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Table of Contents
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1.0 The Eyelids
o 1.1 Common cysts of the eyelid
o 1.2 Benign tumours of the eyelid
o 1.3 Malignant Tumours of the eyelid
o 1.4 Disorders of the eyelashes
o 1.5 Entropion and Ectropion
o 1.6 Ptosis
o 1.7 Dermatitis
2.0 The Orbit
o 2.1 Thyroid Ophthalmology
o 2.2 Fractures
o 2.3 Vascular Abnormalities
o 2.4 Infections
o 2.5 Inflammatory Disease (pseudotumour)
o 2.6 Tumours
References
1.0 The Eyelids
The following section details some of the common eyelid disorders and their clinical features.
Superficially, the eyelids may not appear to be an important region of clinical focus. However,
serious conditions such as myasthenia gravis may initially present in the eyelids and thus
some knowledge of what is normal and pathological is useful in clinical practice.
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1.1 Common cysts of the eyelid
Cyst
Aeitiology
Presentation
Treatment
External
hordeolum
(stye)
Small abscess
caused by
infection of
eyelash
Tender, inflamed,
Often spontaneous
anterior swelling(s) resolution. Antibiotic
of lid margin.
ointment needed to
stop infection
spreading. Hot bath or
compress aids
resolution.
Meibomian
cyst
(chalazion)
Secondary
inflammation
due to retention
of sebum in
obstructed duct
of Meibomian
gland
Painless, roundish,
firm lesion of the
tarsal plate,
gradually
enlarging. External
conjunctival
granuloma may be
present in cyst
region upon lid
eversion.
Eyelid infiltrated with
local anaesthetic. Lid
everted with chalazion
clamp. Contents of cyst
curetted and
granulomatous tissue
excised through
conjunctival incision.
Antibiotic ointment
instilled and eye
padded for two hours.
Internal
hordeolum
Small abscess
caused by
acute Staph.
Infection of
meibomian
glands
Tender inflamed
swelling within
tarsal plate.
Usually more
painful then a stye.
May enlarge and
discharge either
anteriorly or
posteriorly.
As for a stye. Surgical
incision required in the
event of a large
abscess.
Cautions
'recurrent
chalazion' may
actually be
meibomian
gland
carcinoma or
basal cell
carcinoma. If in
doubt, lesion
should be
biopsied.
Cyst of
Moll
Caused by
blockage of the
duct of the Moll
gland (modified
sweat gland).
Small, round, nontender, translucent
lesion on anterior
lid margin.
Contains clear
fluid.
Puncture with
hypodermic needle or
cauterisation.
Cyst of
Zeis
Caused by
blockage of the
duct of the Zeis
gland (modified
sebaceous
gland).
Similar to cyst of
Moll but less
transluscent. Cyst
contains sebum.
As for cyst of Moll
Contains a central
punctum and
retained cheesy
secretions give it a
yellowish-white
colour.
Simple excision.
Sebaceous Caused by duct
cyst
blockage in an
ordinary
sebaceous
gland.
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1.2 Benign tumours of the eyelid
(Illustration: Papilloma on eyelid.
Photo courtesy of Alex Mackay.)
Benign Tumour
Presentation
Comments
Molluscum
contagiosum
Pale, waxy, umbilicated, elevated
nodule which resolves within 6-9
Viral. Treated by expression or
months. Cell shedding from the
cauterisation.
lesion can produce chronic follicular
conjunctivitis and superficial keratitis.
Squamous
papilloma
Lesion may have broad base or it
may be pedunculated.
Most common benign tumour of
eyelids. Excision for cosmetic
purposes.
Verruca vulgaris
Appears as a filiform wart,
occasionally multiple lesions appear
simultaneously.
Caused by a viral infection.
Seborrhoeic
keratosis
Gradually enlarging, greasy, brown,
discrete roundish lesion with a friable
verrucose surface. Very common in
the elderly
Senile keratosis
Multiple flat, scaly lesions which may
May transform into squamous cell
assume a papillomatous
configuration.
