Transcript Disorders of the Eyelids

Disorders of the Eyelids
Dr.Mazen Khwaira
Disorders of the Eyelids
 Benign eyelid lesions
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Malignant eyelid tumours
Disorders of eyelashes
Entropion
Ectropion
Ptosis
Benign Eyelid Lesions
 Chalazion�
 External hordeolum �
 Internal hordeolum �
 Molluscum contagiosum �
 Strawberry naevus �
 Port wine stain �
 Keratoacathoma �
 Pigmented naevi �
 Miscellaneous lesions
Chalazion
 The meibomian glands are modified sebaceous glands located
in the tarsal plates which secrete the outer lipid layer of the
precorneal tear film .
 There are between 30 and 40 glands in the upper tarsus and
fewer (20-30) in the lower tarsus (.
 A chalazion (meibomian cyst) is a chronic inflammatory
lesion caused by blockage of meibomian gland orifices and
stagnation of sebaceous secretions.
 Patients with acne rosacea and seborrhoeic dermatitis are at
increased risk of chalazion formation.
 Examination shows a painless,
roundish, firm lesion in the tarsal
plate
 Eversion of the lid may show an
associated polypoid mass
(pyogenic granuloma) if the
lesion has ruptured through the
tarsal conjunctiva.
 Occasionally, a cyst of the upper
lid presses on the cornea and
causes blurred vision from
induced astigmatism.
Signs of chalazion (meibomian cyst)
Painless, roundish, firm lesion
within tarsal plate
May rupture through conjunctiva
and cause granuloma
 Treatment is usually required for large, persistent lesions
although some small chalazia may disappear spontaneously.
 1. Surgery is by far the most common method of treatment.
The eyelid is everted with a special clamp and the cyst is
incised and its contents curetted through the tarsal plate .
 It is very important that a meibomian gland carcinoma or a
basal cell carcinoma is not mistaken for 'recurrent chalazion'.
 In doubtful cases the lesion should be biopsied and examined
histologically.
 2. Steroid injection into the lesion through the conjunctiva is
a good alternative to surgery.
 The success rate following one injection is about 80%. In
unresponsive cases a second injection can be given 2 weeks
later.
 3. Systemic antibiotics may be required as prophylaxis in
patients with recurrent chalazia who have associated acne
rosacea or seborrhoeic dermatitis.
External hordeolum
 The glands of Zeis are modified sebaceous glands that are
associated with the lash follicles.
 The glands of Moll are modified sweat glands whose ducts
open either into a lash follicle or directly onto the anterior
lid margin between the lashes.
 An external hordeolum (stye) is a small abscess caused by an
acute staphylococcal infection of a lash follicle and its
associated gland of Zeis or Moll.
 It may be associated with chronic staphylococcal blepharitis.
External hordeolum
 Examination shows a tender inflamed swelling in the lid
margin which points anteriorly through the skin (.
 More than one lesion may be present and occasionally minute
abscesses may involve the entire lid margin. In severe cases
there may be a preseptal cellulitis.
External hordeolum
Treatment in most cases is unnecessary because styes frequently resolve
spontaneously or discharge anteriorly, close to the lash roots. Resolution
may be promoted by the application of hot compresses and removal of the
eyelash associated with the infected follicle. Systemic antibiotics may be
necessary if there is severe preseptal cellulitis .
Internal hordeolum
 An internal hordeolum is a small
abscess caused by an acute
staphylococcal infection of
meibomian glands.
 Examination shows a tender inflamed
swelling within the tarsal plate which
is usually more painful than a stye.
The lesion may enlarge and then
usually discharge either posteriorly
through the conjunctiva or anteriorly
through the skin .
 Treatment by incision may be
required in some cases that do not
discharge.
Acute hordeola
Internal hordeolum
( acute chalazion )
External hordeolum (stye)
• Staph. abscess of meibomian
glands
• Staph. abscess of lash follicle and
associated gland of Zeis or Moll
•Tender swelling at lid margin
•Tender swelling within tarsal plate
• May discharge through skin
or conjunctiva
• May discharge through skin
 Molluscum contagiosum
 Molluscum contagiosum is an infection caused by one of the
pox viruses.
 Examination typically shows a pale, waxy, umblicated nodule .
 Ocular irritation may occur as a result of secondary chronic
follicular conjunctivitis and superficial keratitis.
Molluscum contagiosum
Signs
Complications
• Painless, waxy, umbilicated nodule• Chronic follicular conjunctivitis
• May be multiple in AIDS patients • Occasionally superficial keratitis
Treatment options include expression, shave excision, cryotherapy or cauterization.
 Strawberry naevus (Capillary haemangioma)
 Presentation of this rare tumour is typically within the first 6
months of birth.
 Examination shows a raised red lesion .
 The tumour usually grows until the age of about 12 months
and then starts to involute spontaneously.
 Complete resolution occurs in 75% of patients by the age of
3 years.
The upper eyelid is most commonly involved and the tumour may cause a
mechanical ptosis. In some cases there is intraorbital extension .
Capillary haemangioma
• Rare tumour which presents soon after birth • May be associated with intraorbital
extension
• Starts as small, red lesion, most frequently
• Grows quickly during first year
on upper lid
• Begins to involute spontaneously
• Blanches with pressure and swells on crying during second year
 Treatment is indicated if a large tumour threatens to produce
amblyopia by either obstructing the visual axis or inducing severe
corneal astigmatism.
 The most frequently used method of treatment is steroid injection of
a mixture, in equal parts, of triamcinolone 40 mg/ml and
betamethasone 6mg/ml into the lesion using a 30-gauge needle.
