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TITLE: Presentation 3 Ms F Mellington
DATE: 24th February 2017
NUMBER OF SPEAKERS: 1
TRANSCRIPT STYLE: Intelligent Verbatim
FILE DURATION: 30 minutes and 01 seconds
TRANSCRIPTIONIST: Yvette
SPEAKERS
P:
Presenter
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GP Eye Health Network: Lids, Ms F
Mellington
P: When I was thinking about the talk I thought I wanted to try and give
you a fresh perspective on things, rather than sort of keep going down
the usual route of disease after disease after disease. I will be doing
that a little bit but I thought I’d try and mix up the presentation a little bit.
So, if we think of it like a downhill run. We’re going to be looking at all
the different eyelid diseases, and hopefully will have a safe journey. I’m
gonna try and point out some of the dangers along the way, so that we
can avoid any pitfalls and negotiate safe and successful management to
our patients. So, here we go.
These are the objectives of the talk. I’m gonna begin with an
introduction talking about the key functions of the eyelids. Then I’m
going to go over the anatomy of the lids, just to familiarise yourself with
that. And then think about the manifestations of eyelid disease in these
categories: Lids that can’t fully close, lids that won’t open, eyelid
malposition, lid lumps and bumps, and lid swelling. There’s a little bit of
overlap between these last two but we can go through those, and with a
short summary at the end.
So to begin with, the key functions of the eyelids. Well the key function
of the eyelid really is to protect the eye. They’re a physical barrier to
protect the eyes from direct blows such as this, or from chemical
splashes, or from foreign barriers for example. And key to the protection
mechanism is the blink reflex. As with all reflexes it has an afferent
sensory arm. In this case it’s the nasociliary branch of the first division
of the trigeminal nerve which passes via interneurons in the [s.l. medela
00:01:33]. And then the afferent motor arm is via the temporal and
zygomatic branches of the facial nerve to the orbicularis oculi muscle,
which contracts to give us the blink. The stimulus is usually any irritant
to the lids, the cornea or the conjunctiva. Another vital function of the
lids is the production and the drainage of tears which are vital for the
health of the eye and the comfort of the eye. There are three main
layers to the tear film.
From inner to outer we have the mucus layer, which is supplied by the
goblet cells of the conjunctiva, which of course lines the inner aspect of
the lids as well as the surface of the eye. Then there’s the watery layer
produced by the lacrimal gland primarily, but also by accessory lacrimal
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glands of Krause and Wolfring which are located in the superior fornix
under the inner side of the upper lid. And the outer layer is the oily layer,
which is produced by the meibomian glands located near the eyelid
margin as well the glands of Zeis which are associated with the lash
follicles. Eyelids are also important for facial expression, so any
aberrations of the eyelids, or any asymmetry between the two, has a
great impact on cosmesis, and people are very bothered about it. So
here is a section through the upper lid showing normal eyelid anatomy.
And in simple terms the eyelid is a layered structure. So we’re gonna go
from front to back, anterior to posterior, to go through it with you.
So just to point out before I do that, we think of the eyelid also in two
main layers, or a front and a back. There is the anterior lamella which is
outlined in red, and the posterior lamella, and the junction is the
mucocutaneous junction, where the skin finishes and the conjunctiva
starts. The first layer is the skin, then we have the orbicularis oculi
muscle, followed by the septum. The septum runs from the orbital rim,
downwards into the lid, and in the orbital rim it fuses with the periosteum.
As it comes down into the lid it thickens to form the tarsal plate. The
tarsal plate is imperative for the structure and stability of the lid. Behind
this we have the conjunctiva, and as you can see, if I can use the
pointer, as you can see here, these are the accessory lacrimal glands
that I was talking about, that contribute towards the distribution of tears
as well. There are two main elevators to the eyelid.
