The most common lump found in the eyelid is a chalazion, but
the accurate diagnosis of a lid lump is important because the
lump may:
● necessitate a disfiguring operation if not treated early basal cell
carcinoma
● be life threatening
a deeply invading basal cell carcinoma
● be the cause of visual disturbance a chalazion pressing on the
cornea and causing astigmatism
● indicate systemic disease xanthelasmas in a patient with
hyperlipidaemia
● cause amblyopia if it obstructs vision in a young child.
Chalazion
A chalazion (meibomian cyst) is a granuloma of the lipidsecreting
meibomian glands that lie in the lid.
It is probably the
result of a blocked duct, with local reaction to the
accumulation of lipid.
The patient may initially complain of a lump in the lid that
is hard and inflamed.
This settles and the patient is left with a
discrete lump in the lid that may cause astigmatism and
consequent blurring of vision.
Clinically there is a hard lump in
the lid, which is clearly visible when the lid is everted.
Many chalazia settle on conservative treatment.
This
comprises warm compresses (with a towel soaked in warm
water) and the application of chloramphenicol ointment.
However if the chalazion is uncomfortable, excessively large,
persistent, or disturbs vision, it can be incised and curetted
under local anaesthesia from the inner conjunctival side of the
eyelid.
Recurrent chalazia may indicate an underlying problem
such as blepharitis, a skin disorder such as acne rosacea, or
even, though very rarely, a malignant tumour of the meibomian
glands. Stye
A stye and chalazion are often confused.
A stye is an infection
of a lash follicle, which causes a red, tender swelling at the lid
margin. Unlike a chalazion, a stye may have a “head” of pus at
the lid margin.
It should be treated with warm compresses to
help it to discharge, and chloramphenicol ointment should be
used.
Marginal cysts
Marginal cysts may develop from the lipid and sweat secreting
glands around the margins of the eyelids. They are dome shaped
with no inflammation.
The cysts of the sweat glands are filled
with clear fluid (cyst of Moll) and the cysts of the lipid secreting
glands are filled with yellowish contents (cyst of Zeiss).
No treatment is indicated for marginal cysts that cause no
problems. If they are a cosmetic blemish they can be removed
under local anaesthesia.
Papilloma
Papillomas are often pedunculated and multilobular. They are
common and may be caused by viruses.
They should be
removed if they are large and the diagnosis is uncertain, or if
they are disfiguring.
Xanthelasma
Xanthelasmas may be an incidental finding, or the patient may
complain of yellow plaques on the nasal sides of the eyelids;
these contain lipid.
Associated hyperlipidaemia must be
excluded and the lesions may be removed under local
anaesthesia if they are a cosmetic problem.
Basal cell carcinoma
Basal cell carcinoma (rodent ulcer) is the most common
malignant tumour of the eyelid.
It occurs mainly in the lower
lid, which is particularly exposed to sunlight.
The tumour does
not metastasise but may be life threatening if allowed to
infiltrate locally. Tumours in the medial canthal region may
infiltrate the orbit extensively if they are not detected and
dealt with.
If the tumour is large when the patient is referred,
an extensive and often disfiguring operation may be necessary.
The classical basal cell carcinoma has a pearly rounded
edge with a necrotic centre, but it may be difficult to
diagnose if it presents as a diffuse indurated lesion.
It is
particularly easy to miss the invasive form that occurs in
a skin crease, which may be invading deeply with few
cutaneous signs.
The patient should be referred urgently if there is any
suspicion of a basal cell carcinoma.
It usually is excised under
local anaesthesia, unless complicated plastic reconstructive
surgery is required. Radiotherapy may also be used as palliative
therapy in periorbital disease.
Patients with basal cell carcinomas
around the eye will often have other facial skin tumours.
Squamous cell carcinomas are rare in the periorbital region, but
are much more locally invasive and may also metastasise.
Inflammatory disease of the eyelid
Blepharitis
Blepharitis is a common condition but is often not diagnosed.
It is a chronic disease; the patient complains of persistently sore
eyes.
The symptoms may be intermittent and include a gritty
sensation and sore eyelids.
The patient may present with a
chalazion or stye, which are much more common in patients
with blepharitis, and these may be recurrent.
Physical signs
include inflamed lid margins, blocked meibomian gland
orifices, and crusts round the lid margins.
The conjunctiva may
be inflamed, and punctate staining of the cornea may be visible
on staining with fluorescein.
Associated skin diseases include
rosacea, eczema, and psoriasis.
The aims of treatment are to:
● keep the lids clean the crusts and coagulated lipid should be
gently cleaned with a cotton wool bud dipped in warm water.
This can be combined with baby shampoo to help remove
lipid
● treat infection antibiotic ointment should be smeared on the
lid margin to help kill the staphylococci in the lid that may
be aggravating the condition.
