Atlas of Clinical Ophthalmology Samar K Basak
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Diseases of the EyelidsCHAPTER 1

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
  • 2Senile (aponeurotic) 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
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Congenital Lid Conditions
 
Epicanthus
  • Most common congenital lid condition
  • Unilateral or bilateral
  • May give rise to pseudo-convergent squint
  • Semilunar vertical skin folds at the medial canthi running between two eyelids (Fig. 1.1.1)
  • Four types:
    • Epicanthus tarsalis: Fold is most prominent in the upper lid (Fig. 1.1.2)
    • Epicanthus palpebralis: Skin fold is equally distributed is the upper and lower eyelids (Fig. 1.1.3)
    • Epicanthus inversus: Fold is most prominent in the lower eyelid (Fig. 1.1.4)
    • Epicanthus supraciliaris: Skinfold covering the medical canthus, extends high up to the eyebrow.
  • Treatment: By plastic repair.
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Fig. 1.1.1: Epicanthus
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Fig. 1.1.2: Epicanthus tarsalis
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Fig. 1.1.3: Epicanthus palpebralis
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Fig. 1.1.4: Epicanthus inversus
 
Telecanthus
  • Increased distance between medial canthi (Figs 1.2.1 and 1.2.2)
  • 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
  • May also give rise to pseudo-convergent squint (Figs 1.2.4A and B)
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    Fig. 1.2.1: Telecanthus
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    Fig. 1.2.2: Telecanthus
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    Fig. 1.2.3: Hypertelorism
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    Fig. 1.2.4A: Telecanthus—pseudoconvergent squint
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    Fig. 1.2.4B: Telecathus—pseudoconvergent squint—correction after pinch test
 
Coloboma of the Eyelid
  • A notch or defect of the lid margin
  • Unilateral (Fig. 1.3.1) or bilateral (Fig. 1.3.2); upper or lower
  • Upper lid coloboma: At the junction of middle and inner thirds
  • May be associated with Goldenhar syndrome (Figs 1.3.3 and 1.3.4)
  • Lower lid coloboma: At middle and outer thirds junction (Fig. 1.3.5)
  • Associated with Treacher Collins syndrome
  • May be acquired in traumatic cases (Figs 1.3.6 and 1.3.7)
  • Treatment: Urgent plastic repair at a very early age to prevent exposure keratitis and corneal ulcer.
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Fig. 1.3.1: Coloboma left upper eyelid
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Fig. 1.3.2: Bilateral upper lid coloboma
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Fig. 1.3.3: Coloboma left upper lid, limbal dermoid and accessory auricle—Goldenhar syndrome
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Fig. 1.3.4: Coloboma left upper lid with corneal ulcer and cleft palate in Goldenhar syndrome
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Fig. 1.3.5: Congenital coloboma—right lower lid
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Fig. 1.3.6: Acquired coloboma of left upper lid
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Fig. 1.3.7: Coloboma lid with symblepharon following trauma
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Distichiasis
  • Hereditary and congenital condition
  • Extra posterior row of cilia, occasionally present in all four lids
  • Partial (Fig. 1.4.1) or complete (Fig. 1.4.2)
  • They occupy the position of meibomian gland orifices
  • Eyelashes may irritate cause to corneal epithelial defects
  • May be also seen in Stevens Johnson's syndrome—acquired distichiasis (Fig. 1.4.3)
  • Treatment: By cryotherapy or excision with grafting.
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Fig. 1.4.1: Distichiasis of both lids
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Fig. 1.4.2: Distichiasis of upper lid
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Fig. 1.4.3: Acquired distichiasis in Stevens Johnson syndrome
 
Blepharophimosis Syndrome
  • Autosomal dominant (Figs 1.5.1 and 1.5.2)
  • Syndrome consists of bilateral (Fig. 1.5.3)
    • Narrowing of vertical and horizontal palperbral apertures
    • Telecanthus
    • Inverse epicanthus folds
    • Lateral ectropion and moderate to severe ptosis
  • May be asymmetrical (Fig. 1.5.4) and without epicanthic folds (Fig. 1.5.5)
  • Treatment: Plastic reconstruction of lids, along with bilateral brow suspension for ptosis.
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Fig. 1.5.1: Blepharophimosis syndrome—father and son
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Fig. 1.5.2: Blepharophimosis syndrome—mother and daughter
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Fig. 1.5.3: Blepharophimosis syndrome
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Fig. 1.5.4: Blepharophimosis syndrome—asymmetrical
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Fig. 1.5.5: Blepharophimosis syndrome—without epicanthic folds
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Epiblepharon
  • Extra fold of skin in the lower lid with inturning of eyelashes (Fig. 1.6.1)
  • Nasal 1/3rd is most commonly affected
  • Treatment: Plastic repair if necessary to prevent recurrent infection.
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Fig. 1.6.1: Epiblepharon
 