The first one is the levator palpebrae superioris which is supplied by the
third cranial nerve, and the Müller's muscle, which is a smooth muscle,
which is under sympathetic control. In the lower lid there are
rudimentary equivalents of these, and they are divided into which are
just known as the inferior retractors. And they are divided into a
voluntary group and a sympathetic group.
Going onto the manifestations of eyelid disease. So first of all eyes that
can’t fully close. So as you know, we call this lagophthalmos. There are
many reasons why can have lagophthalmos. It can be the status after
facial cosmetic surgery, as shown on the top left here. It can be
following extensive reconstructive surgery, facial nerve palsy, here, we
can see this gentleman has right sided facial nerve palsy and within the
cases here of severe proptosis, lid retraction and severe chemosis. This
is a case of severe thyroid eye disease. This is a case of lagophthalmos
following facial cosmetic surgery, namely upper lid blepharoplasties,
which were done elsewhere. As you can see it’s fairly obvious that too
much skin has been taken, such that there is a vertical deficiency of
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eyelid skin, preventing the eyes from closing. You can see it’s an
unhappy patient, and rightly so, because the eyes will be uncomfortable,
gritty, sore, watery. So the treatment for this in the first instance is
lubricants.
Failing that, it would be to treat the cause, which is to put backs in the
skin, with a skin graft to the upper lids. Here we can see it in more
detail. This lady presented with a rapidly enlarging mass on the left
upper lid. This is her in June 2015, this is her eight days later while
she’s just awaiting biopsy on the day of surgery, rather. She had an
upper lid melanoma. She subsequently went off to the plastic surgery
team, for extensive excision and reconstruction. She then presented
about 18 months later, so September last year, complaining of a very
sore, gritty, watery eye, not really helped by ocular lubricants. If we look
in more detail, she can’t fully close the eye, and this is because she’s
missing most of the upper lid, so it’s not surprising really. So she
underwent extensive reconstruction of the lid, and we replaced the
anterior lamella with skin, and the posterior lamella, so the back layer
with a free tarsal graft.
So that’s tarsal tissue from the fellow upper lid, and she’s now able to
close her eyes. Lid retraction may be seen in thyroid eye disease, as in
this lady, who has inactive thyroid eye disease and proptosis. This is
her before her left upper lid lowering, where she has lagophthalmos, and
this is her after left upper lid lowering, where she can now close her
eyes, and it’s much more comfortable. So, every now and again I’m
gonna put up a warning, so things to look out for. This is severe thyroid
eye disease. It can be sight threatening and vision threatening. So
lagophthalmos, any cause of lagophthalmos can potentially cause loss
of sight, due to dryness, subsequent infection, corneal ulceration. This
is a lady with thyroid eye disease with proptosis and lid retraction on the
left, and this is her a year later, having had bilateral orbital
decompression and upper lid lowering. Her eyes are much more
comfortable now, and she’s a lot happier.
This is lagophthalmos in facial nerve palsy, where we can see the
lagophthalmos here, and this is the staining with fluorescein, which is a
lot of uptake showing a very dry eye. So the management largely
depends on the cause, however the first port of call is ocular lubricants,
followed by, if needed, punctal plugs, which are inserted into the inferior
and superior puncta if necessary. We can close the lid with a temporary
or permanent tarsorrhaphy here, this is a temporary one. Sometimes
Botox can be used to lower the lid. As we know one of the
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complications of Botox for cosmetic reasons is indeed inducing ptosis, or
a droopy lid. So it can be used therapeutically, and applying an upper lid
weight to weigh down the lid.
This is seen here in a lady with right facial nerve palsy, where she has
upper lid retraction, because of the unopposed action of the eyelid
retractors, because her orbicularis oculi muscle is weak. So she has
unopposed action of her levator and her Müller's muscle causing lid
retraction, as well as often a loose lower lid or ectropion. She’s had a
gold weight inserted into the upper lid, here, giving her a very slight
ptosis, but her blink is facilitated, so her eye’s more comfortable now.