 The tumour usually begins to regress within 2 weeks and, if
necessary, second and third injections can be given after about 2
months.
 Reported but infrequent potential complications of steroid injections
include: skin depigmentation, fat atrophy, eyelid necrosis and, very
rarely, occlusion of the central retinal artery.
 Port wine stain
 Presentation is at birth.
 Examination shows a sharply demarcated pink patch which
darkens with age from red to purple (naevus flammeus).
 The tumour is soft and subcutaneous, and composed of large thinwalled vessels and capillaries.
 Occasionally the involved skin is also swollen and coarse.
 The vast majority of lesions occur in isolation, although more
extensive lesions involving the first and second divisions of the
trigeminal nerve are associated with a 45% incidence of glaucoma,
and about 5% are associated with multisystem disorders such as
the Sturge-Weber syndrome.
Treatment with an argon or yellow dye laser can reduce the amount of skin
discoloration.
Port-wine stain (naevus flammeus)
• Rare, congenital subcutaneous lesion
• Segmental and usually unilateral
• Does not blanch with pressure
Associations
• Ipsilateral glaucoma in 30%
• Sturge-Weber or
Klippel-Trenaunay-Weber
syndrome in 5%
 Keratoacanthoma
 Presentation is typically in adult life with a fast-growing skin
lesion.
 Examination shows an erythematous papule which turns into
a firm, pinkish, indurated nodule with a keratin-filled crater
Spontaneous resolution is common but it may take up to a
year and leave a scar.
Treatment involves excision and histological examination because squamous cell carcinoma may have a
similar clinical appearance; rarely, a keratoacanthoma may reveal histological evidence of invasive
squamous cell carcinoma at deeper levels of sectioning.
Keratoacanthoma
• Lesion above surface epithelium
• Uncommon, fast growing nodule
• Acquires rolled edges and keratin-filled
crater
• Central keratin-filled crater
• Involutes spontaneously within 1 year• Chronic inflammatory cellular infiltratio
of dermis
 Pigmented naevi
 Naevi (moles) tend to become more pigmented at puberty. Their
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appearance and classification are determined by their location within the
skin as indicated below.
An intradermal naevus is usually elevated and may be pigmented or
non-pigmented. It is the most common type and, when located on the
eyelid margin, lashes may be seen growing through the lesion. It has no
malignant potential.
A junctional naevus is usually flat and well circum-scribed with a
uniform brown colour .
The naevus cells contained within the lesion are located at the junction
of the epidermis and dermis. It has a low potential for malignant
transformation.
A compound naevus is characterized by both intradermal and
junctional components.
Intradermal naevus
Junctional naevus
Naevi
• Appearance and classification determined by location within skin
• Tend to become more pigmented at puberty
Intradermal
Junctional
Compound
• Flat, well-circumscribed • Has both intradermal
and junctional
• May be non-pigmented • Pigmented
components
• Elevated
• No malignant potential • Low malignant potential
 Miscellaneous lesions
 A cyst of Moll is a small, round,
non-tender, translucent fluid-filled
lesion on the anterior lid margin
 A cyst of Zeis is similar but, because
it contains oily secretions, it is less
translucent .
 A sebaceous cyst arises from an
ordinary sebaceous gland and is
characterized by a central punctum
with retained cheesy secretions. It is
rarely found on the eyelid although
it may occur at the inner canthus .
EyelidEccrine
cysts
sweat gland
Cyst of Moll
•Translucent
• On anterior lid
margin
hidrocystoma
• Similar to cyst of Moll
• Not confined to lid
margin
Cyst of Zeis
Sebaceous cyst
• Opaque
• On anterior lid
margin
• Cheesy contents
• Frequently at
inner canthus
 Milia are small, white, round,
superficial cysts which tend to
occur in crops. They are derived
from hair follicles or sebaceous
glands .
 Squamous cell papilloma is the
most common benign tumour of
the eyelids. It may be broad
based (sessile) or pedunculated .
 Seborrhoeic keratosis (basal cell
papilloma) is a slow-growing,
discrete, greasy, brown, round or
oval lesion with a friable
verrucous surface .
Keratoses
Seborrhoeic
• Common in elderly
• Discrete, greasy, brown lesion
• Friable verrucous surface
• Flat ‘stuck-on’ appearance
Actinic
• Affects elderly, fair-skinned individuals
• Most common pre-malignant skin lesion
• Rare on eyelids
• Flat, scaly, hyperkeratotic lesion
Xanthelasma
• Common in elderly or those with
hypercholesterolaemia
• Yellowish, subcutaneous plaques
containing cholesterol and lipid
• Usually bilateral and located medially
Viral wart (squamous cell papilloma)
• Most common benign lid tumour
• Raspberry-like surface
Pedunculate
d
Sessil
e
 Actinic keratosis is characterized by a
rough, dry, scaly lesion on an erythematous
base .
 It typically affects elderly fair-skinned
individuals who have been exposed to
excessive sunlight. It is a pre-malignant lesion
because it may occasionally undergo
transformation into a squamous cell
carcinoma.
 Xanthelasmata are yellowish subcutaneous
plaques of cholesterol and lipid which
typically occur at the medial aspects of the
eyelids in elderly individuals .
 A cutaneous horn is frequently associated
with an underlying dysplastic (e.g. actinic
keratosis) or neoplastic (e.g. squamous cell
carcinoma) lesion. The lesion should
therefore be biopsied and a portion of the
base excised to determine the underlying
pathology.