Euryblepharon
Rare, congenital, bilateral, not so serious condition
  • Palpebral apertures are larger than normal (Fig. 1.6.2A) and may be with epicanthus (Fig. 1.6.2B)
  • Excessive watering may be a problem due to more exposure
  • Treatment: No treatment for most of the cases; lateral tarsorrhaphy for symptomatic cases.
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Fig. 1.6.2A: Euryblepharon
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Fig. 1.6.2B: Euryblepharon with epicanthus
 
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.
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Fig. 1.7.1: Trichiasis
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Fig. 1.7.2: Trichiasis—multiple lashes
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Fig. 1.7.3A: Trichiasis with PEE
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Fig. 1.7.3B: Trichiasis with PEE—after fluorescein stain
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Fig. 1.7.4: Trichiasis with corneal ulcer
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Fig. 1.7.5: Pseudotrichiasis in entropion
 
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.
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Fig. 1.8.1: Eyelash ptosis
 
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.
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Fig. 1.9.1: Eyelash in lower punctum
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Fig. 1.9.2: Eyelash in upper punctum
 
Eyelash in the Anterior Chamber
  • Rare occurrence after an open globe injury (Fig. 1.10.1)
  • May cause iridocyclitis or implantation cyst.
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Fig. 1.10.1: Eyelash in anterior chamber
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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.
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Fig. 1.11.1: Metaplastic eyelash
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Fig. 1.11.2: Metaplastic eyelash with healed ulcer
 
Poliosis
  • Whitening of eyelashes; partial or total, unilateral or bilateral
  • Causes:
  • Treatment: No specific treatment.
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Fig. 1.12.1: Poliosis—aging
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Fig. 1.12.2: Poliosis—albinism
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Fig. 1.12.3A: Poliosis—VKH syndrome
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Fig. 1.12.3B: Poliosis—VKH syndrome without anterior uveitis
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Fig. 1.12.4A: Poliosis—idiopathic unilateral
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Fig. 1.12.4B: Poliosis—idiopathic bilateral
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Madarosis
  • Partial or complete loss of eyelashes
  • Causes:
  • Treatment of the cause.
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Fig. 1.13.1: Madarosis—blepharitis
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Fig. 1.13.2: Madarosis—HZO
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Fig. 1.13.3: Madarosis—leprosy
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Fig. 1.13.4A: Madarosis—generalized alopecia
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Fig. 1.13.4B: Madarosis—generalized alopecia
 
Brittle Eyelash
  • Rare, bilateral condition
  • Eyelashes break with simple rubbing or with slightest manipulation (Figs 1.14.1 and 1.14.2)
  • Associated with congenital ectodermal dysplasia.
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Fig. 1.14.1: Brittle eyelash
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Fig. 1.14.2: Brittle eyelash
 
Trichomegaly
  • Excessively long and dense luxuriant eyelashes (Figs 1.15.1 and 1.15.2)
  • May be associated with newer antiglaucoma medication, like brimatoprost
  • No treatment is required.
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Fig. 1.15.1: Trichomegaly
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Fig. 1.15.2: Trichomegaly
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Matting of Eyelashes
  • Few eyelashes are stuck together
  • Mostly seen in upper eyelids
  • Causes:
  • Treatment of the cause.
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Fig. 1.16.1: Matting of lashes— conjunctivitis
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Fig. 1.16.2: Matting of lashes— blepharitis
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Fig. 1.16.3: Matting—bacterial corneal ulcer
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Fig. 1.16.4: Matting of eyelashes— panophthalmitis
 
Entropion
Inward turning of the eyelids towards the globe.
 
Congenital Entropion
  • Rare, may be associated with microphthalmos/anophthalmos
  • Medial 1/3rd is commonly involved (Figs 1.17.1 and 1.17.2)
  • May be associated with epiblepharon (Fig. 1.17.3)
  • Treatment: Excess skin may be removed with resection of tarsus.
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Fig. 1.17.1: Congenital entropion—left lower lid
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Fig. 1.17.2: Congenital entropion
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Fig. 1.17.3: Congenital entropion with epiblepharon
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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.
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Fig. 1.18.1: Senile entropion
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Fig. 1.18.2A: Senile entropion—left lower lid
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Fig. 1.18.2B: Senile entropion—both lower lids
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Fig. 1.18.3A: Senile entropion—left upper lid
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Fig. 1.18.3B: Senile entropion—left upper lid
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Fig. 1.18.4: Senile entropion—both lids—same eye
 
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.
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Fig. 1.19.1: Cicatricial entropion— trachoma
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Fig. 1.19.2: Cicatricial entropion—upper lid—chemical injury
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Fig. 1.19.3: Cicatricial entropion—both upper and right lower
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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.
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Fig. 1.20.1: Spastic entropion
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Fig. 1.20.2: Spastic entropion—right lower lid after corneal abrasion
 