She no longer has any lagophthalmos. This is an example of a
temporary tarsorrhaphy in a patient with facial nerve palsy, who had a
secondary corneal ulceration.
Lids that won’t open. So this is a lady with blepharospasm, so this is
bilateral involuntary blinking and closure of the eyes. It’s twice as
common in females. And it’s usually a central blepharospasm is one of
the main causes, but it can be secondary to any cause of ocular surface
irritation, so trichiasis, blepharitis, a corneal foreign body. You might see
people with a corneal foreign body presenting, and they just really won’t
open their eyes, and that’s due to secondary blepharospasm.
Treatment of this is really to treat any underlying cause, so if there’s a
corneal foreign body, that needs to be removed. If they’ve got trichiasis,
the lashes need to be epilated, or have electrolysis, etc. But for
essential blepharospasm, botulinum toxin injections into the periocular
area and into the facial area can have a 98% chance of success. It is
however, as you know, temporary, so usually injections are needed
every three months or so. The caution here is hemifacial spasm. So if
the spasm is unilateral, you need to really be thinking about, this is
usually caused by compressive lesion of the root of the seventh nerve,
so scanning is needed here to exclude a tumour.
Inability to open the eyelid is also a feature of essential blepharospasm
however it can also be seen in extrapyramidal conditions such as
Parkinson’s disease. Here the treatment is botulinum injection
specifically to the orbicularis muscle overlying the tarsal plate.
Going onto lid malpositions and specifically focussing on ptosis,
ectropions and entropion. So with ptosis, or with any disease, we can
think of it in terms of congenital versus acquired. This is a gentleman
with congenital ptosis where there is dysgenesis of the levator muscle,
and this is treated surgically, if needed, with brow suspension. This is
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the gentleman before, so it’s unilateral. Before and after left upper lid
brow suspension. So the lid movement is controlled by moving the
brow. Sometimes you can see, although not really in this gentleman,
some faint little scars just on the forehead. Most cases of ptosis that
you’ll see will actually be involutional, so they’re age related due to the
slackening of the attachment of the levator muscle to the tarsal plate. As
in the case with this gentleman who underwent ptosis correction.
In involutional ptosis what you’ll often see is a very high skin crease,
here and here, so it’s a lot higher than normal, and that’s due to the
loosening of the attachment between the levator muscle and the skin, as
well as the tarsal plate. So these are the causes of Ptosis, so
congenital, aponeurotic or involutional, ageing. Sometimes this is due to
contact lens wear as well, so in a younger patient, contact lens wear
may be a cause of levator dehiscence. Neurogenic causes, myogenic,
mechanical, traumatic, and we also to have to think about pseudoptosis,
so when there’s ipsilateral enophthalmos for example. Caution. In
every case of ptosis it’s imperative that you check the pupils and you
check the eye movements. You also should look under the lid. This
gentleman presented with a very slight ptosis, and if you look, it’s easy
to miss, but if you look, he has a flattening of the eyelid margin. When
you look under the lid, this is what we see. He had malignant
melanoma, and subsequently underwent extensive excision of this, and I
think he went on to have an exenteration of that.
What we need to exclude is these things: Horner’s syndrome, third
nerve palsy, myasthenia gravis, a malignancy, and a chronic progressive
external ophthalmoplegia or Kearns-Sayre syndrome, which I’ll talk
about in a moment. This is a case of Horner’s syndrome. You can see
the mild ptosis and you can see the anisocoria with the small pupil here.
It’s due to an interruption of the sympathetic supply to the Müller muscle
and other areas, anywhere along its route. It’s very important here that
these patients have urgent scanning to exclude life-threatening causes.
This is a case of third nerve palsy. This lady has a complete right third
nerve palsy. She has a complete ptosis. She has a dilated pupil,
compared to the other side, and whilst you can see that her abduction,
which is lateral rectus muscle supplied by the sixth cranial nerve is
working, in all other positions of gaze, she has reduced eye movement.
