CHAPTER OUTLINE
- ■ Congenital Lid Conditions
- ■ Eyelash Abnormalities
- ■ Entropion
- ■ Ectropion
- ■ Ectropion
- ■ Other Lid Conditions
- ■ Benign Lid Conditions
- ■ Malignant Lid Conditions
- ■ Other Malignant Lid Conditions
- ■ Miscellaneous Lid Conditions
Congenital Lid Conditions
- Epicanthus
- Telecanthus
- Coloboma of the eyelid
- Distichiasis
- Blepharophimosis syndrome
- Epiblepharon
- Euryblepharon
Eyelash Abnormalities
- Trichiasis
- Eyelash ptosis
- Lash in the punctum
- Eyelash in anterior chamber
- Metaplastic eyelash(es)
- Poliosis
- Madarosis
- Brittle eyelash
- Trichomegaly
- Matting of eyelashes
Entropion
- Congenital entropion
- Involutional (senile) entropion
- Cicatricial entropion
- Acute spastic entropion
Ectropion
- Involutional (senile) ectropion
- Cicatricial ectropion
- Paralytic ectropion
- Mechanical ectropion
Inflammatory Lid Conditions
- Acute contact dermatitis
- Chronic contact dermatitis
- Atopic dermatitis of the lid
- Angular blepharoconjunctivitis
- Primary herpes simplex of lids
- Herpes zoster ophthalmicus
- Blepharitis
- Meibomianitis
- Preseptal cellulitis
- External hordeolum (stye)
- Internal hordeolum (inflamed chalazion)
- Chalazion
Ptosis: Drooping of Upper Lid
- Ptosis
- Synkinetic ptosis
- Pseudoptosis
- Congenital ptosis
- Acquired ptosis
- Lid retraction
Other Lid Conditions
- Chemosis or lid edema
- Lagophthalmos
- Blepharochalasis
- Dermatochalasis
- Floppy eyelid syndrome
- Symblepharon
- Essential blepharospasm
- Ecchymosis of the eyelids
- Phthiriasis palpebrum
Benign Lid Conditions
- Xanthelasma
- Capillary hemangioma (strawberry nevus)
- Port-wine stain (nevus flammeus)
- Molluscum contagiosum
- Sebaceous cyst
- Keratoacanthoma
- Keratic horn
- Squamous cell papilloma (viral wart)
- Basal cell papilloma (seborrheic keratosis)
- Oculodermal melanocytosis (nevus of Ota)
- Acquired nevus
- Milia and comedones
- Cyst of Moll
- Cyst of Zeis
- Epidermal inclusion cyst
- External angular dermoid
Malignant Lid Conditions
- Basal cell carcinoma (rodent ulcer)
- Squamous cell carcinoma
- Meibomian gland carcinoma
- Carcinoma of gland of Zeis
Other Malignant Lid Conditions
- Lentigo maligna
- Nodular melanoma
Miscellaneous Lid Conditions
- Baggy eyelids
- Depigmentation of periocular skin
- Ankyloblepharon
- Nodular hemangiomas
- Tarsorrhaphy
Congenital Lid Conditions
Epicanthus
- Most common congenital lid condition
- Unilateral or bilateral
- May give rise to pseudo-convergent squint
- Four types:
- Epicanthus palpebralis: Skin fold is equally distributed is the upper and lower eyelids (Fig. 1.1.3)
- Epicanthus supraciliaris: Skinfold covering the medical canthus, extends high up to the eyebrow.
- Treatment: By plastic repair.
Telecanthus
- Due to long abnormal medial canthal tendon
- Should not be confused with hypertelorism (Fig. 1.2.3) in which there is wide separation of bony orbits
Coloboma of the Eyelid
- A notch or defect of the lid margin
- Upper lid coloboma: At the junction of middle and inner thirds
- Associated with Treacher Collins syndrome
- Treatment: Urgent plastic repair at a very early age to prevent exposure keratitis and corneal ulcer.
Distichiasis
- Hereditary and congenital condition
- Extra posterior row of cilia, occasionally present in all four lids
- They occupy the position of meibomian gland orifices
- Eyelashes may irritate cause to corneal epithelial defects
- Treatment: By cryotherapy or excision with grafting.