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.
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Fig. 1.21.1: Senile ectropion
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Fig. 1.21.2: Senile ectropion—unilateral
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Fig. 1.21.3: Senile ectropion—bilateral
 
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)
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    Fig. 1.22.1: Cicatricial ectropion— following contact dermatitis
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    Fig. 1.22.2: Cicatricial ectropion both lower lids following acid burn
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    Fig. 1.22.3: Cicatricial ectropion of all four lids—scleroderma
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    Fig. 1.22.4: Cicatricial ectropion—chemical injury
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    Fig. 1.22.5: Cicatricial ectropion—thermal injury
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    Fig. 1.22.6: Cicatricial ectropion— trauma
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    Fig. 1.22.7: Cicatricial ectropion—all lids in ichthyosis vulgaris
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    Fig. 1.22.8: Cicatricial ectropion—upper lid following trauma
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    Fig. 1.22.9: Cicatricial ectropion—upper lid following acid burn
  • Depending upon the nature of the contracture, upper eyelids may also be affected (Figs 1.22.8 and 1.22.9)
  • Treatment:
    • Excision of the scar with a skin graft to the raw area (Figs 1.22.10A and B)
    • Lengthening of vertical shortening by Z-plasty.
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Fig. 1.22.10A: Cicatricial ectropion—before correction
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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.
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Fig. 1.23.1: Paralytic ectropion
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Fig. 1.23.2: Paralytic ectropion with corneal ulcer
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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.
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Fig. 1.24.1: Mechanical ectropion—plexiform neurofibroma lower lid
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Fig. 1.24.2: Mechanical ectropion at medial third
 
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.
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Fig. 1.25.1: Acute contact dermatitis—with neomycin
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Fig. 1.25.2: Acute contact dermatitis following injury with color in Holi festival
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Fig. 1.25.3: Bilateral acute contact dermatitis following hair dye
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Fig. 1.25.4: Bilateral severe contact dermatitis with atropine
 
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.
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Fig. 1.26.1: Chronic contact dermatitis
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Fig. 1.26.2: Chronic contact dermatitis
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Atopic Dermatitis of the Lid
  • Uncommon and more generalized with skin condition
  • Eyelids are thickened and fissured (Figs 1.27.1A and B)
  • Associated with atopic keratoconjunctivitis.
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Fig. 1.27.1A: Atopic dermatitis—RE
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Fig. 1.27.1B: Atopic dermatitis—LE
 
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.
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Fig. 1.28.1: Angular blepharoconjunctivitis
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Fig. 1.28.2: Angular blepharoconjunctivitis
 
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.
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Fig. 1.29.1: Lid lesions in primary herpes simplex virus (HSV)—bilateral
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Fig. 1.29.2: Primary herpes simplex of lids
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Fig. 1.29.3: Vesicular lid lesions with crust and dendritic keratitis
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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.
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Fig. 1.30.1: Herpes zoster ophthalmicus—fresh lesions
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Fig. 1.30.2: Herpes zoster ophthalmicus—healed lesions
 
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
    • White dandruff-like scales on the lid margins (Figs 1.31.1A and B)
    • Falling of eyelashes (madarosis)
    • Thickening of the lid margins (tylosis)
  • Ulcerative blepharitis:
    • Soreness of the lid margins (Fig. 1.31.2)
    • Loss of eyelashes
    • Yellow crust at the root of the eyelashes with matting (Figs 1.31.3 and 1.31.4)
    • Small ulcers at the base of the crust (Fig. 1.31.5)
    • Marginal keratitis is a common association
  • Traetment: Lid hygiene (lid scrub), vertical lid massage, antibiotic-steroid ointment, systemic tetracycline/doxycycline, treatment of dandruffs, etc.
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Fig. 1.31.1A: Squamous blepharitis—RE
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Fig. 1.31.1B: Squamous blepharitis—LE
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Fig. 1.31.2: Ulcerative blepharitis
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Fig. 1.31.3: Ulcerative blepharitis— madarosis
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Fig. 1.31.4: Ulcerative blepharitis with crust and madarosis
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Fig. 1.31.5: Ulcerative blepharitis—crust formation
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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)
  • Blocked meibomian ducts (Figs 1.32.3 and 1.32.4)
  • 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.
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Fig. 1.32.1: Meibomian seborrhea
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Fig. 1.32.2A: Meibomianitis—plugging of the meibomian duct opening
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Fig. 1.32.2B: Meibomianitis—vertical streak
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Fig. 1.32.3: Meibomianitis—blocked ducts
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Fig. 1.32.4: Meibomianitis—blocked ducts
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Fig. 1.32.5: Meibomianitis—toothpaste sign
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Fig. 1.32.6: Meibomianitis— blepharoconjunctivitis
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Fig. 1.32.7: Meibomianitis with marginal keratitis
 
