Eyelid disorders: diagnosis and management

Author: Susan R. Carter
Date: June, 1998

Eyelids are crucial to the health of the underlying eye. They provide coverage of the cornea and aid in the distribution and elimination of tears. An exposed cornea will develop epithelial defects, scarring, vascularization or infection. Resulting symptoms include ocular irritation, pain and loss of vision. Eyelid closure distributes tears over the surface of the eye and pumps them through the lacrimal puncta into the tear duct (Figure 1). Thus, tearing or epiphora may result from various eyelid disorders.

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Anatomically complex, the eyelids consist of an anterior layer of skin and orbicularis oculi muscle, and a posterior layer of tarsus and conjunctiva (Figure 2). Contraction of the orbicularis muscle, innervated by the seventh cranial nerve, doses the eyelids. The levator muscle, innervated by the third cranial nerve, and the sympathetically innervated Muller's muscle raise the upper lid. The orbital septum, originating from the orbital rim, inserts into the upper lid just above the tarsal border and into the lower lid just below the tarsal border. The orbital septum limits the spread of infection and hemorrhage from the eyelid to the posterior orbital structures.

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Several glands along the eyelid margin contribute to the lipid component of the tear film. These glands commonly become inflamed. The meibomian glands, approximately 30 per lid, are present within the tarsus. The pilosebaceous glands of Zeiss and the apocrine glands of Moll are located anterior to the meibomian glands within the distal eyelid margin.

In evaluating an eyelid problem, the physician should obtain focused but complete information from the patient. Recognition of possible malignant lesions is essential. It is important to ask questions about the duration of the problem, a change in size or appearance of an eyelid lesion or the recurrence of a tumor that has been previously treated. In general, lesions that have not changed for a long time are benign. A previous history of skin cancers should also be noted.

Examination of the eyelids should be systematic, beginning with the upper lid. A ptotic upper lid may droop below the normal resting lid position of 2 mm below the superior corneoscleral junction. Redundant upper lid tissue may hang into the visual axis. Eyelid retraction or inability to dose the lid should be assessed. Eyelid lesions should be examined for size, location, pigmentation and associated lash loss or ulceration.

Inspection of the lower lid may reveal lower lid malpositions such as entropion (inward turning) or ectropion (outward turning). Ectropion of the inferior punctum, through which tears flow to the lacrimal sac, may result in tearing. Misdirected eyelashes may rub on the globe.

Benign Inflammatory Eyelid Processes

Blepharitis

One of the most common eyelid problems is blepharitis, or inflammation of the eyelid margin. Patients typically experience itching, burning, mild foreign-body sensation, tearing and crusting around the eyes on awakening. On examination, the eyelid margins are erythematous, and thickened with crusts and debris within the lashes (Figure 3). Conjunctival injection or a mild mucus discharge may be present. Blepharitis occurs with chronic bacterial lid infection, meibomian gland dysfunction, seborrhea and acne rosacea that affects the eye, known as ocular rosacea.[1] The diagnosis of rosacea is supported by the presence of dilated telangiectatic blood vessels on the lid margins, cheeks, nose and chin.

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Treatment of blepharitis consists initially of warm compresses, eyelid scrubs and application of antibiotic ointment. Warm compresses should be applied for 15 minutes twice a day. This step loosens irritating crusts in the eyelashes and melts the oil produced by the meibomian glands, which can occlude the gland orifices. The eyelids should be scrubbed after the warm compress is removed. Baby shampoo mixed with water produces a soapy solution. With the eyelids dosed, the eyelid margin region should be gently scrubbed with this solution, using a cotton-tipped applicator, wash cloth or finger. Erythromycin or another antibiotic ointment should then be applied to the lid margin. The ointment should be applied only at bedtime, because it may temporarily blur vision. If an obvious infection is present, antibiotic eye-drops may also be used.

If the condition is unresponsive to treatment, eyelid cultures should be obtained to rule out the possibility of resistant organisms. Oral antibiotics may be used in such cases, or in patients with the diagnosis of ocular rosacea. If severe, blepharitis may result in corneal infiltrates or ulcers. Rarely, sebaceous cell carcinoma may masquerade as unilateral or bilateral intractable blepharitis.

