LIDS COMBINED

Name the 6 types of benign lesions

Xanthelasma
Papilloma
Skin tags
Haemangioma
Retention cysts
Milia

Describe the characteristics of xanthelasma

Soft yellowish plaques

variable size

Where are xanthelasma usually found?

Usually on medial upper +lower eyelids, often bilateral

What are xanthelasma associated with?

Assoc’d w/ lipid and cholesterol deposits (50% related to elevated serum lipid levels).

Describe squamous cell papilloma

-Histopathology?

Sessile or pedunculated

H: Excessive convoluted epithelium with central fibrovascular core

What is the appearance and cause of basal cell papilloma?

• Smooth, waxy/warty surface
• Slow growing, not painful or tender
• Flat or raised plaque
• Skin coloured/grey/brown

Describe dermatitis papulosa nigra

-What are they identical to?

Multiple small diameter black or
dark brown papules - face and
neck

ident to small seborrheic keratoses

Describe characteristics of skin tags

Small, soft, skin coloured growth

Variable size, shape, colour and number

What are the cause of skin tags?

Clusters of collagen + blood vessels surrounded by skin

Describe a capillary haemangioma?

Evident in neonatal period

Grows in 1st year ,usually regresses by 5yo

May be cutaneous, orbital or mixed

Systemic associations

What does systemic associations mean in relation to a capillary haemangioma?

GP may need to investigate

Reassure parents it usually regresses with time

How can a capillary haemangioma affect the development of vision?

Can be present on top eyelid-causing ptosis or droopy lid

If lid low enough it can block visual axis

When does vascular malformation become present?

At birth

More prominent with time

What are retention cysts?

Small round non-tender cysts

Describe cysts of Zeis ?

White cheesy (sebaceous) material

Describe cysts of moll

Clear fluid filled

How would you remove cyst of zeis/ moll?

Cosmetic excision

Describe milia

Tiny superficial white yellow dome shaped cysts

Usually multiple

Describe naevi

Congenital or acquired

Pigmented or non pigmented

Flat or slightly raised - ± hairs, warty surface

Rare - turns malignant

Name premalignant lesions

Actinic keratosis

Keratoacanthoma

Describe actinic (solar) keratosis

• Flat, Scaly lesions , rough skin

• R/P/B/Skin coloured

• Older age-history of sun exposure

• May give rise to squamous cell carcinoma

• Occasionally papillomatous/cutaneous horn

Describe a cutaneous horn

• Keratin projection

• Arise from benign, premalignant + malignant lesions

• 10% assoc’d w/ squamous cell carcinoma

• Base= point of interest

Describe keratoacanthoma

• Rapidly enlarges (months)

• Regresses or evolves into squamous cell carcinoma

• Volcano shaped with keratin plug

• Visually, often difficult to distinguish from BBC or SCC

• Histopathology - arises from hair follicle skin cells

Name malignant lesions

1. Basal Cell Carcinoma

2. Squamous cell carcinoma

3. Sebaceous gland carcinoma

4. Malignant Melanoma

5. Kaposi’s sacroma

6. Merkel cell carcinoma

Describe basal cell carcinoma

• Most common periocular malignancy

• Slow growing, painless, often ulcerated

• Do not metastasise but invade locally

• Change in lid contour (shape/skin)/lash redirection

What does periocular mean ?

Around the eye

Name the types of basal cell carcinoma

• Nodular

• Ulcerative

• Sclerosing

How to manage basal cell carcinoma

Optometric management

Low risk skin cancer (don’t spread rapidly)

Urgent referral

Photographic documentation

How to manage basal cell carcinoma

Secondary care

Surgery-To remove lesion

Histology-Find out which cells are involved / type of cancer

Describe the characteristics of squamous cell carcinoma

• May evoke inflammatory response

• Symptomatic - patient concern about lesion, may irritate or itch, may bleed

• Can look similar to BCC but more aggressive

• More likely to metastasise than BCC

How to manage squamous cell carcinoma

Optometric management

Low risk skin cancer (don’t spread rapidly)