Preseptal Cellulitis
  • Unilateral erythema and edema with tenderness involving the upper eyelid (Figs 1.33.1 and 1.33.2)
  • May lead to lid abscess (Fig. 1.33.3) and pyogenic granuloma formation (Figs 1.33.4A and B)
  • 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.
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Fig. 1.33.1: Preseptal cellulitis
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Fig. 1.33.2: Preseptal cellulitis
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Fig. 1.33.3: Lid abscess
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Fig. 1.33.4A: Lid abscess—pyogenic granuloma
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Fig. 1.33.4B: Lid abscess—pyogenic granuloma
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Fig. 1.33.5: Orbial cellulitis
 
External Hordeolum (Stye)
  • Acute suppurative inflammation of the follicle of an eyelash
  • A swollen area at the lid margin (Fig. 1.34.1)
  • A whitish, round, raised pus point at eyelash root (Fig. 1.34.2)
  • May be associated with preseptal cellulitis and conjunctival chemosis (Fig. 1.34.3)
  • Treatment: Hot compress, systemic analgesics, topical antibiotics, epilation of the offending eyelash.
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Fig. 1.34.1: External hordeolum—lower lid
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Fig. 1.34.2: External hordeolum—pus point at eyelash root
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Fig. 1.34.3: External hordeolum with preseptal cellulitis
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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.
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Fig. 1.35.1: Internal hordeolum—pus point at meibomian duct
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Fig. 1.35.2: Internal hordeolum—pus point away from eyelash
 
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)
  • May be single—medium (Fig. 1.36.2) or large/giant (Fig. 1.36.3) and multiple (Fig. 1.36.4)
  • It may turn into ‘marginal chalazion’ (Fig. 1.36.5)
  • Treatment: Steroid-antibiotic ointment for small chalazion and ‘incision and curettage’ for large one.
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Fig. 1.36.1A: Chalazion RLL—skin surface
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Fig. 1.36.1B: Chalazion RLL— conjunctival surface
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Fig. 1.36.2: Chalazion—medium—right lower lid
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Fig. 1.36.3: Giant chalazion
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Fig. 1.36.4: Multiple chalazion of all four lids
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Fig. 1.36.5: Marginal chalazion—lower lid
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Ptosis: Drooping of Upper Lid
 
Ptosis
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Fig. 1.37.1: Unilateral ptosis
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Fig. 1.37.2: Bilateral ptosis
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Fig. 1.37.3: Mild ptosis
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Fig. 1.37.4: Moderate ptosis
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Fig. 1.37.5: Severe ptosis
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Fig. 1.37.6: Severe complete ptosis
 
Synkinetic Ptosis
  • Marcus-Gunn jaw winking phenomenon: Retraction of the ptotic eyelid with ipsilateral jaw movement (Figs 1.38.1A and B)
  • Sometimes, more ptosis occurs with jaw movement—a reverse Marcus-Gunn phenomenon (Figs 1.38.2A B)
  • Misdirected third nerve: Retraction or ptosis of upper lid with various ocular movement (Figs 1.38.3A to C)
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Fig. 1.38.1A: Marcus Gunn phenomenon—ptosis
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Fig. 1.38.1B: Marcus Gunn phenomenon—ptosis corrected on jaw movement
21
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Fig. 1.38.2A: Reverse Marcus-Gunn phenomenon
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Fig. 1.38.2B: Reverse Marcus-Gunn phenomenon
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Fig. 1.38.3A: Ptosis—misdirected third nerve
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Fig. 1.38.3B: Ptosis—misdirected third nerve
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Fig. 1.38.3C: Ptosis—misdirected third nerve
 
Pseudoptosis
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Fig. 1.39.1: Pseudoptosis—anophthalmic socket
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Fig. 1.39.2: Pseudoptosis—phthisis bulbi
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Fig. 1.39.3: Pseudoptosis—left hypotropia
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Fig. 1.39.4A: Pseudoptosis—large conjunctival cyst
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Fig. 1.39.4B: Pseudoptosis—large conjunctival cyst
22
 
Congenital Ptosis
  • Unilateral or bilateral with varying severity—mild, moderate or severe (Figs 1.40.1 to 1.40.3)
  • May be simple or with other anomalies like “jaw-winking phenomenon” (see Figs 1.38.1A and B)
  • May be associated with blepharophimosis syndrome (see Fig. 1.5.2)
  • Treatment: Depends on severity, early intervention is required in severe ptosis to prevent amblyopia.
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Fig. 1.40.1: Congenital unilateral ptosis
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Fig. 1.40.2: Congenital bilateral ptosis
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Fig. 1.40.3: Congenital bilateral ptosis—asymmetrical
 
