Goal’s for Today • Lagophthalmos • Blepharochalaisis • Blepharospasm • Herniation of Orbital • Blepharoclonus Fat • Papilloma/Verruca • Myokymia • Cutaneous Horn/Tag • Trichiasis • Seborrheic Keratosis • Poliosis • Keratocanthoma • Madarosis • Dermoid • Ingrown Cilia • Sebaceous Gland • Dermatochalaisis Cysts • Sudoriferous Cysts • Nevus Dear Dr. Golden Eye: My friends say that I am super hyper and that I do not like things to pass me by. Recently, my new girlfriend took a picture of me when I was sleeping and posted the picture below. Now that I think about it, my eyes do feel a bit irritated. What’s going on? What are the common causes of my condition? Clue me on your evaluation of me? What can you do for me (treatment / management)? Signed: Peek-a-boo Lagophthalmos • Inability to completely close the lids; remain open 2-5mm • Significance – Usually results in exposure of the globe causing epithelial dessication; c/o dry, scratchy eye, possibly secondary infection and/or corneal ulcers. Sterile ulcers can result • Common causes/classification – Paralytic of orbicularis (CN VII palsy) - Bell's palsy – Orbital • Corneal apex more anterior than normal (keratoconus) • Differential diagnosis includes: –Globe displaced forward (retrobulbar mass, thyroid disease) • Larger than normal axial length • Shallow orbit (rare) – Neurogenic • Stimulation of retractors (Mueller's muscle) • Hyperthyroidism (Grave's disease) is most common cause – Mechanical • Scarring • Active lid disease – Physiological or nocturnal lagophthalmos • Signs and symptoms – During sleep lids not in apposition -> tear film evaporation - epithelial dessication – Symptoms of dry, scratchy, irritated eye upon awakening – Look for punctate epitheliopathy across inferior cornea - this may not be present or may be positioned elsewhere – Check for Bell's phenomenon (although this is probably unrelated to position of globe during sleep) – Check passive lid closure, may need to recline patient – Ask spouse if patient sleeps with eyes open – Check whether blink is complete. Check blink rate – Evaluate for anterior segment diseases, especially blepharitis • Management – Mild symptomatic lagophthalmos • Artificial tears PRN (Q1H to QID recommended) • Bland ophthalmic ointment HS if needed (Lacrilube) – Moderate • Artificial tears PRN, ophthalmic lubricants hs • Tape from cheek to brow/forehead while pulling lower lid up • Moisture chamber (Saran Wrap sealed with tape - Transpore surgical tape or Dermocel) – Use broad spectrum antibiotics (TABLES on pages 14 and 15) if significant corneal epithelial dessication or damage (to prevent secondary infection) – Surgery (tarsorrhaphy) – Must have regular follow up to rule out infection or serious drying; every 3 months or more frequently. Blepharospasm • Involuntary contraction of orbicularis • Generally bilateral and symmetric, though onset may be unilateral • Older individuals, females > males • Severity progresses over 6 months to 3 years • Does not occur during sleep • Fatigue and stress may increase intensity • Unknown cause, possibly due to chemical imbalance and/or misfiring of neurons of basal ganglia • Signs and Symptoms – Involuntary lid closure – Facial muscles (jaw, tongue, lower face, mouth) – May be so severe as to cause secondary tempero-mandibular joint syndrome (TMJ) – Various sensory "tricks" may suppress the severity of the contractions • Commonest is placing a finger at the lateral margin of the orbit • Others: coughing, yawning, talking, humming, or singing – Differential diagnosis very complicated • Ocular disease • Myokymia • Tardive dyskinesia caused by antipsychotic medications (Prolixin, Haldol) – Various neurological disorders – Functional (hysterical) • Treatment – Counseling since patient is quite self- conscious – Counseling for depression since many activities of daily life and work are interrupted – Medications interfering with nerve conduction are variably, but not consistently successful – Botulin A toxin injections • Interferes with neural transmission • Relief of symptoms averages 3 months • Typical side effects: – Ptosis – Subcutaneous hemorrhage at injection site – Dry eyes – Double vision – Exposure keratitis • Side effects resolve as toxin wears off • Onset of action after injection: 2-3 days • Full benefit: 5 days • Peak effect: 2-4 weeks • Duration of clinical benefit: 3-4 months, but can vary from few weeks to 6 months – Surgery • Myectomy and/or partial neurectomy • Myectomy removes squeezed muscles in upper lid, eyebrows, forehead, and base of nose • Neurectomy consists of resection and removal of small facial nerve branches innervating orbicularis – Referral to national support groups and organizations for individuals with blepharospasm Blepharoclonus • Exaggerated reflex blinking characterized by increased blink rate or length of lid closure time • Causes – Often no cause found – Commonly in children 5-10 years old with no apparent cause but parents are distressed - this is most common presentation • Evaluation – Workup is the same as for blepharospasm - rule out anterior segment disease, irritation, fb, etc.; complete eye exam • Management – Reassurance - (self limited disorder) – Consult with neurologist if desired – Numerous surgical procedures to interrupt CN VII have been tried Myokymia • Eyelid tic or twitch • Mild to moderate fasiculations of orbicularis • Signs and symptoms – Patient aware of annoying twitch • Unilateral • More often lower lid – Examiner generally sees nothing wrong • Multiple causes – Fatigue, lack of sleep – Stress, anxiety, tension – Anterior segment irritation – Light dazzle – Anemia, nutritional deficiency – Excessive use of tobacco or alcohol – Anticholinesterases used therapeutically (physostigmine, neostigmine, echothiophate) – Rare: M.S., myasthenia gravis, trigeminal neuralgia • Treatment – Reassurance – Rule out irritation, infection, inflammation – Consultation with family MD or psychologist to evaluate stress, tension, etc. – Pharmacological treatment • Topical antihistamine eyedrops (SEE TOPICAL ANTIHISTAMINE