E.

Oghre
Professor of optometry

Disorders of the
Eyelid
Eyelid disorders
 Range from benign, self resolving
processes, to malignant, possibly metastatic
tumours
Most are not vision or life threatening,
Many cause irritative symptoms such as
burning, foreign-body sensation or pain.
complications can lead to involvement of
other tissues which can now become more
morbid
Eyelids
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.
Eyelid closure distributes tears over the surface of the
eye and pumps them through the lacrimal puncta into
the nasolacrinal duct
Eyelids contd
 The eyelids consist of an anterior layer of skin and orbicularis
oculi muscle, and a posterior layer of tarsus and conjunctiva
 Contraction of the orbicularis muscle, innervated by the
seventh cranial nerve, closes the eyelids.
 The levator muscle, innervated by the third cranial nerve, and
the sympathetically innervated Müller's muscle raise the
upper lid.
 The orbital septum, originating from the orbital rim, inserts
into the upper lid just above the tarsal border and into the
lower lid just below the tarsal border. The orbital septum
limits the spread of infection and hemorrhage from the eyelid
to the posterior orbital structures
Eyelids contd
Several glands along the eyelid margin contribute to
the lipid component of the tear film. These glands
commonly become inflammed.
The meibomian glands, approximately 30 per lid, are
present within the tarsus.
The pilosebaceous glands of Zeis and the apocrine
glands of Moll are located anterior to the meibomian
glands within the distal eyelid margin
Types of eyelid disorders.
Eyelid malpositions
Eyelash abnormalities
Congenital Anomalies
Inflammations
Infectious conditions
Trauma
Tumours
Definition of terms
Lesion – Any abnormality in a tissue, usually causd by
disease or trauma.
Nodule- a raised solid area of skin
Cyst– A nodule made up of epithelial lined cavity
filled with fluid or semisolid material
Vesicle– A small circumscribed lesion containing fluid
Plaque– Palpable shallow elevations of skin
Ulcer– A circumscribed area of skin loss that extend
through the epidermis to the dermis
Ectropion
Etiology
1-Cicatrical - due to cicatrical changes in the skin
of the lid-
 Burns from lime,acids, and molten metal.
Surgery
Trachoma,rarly diptheritic conjunc
2-Senile –due to involutional changes in the skin
3-Paralytic -it occurs as a result of weakness of
the orbicularis muscle due to facial nerve paralysis.

-
management
Liberal use of artificial tears, drops during
the day and ointments at night
In more severe cases where there is risk of
excessive dryness, the ectropion can be
corrected surgically.
Entropion
Rolling in of the margin of the lid and with
the lashes. The eyelid margin rotates
inwards and faces the ocular surface
The eyelid margin or eyelashes rub
against the cornea, resulting in corneal
foreign body sensation, lacrimation, red
eye, superficial pontate erosions etc
 most commonly affects the upper lid
Etiology
Cicatricial entropion due to cicatricial changes
in the conjuctiva and distortion of the tarsal plate
Old case of trachoma
Blepharitis
Burns
Operation upon the lids
Spastic -Due to spasm of the palpebral portion of
the orbicularis
Atrophy or absence of eye ball
Old persons
After surgical operation
Blepharosbasm.
Symptoms and sings same as for trichiasis
Entropion
Types
 Involutional
lid laxity, orbital fat atrophy, weakened tarsus,
 Cicatricial
Scarring shortens posterior lamella. Causes
include
trachoma, radiation, chemicalinjury, topical rx,
previous surgery, trauma etc
 Acute spastic
Orbicularis oculi spasm due to ocular irritation or
essential blepharospasm
Management
Liberal use of artificial tears
Hydrophilic soft contact lens bandages
Antibiotic coverage eg. Bacitracin, Erythromycin,
Azasite
Botulinus toxin
In more severe cases at risk, surgical correction
BLEPHAROPTOSIS (PTOSIS)
Drooping of the upper eyelids
Congenital or acquired, Unilateral or bilateral
Backwards torticollis, brow wrinkling, inability to
open the eyes.
There may be diurnal variation
Unilarteral is usually neurological or mechanical,
while bilateral is usually due to aging or
generalized muscle disorder
 MECHANISM
 * weakness of eye muscle that raises eyelid
(superior rectus, superior oblique)
 AETIOLOGY
 Aponuerogenic or involutional
 Myogenic
 Neurological
 Mechanical.
 * familial,
 * trauma
* diabetes mellitus
 * muscular dystrophy
* myasthenia gravis
 * brain tumors
.
Management
Rule out Pseudoptosis ie.Phthisi buli, enophthalmus,
blowout fracture
For mechanical causes, remove resistance
For aponeurotis, use a ptosis crouch attached to
spectacle frame
Surgery
Refer to neuro ophthalmologist
Lagophthalmos
Incomplete closure of the lids
Symptoms of exposure keratitis
Chronic corneal irritation and dry eye syndrome esp in
the mornings
Pat is able to force eye shut, but 2-5mm opening on
normal lid closure
Superficial pontate staining in the band region
Causes

