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Table of Contents 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. [ top ] 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. [ top ] 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. [ top ] 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. [ top ] 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. [ top ] 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. [ top ] 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. [ top ] 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. [ top ] 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. [ top ] 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. [ top ] 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: 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. [ top ] 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. [ top ] 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. [ top ] 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. [ top ] 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. [ top ] 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.