Blepharophimosis Syndrome
-
- Narrowing of vertical and horizontal palperbral apertures
- Telecanthus
- Inverse epicanthus folds
- Lateral ectropion and moderate to severe ptosis
- Treatment: Plastic reconstruction of lids, along with bilateral brow suspension for ptosis.
Epiblepharon
- Nasal 1/3rd is most commonly affected
- Treatment: Plastic repair if necessary to prevent recurrent infection.
Euryblepharon
Rare, congenital, bilateral, not so serious condition
- Excessive watering may be a problem due to more exposure
- Treatment: No treatment for most of the cases; lateral tarsorrhaphy for symptomatic cases.
Eyelash Abnormalities
Trichiasis
- Inward misdirection of eyelash(es) which irritate the cornea and/or conjunctiva (Figs 1.7.1 and 1.7.2)
- It causes punctate epithelial erosion (PEE) (Figs 1.7.3A and B) or may cause frank corneal ulcer (Fig. 1.7.4)
- When associated with entropion— called pseudo-trichiasis (Fig. 1.7.5)
- Treatment: Temporarily by epilation; permanently by electrolysis, cryotherapy, or argon laser cilia ablation. If more cilia are involved: Operative procedure as entropion is most effective.
Eyelash Ptosis
- Downward drooping of upper lid eyelashes (Fig. 1.8.1)
- Congenital or may be seen after prolong use of latanoprost eye drop
- It does not require any treatment.
Lash in the Punctum
- An uncommon phenomenon which may cause a pricking sensation on blinking
- Mostly seen in lower punctum (Fig. 1.9.1), may be in the upper punctum (Fig. 1.9.2)
- Treatment: Simple removal of the offending eyelash.
Eyelash in the Anterior Chamber
- Rare occurrence after an open globe injury (Fig. 1.10.1)
- May cause iridocyclitis or implantation cyst.
Metaplastic Eyelash(es)
- Not so rare situation which may cause redness and irritation (Fig. 1.11.1)
- May be seen in cicatricial lid condition like chemical burn, Stevens-Johnson (SJ) syndrome, ocular cicatricial pemphigoid or raditional injury
- Can also cause corneal ulcer (Fig. 1.11.2)
- Treatment: Just pull the eyelash to remove it.
Poliosis
- Whitening of eyelashes; partial or total, unilateral or bilateral
- Causes:
- Aging (Fig. 1.12.1)
- Albinism (Fig. 1.12.2)
- Sympathetic ophthalmia
- Waardenburg syndrome
- Treatment: No specific treatment.
Madarosis
- Partial or complete loss of eyelashes
- Causes:
- Chronic blepharitis (Fig. 1.13.1)
- Burns
- Post herpes zoster (HZO) (Fig. 1.13.2)
- Leprosy (Fig. 1.13.3)
- Trichotillomania
- Myxedema
- Treatment of the cause.
Brittle Eyelash
- Rare, bilateral condition
- Associated with congenital ectodermal dysplasia.
Trichomegaly
- May be associated with newer antiglaucoma medication, like brimatoprost
- No treatment is required.
Matting of Eyelashes
- Few eyelashes are stuck together
- Mostly seen in upper eyelids
- Causes:
- Bacterial corneal ulcer (Fig. 1.16.3) or panophthalmitis (Fig. 1.16.4)
- Use of eye ointment
- Treatment of the cause.
Entropion
Inward turning of the eyelids towards the globe.
Congenital Entropion
- Rare, may be associated with microphthalmos/anophthalmos
- May be associated with epiblepharon (Fig. 1.17.3)
- Treatment: Excess skin may be removed with resection of tarsus.
Involutional (Senile) Entropion
- Involutional or senile entropion is most common and affects the lower lid only (Fig. 1.18.1). Can be easily corrected by simple digital pressure
- May be unilateral or bilateral (Figs 1.18.2A and B)
- Very rearly in upper lid alone (Figs 1.18.3A and B) or in both eyelids (Fig. 1.18.4)
- It is caused by horizontal lid laxity and over-riding of preseptal part of orbicularis
- Treatment: Temporary—adhesive tape, cautery, transverse lid everting suture, etc.Permanent: Weis’ procedure, horizontal lid shortening, tucking of inferior lid retractors, etc.
