diseases of the lashes and lids

Epicanthal folds

Extra tissue from upper to lower lids, excess skin across the bridge of the nose, decreased scleral show looks like esotropia

Epicanthus tarsalis

Excess skin prominent along upper lid, most common in Asians

Epicanthus inversus

Excess skin prominent along lower lid, surgery is sometimes needed

Epicanthus Palpebralis

Excess skin involves both upper and lower lid

Epicanthus supraciliaris

Excess skin fold starts at the brow and follows down to the lacrimal sac, uncommon

Epiblepharon

Horizontal fold of skin that covers eyelid margin, hypertrophic orbicularis oculi muscle, eyelashes rotate towards the globe (looks like entropion but isn’t)

Trichiasis

Misdirection of lashes, causes irritation and scarring, and can cause PEE

Distichiasis

Cells change morphology from meibomian glands into hair follicles and sebaceous gland. (Cilia grow from meibomian glands). Lashes are farther back than the normal lash line. Can be acquired or congenital.

How to treat eyelash diseases?

Epilation, electrolysis, laser ablation, cryotherapy

Eyelash ptosis

Downward sagging of the upper lid lashes, causes: idiopathic, floppy eyelid syndrome, or dermatochalasis

Trichomegaly

Eyelashes that exceed the normal length or thickness

Causes: congenital heart disease, atopic dermatitis, HIV, venal keratoconjunctivitis, prostaglandins (glaucoma drug and is the most common cause)

Madarosis

Loss of lashes

Causes: anterior lid disease, burns, generalized alopecia, trichtillomania

Poliosis

Premature whitening of the lashes and brows

Causes: anterior bleph, Vogt-Koyanagi-Hamada syndrome, vitiligo, Marian syndrome, Tuberous sclerosis

Ptosis

Abnormally low position of the upper lid, can be congenital or acquired

Types: neurogenic, myogenic, aponeurotic, mechanical

Neurogenic ptosis

Ptosis due to innervational defect

Ex: third nerve palsy, Horner’s syndrome, Marcus Gunn jaw winking syndrome

Marcus Gun Jaw-winking syndrome

Congenital ptosis, unilateral, suspected that mandibular branch of cranial nerve 5 is misdirected into Levator muscle

Myogenic ptosis

Myopathy of the Levator muscle or impairment of impulses at neuromuscular junction (ptosis with some type of muscle involvement)

Ex: myasthenia gravis, myotonic dystrophy

Myasthenia Gravis

Immunologic disorder that affects the neuromuscular junction and transmission

Voluntary muscles are affected and seen as muscle weakness and fatigue due to sustained or repeated muscle activity

In office testing includes the sustained up gaze and/or th ice pack test

Myotonic dystrophy

Autosomal dominant genetic condition, characterized by increased muscle contraction and slow muscle relaxation, muscle weakness and muscle atrophy

Characterized by: ptosis, EOM involvement, cataract, hypotony (low IOP)

Aponeurotic ptosis

Age related defect to the Levator aponeurosis, the aponeurosis becomes thin and detaches from the tarsal plate, worse at the end of the day

Presents bilaterally, high upper lid crease, good Levator function, and sometimes deep upper sulcus with thin eyelid over tarsal plate

Mechanical ptosis

Ptosis caused by gravitational effect of a mass or scarring, can see what is physically causing the ptosis

Ex: chalazion, eyelid inflammation or edema

Pseudoptosis

False impression of ptosis (know based on where the lid margin is)

Caused by: lack of support from prosthetic, contralateral lid retraction, brow ptosis, dermatochalasis

Entropion

Inward turning of the lid margin that pushes eyelashes onto the globe (typically lower lid), commonly see PEE and conjunctival injection

Types: involutional, cicatricial, spastic, congenital

Involutional entropion

Entropion seen with aging, mainly affects lower lid

Caused by: horizontal lid laxity, vertical lid instability, over-riding of the pretarsal, orbital septum laxity*

*difficult to differentiate the causes

Treated with lubrication, lid taping, bandage CL, Botox

Cicatricial entropion

Entropion caused by severe scarring of the palpebral conjunctiva (causes contraction of palpebral conj that pulls the eyelid in)

Treat with lubrication, lid taping, bandage CL

Spastic entropion

Entropion seen in conjunction with involutional entropion (not diagnosed on its own), inward turning of he eyelid with forceful eyelid closure (entropion worse when blinking)

Treat with eyelid taping, bandage CL, lubrication, Botox

Congenital entropion

Rare case of entropion that a patient is born with and is associated with a lot of other conditions, can affect upper or lower lid. Upper affected due to microphthalmos, lower affected due to improper development of the inferior retractor aponeurosis