Exophthalmos as in Graves disease ,proptosis

due to orbital tumour. 1-
2- Facial nerve paralysis
3-Cicatrical ectropion of upper lid
4-Symblepharon
Complications
1-Xerosis of conjuctiva.
2-Chronic conjunctivitis and exposure
keratitis
Treatment
Liberal use of artificial tears
Hydrophilic soft contact lens bandages
Consider taping lids shut at night
In more severe cases at risk, surgical correction
Dermatochalasis
Bilateral condition in which thwere is redundancy and
loss of elasticity of skin of eyelid
Normal eyelid crease is lost, and excessive fold of skin
drapes over the lid margin
Occurs more in upper eyelid
Bilateral andfamilial,
May result in ptosis
Aetiology – Senile changes, including effect of gravity
Blepherospasm(Eyelid myokmia)
Involuntary tonic spsmodic eyelid closure.
Pat may say flickering,twitching,vibrating,etc
Intermittent or constant
Unilateral or bilateral
More common in females
Causes – idiopathic, parkinsons disease, psychogenic,
teteny, drugs
Management
Check lid for masses
Check BP, Refractive error, IOP
Ruleout trichiasis, foreign body, Myasthanis Gravis,
parkinson’s
Consider emotional state, physical stressor habit
It is often benign and self limiting, educate and
reassure
 In exceptional cases Botulinus toxin injections into
orbicularis oculi
SYMBLEPHARON
 Cicatrical attachment between the conjnuctiva of the lid
and the eye ball.
 It may affect both lids,
 Usually the lower, sometimes it includes part of the cornea
 Types
Anterior - when extending bridge like from lid to globe,
leaving a free portion of the conjunctiva corresponding
to the fornix.
Posterior - When in involves only the fornix
Total – when the lids are adherent to the globe
throughout.
ETIOLOGY
1- injuries especially burns from
lime,acid,and molten metal
2- surgery
3- trachoma
Eyelash Disorders
Trichiasis
Misdirected eyelashes. They turn backwards and
irritate the corneal surface
Symptoms – Foreign body sensation, redness, pain,
photophobia
Treatment
Epiliation of offending lashes
Providing protection for ocular surface
Treating corneal injury
With recurrent trichiasis,electrolysis can be used
topermanentlyremove lashes
 Treatment Options for Trichiasis
.

1. .Epilation - but recurrences within few weeks

2. Electrolysis - but frequently repeated treatments req

3. Cryotherapy - for many lashes

4. Laser ablation - for few scattered lashes

5. Surgery - for localized crop resistant to other method

Distichiasis

Abnormal accessory lashes arising near meibomian

gland orifices.
May be congenital, but is more frequently acquired
secondary to scarring, e.g. ocular cicatricial
pemphigoid.
Management similar to trichiasis
Poliosis and madarosis
Madarosis – loss of eyelashes
Poliosis – whitening of eyelashes
Maybe unilateral or acquired, complete or incomplete
Rule out other ocular and systemic conditions eg.
Blepheritis, dry eye, leprosy, exposure to radiation,
sarcoidosis, cancers, anaemia, HIV, Use of medication,
etc
Rule out loss of hair in other parts of body
F accompanied by granulomatous uveitis, it is Vogt
Koyanagi Handara (VKH) disease
Inflammations/ Infections
Stye
Chalazion
Blephritis
Anterior
Posterior
Lid cellulitis
Preseptal/ orbital cellulitis
Hordeolum or Stye (Common Boil)
 Common staphylococcal infection of the glands of the lid.
It is characterized by redness, swelling and an acute painful
area directly adjacent to or surrounding the affected lid
margin gland or cilia.
 Hordeolum can be external or internal
 External
Small abscess
Points anteriorly through the skin
staph infection of the more anteriorly located glands of Zeis or
Moll
 Tender, inflammed swelling in lid margin, single or
multiple, cellulitis
 External Hordeolum

Staph. abscess gland of Zeis or

•
Internal Hordeolum
involves infection of the deeper meibomian
gland
Relatively larger
Chronic eyelid infections such as blepheritis
may be frequently present
Commonly encountered organisms are Staph
aureus and Staph epidemidis.
Untreated hordeolum may lead to spread of
infection to neighbouring eyelid glands or
tissues, resulting in preseptal cellulitis
1 Hordeolum Internal & External
Hordeolum