Cicatricial Entropion
- Due to scarring of the palpebral conjunctiva
- It usually affects the upper lid (Fig. 1.19.1) and cannot be corrected by digital manipulation
- Causes: Chemical burn (Fig. 1.19.2), trachoma, Stevens Johnson syndrome (Fig. 1.19.3), ocular pemphigoid, etc.
- Treatment: Tarsal wedge resection, tarsal fracture, etc.
Acute Spastic Entropion
- Associated with blepharospasm, mainly affects the lower lids (Fig. 1.20.1)
- Causes: Chronic conjunctivitis, keratitis, corneal abrasion (Fig. 1.20.2) and postoperative
- Treatment: Adhesive tape and removal of the cause.
Ectropion
Outward turning of the eyelid away from the globe.
Involutional (Senile) Ectropion
- Age-related condition which affects the lower lid (Fig. 1.21.1)
- It is the most common form—may be unilateral (Fig. 1.21.2) or bilateral (Fig. 1.21.3)
- Due to excessive horizontal eyelid length with weakness of the preseptal part of orbicularis. Laxity of medial canthal tendon is marked
- Treatment: Medial conjunctivoplasty, Bick's procedure, horizontal lid shortening, etc.
Cicatricial Ectropion
- Contracture of the skin and underlying tissues of the lower eyelids
- May be unilateral or bilateral (Figs 1.22.1 to 1.22.3)
- Causes: Chemical (Fig. 1.22.4) or thermal burn (Fig. 1.22.5), trauma/lacerated injury (Fig. 1.22.6) or skin disorders (Fig. 1.22.7)
- Depending upon the nature of the contracture, upper eyelids may also be affected (Figs 1.22.8 and 1.22.9)
- Treatment:
- Lengthening of vertical shortening by Z-plasty.
Fig. 1.22.10B: Cicatricial ectropion—after correction (Fig. 1.22.9A)
Paralytic Ectropion
- Caused by paralysis of orbicularis and associated with lagophthalmos (Fig. 1.23.1)
- Incomplete blinking and epiphora
- May cause corneal ulcer in severe cases (Fig. 1.23.2)
- Treatment:
- Mild cases: Tear substitute to prevent corneal drying and antibiotic eye ointment at night
- Severe cases: Lateral tarsorrhaphy, lateral canthoplasty.
Mechanical Ectropion
- It is just a sequel to a swelling of the lower eyelid, e.g. a tumor, lid edema, or a large chalazion (Figs 1.24.1 and 1.24.2)
- Treatment: Can be corrected by removing the lesion.
Inflammatory Lid Conditions
Acute Contact Dermatitis
- Unilateral (Figs 1.25.1 and 1.25.2) or bilateral (Fig. 1.25.3) condition, caused by sensitivity to topical medication, hair dyes, cosmetics, etc.
- Edema, erythema, vesiculation and later on crusting (Fig. 1.25.4)
- Treatment: Withdrawal of the irritants, antihistaminics and/or corticosteroids.
Chronic Contact Dermatitis
- Caused by chronic irritants, e.g. topical medication (Fig. 1.26.1), cosmetics, spectacles frame
- Thickening and crusting of the skin (Fig. 1.26.2)
- Treatment: Identification of the offending agent and rectify it, antibiotic-steroids ointment.
Atopic Dermatitis of the Lid
- Uncommon and more generalized with skin condition
- Associated with atopic keratoconjunctivitis.
Angular Blepharoconjunctivitis
- Unilateral or bilateral infection, caused by Moraxella
- Frequently associated with conjunctivitis (Fig. 1.28.1)
- Fissuring, maceration, erythema and scaling of one or both canthi (Fig. 1.28.2)
- Treatment: Oxytetracycline eye ointment and zinc oxide.