Presents with no lid crease (when pressure is applied to lower lid the entire lid pulls away from the globe)

Ectropion

Outward turning of the eyelid margin, associated with PEE, conjunctival injection, thickening and keratinization of conj, conjunctival dryness

Types: involutional, cicatricial, paralytic, mechanical

Involutional ectropion

Ectropion seen due to aging, caused by horizontal lid laxity, medial canthal tendon laxity, lateral canthal tendon laxity (can technically determine the cause but that doesn’t change treatment). Presents with lower lid turning outward, can cause epiphora (tearing), inflammation and keratinization of inferior palpebral conj

Treated with surgery

Cicatricial ectropion

Ectropion cause by scarring or contracture of the skin and underlying tissues that pulls the eyelid away from the globe, seen with trauma, chemical burns, surgery (specifically entropion surgery), lid laceration, skin disease

Treat with surgery

Paralytic ectropion

Ectropion caused by ipsilateral facial nerve palsy (Bell’s palsy or removal of acoustic neuroma)

Treated temporarily when spontaneous recovery is expected (lubrication, Botox, sew eyelids closed). Permanent treatment when spontaneous recovery does not occur (surgery).

Mechanical ectropion

Ectropion caused by tumors near the eyelid or herniated orbital fat (pulls the lower lid down/out).

Treated by removing the causative agent

Allergic edema

Inflammatory reaction to pollen or insect bites

Presents with bilateral periorbital edema, hyperemia, itching, and conjunctival swelling (chemosis).

Treated with systemic antihistamines (this is a systemic issue).

Contact dermatitis

Inflammatory reaction to preservatives, medications, cosmetics, or metals (delayed type IV hypersensitivity).

Presents with eyelid itching, hyperemia, lid edema and scaling of the eyelid, conjunctival chemosis(swelling), papillary reaction, and PEE due to inflammation.

Treated by removing allergen exposure, topical steroids, oral antihistamines, as well as cold compresses and artificial tears.

Atopic dermatitis

Eczema, idiopathic condition associated with asthma and hay fever, commonly seen in kids with vernal disease and chronic severe dry eye

Presents with thickening and crusting of eyelids (bleph and madarosis)

Treated with topical steroids, emollients to hydrate skin, and treating the associated bleph

Herpes simplex

Caused by HS1, usually occurs in childhood and spread through droplet transmission. Usually missed the first time around because presentation is similar to upper respiratory infection.

Reoccurrence presents with facial and lid tingling, eyelid or periorbital vesicles on lid margin (atopic patients can get eczema herpeticum), lid swelling, follicular conjunctivitis, corneal dendrites.

Treated with antivirals (oral or topical)

Hopes zoster ophthalmicus

Caused by varicella-zoster virus, commonly seen in elderly patients and immunocompromised (worse for them).

Presents with pain along the first division of the trigeminal nerve, maculopapular rash on forehead, vesicles and pustules, eyelid edema, and unilateral (respects midline).

Treated with oral antivirals (every time), topical antiviral cream, and/or topical antibiotic-steroid cream

What vaccines/shots are available to help prevent shingles in older and immunocompromised patients?

Shingrix (2 shots 2-6 months apart, and more common)

zostavx (single dose shot)

Verruca vulgaris (viral wart)

Hyperplasticity growths of the epidermis caused by human papillomavirus

Presents with small non-pigmented papule, finger-like projections from papule, and located near the lid margin

Treated by excising if necessary or wanted

Molluscum contagiosum

Hyperplastic epidermis with intracytoplasmic inclusion bodies and a central pit, caused by molluscum contagiosum poxvirus, common in children (immunocompromised people as well but have more than one lesion) transmitted by direct contact

Present with pale, waxy, umbilicated nodules (single or multiple), located on lid margin, white discharge may be expressed from legion

Treatment: may resolve spontaneously in 6-12 months, or excision, cryotherapy, laser if spontaneous resolution does not occur

Anterior blepharitis

Inflammation of the eyelids anterior to meibomian glands

Types: staphylococcus aureus (more common), seborrheic (over production of oils)

Anterior bleph due to staphylococcus aureus

Abnormal cell mediated response to the cell wall of bacteria, symptoms include chronic irritation worse in the AM, burning, grittiness, photophobia, and crusting

Present with scales around the base of the lash (collarettes), hyperemic lid margin, if chronic then scarring and hypertrophy of lid margin.