Urgent referral

Photographic documentation

How to manage basal cell carcinoma

Secondary care

Surgery

Histology

Describe the characteristics of malignant melanoma

• V rare

• Can appear out of nowhere or as a malignant transformation of a naevus

• Signs inc itching, bleeding, pigmentary changes, increase in size

• 50% are non-pigmented

Describe sebaceous gland carcinoma

• Originates from meibomian gland

• Highly malignant/rare

• Lump in eyelid -looks like a chalazion-when you invert eyelid =abnormal appearance -new BV’s,dark area

• Urgent referral

Describe Merkel cell carcinoma

V rare

Neuroendocrine tumour

Grow rapidly

Mortality rate =25-30%

Describe Kaposi’s sarcoma

Purple/red-pink tumour

e.g on eyelid margin

Assoc’d w/ HIV/AIDS OR organ transplant in elderly or immunosuppressed

Risk factors for malignancy

• Prior skin cancer

• FH: skin cancer

• Previous radiation exposure (excessive UV)

• Fair skin

• Older patients

• Acute > chronic onset

• Increasing in size

• Bleeding/crusting

Key questions to ask

Suspicious lumps/bumps

• How long has the lesion been present?

• Has it enlarged since onset?

• Has the lesion crusted or bled?

• Has the colour changed?

• Any history of skin cancer?

• Any history of significant UV exposure (e.g. lived in a hot climate, outdoor occupation, use of sunbeds)

Suspicious signs of malignancy

• New

• Increasing in size

• Surface ulceration/induration

• Neovascularisation - new blood vessels in and around the lesion, bleeding

• Crusts

• Lid margin changes - destruction of margin, loss of lashes

• Recurrent infection/inflammation

More reassuring signs

-Benign

• Long standing

• Remain static in size

• Smooth surface

• Does not bleed with minor trauma

• Doesn't form adherent crusts

• Does not destroy eyelash follicles (may distort them)

Things to look for with suspicious lumps and bumps

ABCDE

Asymmetry

Border

Colour

Diameter

Evolving

Optometric management of suspicious lumps and bumps

• Majority of lumps and bumps are benign

• Explain and reassure patient

• Photographic documentation

• If in doubt refer

• Urgent referral (2 week pathway)

Secondary care for the management of suspicious lumps and bumps

• Examination

• Excision & biopsy

Summary

Be able to detect common eyelid positional abnormalities and eyelash disorders

Ectropion

• Outward rotation (eversion) of the eyelid margin (usually lower)

• Occurs in ~4% of >50 yr olds

• 70% bilateral

What are the main causes of an ectropion ?

Age-related (involutional)

Processes occur in BE but asymmetrically

CWMHPC

1. Horizontal lid laxity

2. Weakness of the orbicularis oculi and/or canthal tendons

3. Cicatricial: scarring +/- contracture of skin and underlying tissue- pulls eyelid tissue down (unilateral)

4. Paralytic (VII nerve palsy)

5. Mechanical/Inflammatory

6. Congenital

Be aware of their key signs

Ectropion

• Inferior lid margin not in contact with globe
• Lower punctum spontaneously visible (more exposed when looking at it using slit lamp)
• Exposed palpebral conjunctiva hyperaemia
(keratinisation)
• Exposure keratopathy (pictured)
• Mucous discharge

Be aware of their key symptoms

Ectropion

• Very variable
• Soreness
• Redness
• Watery eye (Epiphora)-bc lower lid puncta is no longer against the globe so tears build up in reservoir and spill over

Risk factors

Ectropion

• Older age

• Lid scarring/pathology

Know how to manage patients with these conditions

Optometric management

Ectropion

• Ocular lubricants (drops for daytime,
  ointment at bedtime)

• Consider taping the lids closed at night

• Advise lid rubbing may increase lid
  laxity

• Monitor

• Routine referral when necessary
  (urgent if exposure keratopathy)

In the case of an ectropion, why can we ask the patient to consider taping the lids closed at night?

Reduces risk of exposure kerotopathy

Know how to manage patients with these conditions

Secondary Care

Ectropion

• Address the cause

• Surgery in the presence of

  • Exposure keratopathy

  • Chronic epiphora and irritation

  • Recurrent bacterial conjunctivitis

  • Poor cosmesis
    

Be able to detect common eyelid positional abnormalities and eyelash disorders

Entropion

• Inward turning (inversion) of the tarsus and lid margin

• Causes lashes to come into contact with the ocular surface

• Affects ~2% of the elderly population

What are the main causes of an entropion ?