Acquired Ptosis
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Fig. 1.41.1: Acquired ptosis—total 3rd nerve palsy
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Fig. 1.41.2: Acquired ptosis—partial 3rd nerve palsy
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Fig. 1.41.3: Horner's syndrome—left side
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Fig. 1.41.4A: Myasthenia gravis (before Tensilon test)
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Fig. 1.41.4B: Myasthenia gravis (after Tensilon test)
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Fig. 1.41.5: Myogenic ptosis—ocular myopathy
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Fig. 1.41.6: Traumatic ptosis
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Fig. 1.41.7: Mechanical ptosis—upper lid mass
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Fig. 1.41.8: Mechanical ptosis—upper lid mass
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Fig. 1.41.9: Mechanical ptosis plexiform neurofibroma
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Fig. 1.41.10: Mechanical ptosis—hemangioma upper lid
 
Senile (Aponeurotic) Ptosis
  • Common unilateral or bilateral ptosis caused by defect in levator aponeurosis (Fig. 1.42.1)
  • Good levator function
  • Absent or high upper lid crease
  • May be with baggy eyelids (Fig. 1.42.2)
  • Thinning of upper lid above the tarsal plate
  • Deep upper supratarsal sulcus (Fig. 1.42.3)
  • Treatment: Surgical correction in severe cases.
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Fig. 1.42.1: Bilateral senile ptosis
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Fig. 1.42.2: Senile ptosis with baggy lids
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Fig. 1.42.3: Senile ptosis—deep supratarsal sulcus
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Lid Retraction
  • May be congenital (Fig. 1.43.1) or acquired
  • 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.
  • To be differentiated from pseudoretraction as seen in unilateral ptosis (Fig. 1.43.8)
  • Treatment is directed towards the cause.
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Fig. 1.43.1: Congenital lid retraction—LE
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Fig. 1.43.2: Congenital lid retraction— both eyes
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Fig. 1.43.3: Lid retraction—thyroid eye diseases
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Fig. 1.43.4: Lid retraction—neurogenic
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Fig. 1.43.5: Lid retraction with right hypotropia following brain abscess drainage—neurogenic
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Fig. 1.43.6: Lid retraction—post-surgical
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Fig. 1.43.7: Lid retraction—pharmacological in LE
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Fig. 1.43.8: Pseudoretraction in LE with ptosis in RE
25
 
Other Lid Conditions
 
Chemosis or Lid Edema
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Fig. 1.44.1: Blepharoconjunctival chemosis
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Fig. 1.44.2: Chemosis of lid— blepharitis
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Fig. 1.44.3: Chemosis of lid— conjunctivitis
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Fig. 1.44.4: Chemosis— blepharoconjunctivitis
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Fig. 1.44.5: Chemosis of lid—acute dacryocystitis
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Fig. 1.44.6: Chemosis of lids— dacryoadenitis
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Fig. 1.44.7: Chemosis of lid—insect bite—left eye
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Fig. 1.44.8: Chemosis of lid—inflammatory orbital disease
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Fig. 1.44.9: Chemosis of lids—orbital cellulitis
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Lagophthalmos
  • Inadequate closure of the upper eyelid (Fig. 1.45.1A)
  • Associated ectropion of lower eyelid
  • Dryness of the lower part of the bulbar conjunctiva and cornea, and causing exposure keratitis (Fig. 1.45.1B)
  • Rarely it may be bilateral with corneal ulceration (Fig. 1.45.2A and B)
  • Treatment: Artificial tears, tarsorrhaphy and lid-load operation.
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Fig. 1.45.1A: Lagophthalmos—incomplete closure
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Fig. 1.45.1B: Lagophthalmos—healed exposure keratitis
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Fig. 1.45.2A: Bilateral lagophthalmos
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Fig. 1.45.2B: Bilateral lagophthalmos—exposure keratitis—LE
 
Blepharochalasis
  • Younger individuals; may be unilateral or bilateral
  • Starts at puberty with an intermittent angioneurotic edema (Fig. 1.46.1) and redness of the lid
  • Skin hangs down over the upper eyelid (Figs 1.46.2 and 1.46.3)
  • Treatment: Towards the allergic problems and surgical correction if required.
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Fig. 1.46.1: Blepharochalasis— angioneurotic edema
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Fig. 1.46.2: Blepharochalasis— unilateral
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Fig. 1.46.3A: Blepharochalasis— bilateral
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Fig. 1.46.3B: Blepharochalasis—loose skin
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Dermatochalasis
  • Older individual; usually bilateral
  • Loss of skin elasticity of the lids
  • Prolapse of the fat, mainly nasally in the upper lid (Fig. 1.47.1)
  • Loose upper lid skin. Lower lid is also involved with bagginess (Figs 1.47.2A and B)
  • Treatment: Cosmetic surgery is useful, but a recurrence is common.
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Fig. 1.47.1: Dermatochalasis
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Fig. 1.47.2A: Dermatochalasis
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Fig. 1.47.2B: Dermatochalasis—lifting the loose skin
 