Xanthelasma
Very common. Yellowish, elevated
lipid deposits, most frequently
located on the medial aspects of both
eyelids.
Typically originates as an
erythematous papule. Within weeks,
Keratoacanthoma it grows into a firm, raised, pinkish,
indurated nodule with a keratin-filled
crater.
Cutaneous horn
carcinoma.
Consists of a firm, projecting
keratinised mass. Fairly common.
If it does not spontaneously
resolve within three months, it
should be excised for biopsy.
Occasionally overlies a senile
keratosis or basal cell carcinoma.
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1.3 Malignant Tumours of the eyelid
Basal cell carcinoma
Most common primary malignant tumour of the eyelid. The incidence of presentation is
highest in the 70-90 year old. Clinical features include a slow growing, locally invasive tumour,
most frequently arising from the lower eyelid or medial canthus. Physical appearance of the
tumour is variable and can range from an asymptomatic, well defined nodule
(noduloulcerative basal cell carcinoma) to a flat, scar-like lesion that spreads radially under
the dermis (sclerosing basal cell carcimoma). Correct diagnosis from external inspection
alone may therefore be unreliable.
Treatment can involve surgical excision, radiotherapy, cryotherapy or exenteration of the
globe in severe cases. Local surgical excision with a 3mm margin outside the obvious tumour
is associated with the lowest rate of recurrence. The resected specimen should be examined
histologically to ensure the margins are free of tumour cells.
Squamous cell carcinoma
Much less common then basal cell carcinoma, it accounts for only 5% of malignant lid
tumours. Squamous cell carcinoma may present as a nodule, an ulcerated lesion or a
'papilloma' which may metastasise to the regional lymph nodes. Treatment is the same as
that of basal cell carcinoma but the extent of surgical excision should be larger as the tumour
is more aggressive.
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1.4 Disorders of the eyelashes
Trichiasis
Trichiasis is an inward misdirection of the lashes not caused by entropion. It causes irritation
of the cornea and erosion of the bulbar conjunctiva. Treatment involves removal of the
offending eyelashes via forceps, electrolysis, cryotherapy or irradiation in severe cases.
Contact lenses to protect the cornea may be useful as a temporary measure in severe
trichiasis.
Distichiasis
The clinical feature of distichiasis is an accessory row of lashes situated on or near the
openings of the Meibomian glands. The condition can be congenital or secondary to scarring.
Referral for cryotherapy treatment is required.
Blepharitis
(Illustration: Blepharitis in a middle aged man.
Photo courtesy of Peter Devitt, University of Adelaide)
Clinical features of mild squamous blepharitis include abundance of grease and skin scale on
the lid margin and slightly inflamed eyelids. Treatment involves twice daily cleaning with
cotton wool soaked in bicarbonate of soda solution performed indefinitely. In the more severe,
ulcerative blepharitis, the lash follicles are infected and require treatment with local and
systemic antibiotics as well as eyelid cleaning.
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1.5 Entropion and Ectropion
Entropion refers to the inversion of an eyelid. Senile entropion is the most common
presentation, where laxity of the tarsal sling combined with tissue atrophy means that the
orbicularis oculi can force the eyelid to turn inwards. Entropion may present to the GP as a
red eye due to conjunctival and corneal irritation by the in-turned lashes.
Ectropion is characterised by the eversion of an eyelid. Senile ectropion is again the most
common form and is caused by excessive weakness of the tarsal orbicularis muscle.
Ectropion may cause red eye because the everted conjunctiva and stagnant pool of tears
may become secondarily infected.
Ectropion treatment aims to prevent corneal drying and exposure by the instillation of artificial
tears and strapping the lids together during sleep. In both Ectropion and Entropion, treatment
may require surgical tightening of the muscles.
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1.6 Ptosis
Ptosis is an abnormally low position (drooping) of the upper eyelid. Ptosis can be caused by a
number of conditions with either neurogenic, aponeurotic, myogenic or mechanical origins.