Treat with lid hygiene, topical antibiotic ointment, or a combo topical antibiotic/steroid ointment.

Complications include tear film instability, styes, PEE, vascularization and infiltrates

Seborrheic anterior blepharitis

Aka squamous blepharitis, caused by the malfunctioning glands of Zeis (overproduction of oil).

Presents with hyperemia, greasy lid margin, scaling of lid margin and lashes, and lashes stuck together due to oil

Complications are dry eye, PEE, vascularization, infiltrates

Treat with lid hygiene (everyday for life)

Angular blepharitis

All symptoms at temporal aspect of the eye, caused by staphylococcus aureus or moraxella lacunata

Presents with scaling and hyperemia of the lateral or medial canthus (usually lateral and unilateral), usually seen in conjunction with something else

Treatments: lid hygiene, topical antibiotic ointment

True

True or false: most patients have both anterior and posterior blepharitis

Posterior blepharitis (aka meibomianitis or MGD)

Inflammation of the meibomian glands and the lid margin posterior to the meibomian glands, altered meibomian gland secretions (melting point of meibum increased, expression reduced, staphylococcus aureus growth increase)

Presents with chronic irritation worse in AM, burning, grittiness, photophobia, crusting, capping of MG, thickened meibum when expressed, lid hyperemia, telangiectasia, gland loss (chronic), frothy or oily tear film.

Treat with lid hygiene, warm compresses and massage, oral tetracyclines (used for anti inflammatory properties)

Complications include dry eye, notching of lid margin, foaming of tears, PEE, neovascularization, and infiltrates.

External hordeolum (stye)

Acute staphylococcal infection of the eyelash and gland of zeis. Presents with pustule at the lash or gland of Zeis, sometimes associated with localized or general lid edema

Treatment: topical antibiotics, hot compresses, eyelash epilation

Internal hordeolum

Infection of the meibomian gland (typically caused by staph infection), commonly associated with blepharitis, acne and rosacea. Presents with inflamed meibomian gland, tenderness over inflamed meibomian gland, eat, overlying hyperemia. Complications can include preseptal cellulitis

Treatment: may spontaneously resolve, lid hygiene, oral antibiotics

Preseptal cellulitis

Infection of te subcutaneous tissue anterior to the orbital septum, caused by spread of local infection (acute hordeolum, dacryocystitis, or sinusitis). Presents with hyperemic lid with periorbital edema, tenderness, heat.

Treat with oral antibiotics since deeper tissue is affected.

Orbital cellulitis

Infection of soft tissue behind the orbital septum. Caused by extension of preseptal cellulitis, sinus related, local spread, post trauma, or post surgical. Presents with unilateral periorbital edema (tender and hot), proptosis, pain on eye movement, restriction on eye movement, optic nerve abnormalities.

Treatment: hospital admission and consult infectious disease, broad spectrum IV antibiotics and then switch to oral antibiotics

Phthiriasis palpebrarum

Crab louse Phthirus pubis (lice) causes chronic irritation and itching of the lids. Presents with lice anchored to lashes, small brownish opalescent pearls adhered to base of lashes, affecting children in poor hygienic conditions.

Treated with mechanical removal of lice and petroleum jelly.

Demodex

Common parasite that lives on the skin, affects all ages, more common in whites, more common in people with poor hygiene or rosacea. Types: folliculorum and brevis. Symptoms include itching, foreign body sensation, dryness, eyelash crusting, hyperemia of lid margin, eyelash loss or misdirection.

Treated with tea tree oil lid scrubs (for 30 days or more) or Xdemvy drop.

Demodex folliculorum

Demodex found on eyelashes and small hair follicles (bigger of the two) presents with cylindrical dandruff, and conjunctival hyperemia

Demodex brevis

Demodex found in sebaceous glands including meibomian glands. Have a rounder body and shorter tail. Presents with meibomian gland capping, conjunctival hyperemia, and in severe cases corneal modular scarring.

Rosacea

Most commonly found in middle aged females. Presents with red patches on the nose and cheek area, small blood vessels become dilated and visible, swollen red bumps-resemble acne, and an enlarged nose. Aggravated by sun, spicy food, stress, alcohol, and exercise

Ocular rosacea

Equally common in me and women, presents with foreign body sensation, pain/irritation, burning, photophobia, redness, epiphora, decreased vision. Associated with rosacea.

Treatment: lid hygiene, oral antibiotics (tetracycline for anti inflammatory properties)

Chalazion

Granulomatous inflammatory lesion of the meibomian gland. Caused by sebaceous secretion leaking from meibomian gland or adjacent sebaceous glands. Presents as a painless nodule (typically on the upper lid within the tarsal plate).