This may be done for several
months
● replace tears the tear film in patients with blepharitis is
abnormal, and artificial tears may provide considerable relief
of symptoms
● treat sebaceous gland dysfunction in severe cases, or those
associated with sebaceous gland dysfunction, such as rosacea,
oral tetracycline may be invaluable.
Indications for referral
are poor response to treatment and corneal disease.
Acute inflammation of the eyelid
It is important to achieve a diagnosis in a patient with an
acutely inflamed eyelid, as some conditions may be blinding
for example, orbital cellulitis.
Chalazion and stye
Routine treatment should be given for these conditions.
If infection is spreading, prescribe systemic antibiotics.
Spread of local infection
Infection may have spread from a local lesion such as a
“squeezed” comedo.
Again, if there is spread of infection,
systemic antibiotics are needed.
Acute dacryocystitis
The site of the inflammation is medial, over the lacrimal sac.
There may be a history of previous watering of the eye as a
result of a blocked lacrimal system that has since become
infected.
Treatment is with topical chloramphenicol and
systemic antibiotics until the infection resolves.
Recurrent
attacks of dacryocystitis or symptomatic watering of the eye are
indications for operation.
Allergy
There may be a history of contact with an allergen, including
animals, plants, chemicals, or cosmetics.
Itching is an indicator
of allergy.
Treatment may include weak topical steroid
ointment (hydrocortisone 1%) applied to the eyelid for a short
period.
The use of steroid ointments in the periorbital area
should be monitored very closely, because of the potentially
serious complications of even short term usage (glaucoma,
cataract, herpes simplex keratitis, and atrophy of the skin).
Herpes simplex
This may present as a vesicular rash on the skin of the eyelid.
There may be associated areas of vesicular eruption on the face.
An “experienced” patient may be able to discern the prodromal
tingling sensation.
Early application of aciclovir cream will
shorten the length and severity of the episode. Associated ocular
herpetic disease should be considered if the eye is red, and the
patient should then be referred immediately.
Herpes zoster ophthalmicus (shingles)
This presents as a vesicular rash over the distribution of the
ophthalmic division of the fifth cranial nerve.
There may be
associated pain and the patient usually feels unwell.
The eye is often affected, particularly if the side of the
nose is affected (which is innervated by a branch of the
nasociliary nerve that also innervates the eye).
Common
ocular problems include conjunctivitis, keratitis, and uveitis.
The eye is often shut because of oedema of the eyelid, but an
attempt should be made to inspect the globe.
If the eye is red
or if there is visual disturbance the patient should be referred
straight away.
The ocular complications of herpes zoster may
occur after the rash has resolved and even several months
after primary infection, so the eye should be examined at
each visit.
Serious ophthalmic complications include
glaucoma, cataract, uveitis, choroiditis, retinitis, and
oculomotor palsies.
Treatment includes application of a wetting cream to the
skin after crusting to prevent painful and disfiguring scars.
If the eye is affected, topical antibiotics may prevent secondary
infection, and aciclovir ointment is used. Oral antiviral therapy
(for example, aciclovir) given early in the course of the disease
may reduce the incidence of long term sequelae such as
postherpetic neuralgia.
Proptosis and enophthalmos
Globe protrusion (proptosis) and sunken globe
(enophthalmos) result in an asymmetrical position of the
globes, which can often be best appreciated by standing behind the patient and looking from above their head (comparing the
position of the eyes relative to the brows).
The degree of
proptosis or enophthalmos can be quantified by using an
exophthalmometer.
All patients with proptosis or
enophthalmos need full ophthalmic and systemic investigation.
There are many causes of proptosis and enophthalmos: some of
the more common and important diseases are listed below.
Causes of proptosis
Orbital cellulitis This is a potentially life threatening and
blinding condition and must not be missed.
Orbital cellulitis
usually results from the spread of infection from adjacent
paranasal sinuses.
It is particularly important in children, in
whom blindness can ensue within hours, because the orbital
walls are so thin.
The patient usually presents with unilateral
swollen eyelids that may or may not be red. Features to look
for include:
● the patient is systemically unwell and febrile
● there is tenderness over the sinuses
● there is proptosis, chemosis, reduced vision, and restriction
of eye movements.
The possibility of orbital cellulitis should always be kept in
mind, especially in children, and patients should be referred
immediately without any delay.
Orbital inflammatory disease Non-specific orbital
inflammatory disease can occur as an isolated finding or in
association with a number of systemic vasculitides, including
Wegener’s granulomatosis.
Deposits of lymphoma in the orbit need
confirmation by orbital biopsy and should alert the clinician to
the need for a full systemic work up for lymphoma elsewhere.
Lacrimal gland tumour These tumours in the upper outer
part of the orbit displace the globe inferiorly and medially.