38
Management
Usually self limiting, resolves in 5-7 days
Treatment is similar to an abscess any where in the body
 hot compresses for 15min, 3-4 times daily
Topical antibiotic ointment BD, eg bacitracin or
Erythromycin.
Removal of offending eyelash
Perforate and Drain if the abscess is pointing
Where these fail, systemic antibiotics in severe cases eg,
Doxycycline 200mg stat then 100mg daily X 7 or
Amoxicillin 500mg QID X 10
Reassessment should be done weekly until resolution.
Clinical perils
Kaposi sarcoma in HIV patients may
mimick Hordeolum
Recurrent lesions with madarosis should
undergo biopsy to rule out sebaceous cell
cacinoma
Chalazion (Tarsal cyst or
meibomian cyst)
Localized firm painless nodule on upper or lower
lid
the most common inflammatory lesions of the
eyelid.
Chronic non-infectious, non-tender inflammatory
granuloma of meibomian gland
Due to blockage and accumulation of secretions
One or more glands involved,
mainly children and young adults involved
Swelling, heaviness, irritation
Blurring if large- induced astigmatism
 Chalazion (Tarsal cyst or
mebomian cyst)
Cystic, hard swelling a little away from the lid
margin, fixed to tarsus, non-tender
No signs of inflammation, no
lymphadenopathy
The aetiology is obstruction of the meibomian
gland duct, with resultant retention of
glandular secretions.
Small may resolve,
may remain the same,
 may burst on skin- fistula

Signs of chalazion (meibomian cyst)

Painless, roundish, firm lesion May rupture through conjunctiva

within tarsal plate and cause granuloma
Chalazion on left lateral upper lid.
 Management
 About one third drain and resolve spontaneously
 Standard therapy aimed at stimulating and speeding draining by
Warm compress 3-4 x daily accompanied by gentle massage
 Steroid injection through the palpebral conjunctiva
 0.1-0.2 ml Kenalog (triamcinolone),80% success rate
 All superficial infections should be treated before incision
 May cause local depigmentation of the skin
 Oral tetracycline/doxycycline useful in patients with chronic lid
inflammation
 Do not use in children or pregnant/nursing women!
 250mg PO qid tetracycline
 100mg PO bid doxycycline
 1-2 week course
large lumps can sometimes put pressure on the eyelid
and cause astigmatism, in which case surgical removal
is indicated.
Sometimes a chalazon leads to the formation of a
granuloma

 A very hard or recurrent chalazon should be sent for

biopsy to rule out meibomian cell carcinomia
especially if associated with madarosis.
 Treatment of chalazion

Injection of local anaesthetic Insertion of clamp Incision & curettage

Blepheritis
Commonest eyelid disorder
Usually chronic infection and inflammation of the skin
of the eyelid, eyelid margins, eyelashes and the glands
Typically bilateral
Causes—not clear but staph infection and sebhorrea
play a part
Associated with tear film instability
Maybe classified into
Anterior blepheritis
Posterior blepheritis
symptoms
itching, burning, grittiness or foreign body sensation,
generalized irritiation of the eyelid.
heaviness
Crusty and scaly debris in and around eyelashes on
wakening
other visible signs include
erythema, concretion and collaretes on lid margins,
madarosis, trichiasis, meibomian gland inspissations
(plugging), conjunctival injection and superficial
punctate staining on lower third of cornea.
Complications
In severe or untreated cases, ulcerative blepheritis may
occur,
 local hemorrhagic erosions of lid margins
other complications include
 hordeola,
 chalazia,
 preseptal cellulitis.
CHRONIC MARGINAL
BLEPHARITIS

1. Anterior blepheritis : This affects the eyelid

margin, eyelashes and pilosebeacious glands.
There are two types.
 Staphylococcal
 Seborrhoeic

2. Posterior blepheritis : This is called meibomian

glad disfunction, and it affects the meibomian
glands
 Meibomianitis
 Meibomian seborrhoea
Staph Anterior Blephritis
Erythematous lid margins, Dry crusty debris on lashes
and base of cillia.
Chronic infection of the bases of the lashes resulting in
tiny intrafollicular abscesses
Secondary dermal and epidermal ulceration and tissue
distruction
The bacteria creates irritative toxins, leading to
proinflammatory factors which triggers an
inflammatory response
More common in children but may affect any age
group
Females more affected than males
Unhygienic conditions and dietary factors involved
 Staph Anterior Blephritis—Cont.
Symptoms:
Sourness of lid margin, burning, foreign body sensation,
heaviness, generalized irritation, Lacrimation, itching and
photophobia
Signs:
Crusty and scaly debris at the roots of the eyelashes,
On removing the crusts, small ulcers may appear
Falling off of the lashes—either not replaced or abnormal
replacement
others include erythema, concretion and collaretes on lid
margins, madarosis, trichiasis meibomian gland
inspissations (plugging),
4 Staphylococcal blepharitis