Treatment: monitor, surgery, steroid injections, oral antibiotics.

Xanthelasma

Lipid histiocytes in the dermis. Present with yellow plaques located medially, typically found in middle aged to elderly individuals, bilateral, can be associated wit elevated cholesterol levels. Treated with excision or laser removal.

Moll

Benign small retention cyst on the anterior lid margin, not painful.

Treatment: observation

Sebaceous cyst

Benign cyst caused by blocked pilosebaceous follicle that contains sebaceous secretions. Occurs at the inner canthus.

Treatment: observation

Milia cysts

Tiny epidermal cysts that are caused by occlusions of pilosebaceous units. These appear as white round papule that occur in groups.

Treatment: observation

Zeis cyst

Small translucent cyst on the anterior lid margin. Caused by obstructed sebaceous gland associated with the eyelash follicle.

Treatment: observation

Eccrine hidrocystoma

Sweat gland cyst, appears at medial or lateral aspect of the lid, does not directly involve lid margin.

Treatment: observation

Squamous cell papilloma

Finger-like projections of fibrovascular connective tissue covered by irregular squamous epithelium. Present with pedunculated (stalk-like) flesh colored lesion or a sessile (broad base) lesion that has a raspberry appearance.

Treatment: excision (if necessary)

Seborrhoeic keratosis (Basal cell papilloma)

Expansion of squamous epithelium of the epidermis. Presents as discrete, brown, greasy plaques (tend to be slow growing and more commonly seen in the elderly).

Treatment: excision

Actinic keratosis (solar keratosis)

Irregular dysplastic epidermis with hyperkeratosis. Presents with hyperkeratotic plaque with scaly surface, typically affects elderly, seen with large amounts of UV exposure, more common on forehead and back of hands, potential to develop into cutaneous horn or squamous cell carcinoma.

Treatment: excision or cryotherapy with biopsy

Cutaneous horn

Compact keratin, presents as a conical or coned like keratinized mass protruding from the skin (more common in fair skinned elderly individuals, and found on sun exposed areas).

Treatment: cryotherapy with biopsy

Pyogenic granuloma

Vascularized proliferation of connective tissue (tissue is infiltrated with inflammatory cells). Presents with red polypodial lesion (painful, bleeds easily with minor trauma).

Treatment: excision

Dermatochalasis

Excess skin of the upper or lower eyelid caused by aging (weakening of connective tissue). Presents with redundant upper eyelid skin, obstruction of the superior visual field, and wrinkling/ thinning of the skin.

Treatment: surgical removal of excessive skin

Blepharochalasis

Episodes of painless non-pitting edema of the upper and lower lids (more common in upper, recurrent in nature, onset is puberty and then decrease overtime). Females more than males, thought that hormones play a role. Presents with episodic, painless eyelid swelling, orbital fat and lacrimal gland prolapse, redundant thin and wrinkly skin, lid malposition.

Treatment: surgical removal of excess skin and orbital fat

Floppy eyelid syndrome

Chronic irritation from lid eversion or chronic eye rubbing. Typically affects obese middle aged males, strongly associated with sleep apnea, diabetes, hypertension, hyperlipidemia, keratoconus, and chronic eye rubbing. Presents with redundant upper eyelid skin, loose or rubbery tarsal plates that are easy to evert, mild papillary reaction of superior palpebral conj, PEE, filamentary keratitis, lagophthalmos, eyelash ptosis, lacrimal gland prolapse, ectropion, aponeurotic ptosis.

Treatment: night shields/ taping lids, lubrication as needed, surgery if severe.

Lid retraction

The upper lid margin is at or above the superior limbus. Caused by thyroid eye disease, neurologist (Marcus Gunn Jaw winking), mechanical (surgical over-correction of ptosis), congenital (Down syndrome), or idiopathic.

Treatment: surgery

Lagophthalmos

Inability to fully close eyelids (leads to dryness and ocular irritation). Caused by: 7th nerve palsy, trauma, eyelid surgery, proptosis, floppy eyelid syndrome. Symptoms include dryness, foreign body sensation, increase tearing, pain worse in am, blurred vision.

Treatment: lubrication, surgery (tarsorrhaphy, gold weight implantation, upper eyelid muscle surgery, lower lid tightening and elevation surgery)

Hyperthyroidism

Excessive secretion of thyroid hormone. Autoimmune disorder where IgG antibodies bind to thyroid stimulating hormone receptors in thyroid gland and stimulate the secretion of thyroid hormones. affects females more than males.