Orbital invasion from paranasal sinus infection or tumour Look
for features of nasal or sinus disease in the history and examine
the nose, oropharynx, and lymph nodes.
Causes of enophthalmos
Microphthalmos If one eye is smaller than the other due to
developmental problems in embryogenesis, then the eye will
appear enophthalmic. Microphthalmic eyes often have other
problems including cataract and refractive errors.
Cicatrising metastatic breast carcinoma This rare form of
progressive enophthalmos is associated with very poor
prognosis for survival.
Malpositions of the eyelids and
eyelashes
Malpositions of the eyelids and eyelashes are common and give
rise to various symptoms, including irritation of the eye by lashes
rubbing on it (entropion and ingrowing eyelashes) and watering
of the eye caused by malposition of the punctum (ectropion).
The eyelids are folds of skin with fibrous plates in both the
upper and lower lids, and the circular muscle (orbicularis)
controls the closing of the eye.
Any change in the muscles or
supporting tissues may result in malposition of the lids.
Entropion
Entropion is common, particularly in elderly patients with some
spasm of the eyelids. The patient may present complaining of
irritation caused by eyelashes rubbing on the cornea.
This may be immediately apparent on examination but may be
intermittent, in which case the lid may be in the normal
position.
The clue is that the eyelashes of the lower lid are
pushed to the side by the regular inturning.
The entropion can
be brought on by asking the patient to close their eyes tightly,
and then open them.
The great danger of entropion is ulceration and scarring of
the cornea by the abrading eyelashes.
The cornea should be
examined by staining with fluorescein.
Temporary treatment of entropion consists of taping
down the lower lid and applying chloramphenicol ointment.
An operation under local anaesthesia is required to correct
the entropion permanently.
Scarring of the cornea,
associated with entropion of the upper eyelid resulting from
trachoma, is one of the most common causes of blindness
worldwide.
Trichiasis
Sometimes the lid may be in a normal position, but aberrant
eyelashes may grow inwards.
Trichiasis is more common in the
presence of diseases of the eyelid such as blepharitis or
trachoma.
The eyelashes can be seen on examination,
especially with magnification.
They can be pulled out, but they
frequently regrow.
The application of chloramphenicol ointment helps to
prevent corneal damage, and electrolysis of the hair roots
or cryotherapy may be necessary to stop the lashes
regrowing.
Ectropion
The initial complaint may be of a watery eye.
The tears
drain mainly via the lower punctum at the medial end of
the lower lid.
If the eyelid is not properly apposed to the eye,
tears cannot flow into the punctum and the result is a
watery eye.
The patient may also complain about the unsightly
appearance of the ectropion.
The most common reason for
ectropion is laxity of tissues of the lid as a result of ageing, but
it also occurs if the muscles are weak, as in the case of a facial
nerve palsy. Scarring of the skin of the eyelid may also pull the
lid margin down.
Ectropion can be rectified by an operation under local
anaesthesia. Use of a simple lubricating ointment before the
operation will help to protect the eye and prevent drying of the
exposed conjunctiva.
Ptosis
Ptosis or drooping of the eyelid may:
● indicate a life threatening
condition such as a third nerve palsy
secondary to aneurysm or a Horner’s syndrome secondary to
carcinoma of the lung
● indicate a disease that needs systemic treatment such as
myasthenia gravis
● cause irreversible amblyopia in a child as a result of the lid
obstructing vision. If there is any question of a ptosis
obstructing vision in a child, he or she should be referred
urgently.
● be easily treated by a simple operation as in senile ptosis.
The patient will usually complain of a drooping eyelid. The
upper eyelid is raised by the levator muscle, which is controlled
by the third nerve.
There is also Müller’s muscle, which is
controlled by the sympathetic nervous system.
These muscles
are attached to the fibrous plate in the eyelid and other lid
structures.
The ptosis can occur because of tissue defects, as
described below.
Lid tissues
With ageing, the tissues of the eyelid become lax and the
connections loosen, resulting in ptosis; this is common in the
elderly.
The eye movements and pupils should be normal.
A pseudoptosis may occur when the skin of the upper lid
sags and droops down over the lid margin.
Both these
conditions are amenable to relatively simple operations
under local anaesthesia.
Muscle tissue
It is important not to miss a general muscular disorder such as
myasthenia gravis or dystrophia myotonica in a patient who
presents with ptosis.
Any diplopia, worsening symptoms
throughout the day, and other muscular symptoms should lead
one to suspect myasthenia.
The patient’s facies and a “clinging”
handshake may give clues to the diagnosis of dystrophia
myotonica.
Nerve supply
A third nerve palsy may present as a ptosis.
This, together with
an abducted eye and dilated pupil, indicates the diagnosis.
The
patient should be referred urgently, as causes of third nerve
palsy include a compressive lesion of the third nerve such as an
aneurysm.