54
Complications
If not treated, it may lead to
Poliosis, madarosis, trichiasis, tylosis
Treatment:
Lid hygiene, Warm compress, topical and oral
medication
Dilute baby shampoo can be used to cleans lids, continuous
effort at lid cleansing must be maintained to prevent
reoccurrence
Ocular lubrication can be used to relieve irritation
Topical antibiotic ointment e.g. Azithromycin, Bacitracin,
Erythromycin, Sulphacetamide
Topical steroid + antibiotic e.g. Tobradex
Azithromycin 500mg daily x 3days
For more chronic or severe case e.g. miebomianitis oral
tetracycline derivatives i.e. Doxycycline 100mg BD po x
4weeks than qd, for another 4-6weeks
 Staphylococcal blepharitis

• Chronic irritation worse in mornings

•. Scarring and hypertrophy if
longstanding.
. Scales around base of lashes
(collarettes)
Sebhorroeic Ant Blephritis
Disorder of the pilosebeacous glands of
Zeis and Moll
Cause is unknown but related to a yeast
(fungi) called malassezia which normally
resides near the hair follicle
Sebhorreoa (flaky skin) may involve scalp,
eyebrows, retroauricular area and sternum.
Oily type and dry type (true seborrheoa)
Sebhorroeic Ant Blephritis
Symptoms:
less severe, discomfort in the eyes, lacrimation,
tear film instability (stinging)
Signs:
Shiny, waxy appearance of the anterior lid margin,
dandruff like desquamation lid epidermis (yellow,
greasy scales)
Management
 Lid hygiene— dilute baby shampoo
 artificial tears
 topical antibiotics i.e. Bacitracin,
erythromycin
 Scalp treatment with antidandruff
lotion
For more chronic cases- Doxycycline
100mgBD x 4/52,then QD x 4/52 OR
Azithromycin, 500mg QD x3/7
 Seborrhoeic blepharitis

• Shiny anterior lid margin • Greasy scales

• Hyperaemia of lid margin • Lashes stuck together
Posterior Blepheritis (meibomian gland
dysfunction)
bilateral chromic inflammation and obstruction of the
meibomian glands.
It is seen as a plugging of the meibomian orifaces with
cloudy, viscous secretions.
more common during or after the middle ages of life.
 The meibomian glands are prominent, lid margins are
red.
 A soft yellowish material may be expressed from the
glands.
An irritating conjunctivitis may occur. The lid margins
may be soft and edematous.
Primary Mebominitis
Diffuse inflammation around glands
Associated with acne rosacea (2/3rd) or Seb.
Dermatitis (1/3rd)
Signs:
*Pouting of gland orifices with dome of secretions
—may become solid. (tooth-past like)
*Obliteration of ducts—dilatation (thick, round,
vascularised, notched Posterior border)
*Secondary changes include papillary
conjunctivitis, punctate epitheliopathy, and tear
film instability (stinging)
Mebomian Seborrheoa
Dilated mebomian glands—easily expressed
Tear film is oily and foamy
In severe cases—mebomian foam at medial canthus.
 Meibomian seborrhoea

Oil globules over meibomian gland Oily and foamy tear film
orifices
Treatment:
A: Systemic antibiotics
Oral tetracycline i.e. Doxycycline or
Minocycline 100mg po BD x 4/5 2 than qd x
4-8 weeks.
B: Others:
Lid hygiene, topical steroids, artificial
tears.
C: Local measures:
Hot compress TID-QID
Lid message and expression of glands BD
Supplements of essential fatty acids (EFA
supplements should be used with caution in
patient using anticoagulant)
 Complications

trichiasis, madarosis poliosis Recurrent styes

Marginal keratitis Tear film instability

Preseptal cellulitis
 Inflammation of the eyelid anterior to the orbital septum.
 Peri-orbital swelling and tenderness, often seen in children
secondary to sinus disease. Urgent referral is required if the eye
is involved, e.g. injected conjunctiva, proptosis, restricted eye
movements, as this signifies orbital cellulitis
 Symptoms
 –Tender, red swollen lids and adnexa
 •Signs
 –Eyelid erythema, edema, warmth
 –Mild fever possible
 –Photo credit-Kanski
 NEGATIVE findings
 –Proptosis
 –Optic neuropathy
 –EOM restriction
 –Conjunctival injection
 –Pain
Causes