Floppy Eyelid Syndrome
  • Floppy, easily eversible upper eyelid with papillary conjunctivitis (Fig. 1.48.1)
  • 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.
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Fig. 1.48.1: Floppy eyelid syndrome
 
Symblepharon
  • Adhesion of lid with the globe as a result of adhesion between bulbar and palpebral conjunctiva
  • May be in the form of small band (Fig. 1.49.1) or frank broad adhesion (Fig. 1.49.2)
  • 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.
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Fig. 1.49.1: Symblepharon—chemical burn
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Fig. 1.49.2: Symblepharon—broad adhesion
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Fig. 1.49.3: Symblepharon—chemical burn
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Fig. 1.49.4: Symblepharon—traumatic
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Fig. 1.49.5: Symblepharon and cicatricial ectropion following thermal burn
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Fig. 1.49.6A: Symblepharon in ocular cicatricial pemphigoid
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Fig. 1.49.6B: Symblepharon in ocular cicatricial pemphigoid
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Fig. 1.49.7A: Symblepharon in Stevens-Johnson syndrome—RE
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Fig. 1.49.7B: Symblepharon in Stevens-Johnson syndrome—LE
 
Essential Blepharospasm
  • Spontaneous in older patient
  • Involuntary tonic, spasmodic, bilateral contraction of orbicularis oculi (Figs 1.50.1 and 1.50.2)
  • 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.
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Fig. 1.50.1: Essential blepharospasm
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Fig. 1.50.2: Essential blepharospasm
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Fig. 1.50.3: Reflex blepharospasm—left eye
29
 
Ecchymosis of the Eyelids
  • Occurs after a blunt trauma (Fig. 1.51.1)
  • 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.
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Fig. 1.51.1: Adult phthirus pubis
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Fig. 1.51.2: Bilateral ecchymosis of lids—Panda bear (Raccoon eyes) sign
 
Phthiriasis Palpebrum
  • Infestation of eyelashes with crab louse “Phthirus pubis(Fig. 1.52.1) and its ova, called nits
  • Typically affects children and young female
  • The lice are adherent to the skin and nits stuck to the eyelashes (Fig. 1.52.2)
  • 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.
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Fig. 1.52.1: Adult phthirus pubis
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Fig. 1.52.2: Phthiriasis palpebrum with nits
 
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.
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Fig. 1.53.1: Xanthelasma—upper lids
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Fig. 1.53.2: Xanthelasma—lower lids
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Fig. 1.53.3: Xanthelasma—all four lids
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Fig. 1.53.4: Xanthelasma—circular pattern
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Fig. 1.53.5: Xanthelasma—extensive periocular mask
 
Capillary Hemangioma (Strawberry Nevus)
  • Develop soon after birth, then grows for 6 months to 1 year
  • Irregular, raised, bright red lesion (Figs 1.54.1 and 1.54.2)
  • 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.
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Fig. 1.54.1: Capillary (strawberry) hemangioma
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Fig. 1.54.2: Capillary (strawberry) hemangioma
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Fig. 1.54.3: Capillary hemangioma— solitary
 
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.
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Fig. 1.55.1: Port-wine stain
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Fig. 1.55.2: Port-wine stain—Sturge-Weber syndrome
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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)
  • May be a presenting feature in AIDS (Fig. 1.56.2) and ulceration seen in severe cases (Fig. 1.56.3)
  • Associated with keratitis or follicular conjunctivitis (Fig. 1.56.4)
  • Treatment: Investigations for immune defficiency states, chemical cautery in some cases.
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Fig. 1.56.1: Molluscum contagiosum—solitary lesion
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Fig. 1.56.2: Molluscum contagiosum in crops in HIV positive patient
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Fig. 1.56.3: Giant molluscum contagiosum with ulceration in AIDS
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Fig. 1.56.4: Molluscum contagiosum—multiple with conjunctivitis
 
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
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Fig. 1.57.1: Sebaceous cyst—bilateral and multiple
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Fig. 1.57.2: Sebaceous cyst—solitary
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Fig. 1.57.3: Large sebaceous cyst
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Fig. 1.57.4: Large sebaceous cyst
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Keratoacanthoma
  • Rare, fast-growing benign tumor
  • Firm, pinkish nodule with rolled out edge and a keratin filled crater (Figs 1.58.1 and 1.58.2)
  • Treatment: Excision in case of large lesion.
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Fig. 1.58.1: Keratoacanthoma
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Fig. 1.58.2: Keratoacanthoma
 
