DISORDERS OF THE EYELIDS 2 Dr Russell J Watkins
Entropion <ul><li>Types </li></ul><ul><ul><li>Involutional </li></ul></ul><ul><ul><li>Cicatricial </li></ul></ul><ul><ul><...
Involutional Entropion <ul><li>Affects  lower  lid </li></ul><ul><li>Possible pathological mechanisms are: </li></ul><ul><...
Involutional Entropion <ul><li>Treatment of involutional entropion </li></ul><ul><ul><li>Taping </li></ul></ul><ul><ul><li...
Cicatricial Entropion <ul><li>Affects upper or lower lid </li></ul><ul><li>Scarring shortens posterior lamella </li></ul><...
Acute Spastic Entropion <ul><li>Orbicularis oculi spasm due to ocular irritation or essential blepharospasm </li></ul><ul>...
 
 
Ectropion <ul><li>Types of ectropion </li></ul><ul><ul><li>Involutional </li></ul></ul><ul><ul><li>Cictatricial </li></ul>...
Involutional Ectropion <ul><li>Usually lower lid </li></ul><ul><li>Tarsal stretching ± orbicularis weakness  </li></ul><ul...
Cicatricial Ectropion <ul><li>Upper or lower lid </li></ul><ul><li>Causes include trauma [lacerations, burns, surgery], tu...
Paralytic Ectropion <ul><li>Lower lid ±lagophthalmos </li></ul><ul><li>Causes: myopathy; CN VII disorders </li></ul><ul><l...
 
 
 
Blepharospasm <ul><li>Involuntary tonic, spasmodic, bilateral eyelid closure </li></ul><ul><ul><li>F>M </li></ul></ul><ul>...
Floppy Lid Syndrome <ul><li>Generalised laxity of eyelid tissues </li></ul><ul><li>Can be unilateral or bilateral </li></u...
Orbicularis Myokymia <ul><li>Involuntary contraction producing an annoying twitching sensation </li></ul><ul><li>Related t...
Benign Eyelid Tumours <ul><li>Xanthelasma </li></ul><ul><ul><li>Fatty plaques (foam cells in epidermis), usually medial, u...
 
 
Benign Eyelid Tumours <ul><li>Basal cell papilloma </li></ul><ul><ul><li>Also known as seborrhoeic keratosis </li></ul></u...
 
Benign Eyelid Tumours <ul><li>Squamous cell papilloma </li></ul><ul><ul><li>Common </li></ul></ul><ul><ul><li>Sessile or p...
 
Benign Eyelid Tumours <ul><li>Solar keratosis </li></ul><ul><ul><li>Flat, multiple, scaly lesions </li></ul></ul><ul><ul><...
 
Benign Eyelid Tumours <ul><li>Keratoacanthoma </li></ul><ul><ul><li>Rapidly enlarges (months), then regresses </li></ul></...
 
 
Benign Eyelid Tumours <ul><li>Haemangioma </li></ul><ul><ul><li>Strawberry naevus: evident in neonatal period </li></ul></...
 
Benign Eyelid Tumours <ul><li>Neurofibroma </li></ul><ul><ul><li>Associated with neurofibromatosis </li></ul></ul><ul><ul>...
Benign Eyelid Tumours <ul><li>Naevi </li></ul><ul><ul><li>Congenital collections of naevus cells </li></ul></ul><ul><ul><l...
Benign Eyelid Tumours <ul><li>Naevi are classified according to location  </li></ul><ul><ul><li>Epidermal - slightly thick...
 
 
Benign Eyelid Tumours <ul><li>Cyst of Moll </li></ul><ul><ul><li>Retention cyst </li></ul></ul><ul><ul><li>Clear & fluid f...
 
 
Miscellaneous Benign Lumps <ul><li>Milia </li></ul><ul><li>Cutaneous horn </li></ul><ul><li>Meibomian cyst </li></ul><ul><...
 
 
 
 
 
 
Malignant Eyelid Tumours <ul><li>Basal cell carcinoma </li></ul><ul><ul><li>Most common malignant carcinoma </li></ul></ul...
 
 
 
 
 
Malignant Eyelid Tumours <ul><li>Carcinoma  in situ  (Bowen’s disease) </li></ul><ul><ul><li>5% of eyelid tumours </li></u...
Malignant Eyelid Tumours <ul><li>Squamous cell carcinoma </li></ul><ul><ul><li>Arise  de novo  from premalignant states su...
 