–Local skin trauma

–Infection
•Organisms
–Staphylococcus aureus and streptococcus
–Haemophilus influenzae
Treatment-Preseptal Cellulitis

–Oral antibiotics for 10 days such as:

–Amoxicillin/clavulanate 500mg /125mg po tid
–Cephalexin 500mg po tid
–Trimethoprim 320 mg/sulfamathoxazole 1600mg po
bid
–Moxifloxacin 400mg po qd
Herpes Zoster Ophthalmicus
 An infection caused by the varicella Zoster virus
 An active immune system suppresses the virus which lies dormant in
the dorsal ganglia
 The virus enters thru the conjunctival, nasal or oral mucosa.
 Viruses passes along the sensory nerve where it has been latent in the
ganglion.
 – Tissue innervated by that nerve (dermatome) becomes affected.
 – This reactivation occurs in 10 – 25% of the population.
 • Thoracic ganglion is the most common site, followed by the
trigeminal ganglion.
 – The ophthalmic division is 20X more affected than the maxillary or
mandibular
Rash is unilateral, red, painful
Progresses to vesicles and pustles
Disharges clear liquid, forms csabs
Signs and Symptoms

 • Flu--‐like illness (fever, malaise, headache, and chills) first.

 – Some patients may report pain, itching, burning, and stinging
in the area of the nerve.
 • 2--‐3 days later: Develop rash and vesicles
 – SEVERE Pain will be reported both while the lesions are
present and after they heal.
 – Lesions will become pustular in 3--‐4 days and crust over in
7--‐10 days if untreated.
 – This will not cross the midline.
 • Studies show the importance of initiating treatment in the first
48 hours

Ocular Involvement in HZO
Can develop days to years a[er the vesicles have
formed.
• Signs:
– Lid Edema
– Follicular conjunctivitis
– Corneal Changes
– Uveitis
– Optic Neuritis
– EOM palsy
– Chorioretinitis
• Management

 Oral antivirals:
• 800mg acyclovir 5x/day
• valacyclovir (Valtrex) 1g TID,
• famciclovir (Famvir) 500mg TID
 – Effectiveness of therapy is best started within 72 hours
 – oral steroids, and
 – management of pain (tricyclic antidepressants,
gabapen,n).
 – If ocular complications, consider topical steroids
Herpes simplex ophthalmicus
Caused by infection with the herpes simplex virus type 1
and type 2 and affects all the structures of the eye.
 Primary infection often occurs in childhood, through
orofacial mucus membrane transmission. and presents as a
form of blepharoconjunctivitis. By adulthood almost
everyone has had it.
 Primary infection is often self-limiting, however the virus
ascends through the cutaneous nerves and stays latent in
the trigeminal nerve ganglion.
 Reactivation occurs due to unfavorable immune
conditions, a secondary infection may involving eyelids,
conjunctiva, cornea, uvea, and rarely retina.
Recurrent infection occurs due to the reactivation of the latent virus in the trigeminal ganglion.
•Blepharoconjunctivitis: Lid vesicles are focal along the lid margin or eyelid skin. The weeping
ulcers shed virus for only 2-3 days and last for only a week.M
•Epithelial Keratitis: It starts as punctate epithelial opacities caused by actively replicating virus.
These opacities coalesce centrally and then break down to form central desquamation. The
presentation includes mild irritation, redness, watering, photophobia, and corneal hypesthesia.[
•Dendritic ulcer: Central epithelial desquamation develops into a dendritic ulcer with mild
subepithelial haze, dichotomous branching, and terminal buds. The bed with dead epithelial cells
stains with fluorescein, while the margins with virus-laden cells stain with rose bengal. Inadvertent
use of topical corticosteroid drops would cause a dendrite to enlarge into a “Geographic ulcer”
•Necrotizing stromal keratitis

•Metaherpetic keratitis
•Immune-mediated: endotheliitis and keratouveitis.
•Acute retinal necrosis
 Herpes Simplex