So this is a third nerve palsy. Myasthenia gravis occurs when there’s
fatigability. That’s pretty rare, 1 in 10,000, but ptosis can be the
presenting feature in about 70% of cases. This will require medical
management. Myopathic ptosis. So I mentioned earlier chronic
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progressive external ophthalmoplegia where there’s bilateral slowly
progressive reduction of the eye movements with ptosis as seen above.
When combined with a heart block this is Kearns-Sayre syndrome, sorry
wrong button. As we can see here, the treatment is actually ptosis
props. So this is the lady without her glasses, with her glasses, with the
ptosis prop in situ. So she’s able to function very well, doesn’t need
surgery. The problem with surgery is if you lift the upper lid, because
her eyelids won’t roll up, there’s a risk that her corneas will dry out, and
she gets exposure keratopathy. So in these cases I would actually
encourage ocular lubricants and ptosis props. Maybe a family history,
they don’t tend to have double vision, and she needs multi-disciplinary
input.
Have a look at this video. [Video playing – Okay, so if you could move
your jaw from side to side, that’s it, and then if you move your jaw
forward and backward]. There we are, a bit loud, so I thought I’d skip
over it. This is a miscellaneous ptosis, it’s Marcus Gunn jaw-winking
ptosis. I don’t know whether you’ve ever heard of it? It’s congenital, it’s
due to a miswiring, so on chewing when there’s stimulation of the
ipsilateral pterygoid muscle, there’s elevation of the lid. So in a patient
with ptosis it’s often masked because people often hold their chin in a
certain position, particularly for photos, to elevate the lid, to mask it.
Sometimes these people require surgery for cosmetic reasons, more
than anything. It’s also quite useful to just double check jaw movement
and then you’ve got your cause of your ptosis.
This is a lady who presented to eye casualty with ptosis. She’d had, the
key thing here is you look how smooth her forehead is, so she’s been
having some Botox injections, actually for headache management, and
she presented with one of the complications which is ptosis. This is her
after I put some Iopidine drops into her right eye. The effects of the
ptosis from the Botox will resolve, because it’s a temporary thing,
however they might have up to three months of the ptosis, so what we
can do is give them Iopidine drops or Apraclonidine is the generic name,
and this is a selective a2 agonist, acting on Müller's muscle. And
because Müller's muscle is under sympathetic control, and it’s a smooth
muscle, that can be stimulated, and is used as a temporary relief for this
condition. Some people advocate using Phenylephrine drops, but I’d
probably just use Apraclonidine really. In particular, just sit back, have a
look at them, and compare the superior sulci.
This gentleman has quite a hollow sulcus, and it’s quite full here, on the
side of his ptosis. He has, has it happens, bilateral orbital lymphoma,
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which turned out to be rather aggressive, and was treated with
radiotherapy. Again, looking at the difference in superior sulci, this lady
has quite a full sulcus, normal [unclear 00:18:42] position, hollow sulcus
ptosis. If you look from above, which is a nice way to check for proptosis
or indeed enophthalmus, this lady is enophthalmic, so she has
pseudoptosis.
Ectropion and entropion. Ectropion is out turning of the lid. Entropion
is in turning of the lid. There are multiple causes, congenital, age
related, scarring and facial nerve palsy, for example, causing paralytic
ectropion. You get a watery eye, irritated eye, red eye. Treated with
lubricants and surgically. This here is an example of a lesion on a lower
lid. It’s a basal cell carcinoma, causing subtle ectropion. And in a bit
more detail here, so you can see the basal cell carcinoma. You need to
feel with your finger, and if you feel a thickening, think about whether or
not there’s a tumour here. This lady had cicatricial ectropion due to
eczema. She underwent left lower lid tightening, followed by a skin graft
to the lower lid, taken from the supraclavicular fossa, which gives a good
colour match.