• Age-related (involutional)

• Degenerative changes result in horizontal lid laxity

• Cicatricial

  • Scar tissue pulls the lid inwards

  • Burns, surgery, rheumatoid arthritis

• Muscle Spasm

• Congenital (rare)
  

Risk factors of an entropion?

• Increasing age

• Severe cicatrising disease

• Ocular irritation or previous surgery

Be aware their key signs and symptoms
Entropion

• Inward directed lower lid (can be intermittent)

• Lashes contact globe

• Vertical corneal +/- conjunctival staining

• Lid laxity

• Localised conjunctival hyperaemia

• Risk of corneal scarring

Be aware their key symptoms
Entropion

• Foreign body sensation

• Watering

Know how to manage patients with these
conditions

Optometric management

Entropion

• Taping eyelid (temporary)-protect cornea from scratches

• Ocular lubricants

• Referral - speed depends on extent of
  corneal involvement

Know how to manage patients with these
conditions

Sequelae

Entropion

• Ocular irritation

• Recurrent bacterial conjunctivitis

• Ulceration and microbial keratitis

Know how to manage patients with these
conditions

Secondary care

Entropion

• Surgery

• Botulinum toxin if unfit for surgery

What is ptosis

Drooping / abnormally low position of the upper lid

Assoc’d w/ the reduction in the palpebral fissure height (lid to lid)

Normal lid measurements

Be able to detect common eyelid positional
abnormalities and eyelash disorders

Acquired ptosis

Age-related (Aponeurotic or involutional)

• Muscle is stretched out or disinsertion of the levator palpebrae superioris

• Inc’s w/ age (post surgery, trauma + CL use)

• Uni/bilateral

• High upper crease

• Compensatory brow lift

• Low relative position in downgaze

• Refer routinely if functional-consider surgery

Be able to detect common eyelid positional
abnormalities and eyelash disorders

Acquired ptosis

Myogenic

• Weak muscle

• Muscular dystrophy

bilat ptosis in pic

Be able to detect common eyelid positional
abnormalities and eyelash disorders

Acquired ptosis

Neurogenic

Problem with the nerve controlling the lid

• Third Nerve Palsy

• Horner’s syndrome

• Marcus gun jaw-winking

• Myasthenia gravis

  (variable Coogan’s sign)

Be able to detect common eyelid positional
abnormalities and eyelash disorders

Acquired ptosis

Mechanical

Physical pushing or weighing the lid down

• Blepharochalasis

• Eyelid tumours

• Oedema

Be able to detect common eyelid positional
abnormalities and eyelash disorders

Acquired ptosis

Traumatic

Result of injury

e.g could be result of severed nerve -complete ptosis

Be able to detect common eyelid positional
abnormalities and eyelash disorders

Acquired ptosis

Pseudotosis

Normal lid, another anatomical anomaly

• Microphthalmia

• Hypertropia

e.g smaller (red) cornea to other eye ,bc eye=smaller ,eyelid comes down lower bc of size of globe

OR

hypertropia ,if one eye higher than other,can look like ptosis

Be aware their key signs

Acquired ptosis

• Brow elevation (frontalis overaction)

• Chin up head posture

• Reduction in the palpebral fissure (narrow)

• Signs relating to the underlying
  cause

Be aware their key symptoms

Acquired ptosis

• Cosmesis e.g droopy lid

• Tired eyes

• Neck pain

What should you do first when assessing ptosis ?

RUle out any serious (underlying) causes e.g

• Third Nerve palsy (eye positioned down and out, dilated pupil)

• Malignancy (sudden onset, exophthalmos)

• Myasthenia Gravis (variable with fatigue, Coogan’s sign)

• Potential for amblyopia in childre

How to assess pt’s with ptosis ?

1. History - onset, progression, variability/fatigue

2. Check ocular motility & pupils (neurological cause)

3. Consider old photos

4. Exclude pseudoptosis (e.g. microphthalmia, hypertropia in eye with ptosis OR lid retraction, prominent eye, hypotropia in fellow eye

Know how to manage patients with these
conditions

Ptosis

• Treat underlying cause e.g. myasthenia gravis

• Surgery proportional to levator function

• Lubricants with myogenic ptosis as risk of corneal exposure

• Spectacles with ptosis props; scleral contact lenses

Be able to detect common eyelid positional
abnormalities and eyelash disorders

Congenital ptosis

• Dysgenesis of the levator

• Usually idiopathic

• Present from birth-check photos

• Can indicate other pathology

• Ptosis reversal in downgaze
  

Why is there a risk of amblyopia/astigmatism with congenital ptosis ?

if lid goes over pupil vision can’t develop properly

Be able to detect common eyelid positional
abnormalities and eyelash disorders

Lid retraction

Suspected when eyelid margin is above or level with the superior limbus

Possible causes of lid retraction?