79
Management
Antiviral agents, both topical and systemic antivirals,
are the treatment of choice.
Severe infections and their sequelae can often cause
severe impairment to the vision.
 Once infected, it is impossible to eradicate the virus
from the body.
Acne Rosacea
A chronic skin condition that affects the face with
redness, acne-like swelling and bumps, broken blood
vessels etc
Frequent flare-ups
May be concentrated around the eye and is known as
ocular Rosacea
Acne Rosacea
85% of patients have secondary ocular complications
and often precede other skin manifestations include
erythema, itching and burning.
Mainstay oral Tx is
Oracea (40 mg in morning) or
– doxycycline 50 mg po qd or minocycline 100 mg po
qd for 4-12 wks.
– NOTE: Oracea is subantimicrobial therapy
Eyelid lumps
Eyelid tumours are broadly classified into two:
(a) Benign
(b) Malignant
This classification is based on the biological behaviour of
the neoplastic forming cell
Characteristics of a benign lesion
No induration (discharge) or ulceration
Uniform colour
Regular outline
Limited growth
Preservation of normal lid margin structure
Diagnosis is normally straight forward, but some may
require biopsy
Benign Non-inflammatory Eyelid
Lesions
Dermoid
Developmental out pocketing of tissue.
firm collagenous lumps that can be found on numerous
sites in the body, including the eyelid.
They are usually noted at birth or in the early years
and are more common in the superior temporal brow
region.
They are smooth and stationary to slightly movable,
usually they don’t cause any problem, and hence all that
is required is patient education and reassurance. Other
cysts include epidermal inclusion cysts, epidemoid,
sebaceous, cyst of zies, cyst of molls, milia, condones
Epidermoid Cyst

 What is it?
 AKA sebaceous cyst
 Cyst lined by stratified squamous epithelium and containing keratin and
sebaceous material
 Result from ingrowth of surface epidermis after trauma or surgery

◦ Appearance
 Round, well defined, non-tender mass
 Ruptured cysts cause an acute inflammatory response and possible secondary
infection
◦ Treatment
 Complete surgical excision
Epidermal inclusion cyst (epidermoid
cyst)
 This often presents as a slow-growing, elevated, round, smooth,
white lesion. These lesions do not trans-illuminate and can have a
central pore that designates the remaining pilar duct. These lesions
can become secondarily infected or rupture and incite an
inflammatory reaction.

 Sebaceous cysts
Benign Non-inflammatory Eyelid Lesions
Squamous papilloma

Common benign tumour of eyelids.

May be pedunculated or broad based.
Other lesions which can grow in a
papillomatous configuration include verruca
vulgaris (common wart), actnic keratosis or
seborrheic keratosis.
Benign Tumors
 Squamous Cell Papilloma
 What is it?
 Outgrowth of fibrovascular connective tissue
 Covered by irregular keratinized stratified squamous epithelium
 Appearance
 Variable presentations
 “Skin tag” type: narrow base, pedunculated, skin colored
 Board base with “raspberry like” appearance
 May be difficult to differentiate from viral wart (human papillomavirus)
 Who gets it?
 No predilection to race or gender
 Management
 Removed by excision
Actinic Keratosis
What is it?
 Slow growing keratinization of the epithelium
 Results from excessive sun exposure
 Pre-malignant: may transform into squamous cell carcinoma
Appearance
 Rough, dry, and scaly plaque that is flat or slightly raised
 Up to 2.5 cm diameter individually
 Often multiple lesions in a single area that coalesce
 Distinct boarders
 May be skin colored to dark brown
Who gets it?
 Elderly individuals with lightly pigmented skin
 Rarely develops on the eyelid
 Common on the scalp, ears, forehead, and backs of hands
 The patient may notice itching or burning of the lesion
Actinic Keratosis

Management
Biopsy for definitive diagnosis
 Usually frozen (cryotherapy) or excised
SEBORRHEIC KERATOSIS

Seborrheic keratoses are pigmented, greasy

hyperkeratotic lesions that appear to be stuck on the
skin
Commonly occurring in the elderly, these lesions may
occasionally become irritated. Surgical excision is
curative.
Haemangiomas

Vascular anomalies of the superficial blood vessels.

Slightly elevated or flat coloured lesions on the skin
surface;
they are benign vascular tumours that may be present
at birth or shortly after. They may enlarge during the
first 6month of life, followed by regression.
They are usually painless, but sometimes associated
with other congenital abnormalities or syndromes.
There are various types.
Capillary haemangiomas
Spider haemagiomas
Port wine stains
Capillary haemangioma