Looking at entropion now. Entropion, in turning of the lid, tends to affect
the lower lid more than the upper lid, because the lower lid is less stable
because it has a shorter tarsus. It’s important to treat, because it can be
vision-threatening, because it can cause secondary infection and
corneal ulceration. Usually due to age-related laxity of the lower lids, but
it maybe secondary to scarring of the inner aspect of the eyelid. It may
cause secondary blepharospasm. It’s treated in the first instance with
ocular lubricants. The temporary measure may be Botox and lower lid
tightening. Just looking in a moment towards lumps and bumps. It’s
important to look under the lid. This gentleman had a squamous
conjunctival papilloma.
Briefly moving onto lid lumps and bumps. A stye, this is an abscess of
the lash follicle and it’s associated and of Zeis or Moll, seen towards the
bottom of the picture here. Can discharge through the skin. Treatment,
hot compresses, oral antibiotics such as co-amoxiclav or flucloxacillin.
Here a number of benign lid lesions and abscesses. This is a cyst of
Moll, it’s translucent. A cyst of Zeis, opaque. These are benign lesions,
they don’t need to be removed. Removal is thought to be cosmetic, and
is not paid for currently by the CCG, as I understand it. Similarly,
xanthelasma is deemed to be a cosmetic legion these days, and one
has to check the cholesterol level, as you know, from people with
xanthelasma. Somebody with unilateral non-resolving conjunctivitis,
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look at the eyelid margin, see if they’ve got molluscum contagiosum, a
double-stranded DNA virus of the pox group. That needs to be
removed.
This is a large sebaceous cyst, arising from the eyebrow hairs, and this
is a greasy stuck on lesion seborrheic keratosis, again it’s a benign
lesion. It can be removed for cosmetic reasons, but that’s the main
indication really. An acute chalazion is an abscess of the meibomiam oil
glands within the tarsal plate. Hot compresses, oral antibiotics, so coamoxiclav five day course will help. If not resolving, incision and
curettage. You can get more of a chronic lymphogranulomatis
inflammation of the meibomiam glands, due to chronic blockage of
meibomiam gland, which is also a chalazion, but not an acute one. If it
bursts through the tarsal conjunctiva you can get a granuloma, seen
here. If persistent, incision and curettage.
Other lumps and bumps, racing through now. Papillomas, benign warty
lesions. Again, if they are impeding in the vision there’s an indication for
removal, with a shave biopsy, and these are epidermal inclusion cysts.
This is a pyogenic granuloma. It’s a highly vascular tissue, and it’s
usually, as a benign lesion, it’s usually due to trauma. Often people, I’ve
seen a couple in young men, if they’ve been picking, so consistently
stirring up this abnormal inflammatory response. It ended up being quite
a huge legion and was excised successfully. Malignant legions,
keratoacanthoma, usually rapidly grows over a period of 2-4 weeks,
followed by involution. It often has a keratin filled crater. It’s now
thought to be on the spectrum of squamous cell carcinomas, so they
need to be excised. The most common eyelid malignancy is a basal cell
carcinoma, more common in people who have had excessive sun
exposure and smokers. Lots of different types, and slightly more
common in women, but not necessarily.
The most important thing is they’re not all nodular, and that’s where the
confusion can come in. They can be cystic, they can be pigmented.
They can be superficial, and like here, well a red plaque. Treatment is
largely surgical excision, a topical imiquimod can be used. Vismodegib
is a fairly new treatment for those people with metastatic disease, or
recurrent disease, or those too unwell for surgery. This gentleman had
three lesions, which were all excised. If you can see here, this is ever
such a small lesion, but if somebody’s got one lesion, they’ve got a very
high chance, because they’ve got sun exposed damaged skin, they’re
very likely to have other lesions elsewhere. So also look in the hairline,
that’s another area often missed. So if you can have a think where the
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lesions are, you may well be wrong, because it’s here. Okay, so this is
more [unclear 00:25:11] BCC, so it’s [unclear 00:25:14], difficult to spot,
sometimes can be thought of as misdiagnosis chronic inflammation of
the eyelid margin.