Thyroid eye disease / Graves’ disease

Presents in the 3rd-4th decade, patients will have weight loss, sweating, nervousness, heat intolerance, irritability, heart palpitations, weakness, fatigue, gastrointestinal abnormalities.

Ocular presentations can include ocular surface disease, exposure keratitis, upper and lower eyelid retraction, swelling o the ocular muscles, and enlargement of orbital fat.

Ocular surface disease

Deals with lid and cornea interaction in regards to TED. Symptoms include light sensitivity, gritty or painful eyes, tearing, blurry vision. Unstable tear film due to inflammation of the mucous producing cells, lacrimal gland and corneal surface.

Treatment: artificial tears, topical steroids, systemic control of thyroid disease

Eyelid issues associated with TED

90% of patients affected, upper and lower lid retraction, lagophthalmos (causes disruptions in the tear film, PEE.

Treatment: eyelid surgery

EOM presentation with TED

Present in 50% of associated patients, swelling of muscles, can cause strabismus and have restrictions on movements.

Treatment: spectacle prism, strabismus surgery

Orbital presentation with TED

Occurs in 2-5% of affected patients, enlargement of orbital fat, extraocular muscles and fibrous tissue. Proptosis, ears to ocular surface disease, lid retraction, lagophthalmos, and/or exposure keratitis. Also can cause compression of the optic nerve.

Treatment: surgery

Ted ocular presentation pneumonic

N- no signs

O- ocular symptoms

S- soft tissue involvement

P- proptosis

E- EOM involvement

C- corneal involvement

S- sight

Blepharospasm

Uncontrolled blinking, twitching, or closure of the eyelids. Can be episodic, involuntary contractions of the orbicularis oculi muscle.

Treatment: Botox injection

Eyelid myokymia

Presents with eyelid twitching, caused by stress, increased caffeine, or ocular irritation, sleep as well.

Treatment: topical antihistamines (off label- not a known treatment)

Capillary hemangioma (strawberry nevus)

Most common tumor of infancy: presents shortly after birth (more common in females). Proliferation of varying vascular channels in the dermis and subcutaneous tissue. Presents unilaterally, raised bright lesion that is red, dark blue or purple (depends on deepness). Predilection for the upper lid, blanches with pressure, swells with crying, superficial will be bright red, preseptal will be dark blue to purple.

Treatment: observation (main), beta blocker, laser, steroid injection, systemic steroid, resection.

Nevus of Ota (oculodermal melanosis)

Hyperpigmentation of the eye and the adnexa along the ophthalmic and maxillary divisions of the trigeminal nerve. Typically presents at birth or puberty, more common in females, Asian and African population. Melanocytes in the upper third of the dermis. Presents with bluish or brownish pigmentation of the eyes and/or face skin and lids. All pigmented lesions will be on the same side, scleral lesions have an increase risk of developing glaucoma (66%), presentation will darken with age.

Treatment: observation and monitor for development of glaucoma and/or melanoma

Congenital nevus

Present in 2-3% of infants, large benign lesion that may develop into malignant melanoma. Presents with pigmented lesions with regular margins, may have smooth or lobular surfaces, long coarse hair, and may result in ptosis, ectropion/entropion, and chronic cornea irritation.

Treatment: observation, if large enough then surgery

Acquired nevus

Presents between ages 5-15 years of age, pigmentation increases during puberty and will be lost later in life. Clumps of melanocytes in the epidermis and dermis. Types: junctional, compound, intradermal

Junctional nevus

Type of acquired nevus that occurs in young individuals, appears as a brown plaque, located where the epidermis and dermis connect, and low potential for malignancy.

Treatment: observation unless removal is needed for cosmetic reasons or concern for malignancy

Compound nevus

Type of acquired nevus that occurs in middle aged individuals, extends from the epidermis to the dermis, appears as a tan to dark brown raised popular lesion, and has a low malignancy potential.

Treatment: observation unless removal is needed for cosmetic reasons or concern for malignancy

Intradermal nevus

Most common type of acquired nevus, occurs in elderly individuals, found in dermis, papilloma like appearance with little to no pigmentation (will also have protruding eyelashes). No malignancy potential.

Treatment: observation unless removal is needed for cosmetic reasons

Port wine stain (nevus flammeus or cavernous hemangioma)

Large blood filled spaces separated by fibrous tissue, congenital condition. Presents with demarcated pink patch that does not blanch with pressure, darkens to red or purple with age, overlying skin becomes coarse with age (area may bleed easily).

Treatment: laser