Primary Herpes Simplex of Lids
- Uncommon, unilateral condition, may be associated with immune deficiency states
- Crops of small vesicles, ruptures and crust formation, may be with secondary infection (Figs 1.29.1 and 1.29.2)
- Healing without scarring by seven days
- May be associated with acute follicular conjunctivitis and dendritic keratitis (Fig. 1.29.3)
- Treatment: Topical acyclovir ointment.
Herpes Zoster Ophthalmicus
- More common unilateral condition, may be severe in immunocompromised conditions
- Painful maculopapular rash involving the first division of trigeminal nerve with chemosis of lid (Fig. 1.30.1)
- Development of vesicles, pustules, and ulceration with crusting (Fig. 1.30.2)
- Periorbital edema, secondary infection may lead to bacterial cellulitis
- Treatment: High dose of oral acyclovir, investigation to find out the cause of immune deficiency.
Blepharitis
- Sub-acute or chronic inflammation of the eyelids
- Mostly in children and usually bilateral
- Associated with seborrhea (dandruff) of the scalp
- Squamous blepharitis:
- Hyperemia of lid margins
- Falling of eyelashes (madarosis)
- Thickening of the lid margins (tylosis)
- Ulcerative blepharitis:
- Soreness of the lid margins (Fig. 1.31.2)
- Loss of eyelashes
- Marginal keratitis is a common association
- Traetment: Lid hygiene (lid scrub), vertical lid massage, antibiotic-steroid ointment, systemic tetracycline/doxycycline, treatment of dandruffs, etc.
Meibomianitis
- Chronic infection of the meibomian glands
- Occurs in the middle age
- White, frothy secretion on the eyelid margins and at the outer canthus (seborrhea) (Fig. 1.32.1)
- Plugged duct opening (Fig. 1.32.2A) and vertical yellowish streaks shining through the conjunctiva (Fig. 1.32.2B)
- Thick secretion on expression (‘toothpaste sign’) (Fig. 1.32.5)
- Recurrent blepharoconjunctivitis (Fig. 1.32.6) and marginal keratitis (Fig. 1.32.7) may be a common association
- Treatment: Tarsal (vertical lid) massage, steroid-antibiotic ointment, systemic doxycycline, tears substitutes, etc.
Preseptal Cellulitis
- Differential diagnosis with orbital cellulitis (Fig. 1.33.5)
- No proptosis
- Normal visual acuity, ocular movement and pupillary reactions
- Treatment: Systemic antibiotics, analgesics, hot compress and topical antibiotics.
External Hordeolum (Stye)
- Acute suppurative inflammation of the follicle of an eyelash
- Treatment: Hot compress, systemic analgesics, topical antibiotics, epilation of the offending eyelash.
Internal Hordeolum (Inflamed Chalazion)
- Unilateral acute infection of the meibomian gland
- Tender, diffuse, inflamed swelling within the tarsal plate
- The swelling is away from the lid margin (Fig. 1.35.1)
- Pus-point away from the eyelash root (Fig. 1.35.2)
- May be associated with preseptal cellulitis
- Treatment: Treatment of acute infection followed by incision and curettage of the chalazion later on.
Chalazion
- A chronic nonspecific inflammatory granuloma of the meibomian gland
- Painless nodular swelling of the eyelid (Fig. 1.36.1A)
- Tarsal conjunctiva underneath the nodule is velvety red or purple and slightly elevated (Fig. 1.36.1B)
- It may turn into ‘marginal chalazion’ (Fig. 1.36.5)
- Treatment: Steroid-antibiotic ointment for small chalazion and ‘incision and curettage’ for large one.
Ptosis: Drooping of Upper Lid
Ptosis
- Drooping of the upper eyelid
- Unilateral (Fig. 1.37.1) or bilateral (Fig. 1.37.2), and partial or complete
- Mild ptosis: 2 mm (Fig. 1.37.3)
- Moderate ptosis: 3 mm (Fig. 1.37.4)
Synkinetic Ptosis
- Marcus-Gunn jaw winking phenomenon: Retraction of the ptotic eyelid with ipsilateral jaw movement (Figs 1.38.1A and B)
- Misdirected third nerve: Retraction or ptosis of upper lid with various ocular movement (Figs 1.38.3A to C)
Pseudoptosis
Congenital Ptosis
- Treatment: Depends on severity, early intervention is required in severe ptosis to prevent amblyopia.