Here it’s quite difficult to point out, but he’s actually got a loss of lashes
and there is a slight change in the lid architecture and it’s thickened skin
along there with a mild ectropion. If you look at what he went onto have.
If you look at the extent of the excision that he had, you can see how
[unclear 00:25:36] it is, and it’s often larger than clinically apparent. This
is him after a reconstructive surgery. Squamous cell carcinomas, they
can also occur in Asian people, and people of colour, it’s not all just
Caucasian patients. This gentleman had right lateral canthal squamous
cell carcinoma proven on punch biopsy. This is the extent of the
excision. It’s fully excised, and this is him perioperatively, just at the end
of his operation following reconstruction. So, which one’s the
melanoma? I’ll give you the answer, it’s this one. This one is a
pigmented BCC. It’s very easy to get into the mind-set that all BCCs
look the same and their nodular. They’re not, and they can be cystic,
they can pigmented.
If there’s a change, or if there’s change in mid-architecture, it’s growing,
it’s bleeding, any pigmented legion along these lines, one needs to
biopsy it. This is a lady who complained of a little bit of pigmentation on
the right upper lid, seen a little bit here, it’s very faint. On eversion of the
lid you can see she’s got a malignant melanoma. Malignant melanoma’s
pretty rare around the eyelid, less than 1% but they can have various
types. It’s important to look under the lid if you can. Other important
lesions are Kaposi sarcoma, which we are not seeing so often now, but
more often seen in patients with AIDS, as you know. Treatment’s
radiotherapy, the disease is not curative, and Merkel cell carcinoma is a
rapidly growing lesion, usually in elderly women, it’s a purple nodule.
Again, anything rapidly growing, needs excision.
Onto the last few slides. Beware of the first chalazion in anybody over
40, okay. That’s the take home message really. One of the differential
diagnoses is actually sebaceous gland carcinoma, a very aggressive,
10% overall mortality rate, and 67% five year mortality rate if metastasis.
Beware the chalazion again in people over 40, this lady, she’s in her
70’s, was treated for several weeks with a left upper lid chalazion. On
biopsy, she had a lymphoma. She’s done very well with treatment
actually, she’s had some rituximab chemotherapy, and it’s resolved.
When you evert the lid, it’s not always a chalazion or a granuloma,
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especially in an elderly gentleman. You have to really think about
malignancies, rather than going for the diagnosis of chalazion. Again
this is a lymphoma.
Brief run through for eyelid swellings. Acute dacrocystitis due to
nasolacrimal duct obstruction. Treat with antibiotics and they need DCR
operation. Preseptal cellulitis is inflammation, infection in front of the
orbital septum. The key things here are that the eye is white. You can
move your eye, there is no visual compromise. There is no pain on eye
movement. Compared to orbital cellulitis, where you have all of those
features. Proptosis, pain on eye movement, red eye, reduced vision,
may have pupil abnormalities, so relative afferent pupillary defect. You
need to gently, if you can, prize the eyelids open, and have a look. They
need to be admitted for IV antibiotics.
So in summary, we’ve talked about eyes that won’t fully close, eyes that
won’t fully open, eyelid malpositions and eyelid lumps and bumps. As
you can see, on the whole, a lot of things that you see are benign.
Mostly they will be, but you need to be aware of the warning signs. So a
few key pointers, with ptosis, check the pupils and eye movements. If
they’re abnormal they need urgent referral. For chalazia, watch out for
the first chalazion in anybody over 40. For lid lesions, this is very subtle,
can easily be missed, but look out for a loss of lashes, and a change in
the lid architecture. So hopefully, we’ve gone down a downhill route of
looking at all the possible lid diseases, avoided some pitfalls, and
hopefully our patients will be managed successfully and safely. Thank
you. [Clapping].
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