Third nerve palsy and Horner's syndrome are examples of neurogenic ptosis. Aponeurotic
ptosis is caused by a defect in the distribution of force from the levator superioris muscle to
the upper eyelid. Involutional (senile) ptosis is a good example of this and clinical features
include a high or absent eyelid crease, thinning of the eyelid above the tarsal plate, good
levator function, a palpable defect in the levator aponeurosis and a bilateral occurrence.
(Illustration: Senile ptosis in a 47 year old man)
Myogenic ptosis is caused by a disorder of the levator muscle itself or of the myoneural
junction (eg myasthenia gravis). Mechanical ptosis is due to either excessive weight on the
upper lid or conjunctival scarring.
Patients with ptosis should be referred to an ophthalmologist for treatment, which may involve
surgery.
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1.7 Dermatitis
Contact dermatitis involving the eyelids is very common. The acute form is characterised by
erythema, oedema, vesiculation and crusting. Burning or itching is also common. Treatment
involves patch testing to determine the irritant causing the dermatitis and consequently its
withdrawal. Acute cases can be managed with cool compresses and hydrocortisone 1%
cream.
Atopic dermatitis may appear on the eyelids as well. It occurs most often in patients with other
'atopic' diseases such as asthma. Other ocular manifestations include keratoconjunctivitis.
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2.0 The Orbit
Patient history and examination should precede radiological and laboratory investigations
during a clinical evaluation of the orbit. The primary features of orbital disease are proptosis,
pain, double vision (diplopia), visual impairment and occasionally enophthalmos. Proptosis
refers to the anterior displacement of the globe beyond the orbital margin when the patient is
looking straight ahead - the term is analogous to exophthalmos.
Clinical examination of the orbit is often difficult for the general practitioner, as a thorough
investigation requires specialized tools. It is important however to test ocular motility, visual
acuity and pupillary reactions, and to try and identify the characteristics of the proptosis, if
present. Measure the degree of proptosis with a ruler positioned at the lateral canthus and
resting on bone. Measure the distance between the apex of the cornea and the lateral orbital
rim in both the erect and supine positions. A distance of more then 21mm is considered
abnormal and a difference of more then 2mm between the two eyes warrants further
investigation. Look for pulsation in the proptosis and test whether the proptosis changes
dynamically eg due to head position.
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2.1 Thyroid Ophthalmology
Thyroid diseases, eg Graves' disease, are important autoimmune diseases that present
clinical features in the eye. A common characteristic of thyroid disease is exophthalmos
(protrusion of the globes), presenting with retraction of the upper and lower eyelid with upperlid lag on down gaze. The resulting appearance is commonly called the "thyroid stare".
Upper and lower eyelid retraction and exophthalmos can cause the patient to complain of
irritation, foreign body sensation and tearing as a result of corneal exposure and drying.
These symptoms can be remedied with artificial tear preparations and lubricating eye
ointment at night. The underlying thyroid condition must also be treated.
In severe cases, surgery involving orbital decompression extraocular muscle surgery may be
needed. Seek the advice of an ophthalmologist if you are uncertain.
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2.2 Fractures
The term 'blow-out fracture of the orbit' is used to describe a specific type of orbital fracture
that is not associated with involvement of the orbital rim. The most common blow-out fracture
is of the orbital floor and is usually caused by a sudden increase in intraorbital pressure
caused by a high velocity contact with an object greater then 5cm in diameter (eg a fist).
Clinical features are as follows:
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Initial periocular ecchymosis and oedema
Enophthalmos appearing after 10 days to 2 weeks
Numbness of the lower lid, cheek, side of nose, upper lip and upper teeth due to
infraorbital nerve anaesthesia.
Diplopia
Nasal bleeding
Periocular subcutaneous emphysema
Ocular damage
Management of orbital fractures involves special investigations such as X-rays and CT
scanning and referral to an ophthalmologist to prevent permanent diplopia and/or
enophthalmos.