Benign tumour of small capillaries usually

noticed at birth of soon after.
Often enlarge over the first 18 months of
life prior to spontaneously involuting over a
period of five years.
Refer early for monitoring of visual
development as can induce astigmatism and
cause amblyopia
Large capillary haemangioma
NEVUS
Nevi are well-demarcated, flat or elevated, pigmented
or nonpigmented congenital lesions
They may become more pigmented, more elevated or
cystic during adolescence or young adulthood.
Junctional nevi, occurring at the junction between
epidermis and dermis, have some malignant potential.
Because of the risk for malignant transformation,
pigmented lesions that have changed in appearance
should be excised.
XANTHELASMA
Xanthelasma are soft, yellowish plaques in the medial
canthal area.
Hypercholesterolemia or congenital disorders of
cholesterol metabolism may be associated conditions.3
 Xanthelasma may be treated with excision or with a
carbon dioxide laser if desired for cosmetic reasons.
Xanthelasma
MOLLUSCUM CONTAGIOSUM
 Raised round lesions around the ocular adnexia
 2-3mm diameter, translucent, dome shaped with
umblicated center
 An infection caused by the pox virus (Molluscum
Contagiosum (MCV)).
 Painless, mild itching, mildly contagious
 May be unilateral or bilateral,
 Single or multiple
 If present on the eyelids, they may produce a follicular
conjunctivitis
 In many cases they are self-limited and resolve with time in
immunocompetent individuals.
MOLLUSCUM CONTAGIOSUM
may be treated with cryotherapy, curettage, laser
therapyor topical creams containing acids eg,
trichloroacetic acid,
Molluscum contagiosum
NEOPLASTIC LUMPS OF THE
EYELID
An eyelid neoplasm should be considered if
If the lesion has neovascular patterns around it
If there is recurrent infection & inflammations
Bleeding and ulceration of the lesion
Changes in the lesion that are inconsistent
If the surface integrity and quality is questionable
If it is an uncharacteristically large lump
If there is a history of neoplasm elsewhere
If there is excessive exposure to sunlight
If the person is fair in complexion
If there is a history of skin cancers
Malignant tumors of the eyelid
Basal Cell Carcinoma
Most common malignant lesion of the eyelid (>80%)
most frequently on the lower lid at the medial canthus
as a firm, raised, pearly nodules with fine
telangiectasias Often begins as a small scar with
irregular edges or undurated ulcerating nodule
Patients are typically middle-aged or older and often
fair-skinned
Never metastsises, but requires prompt referral to
avoid serious local destruction
Basal Cell Carcinoma
 What is it?
 Locally invasive proliferation of pluripotent epidermal basal cells
 Most common human malignancy and most common eyelid malignancy
 Slow growing with no metastatic potential
 Appearance
 Usually on the lower eyelid
 Non-tender ulceration
 Irregular boarders
 Possible keratinization
 Destruction of eyelid architecture
 Nodular type: pearl like appearance with dilated blood vessels on surface
 Noduloulcerative type: central ulcer with raised pearly edges
 Sclerosing type: lateral, hardened, infiltration beneath the epidermis.
May be confused with chronic blepharitis
Basal Cell Carcinoma

 Who gets it?

 Common in the elderly
 Risk factors include fair skin and high cumulative sun exposure
 Management
 Diagnosis confirmed with biopsy
 Excision is the common removal technique
 Mohs micrographic surgery removes the tumor along with a thin
layer of surrounding tissue. The surround is immediately
examined for tumor cells and the procedure repeated if any are
found. Highest cure rate at 98%.
 Recurring tumors tend to be more invasive and difficult
 Basal cell
carcinoma

Note the pearly edges and central scab

Squamous cell carcinoma
Second most common malignancy,
Usually on the upper eyelid
often with a painless nodular lesion with irregular
rolled edges, pearly borders, telangiectasias and central
ulceration, similar to BCC
May be nodular or ulcerated
Arising either spontaneously or within an existing
lesion ie. actinic keratosis.
 Can spread to regional lymphnodes or metastsise to
distant sites
Squamous Cell Carcinoma
 What is it?
 Proliferation of invasive cells arising from the squamous cell
layer of the epidermis
 Can arise de novo or from existing actinic keratosis or
keratoacanthoma
 Less common, but more aggressive than basal cell carcinoma
 Lymph node metastasis in 20% of cases
 Appearance
 Variety of appearances and may be difficult to distinguish from
BCC
 Scaly with irregular boarders
 Absence of surface vasculature
 Extensive keratinization usually present
 Lesions may bleed
 Nodular type: keratinized nodule that develops erosions and
fissures
 Ulcerating type: everted boarders with a red, well defined base
Squamous Cell Carcinoma

Who gets it?

Most common occurrence is in the elderly
Risk factors include fair skin, sun exposure,
and immune suppression
Management
Can be fatal if left untreated (2,500 annual
deaths in USA)
Confirmed with biopsy
Malignant Tumors
 Squamous Cell Carcinoma

Nodular Ulcerative

Cutaneous horn Large ulcerative

Sebaceous carcinoma
originates in the meibomian glands or the glands of
Zeis and presents clinically as yellowish discoloration
due to its lipid content; it can mimic
blepharoconjunctivitis, chronic chalazia, BCC, SCC or
other tumours
 Sebaceous carcinoma of

the left lower lid in a 52-

year-old female. Patient

presented with chronic

unilateral

blepharoconjunctivitis for

12 months, madarosis

and eyelid lesion.