• Neurogenic

• Mechanical

• Congenital

• TED – thyroid eye disease

  • auto immune condition where the eyes appear to bulge

• Neurogenic

  • e.g. Marcus Gunn Jaw Winking

• Mechanical

  • e.g. surgical overcorrection of a ptosis

• Congenital

  • e.g. Duane’s syndrome

Due to lid retraction there is a risk of …

Exposure keratitis

Be able to detect common eyelid positional
abnormalities and eyelash disorders

Lagophthalmos

Inadequate eyelid closure leads to
• Tear film disturbance
• Corneal desiccation

Be aware their key symptoms

Lagophthalmos

• Grittiness

• Burning

• Increased lacrimation

Be aware their key signs/associated with

Lagophthalmos

• CN VII (facial nerve) palsy

• Proptosis e.g. TED

• Night time (while sleeping) incomplete eyelid closure

Know how to manage patients with these
conditions

Lagophthalmos

• Ocular lubricants

• Eyelid taping (esp. nocturnal)

• Surgery - depending on cause

Be able to detect common eyelid positional
abnormalities and eyelash disorders

Floppy Eyelid Syndrome

• Generalised laxity of eyelid tissues

• Unilateral / bilateral

• Lids spontaneous evert during sleep

Be aware their key signs

Floppy Eyelid Syndrome

• SPK

• easy distraction of lid from globe

• easy upper lid eversion, lower lid ectropion

• ptosis

• chronic papillary conjunctivitis

• whitish mucous discharge

Be aware their key symptoms

Floppy Eyelid Syndrome

• Non-specific ocular irritation

• Redness

Know how to manage patients with these
conditions

Floppy Eyelid Syndrome

• Lubricants

• Eye shield for sleep

• Wedge excision

• Canthal tendon repair

Floppy eyelid syndrome is associated with…

Sleep apnoea (life threatening)

Be able to detect common eyelid positional
abnormalities and eyelash disorders

Facial Nerve Palsy

Partial or complete paralysis of the facial nerve (VII cranial nerve)

• Facial nerve

• Bell’s palsy

Which functions does the facial nerve control?

Sensory, motor + parasympathetic

What is Bell’s palsy?

Idiopathic lower motor neurone facial nerve dysfunction

Aetiology of facial nerve palsy

• Idiopathic

• Latent virus infection (HSV, herpes zoster)

• Others (infection, trauma, tumour)

Risk factors of facial nerve palsy

• Pregnancy

• Diabetes

• HIV

Be aware their key signs

Facial Nerve Palsy

• Sudden onset

• Unilateral

• Weakness or inability to move one side of the face

  • Eyebrow droop/inability to raise

  • Incomplete blink → corneal drying

  • Lagophthalmos

  • Ectropion

  • Epiphora and tear pooling (loss of lacrimal pump mechanism)

Be aware their key symptoms

Facial Nerve Palsy

Possible changes in taste and salivation

Know how to manage patients with these
conditions

Facial Nerve Palsy

e.g New case with loss of corneal sensation

First aid measures and same day referral

Know how to manage patients with these
conditions

Facial Nerve Palsy

e.g Recovering and established cases (no referral necessary)

• Tape lids at night

• Sunglasses for photophobia

• Ocular lubricants

Know how to manage patients with these
conditions

Facial Nerve Palsy

Secondary care

• Steroids

• Tarsorrhaphy

Be able to detect common eyelid positional
abnormalities and eyelash disorders

Blepharospasm

• Involuntary tonic, spasmodic, bilateral eyelid closure

• More common in older indiv’s (60+)

What are the causes of Blepharospasm?

Idiopathic, Parkinson’s disease, psychogenic drugs e.g. psychotropics

Know how to manage patients with these
conditions

Blepharospasm

botulinum toxin injections into orbicularis oculi