Keratic Horn
  • A rare benign condition
  • Hyperkeratotic horn-like lesion which protrudes from skin surface (Figs 1.59.1 and 1.59.2)
  • Treatment: Excision of the mass if necessary.
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Fig. 1.59.1: Keratic horn—small
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Fig. 1.59.2: Keratic horn—large
 
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.
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Fig. 1.60.1: Squamous cell papilloma
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Fig. 1.60.2: Squamous cell papilloma
 
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.
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Fig. 1.61.1: Basal cell papilloma
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Fig. 1.61.2: Multiple basal cell papilloma
33
 
Oculodermal Melanocytosis (Nevus of Ota)
  • Rare, congenital condition
  • Bluish-gray discoloration of the skin affecting the 5th nerve (Fig. 1.62.1)
  • Associated conjunctival melanosis
  • Hyperpigmentation of the iris (heterochromia).
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Fig. 1.62.1: Oculodermal melanocytosis (nevus of Ota)
 
Acquired Nevus
  • Three types: Junctional (Fig. 1.63.1), compound (Fig. 1.63.2) and intradermal (Fig. 1.63.3)
  • 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)
  • May be of kissing type in any variety (Fig. 1.63.5)
  • 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.
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Fig. 1.63.1: Junctional nevus
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Fig. 1.63.2: Compound nevus
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Fig. 1.63.3: Intradermal nevus
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Fig. 1.63.4A: Intradermal nevus—obstructing the visual axis
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Fig. 1.63.4B: Intradermal nevus—obstructing the visual axis
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Fig. 1.63.5: Intradermal nevus—kissing type
 
Milia and Comedones
  • Small, multiple, round, superficial cysts (Fig. 1.64.1)
  • 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.
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Fig. 1.64.1: Milia
34
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Fig. 1.64.2: Sebaceous cyst with white head comedones
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Fig. 1.64.3: Black head comedones
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Fig. 1.64.4: Black head comedones
 
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
    • It contains oily secretion (Fig. 1.65.2)
  • Eccrine hidrocystoma:
    • Less common and similar to cyst of Moll.
    • It occurs near medial or lateral angle and does not involve the lid magin (Fig. 1.65.3)
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Fig. 1.65.1A: Cyst of Moll
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Fig. 1.65.1B: Cyst of Moll
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Fig. 1.65.2: Cyst of Zeis
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Fig. 1.65.3: Eccrine hidrocystoma
 
Epidermal Inclusion Cyst
  • Rare condition, due to trauma or after surgery
  • Solitary, firm slowly progressive subepithelial nodule (Fig. 1.66.1)
  • Most commonly found in upper lid, may be mistaken as a chalazion
  • Treatment: Removal of cyst from skin surface or marsupialization.
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Fig. 1.66.1: Epidermal inclusion cyst
35
 
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.
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Fig. 1.67.1A: External angular dermoid
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Fig. 1.67.1B: External angular dermoid
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Fig. 1.67.2: Angular dermoid—medial canthus
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Fig. 1.67.3: Angular dermoid—internal
 
Malignant Lid Conditions
 
Basal Cell Carcinoma (Rodent Ulcer)
  • Most common malignant tumor of the eyelid
  • The lower lid is more commonly involved, especially near the inner canthus (Fig. 1.68.1)
  • Initially, it starts as a small ulcer, then slowly progresses (Figs 1.68.2 and 1.68.3)
  • The edges are raised (rolled out edges) and indurated (Fig. 1.68.4)
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    Fig. 1.68.1: Basal cell carcinoma—noduloulcerative
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    Fig. 1.68.2: Basal cell carcinoma—ulcerative type
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    Fig. 1.68.3: Basal cell carcinoma—ulcerative type
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    Fig. 1.68.4: Basal cell carcinoma—rolled out edges
  • 36It may be sclerosing (Fig. 1.68.5), ulcerative, nodular (Fig. 1.68.6) or noduloulcerative type (Fig. 1.68.7)
  • Ulcer may erode the lid margin like a bridge (Figs 1.68.8A and B)
  • With time, it may destroy both the lids (Fig. 1.68.9)
  • It does not metastasize to the lymph nodes
  • Treatment: Surgical excision, radiotherapy.
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Fig. 1.68.5: Basal cell carcinoma— sclerosing
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Fig. 1.68.6: Basal cell carcinoma—nodular type
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Fig. 1.68.7: Basal cell carcinoma—noduloulcerative—extensive
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Fig. 1.68.8A: Basal cell carcinoma—bridge formation
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Fig. 1.68.8B: Basal cell carcinoma—bridge formation
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Fig. 1.68.9: Basal cell carcinoma—ulcerative with extensive extension
 