Acquired Ptosis
- Myogenic
- Myasthenia gravis: Tensilon (edrophonium) or Prostigmin test (neostigmine)—a positive test means improvement of ptosis with intravenous injection (Figs 1.41.4A and B)
- Senile ptosis
Senile (Aponeurotic) Ptosis
- Good levator function
- Absent or high upper lid crease
- Thinning of upper lid above the tarsal plate
- Deep upper supratarsal sulcus (Fig. 1.42.3)
- Treatment: Surgical correction in severe cases.
Lid Retraction
- Unilateral or bilateral retraction (Fig. 1.43.2) of the upper lid or sometimes both lids in the primary position
- Causes: Thyroid eye diseases (Fig. 1.43.3), neurogenic (Figs 1.43.4 and 1.43.5 ), surgical overcorrection (Fig. 1.43.6), phenylephrine eye drops (Fig. 1.43.7), hydrocephalus, etc.
- Treatment is directed towards the cause.
Other Lid Conditions
Chemosis or Lid Edema
- Diffuse edematous swelling of the eyelids
- May be associated with conjunctival chemosis (Fig. 1.44.1)
- Causes:
- Blepharitis (Fig. 1.44.2)
- Conjunctivitis (Fig. 1.44.3)
- Blepharoconjunctivitis (Fig. 1.44.4)
- Acute dacryocystitis (Fig. 1.44.5) and dacryoadenitis (S-shaped lid margin) (Fig. 1.44.6)
- Simple allergy (insect bite or urticaria) (Fig. 1.44.7)
- Postsurgical
- Inflammatory orbital diseases (Fig. 1.44.8) or orbital cellulitis (Fig. 1.44.9)
- Treatment is directed towards the cause.
Lagophthalmos
- Associated ectropion of lower eyelid
- Dryness of the lower part of the bulbar conjunctiva and cornea, and causing exposure keratitis (Fig. 1.45.1B)
- Treatment: Artificial tears, tarsorrhaphy and lid-load operation.
Blepharochalasis
- Younger individuals; may be unilateral or bilateral
- Treatment: Towards the allergic problems and surgical correction if required.
Dermatochalasis
- Older individual; usually bilateral
- Loss of skin elasticity of the lids
- Treatment: Cosmetic surgery is useful, but a recurrence is common.
Floppy Eyelid Syndrome
- Chronically red and irritable eye
- Typically obese and with sleep apnea syndrome
- Treatment: Artificial tears, antibiotic ointment at night, correct sleep posture and lid taping.
Symblepharon
- Adhesion of lid with the globe as a result of adhesion between bulbar and palpebral conjunctiva
- Causes: Chemical burn (Fig. 1.49.3), traumatic (Fig. 1.49.4), thermal burn (Fig. 1.49.5), ocular pemphigoid (Figs 1.49.6A and B), Stevens Johnson's syndrome (Figs 1.49.7A and B), trachoma, etc.
- May be anterior, posterior or total
- Treatment: Radical excision of scar tissue along with diseased conjunctiva and conjunctival autograft.Amniotic membrane transplantation may be helpful. Prevention by sweeping a glass rod, and symblepharon ring.
Essential Blepharospasm
- Spontaneous in older patient
- Other muscles of face may involve simultaneously
- Treatment: Botulinum toxin, alcohol injection
- Reflex blepharospasm may occur in superficial corneal problems (Fig. 1.50.3) and is abolished by topical anesthesia.
Ecchymosis of the Eyelids
- Painful edema with variable degree of ecchymosis
- Called ‘Panda bear’ or ‘Raccoon eyes’ sign (Fig. 1.51.2) when both lids are involved as after a head injury or severe whooping cough
- Treatment: No active treatment is required.
Phthiriasis Palpebrum
- Typically affects children and young female
- Treatment: Cotton pellet soaked in pilocarpine eye drop applied over the eyelashes for few minutes then the lice can be easily removed
- Simultaneous treatment for body louse infestation for both partners.
