by the time pt is10yo