Patients must be cautioned that blepharitis is a chronic disease and that eyelid hygiene may need to be continued indefinitely. When the process is brought under better control, once-daily eyelid scrubs may be sufficient to keep the problem in check.

Chalazion

Chalazia appear most commonly as chronic subcutaneous nodules within the eyelid (Figure 4). Initially, a chalazion may be tender and erythematous before evolving into a non-tender lump. Blepharitis is frequently associated with chalazia.

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A chalazion results from the obstruction of the meibomian and. The blockage of the gland's duct at the eyelid margin results in release of the contents of the gland into the surrounding eyelid soft tissue. A lipogranulomatous reaction ensues. Occasionally, chalazia become secondarily infected.

Management includes warm compresses applied for 15 minutes four times a day. Blepharitis, if present, should be treated. A topical antibiotic may be used if signs of infection are present. If the lesion persists after four weeks of medical therapy, it may be incised and drained. Rarely, the chalazion is injected with steroids; however, this may result in hypopigmentation of the overlying skin.[2]

Hordeolum

A hordeolum, also known as a stye, is an acutely presenting, erythematous, tender lump within the eyelid (Figure 5). An internal hordeolum involves infection of the meibomian gland and may evolve into a chalazion. An external hordeolum occurs with infection of the more anteriorly located glands of Zeiss or Moll, present just anterior to the lash line. Hordeola usually drain spontaneously after one week of treatment with warm compresses four times a day and topical antibiotic ointment twice daily. Incision and drainage are required for nonresolving lesions.

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Benign Noninflammatory Eyelid Lesions

Seborrheic Keratosis

Seborrheic keratoses are pigmented, greasy hyperkeratotic lesions that appear to be stuck on the skin (Figure 6). Commonly occurring in the elderly, these lesions may occasionally become irritated. Surgical excision is curative.

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Actinic Keratosis

This flat, flaky, white, scaly lesion occurs in sun-exposed areas. Unlike seborrheic keratosis, actinic keratosis is a premalignant condition. Excisional biopsy should be performed to discover dysplasia or carcinoma-in-situ.

Nevus

Nevi are well-demarcated, flat or elevated, pigmented or nonpigmented congenital lesions (Figures 7 and 8). They may become more pigmented, more elevated or cystic during adolescence or young adulthood. Junctional nevi, occurring at the junction between epidermis and dermis, have some malignant potential. Because of the risk for malignant transformation, pigmented lesions that have changed in appearance should be excised.

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Xanthelasma

Xanthelasma are soft, yellowish plaques in the medial canthal area (Figure 9). Hypercholesterolemia or congenital disorders of cholesterol metabolism may be associated conditions.[3] Xanthelasma may be treated with excision or with a carbon dioxide laser if desired for cosmetic reasons.

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Molluscum Contagiosum

Found commonly in immunosuppressed as well as immunocompetent patients, these waxy nodules have a central umbilication[4] (Figure 10). If present on the eyelids, they may produce a follicular conjunctivitis. These viral lesions may be treated with excision, cryotherapy or curettage, although in many cases they are self-limited and resolve with time.

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Hydrocystoma

A hydrocystoma is a translucent cyst located near the lid margin, usually resulting from blockage of the sweat glands of the eyelid. Complete excision may be performed.

Malignant Eyelid Lesions

Basal Cell Carcinoma

[16.] Dutton JJ. Botulinum-A toxin in the treatment of craniocervical muscle spasms: short- and long-term, local and systemic effects, Surv Ophthalmol 1996;41:51-65.

SUSAN R. CARTER, M.D., is assistant professor of ophthalmology at the University of California, San Francisco (UCSF), School of Medicine. She is co-director of the Ophthalmic Plastic and Reconstructive Service at UCSF, as well as chief of the Oculoplastics Service at the San Francisco Veterans Affairs Medical Center. Dr. Carter graduated from Yale University School of Medicine, New Haven, Conn., and completed both a residency in ophthalmology and a fellowship in ophthalmic plastic and reconstructive surgery at UCSF.

Address correspondence to Susan R. Carter M.D., Department of Ophthalmology University of California, San Francisco, 400 Parnassus Ave., Suite A-750, San Francisco, CA 94143. Reprints are not available from the author.

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