Benign Lid Conditions
Xanthelasma
- Raised, yellow plaques, most commonly found at the inner portion of the upper eyelids (Fig. 1.53.1) rarely in lower lid (Fig. 1.53.2)
- Often symmetrical and progress slowly
- Eventually, it spreads towards all four lids (Fig. 1.53.3) and may be in circular fashion (Fig. 1.53.4) and like a periocular mask (Fig. 1.53.5)
- May be associated with familial hypercholesterolemia
- Produce only a cosmetic defect
- Treatment: Cosmetic surgery may be tried.
Capillary Hemangioma (Strawberry Nevus)
- Develop soon after birth, then grows for 6 months to 1 year
- May involute spontaneously in some cases as an elevated solitary mass (Fig. 1.54.3)
- It blanches on pressure and may swell on crying
- Associated with similar skin lesions elsewhere
- Treatment: Hypertonic saline/corticosteroids injection and laser therapy.
Port-wine Stain (Nevus Flammeus)
- Congenital bilateral or unilateral lesion
- Sharply demarcated red to purple patch along the first and second divisions of the fifth nerve (Fig. 1.55.1)
- Lesion does not blanch on pressure
- Smaller lesion does not have any implication
- Larger lesion may be associated with Sturge-Weber syndrome (choroidal hemangioma with secondary glaucoma and hemangioma of leptomeninges) (Fig. 1.55.2)
- Treatment: Laser therapy and treatment of glaucoma if present.
Molluscum Contagiosum
- Unilateral or bilateral disease with single or multiple lesions
- In immunodeficiency conditions, it may be more severe and confluent, often simultaneously with other parts of body
- Small, pale, yellowish-white umbilicated lesions (Fig. 1.56.1)
- Associated with keratitis or follicular conjunctivitis (Fig. 1.56.4)
- Treatment: Investigations for immune defficiency states, chemical cautery in some cases.
Sebaceous Cyst
- Bilateral and multiple cysts are more common (Fig. 1.57.1)
- They vary in shape and size
- Solitary cyst is more common near the canthus (Fig. 1.57.2)
- Yellowish-white color and cyst is filled up with inspissated sebaceous secretion, often large in size (Figs 1.57.3 and 1.57.4)
- Treatment: Excision for cosmetic reason or if there are symptoms for mechanical reasons
Keratoacanthoma
- Rare, fast-growing benign tumor
- Treatment: Excision in case of large lesion.
Keratic Horn
- A rare benign condition
- Treatment: Excision of the mass if necessary.
Squamous Cell Papilloma (Viral Wart)
- Most common benign tumor of the lid
- Pedunculated or sessile lesion with a characteristic irregular raspberry like surface (Figs 1.60.1 and Figs 1.60.2)
- Treatment: Excision if necessary.
Basal Cell Papilloma (Seborrheic Keratosis)
- Common in middle-aged and elderly people
- Discrete, round, brownish or blackish lesion with variegated surface (Fig. 1.61.1)
- It may have papillomatous appearence (Fig. 1.61.2)
- Treatment: Excision if necssary in severe cases.
Oculodermal Melanocytosis (Nevus of Ota)
- Rare, congenital condition
- Associated conjunctival melanosis
- Hyperpigmentation of the iris (heterochromia).
Acquired Nevus
- Elevated or flat lesions with variable degree of brown to black pigmentation
- Intradermal type may be of large size to obscure the visual axis and lash may protrude through it (Figs 1.63.4A and B)
- Junctional and compound nevi have low malignant potential whereas intradermal nevus is benign
- Treatment: Surgical excision for cosmetic reason and when there is obstruction of visual axis.
Milia and Comedones
- It tends to occurs in crops and often bilateral
- No treatment is required
- Comedones: More common in acne vulgaris patients and consist of keratin and/or sebum filled multiple cysts. They may be black-headed or white headed depending upon presence of melanin (Figs 1.64.2 to 1.64.4)
- Treatment: For cosmetic reason.