Malignant Eyelid Tumours <ul><li>Malignant melanoma </li></ul><ul><ul><li>Very rare  (of the eyelid) </li></ul></ul><ul><u...
Malignant Eyelid Tumours <ul><li>Types of malignant melanoma </li></ul><ul><ul><li>Lentigo maligna - superficial, premalig...
 
 
Malignant Eyelid Tumours <ul><li>Meibomian gland carcinoma </li></ul><ul><ul><li>Rare </li></ul></ul><ul><ul><li>Localised...
 
Miscellaneous Malignant Lumps <ul><li>Metastatic deposit </li></ul><ul><li>Lymphomatous infiltrate </li></ul><ul><li>Sebac...
 
 
 
 
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DISORDERS OF THE EYELIDS 2

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DISORDERS OF THE EYELIDS 2

  1. 1. DISORDERS OF THE EYELIDS 2 Dr Russell J Watkins
  2. 2. Entropion <ul><li>Types </li></ul><ul><ul><li>Involutional </li></ul></ul><ul><ul><li>Cicatricial </li></ul></ul><ul><ul><li>Acute spastic </li></ul></ul>
  3. 3. Involutional Entropion <ul><li>Affects lower lid </li></ul><ul><li>Possible pathological mechanisms are: </li></ul><ul><ul><li>Preseptal portion overrides pretarsal portion of orbicularis oculi </li></ul></ul><ul><ul><li>Horizontal lid laxity due to stretched canthal tendons, orbital fat atrophy </li></ul></ul><ul><ul><li>Weakened tarsus allowing flexure </li></ul></ul><ul><ul><li>Vertical instability due to dehiscence of retractors </li></ul></ul>
  4. 4. Involutional Entropion <ul><li>Treatment of involutional entropion </li></ul><ul><ul><li>Taping </li></ul></ul><ul><ul><li>Botulinum toxin if unfit for surgery </li></ul></ul><ul><ul><li>Surgery </li></ul></ul>
  5. 5. Cicatricial Entropion <ul><li>Affects upper or lower lid </li></ul><ul><li>Scarring shortens posterior lamella </li></ul><ul><li>Causes include trachoma, radiation, chemical injury, topical rx, previous surgery, trauma, SJS & mucous membrane pemphigoid </li></ul><ul><li>Treatment is usually surgical </li></ul>
  6. 6. Acute Spastic Entropion <ul><li>Orbicularis oculi spasm due to ocular irritation or essential blepharospasm </li></ul><ul><li>Usually associated with involutional entropion </li></ul><ul><li>Management is by removal of irritant, treatment of associated involutional entropion, botulinum toxin </li></ul>
  7. 9. Ectropion <ul><li>Types of ectropion </li></ul><ul><ul><li>Involutional </li></ul></ul><ul><ul><li>Cictatricial </li></ul></ul><ul><ul><li>Paralytic </li></ul></ul>
  8. 10. Involutional Ectropion <ul><li>Usually lower lid </li></ul><ul><li>Tarsal stretching ± orbicularis weakness </li></ul><ul><li>Treatment is by cicatrising cautery or surgery </li></ul>
  9. 11. Cicatricial Ectropion <ul><li>Upper or lower lid </li></ul><ul><li>Causes include trauma [lacerations, burns, surgery], tumours, infections </li></ul><ul><li>Optometric management - refer </li></ul><ul><ul><li>Pay attention to prevention of exposure keratopathy </li></ul></ul><ul><li>Surgical management aimed at release of scarring including skin grafts </li></ul>
  10. 12. Paralytic Ectropion <ul><li>Lower lid ±lagophthalmos </li></ul><ul><li>Causes: myopathy; CN VII disorders </li></ul><ul><li>Optometric management – refer </li></ul><ul><ul><li>Pay attention to prevention of exposure keratopathy </li></ul></ul><ul><li>Botulinum toxin induced ptosis; tarsorrhaphy </li></ul><ul><li>Various other surgical techniques including nerve transposition </li></ul>