Sebaceous Gland Carcinoma
What is it?
Slow growing tumor
Arises from the meibomian glands, glands of Zeis, or
sebaceous glands in the caruncle
More likely to occur on the upper lid where glands are more
numerous
Appearance
No pathognomonic presentation
Initially can appear similar to chalazion or chronic blepharitis
Yellowish material may be seen within the tumor
Nodular type: hard, painless, immobile nodule similar to
chalazion
Spreading type: thickened lid margin, loss of lashes, similar to
chronic blepharitis
Burns of the eyelid
There is usually a history of thermal or radiation burn
or chemical splash to the eyelid. There will be pain,
ranging from mild discomfort to severe pain.
Objective examination will determine the degree of
burn. Primary degree burns are the more common and
they usually involve superficial dry erythema with
mild to moderate oedema. Second degree burns may
involve blustering of skin and tissue weeping. Third
degree involves deeper tissue reaction with whitening
and charring, extensive erythema and oedema.
Management
All third degree burns should be referred for specialist
care.
-For first degree burns, cleanse the tissue surface and
apply topical antibacterial ointment 4 times daily for 3-
5 days
-For second degree burns, cleanse the area with cold
sterile solution, usually saline solution or burrow
solution, debride loose burnt tissue, Remove any
foreign matter, Open blisters and let them drain, Apply
cold compress, Apply heavy antibacterial cream.
Management cont.
Oral analgesic may be given if necessary
A loose gauze dressing may be applied over ointment
Dressing should be changed daily for 1st 3days
depending on the degree of burn
Upon scar formation, dressing should be discontinued
Thinner layers of antibacterial cream should be
continued for 7-10days
CONTUSION INJURY

history of blunt blow to the orbital region.

characterized by lid oedema and ecchymosis (bruise
resulting from release of blood into the tissue). The
blood accumulation is usually greater in the lower lid,
sometimes loose blood may seep to the bridge and the
nose, occasionally the blood may for organized
hematomas.
There may be pain on palpation, the orbital rim may be
tender, there may be subconjunctival haemorrhage,
Trauma
Lid margin
Lid tissue
Loss of lid tissue

Basal skull fracture - bilateral ring

haematomas (‘panda eyes’)
associated trauma to globe or
orbit
other possible complications include
anterior uveitis,
hypehma,
lens subluxation or dislocation,
traumatic cataract,
anterior chamber angle recession and secondary
glaucoma,
iridodialysis/separation of the thinnest part of iris from
the ciliary body)
cyclodialysis (separation of ciliary body from sclera
spur, retinal tear or detachment
Management
Check for orbital fracture and entrapment of the
extraocular muscles (esp blow out fracture)
Check for numbness (associated with nerve damage)
Carefully palpate for crepitation (air in tissue) which is
indicative of sinus fracture
In uncomplicated cases
Cold comprises for the first 24hrs to reduces bleeding,
Warm compress or 3-5days
Management contd.
Cycloplegic drug to reduce iris movment and prevent
synechia
Oral NSAID
If uveitis present, topical steroid drops
If hyphema present, patients should be confined to bed
rest and iop lowering agents can be given
If crepitation or fractures present, oral antibiotics
(broad spectrum) should be given for 7-10day
(Radiological diagnosis may be required for this)
If substantial fracture, blow, out or entrapment refer
for ophthalmologic consultation
LACERATING

INJURIES
This refers to an irregular open wound caused by a blunt
impact to soft tissue.
 usually a history of the trauma responsible for the laceration.
 In assessing the patient, we must consider
the depth of the laceration, whether superficial (affecting only the
dermis) or deeper (affecting the muscle layer).
The orientation (whether parallel to lid margin or vertical cutting
through the lid margin).
The wound edges must be considered whether smooth edges or
jagged and irregular edges (which are more likely to leave a
scar).
 The length of the laceration is also important.
look for involvement of the lid margins, the lacrimal system, and
even involvement of the eyeball.
Management
For simple superficial lacerations less than 10mm in
length,
clean wound thoroughly with hydrogen peroxide or other
disinfecting agent,
remove any foreign matter,
apply broad spectrum antibacterial ointment,
apply dressing.
For problem laceration or secondary tissue damage
refer for appropriate suturing and surgical care.
Thank you for your
attention.
Comments?
Observations?
Queries?
Questions?