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2.3 Vascular Abnormalities
A varix is the most common orbital vascular lesion and is characterised by a pathological
enlargement of one or more pre-existing venous channels. A varix presents as intermittent,
non-pulsatile proptosis. Compression of the jugular veins can precipitate the proptosis.
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2.4 Infections
Preseptal (Periorbital) Cellulitis
(Illustration: Preseptal cellulitis)
Preseptal cellulitis is an infection in the space between the orbital septum and the skin of the
eyelid. Dental or sinus infection is a common precedent as is a history of sharp or blunt
trauma.
There is a well demarcated pink or purplish swelling of the lids which are very oedematous.
There are no signs, such as proptosis or reduced ocular motility, indicating involvement of
intra orbital structures. Treatment involves oral antibiotics on an outpatient basis.
Orbital Cellulitis
Orbital cellulitis refers to severe inflammation (usually due to infection) within the orbit. True
orbital cellulitis is less common than preseptal cellulitis but potentially much more dangerous.
The onset is acute with signs of orbital soft tissue involvement such as proptosis, chemosis
and limited ocular motility. Most cases are caused by spread from infected sinuses. Vision
may be lost due to optic neuritis.
Culture from the conjunctiva is often misleading. Blood cultures should always be taken. CT
scanning of the orbit and sinuses should be undertaken in all cases of orbital cellulitis and in
cases of preseptal cellulitis where there is doubt whether infection is contained in the
preseptal space.
Orbital cellulitis is potentially life threatening and parenteral antibiotics and hospital admission
is strongly recommended. Topical antibiotics are useless, as they do not penetrate into the
soft tissue spaces involved.
Mucormycosis
Rhino-orbital mucormycosis is a very rare opportunistic fungal infection. A black eschar on the
palate, nasal septum or skin is an important diagnostic sign. Ocular features include cellulitis,
proptosis, headache and acute visual loss. Immediate emergency hospital care is required.
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2.5 Inflammatory Disease (pseudotumour)
Inflammatory orbital disease (IOD) is the general term for rare, idiopathic, non-neoplastic,
space occupying periocular lesions. IOD typically affects middle-aged individuals with
unilateral symptoms such as pain, lid oedema, chemosis, injection of the conjunctiva,
limitation of gaze and proptosis. Clinical features of IOD differs from thyroid ophthalmopathy
in its quicker onset and minimal eyelid retraction and lag. Patients suspected of IOD should
be referred to an ophthalmologist for further investigation.
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2.6 Tumours
Tumour
Features
Cavernous
haemangioma
Cavernous haemangioma is the most common orbital tumour in
adults generally presenting during the age of 20-50years as a slowly
progressing unilateral proptosis
Lymphangioma
Presents as a slowly progressive proptosis in a young person.
Occasionally, the proptosis becomes rapid and is linked to pain
resulting from the tumour bleeding
Lacrimal gland
tumours
May present with proptosis and/or a palpable mass in the lacrimal
gland fossa. A careful palpation of the fossa is therefore indicated in
all patients with proptosis.
Lymphoproliferative
disorders
Usually affect patients over 60 years of age and can involve any
part of the orbit.
Dermoid Cysts
Characteristically lined by keratinising epithelium and may contain
sebaceous glands and hair follicles. Complicated dermoid cysts
typically present in adolescence or later life with proptosis or a mass
lesion with indistinct posterior margins.
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References
1. Gole, G.A. 2001, PAEDIATRIC OPHTHALMOLOGY NOTES, Dept of Ophthalmology,
Royal Children's Hospital, Brisbane.
2. Gaston, H. 1989, 'Managing the red eye', Practitioner. Vol. 22, no. 233(1479), pp.
1566-72.
3. Mars, S. Keightley, S. 1989, 'The Ageing Eye', Practitioner, vol. 22, no. 233(1479),
pp. 1560-4.
4. Kanski, J.J. 1989, Clinical Ophthalmology - A Systematic Approach. Butterworth &
Co, Hong Kong.