Cyst of Moll
- Very common, painless, chronic, transparent cystic nodule just on the lid margin containing serous secretion (Figs 1.65.1A and B)
- Cyst of Zeis:
- Similar kind of cystic swelling on the external aspect of lid margin
- Eccrine hidrocystoma:
- Less common and similar to cyst of Moll.
Epidermal Inclusion Cyst
- Rare condition, due to trauma or after surgery
- Most commonly found in upper lid, may be mistaken as a chalazion
- Treatment: Removal of cyst from skin surface or marsupialization.
External Angular Dermoid
- Not so rare condition, present since early infancy
- Smooth, subcutaneous, firm, slow growing swelling most frequently located just below the lateral eyebrow (Figs 1.67.1A and B)
- May be associated with bony orbital defect
- It may occur at the inner canthus (Fig. 1.67.2) or near medial and anterior part of orbit (Fig. 1.67.3)
- Treatment: Excision of the mass, internal extension should be dissected carefully.
Malignant Lid Conditions
Basal Cell Carcinoma (Rodent Ulcer)
- Most common malignant tumor of the eyelid
- 36It may be sclerosing (Fig. 1.68.5), ulcerative, nodular (Fig. 1.68.6) or noduloulcerative type (Fig. 1.68.7)
- It does not metastasize to the lymph nodes
- Treatment: Surgical excision, radiotherapy.
Squamous Cell Carcinoma
- Second most common malignancy of the eyelid
- Appears as a nodule (Fig. 1.69.1) or an ulcerative lesion (Figs 1.69.2 and 1.69.3), or a papilloma (Figs 1.69.4 and 1.69.5)
- Sometimes the growth covers the whole eyeball (Fig. 1.69.6) or may cause ankyloblepharon (Fig. 1.69.7)
- Growth rate is faster than basal cell carcinoma
- It metastasizes into the regional lymph nodes
- Treatment: Radical surgery with reconstruction.
Meibomian Gland Carcinoma
- Appears as a discrete, yellow, firm nodule which is sometimes incorrectly diagnosed as ‘recurrent chalazion’ (Figs 1.70.1 and 1.70.2)
- Prognosis is always poor
- Treatment: Radical excision with reconstruction of the involved lid.
Carcinoma of Gland of Zeis
- Affects elderly patients
- May be associated with loss of local eyelashes
- Treatment: Radical excision with reconstruction of the lid.
Other Malignant Lid Conditions
Lentigo Malignum
- Affects elderly patients
- Preinvasive stage of malignant melanoma
Nodular Malignant Melanoma
- May show rapid growth with break down of epithelium
- Treatment: Radical excision or exenteration.
Miscellaneous Lid Conditions
Baggy Eyelids
- Usually bilateral, age related condition
- Initially, fat-pockets herniate into the medial aspect of the upper lid, then lower lids (Fig. 1.74.2)
- Treatment: Cosmetic surgical correction, but recurrence is common
Depigmentation of Periocular Skin
- Rare, unilateral condition
- Cause
- Sympathetic ophthalmia
- Drug induced; like topical sparfloxacin, trimethoprim drops, topical prostaglandin analogs, etc. (Figs 1.75.2 to 1.75.4)
- Treatment: Withdrawal of topical drops in selective cases.
Ankyloblepharon
- Adhesion between upper and lower eyelids
- May be partial or complete
- Causes
- Eyeball is usually disorganized
- Treatment is difficult and may be considered only in extreme situation.
Nodular Hemangiomas
- May be cavernous or capillary type
- Bright red in color
- Treatment: Excision of the mass and histopathological examination which confirms the diagnosis.
Tarsorrhaphy
- It is required to protect the integrity of the eyeball as in—impending corneal perforation, usually done for a temporary period—lateral (Fig. 1.78.1) or paramedian (Fig. 1.78.2)
- To prevent exposure keratitis, as in case of chronic lagophthalmos (Figs 1.78.3 and 1.78.4), after cerebellopontine angle (CPA) tumor operation—usually permanent (Fig. 1.78.5) or in case of severe dry eye (Figs 1.78.6A and B)
- In temporary cases—the tarsorrhaphy is released after satisfactory recovery.