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)
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    Fig. 1.69.1: Squamous cell carcinoma—nodular type
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    Fig. 1.69.2: Squamous cell carcinoma—ulcerative type
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    Fig. 1.69.3: Squamous cell carcinoma—noduloulcerative
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    Fig. 1.69.4: Squamous cell carcinoma—papillomatous
    37
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    Fig. 1.69.5: Squamous cell carcinoma—papillomatous
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    Fig. 1.69.6: Squamous cell carcinoma—large nodular
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    Fig. 1.69.7: Squamous cell carcinoma—ulcerative type with ankyloblepharon
  • 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)
  • It may infiltrate along the lid margin (Fig. 1.70.3)
  • Widespread metastasis is common in large tumor (Figs 1.70.4 and 1.70.5)
  • Prognosis is always poor
  • Treatment: Radical excision with reconstruction of the involved lid.
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Fig. 1.70.1A: Meibomian gland carcinoma—lower lid
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Fig. 1.70.1B: Meibomian gland carcinoma—lower lid
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Fig. 1.70.1C: Sebaceous gland carcinoma—lower lid
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Fig. 1.70.2A: Meibomian gland carcinoma—mimicking chalazion upper lid
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Fig. 1.70.2B: Meibomian gland carcinoma—mimicking chalazion upper lid
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Fig. 1.70.3: Meibomian carcinoma—lower lid infiltrative type
38
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Fig. 1.70.4A: Meibomian gland carcinoma—large
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Fig. 1.70.4B: Meibomian gland carcinoma—large
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Fig. 1.70.5: Meibomian gland carcinoma—extensive orbital extension
 
Carcinoma of Gland of Zeis
  • Affects elderly patients
  • Discrete nodular slow growing tumor on the lid margin (Fig. 1.71.1)
  • May be associated with loss of local eyelashes
  • Treatment: Radical excision with reconstruction of the lid.
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Fig. 1.71.1: Carcinoma of gland of Zeis
 
Other Malignant Lid Conditions
 
Lentigo Malignum
  • Affects elderly patients
  • Preinvasive stage of malignant melanoma
  • Pigmented macular lesion may transform to nodular lesion (Fig. 1.72.1)
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    Fig. 1.72.1: Lentigo malignum
 
Nodular Malignant Melanoma
  • May arise de novo or from precancerous melanoma (Figs 1.73.1 and 1.73.2)
  • Large nodule with irregular pigmentation (Fig. 1.73.3)
  • May show rapid growth with break down of epithelium
  • Treatment: Radical excision or exenteration.
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Fig. 1.73.1: Precancerous melanoma
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Fig. 1.73.2: Precancerous melanoma
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Fig. 1.73.3: Malignant melanoma
39
 
Miscellaneous Lid Conditions
 
Baggy Eyelids
  • Usually bilateral, age related condition
  • Due to orbital fat herniation through the weakened orbital septum (Fig. 1.74.1)
  • 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
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Fig. 1.74.1: Baggy eyelids
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Fig. 1.74.2: Baggy eyelids with mechanical ptosis—right eye
 
Depigmentation of Periocular Skin
  • Rare, unilateral condition
  • Cause
    • VKH syndrome (Fig. 1.75.1)
    • 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.
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Fig. 1.75.1: Periocular depigmentation—VKH
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Fig. 1.75.2: Periocular depigmentation—drug induced
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Fig. 1.75.3: Periocular depigmentation following eye drop
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Fig. 1.75.4: Periocular depigmentation—following trimethoprim drop
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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.
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Fig. 1.76.1: Ankyloblepharon— congenital
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Fig. 1.76.2: Ankyloblepharon— acquired
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Fig. 1.76.3: Ankyloblepharon—severe acid burn
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Fig. 1.76.4: Ankyloblepharon following malten metal burn
 
Nodular Hemangiomas
  • Localized solitary nodular lesion just away from the lid margin (Figs 1.77.1 to 1.77.4)
  • May be cavernous or capillary type
  • Bright red in color
  • Treatment: Excision of the mass and histopathological examination which confirms the diagnosis.
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Fig. 1.77.1: Capillary hemangioma—isolated nodular
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Fig. 1.77.2: Capillary hemangioma—isolated nodular
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Fig. 1.77.3: Capillary hemangioma upper lid—solitary
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Fig. 1.77.4: Cavernous hemangioma—left upper lid
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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.
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Fig. 1.78.1: Temporary lateral tarsorrhaphy
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Fig. 1.78.2: Temporary median tarsorrhaphy
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Fig. 1.78.3: Permanent lateral tarsorrhaphy—in lagophthalmos
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Fig. 1.78.4: Permanent tarsorrhaphy in lagophthalmos
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Fig. 1.78.5: Permanent tarsorrhaphy in operated CPA tumor
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Fig. 1.78.6A: Permanent lateral tarsorrhaphy—RE (severe dry eye)
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Fig. 1.78.6B: Permanent lateral tarsorrhaphy—RE (severe dry eye)
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