  11. 16. Blepharospasm <ul><li>Involuntary tonic, spasmodic, bilateral eyelid closure </li></ul><ul><ul><li>F>M </li></ul></ul><ul><ul><li>More common in older individuals (60+ yrs) </li></ul></ul><ul><ul><li>Causes - idiopathic, Parkinson’s disease, psychogenic, post-encephalitic, tetany, drugs e.g. psychotropics </li></ul></ul><ul><ul><li>Treatment - botulinum toxin injections into orbicularis oculi </li></ul></ul>
  12. 17. Floppy Lid Syndrome <ul><li>Generalised laxity of eyelid tissues </li></ul><ul><li>Can be unilateral or bilateral </li></ul><ul><li>Symptoms - ocular irritation, redness </li></ul><ul><li>Signs - SPK, easy distraction of lid from globe, easy upper lid eversion, lower lid ectropion, ptosis </li></ul><ul><li>Treatment - wedge excision, canthal tendon repair </li></ul>
  13. 18. Orbicularis Myokymia <ul><li>Involuntary contraction producing an annoying twitching sensation </li></ul><ul><li>Related to fatigue - a very common presentation in optometric practice </li></ul><ul><li>Rarely due to a sinister cause </li></ul><ul><ul><li>Hemifacial spasm </li></ul></ul><ul><ul><li>Multiple sclerosis </li></ul></ul>
  14. 19. Benign Eyelid Tumours <ul><li>Xanthelasma </li></ul><ul><ul><li>Fatty plaques (foam cells in epidermis), usually medial, usually bilateral </li></ul></ul><ul><ul><li>Associated with 1° hyperlipidaemic states, DM, hypothyroidism, primary biliary cirrhosis </li></ul></ul><ul><ul><li>Optometric management - refer to GP for exclusion of underlying cause </li></ul></ul><ul><ul><li>Surgical management - excision (60% recur), laser ablation, chemical cautery </li></ul></ul>
  15. 22. Benign Eyelid Tumours <ul><li>Basal cell papilloma </li></ul><ul><ul><li>Also known as seborrhoeic keratosis </li></ul></ul><ul><ul><li>Common </li></ul></ul><ul><ul><li>Sessile </li></ul></ul>
  16. 24. Benign Eyelid Tumours <ul><li>Squamous cell papilloma </li></ul><ul><ul><li>Common </li></ul></ul><ul><ul><li>Sessile or pedunculated </li></ul></ul><ul><ul><li>Histopathology - excessive convoluted epithelium with central fibrovascular core; may form keratin horn </li></ul></ul>
  17. 26. Benign Eyelid Tumours <ul><li>Solar keratosis </li></ul><ul><ul><li>Flat, multiple, scaly lesions </li></ul></ul><ul><ul><li>Occasionally papillomatous with keratin horn formation </li></ul></ul><ul><ul><li>NB: premalignant </li></ul></ul><ul><ul><li>Histopathology - epithelial dysplasia with keratosis BUT no invasion </li></ul></ul>
  18. 28. Benign Eyelid Tumours <ul><li>Keratoacanthoma </li></ul><ul><ul><li>Rapidly enlarges (months), then regresses </li></ul></ul><ul><ul><li>Volcano shaped with keratin plug </li></ul></ul><ul><ul><li>Visually, often difficult to distinguish from BCC , whereas: </li></ul></ul><ul><ul><li>Histopathology - difficult to differentiate from SCC unless whole lesion examined; no invasion, but basal inflammation </li></ul></ul>
  19. 31. Benign Eyelid Tumours <ul><li>Haemangioma </li></ul><ul><ul><li>Strawberry naevus: evident in neonatal period </li></ul></ul><ul><ul><li>Grows then usually regresses by 5yrs </li></ul></ul><ul><ul><li>May be cutaneous, orbital or mixed </li></ul></ul><ul><ul><li>Histopathology - capillary proliferation, some of which are uncanalised </li></ul></ul>
  20. 33. Benign Eyelid Tumours <ul><li>Neurofibroma </li></ul><ul><ul><li>Associated with neurofibromatosis </li></ul></ul><ul><ul><li>Histopathology - Schwann cell & fibroblast proliferation </li></ul></ul>
  21. 34. Benign Eyelid Tumours <ul><li>Naevi </li></ul><ul><ul><li>Congenital collections of naevus cells </li></ul></ul><ul><ul><li>Pigmented or non-pigmented </li></ul></ul><ul><ul><li>May become pigmented post-puberty </li></ul></ul>