Diabetes should be excluded.
Horner’s syndrome resulting from damage to the sympathetic chain
The pupil will be small but reactive, and sweating over the
affected side of the face may be reduced.
The eye movements
should be normal.
Causes of Horner’s syndrome include
lesions of the brain stem and spinal cord, dissection of the
carotid artery and apical lung tumours, so the patient should
be referred.
Lid retraction
Lid retraction and associated lid lag are features of thyroid eye
disease.
These signs can occur in patients who are
hyperthyroid, euthyroid, or hypothyroid.
Blepharospasm
In essential blepharospasm there is episodic bilateral
involuntary spasm of the orbicularis oculi muscles, which leads
to unwanted forced closure of both eyes.
Treatment options for
this disabling condition include muscle relaxants, botulinum
toxin injection, and surgical stripping of some of the
orbicularis fibres.
Lacrimal system
Watering eye
Tears are produced by the lacrimal glands that lie in the
upper lateral aspect of the orbits.
They flow down across the
eye along the lid margins and are spread across the eye by
blinking.
They then flow through the upper and lower puncta
to the lacrimal sac and down the nasolacrimal duct into the
nose.
Although rare, it is important to remember that children
with congenital glaucoma may present with watery eyes.
A watering eye may occur for several reasons.
Excessive production of tears
This is rare, but can occur paradoxically in a patient with “dry
eyes.”
Basal secretion of tears is inadequate and this results in
drying of the eye. This gives rise to a reactive secretion of tears
that causes epiphora.
The patient may have a history of
intermittent discomfort followed by watering of the eye.
Punctal malposition secondary to lid malposition
The punctum must be well apposed to the eye to drain tears.
Even mild ectropion can result in pooling of tears and
overflow.
Careful examination of the lid will usually show any
malposition, which may be remedied by performing a minor
operation.
Punctal stenosis
The punctum may close up and this will result in watering.
If this is the case, the punctum cannot be seen easily on
examination with a magnifying loupe.
It can be surgically
dilated or opened by a minor operation under local
anaesthesia.
Blockage of the lacrimal sac or nasolacrimal duct
If the nasolacrimal duct is blocked and cannot be freed by
syringing, an operation may be required.
A common operation
to bypass the obstruction is a dacryocystorhinostomy (DCR), in
which a hole is made into the nose from the lacrimal sac.
Sometimes plastic tubes are left in for several months to create
a fistula.
This major operation usually is performed under
general anaesthesia.
A recent addition to the range of procedures for the
surgical treatment of watery eyes is endoscopic DCR, in which
the operation is performed through the nasal cavity.
Good
results are reported for this procedure, although external DCR
still has the higher success rate.
In children the lacrimal drainage system may not be
patent, particularly in the first few years of life.
The child
will present with a watering eye or sometimes with recurrent
conjunctivitis.
Treatment is usually with chloramphenicol
eye drops for episodes of conjunctivitis, and the parents
should massage the lacrimal sac daily to encourage flow.
Most
cases in childhood will resolve spontaneously.
If the
watering persists, the child may have to have the sac and duct
syringed and probed under general anaesthesia.
This procedure is generally best done between 12 and 24 months
of age.
If the blockage persists, a dacryocystorhinostomy may
be performed when the child is older, but this is not often
necessary.
Dry eye
Dry eye is common in the elderly, in whom tear secretion is
reduced.
The patient usually presents complaining of a chronic
gritty sensation in the eye, which is not particularly red.
Sjögren’s syndrome is an autoimmune disease, with features of
dry eyes and dry mouth, which can occur with certain
connective tissue diseases such as rheumatoid arthritis.
Drugs
such as diuretics and agents with anticholinergic action (for
example, certain drugs used in the treatment of depression,
Parkinson’s disease, and bladder instability) may also
exacerbate the symptoms of dry eye.
Staining of the cornea may be apparent with fluorescein
and rose bengal eye drops.
(If rose bengal eye drops are used
the eyes must be washed out very thoroughly, as these drops are
a potent irritant.)
A Schirmer’s test can be carried out.
A strip
of filter paper is folded into the fornix and the advancing edge
of tears is measured.
Treatment includes:
● artificial tear drops, which may be used as frequently as
necessary (it may be necessary to use preservative free
artificial tears in severe cases)
● simple ointment, which helps to give prolonged lubrication,
particularly at night when tear secretion is minimal
● acetylcysteine (mucolytic) eye drops, which are useful if there is
clumping of mucus on the eye (filamentary keratitis).
However many patients find that the drops sting
● treatment of any associated blepharitis
● temporary collagen or silicone lacrimal plugs may be inserted into
the upper or lower puncta, or both, to assess the effect of
tear conservation
● permanent punctal occlusion can be produced by punctal
cautery in refractory cases, often with dramatic effect.