  22. 35. Benign Eyelid Tumours <ul><li>Naevi are classified according to location </li></ul><ul><ul><li>Epidermal - slightly thickened epithelium with naevus cells forming cysts </li></ul></ul><ul><ul><li>Junctional - activity at epidermal/dermal junction, occuring at puberty </li></ul></ul><ul><ul><li>Dermal - collections of naevus cells within the dermis; Can be associated with choroidal melanomas </li></ul></ul><ul><ul><li>Compound - malignant </li></ul></ul>
  23. 38. Benign Eyelid Tumours <ul><li>Cyst of Moll </li></ul><ul><ul><li>Retention cyst </li></ul></ul><ul><ul><li>Clear & fluid filled </li></ul></ul><ul><li>Cyst of Zeis </li></ul><ul><ul><li>Retention cyst </li></ul></ul><ul><ul><li>White cheesy (sebaceous) material </li></ul></ul>
  24. 41. Miscellaneous Benign Lumps <ul><li>Milia </li></ul><ul><li>Cutaneous horn </li></ul><ul><li>Meibomian cyst </li></ul><ul><li>Naevus flammeus </li></ul><ul><li>Dermoid cyst </li></ul>
  25. 48. Malignant Eyelid Tumours <ul><li>Basal cell carcinoma </li></ul><ul><ul><li>Most common malignant carcinoma </li></ul></ul><ul><ul><li>Lower lid most common site </li></ul></ul><ul><ul><li>Do NOT metastasise but invade locally </li></ul></ul><ul><ul><li>Types </li></ul></ul><ul><ul><ul><li>Noduloulcerative - well defined; Ulcerated & inflamed lesion </li></ul></ul></ul><ul><ul><ul><li>Sclerosing (morphoea) - tends to be multifocal </li></ul></ul></ul><ul><ul><li>Optometric management - refer for cryo, RT or surgery </li></ul></ul>
  26. 54. Malignant Eyelid Tumours <ul><li>Carcinoma in situ (Bowen’s disease) </li></ul><ul><ul><li>5% of eyelid tumours </li></ul></ul><ul><ul><li>Upper lid most common site </li></ul></ul><ul><ul><li>Histopathology - dedifferentiation of epithelial cells; localised to epidermis; premalignant for SCC </li></ul></ul>
  27. 55. Malignant Eyelid Tumours <ul><li>Squamous cell carcinoma </li></ul><ul><ul><li>Arise de novo from premalignant states such as solar keratoses & xeroderma pigmentosum </li></ul></ul><ul><ul><li>Lymphatogenous spread </li></ul></ul><ul><ul><li>May evoke inflammatory response </li></ul></ul><ul><ul><li>Histopathology can be from well differentiated to anaplastic </li></ul></ul><ul><ul><li>Optometric management - refer (radical excision) </li></ul></ul>
  28. 57. Malignant Eyelid Tumours <ul><li>Malignant melanoma </li></ul><ul><ul><li>Very rare (of the eyelid) </li></ul></ul><ul><ul><li>Can arise de novo or as a malignant transformation of a junctional naevus </li></ul></ul><ul><ul><li>Signs include itching, bleeding, pigmentary changes, increase in size </li></ul></ul>
  29. 58. Malignant Eyelid Tumours <ul><li>Types of malignant melanoma </li></ul><ul><ul><li>Lentigo maligna - superficial, premalignant (seen in the elderly) </li></ul></ul><ul><ul><li>Superficial spreading melanoma </li></ul></ul><ul><ul><li>Nodular - occurs only on covered areas not on face </li></ul></ul><ul><ul><li>Optometric management - refer </li></ul></ul><ul><ul><li>Prognosis depends on site, depth of invasion (poor if >1.5mm) & degree of inflammation </li></ul></ul>
  30. 61. Malignant Eyelid Tumours <ul><li>Meibomian gland carcinoma </li></ul><ul><ul><li>Rare </li></ul></ul><ul><ul><li>Localised </li></ul></ul><ul><ul><li>May present as recurrent chalazion </li></ul></ul><ul><ul><li>Optometric management - refer (radical excision & RT) </li></ul></ul>
  31. 63. Miscellaneous Malignant Lumps <ul><li>Metastatic deposit </li></ul><ul><li>Lymphomatous infiltrate </li></ul><ul><li>Sebaceous gland carcinoma </li></ul><ul><li>Kaposi sarcoma </li></ul>
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