TABLE on page 21) QID x 1 week BID x 1 week Re-eval • Stubborn cases may warrant oral quinine, 200-300 mg, QD to TID; CONTRAINDICATED in pregnant women, since increases risk of abortion • Oral antihistamine – Benadryl • Dirty water = tonic water with lime • Drink prn Trichiasis • Lashes touch globe • Causes – Entropion – Growths on lid margin – Lid trauma – Scarring of conjunctiva (trachoma, Stevens-Johnsons syndrome) – Blepharitis is most common • Signs and symptoms – Discomfort or pain, foreign body sensation, injection – Chronic tearing due to foreign body sensation – May traumatize the epithelium • corneal epithelial defects - infections, ulcers • damage and scarring of conj or cornea – Can cause vision loss due to corneal scarring • Evaluation – Find the underlying cause of the trichiasis if possible - blepharitis is a common underlying cause – Careful slit lamp evaluation for both trichiasis and epith damage – Use fluoroscein - check for staining; epithelial damage • Management – Epilate in-turning lashes • Forceps or epilation tweezers • Soak tools in zephiran chloride solution (1:3OOO) with anti-rust tablets added • Can anesthetize lid • Firmly grasp lash at its base and pluck • Do not clip lashes – Lashes grow back •Children: 2-4 weeks •Adults: 4-8 weeks – Cauterization of follicles generally gives poor results – Electrolysis destroys lash follicles; successful but quite painful – If > 1/3 of lashes are turned in, surgery is warranted rather than electrolysis •Cryosurgery •Argon laser photocoagulation – Regular use of ocular lubricants Q1H to QID – Prophylactic broad spectrum antibiotic coverage Poliosis • Whitening of lashes • Usually due to staph blepharitis • Vitiligo is not due to staph • If both poliosis and vitiligo evaluate internal ocular health (c/o uveitis), if negative get dermatology consult Madarosis • Lash loss • Causes – Very common cause is staph blepharitis – Trichotellomania (neurotic pulling of lashes) • Evaluation – Look for any evidence of staph blepharitis – Inquire about history of infection…eg Chicken Pox – Rule out anterior segment disease of any kind (especially staph) • Management – Treat blepharitis if present – Could photodocument to monitor therapy – If caused by trichotellomania • seek psychological counseling • mascara use to minimize pulling Ingrown Cilia • Eyelash grown into the epidermis of the lid • Can be directed against globe (trichiasis) – may have foreign body sensation • Look for more than a single ingrown cilia • Look for cause, lid trauma and scarring • Management – Cut lash near follicle – Remove distal portion of lash – Epilate remainder of lash – Prophylaxis with antibiotic •* Dermatochalaisis • Redundancy of skin of the upper lid such that it drapes downward over lid margin. May look like ptosis - hold the redundant skin flap up • Middle aged to elderly patient; bilateral • May be familial tendency • May have herniation of orbital fat through the orbital septum causing puffy, "swollen“ appearance • Evaluation – Usually quite easy to notice and diagnose (just "baggy" eyelids) – Watch for true ptosis and for lid edema • Management – If no trichiasis and no field loss the problem is cosmetic only - reassure the patient – If trichiasis, treat it. (Consider surgery - cryo, electrolysis, etc.) • If field loss and desire to obtain cosmetic improvement, do a careful formal visual field evaluation with and without lids held to document functional vision defect (10˚ difference in VF loss). Insurance needs this in most cases to allow a claim for blepharoplasty • Surgery - blepharoplasty remember VF necessary with and without lid held to obtain insurance funding • Referral to oculoplastic specialist or cosmetic surgeon Blepharochalaisis • Younger to middle aged patient with baggy lids secondary to recurrent swelling of lids due to recurrent inflammation or edema • These recurrences of edema result in stretching of periorbital skin, loss of elasticity • Superior lid drapes over lid margin in many cases • May mimic ptosis. Be sure to rule out true ptosis. Note that a ptosis (not of neurogenic origin) can result from damage to the levator aponeurosis. May be some cases with familial tendency • Evaluation – Rule out active cause, i.e. lid mass, edema, inflammation – Rule out ptosis – Look for underlying cause - recurrent edema due to allergy, high BP, kidney disease • Management – Treat any active cause – Cool compressed during swelling may help to decrease – Steroids usually not helpful – Consult with physician may help to rule out allergic disease, cardiac or renal diseases if suspected – If cosmetically displeasing to patient - VF's and referral to plastic surgeon particularly oculoplastics specialist for blepharoplasty – May need medical consult to determine cause of recurrent edema, i.e., rule out cardiac, renal causes and angioneurotic edema Herniation of Orbital Fat • As orbital septum atrophies with age orbital fat herniates through small dehistences resulting in a soft mass usually located in upper lid medially • May get referrals to evaluate "tumor“ • Occurs in elderly (secondary to weakening of orbital septum involutional change) • Presents as localized (inner canthus) soft, spongy mass within lid, anterior to tarsal plate • Evaluation – Generally easily differentiated from lid or orbital growth (or lid edema) – Pressure to globe results in further herniation of orbital fat in front of the septum • Management – Reassure patient – Cosmetic surgery, if desired – Excision of orbital fat plus blepharoplasty for dermatochalaisis if present Papilloma Benign Epithelial Tumor • A common benign overgrowth of the epidermal portion of the skin of the eyelid (mainly the squamous epith) • Can have vascular core • Benign growths but varied appearance • Malignancies may look like these but are generally clinically differentiated on appearance • May be caused by virus (if so called verruca); more common in young • Can have numerous presentations; can be pigmented, variety of colors • Types – Non-viral • Usually in elderly – Viral • Verruca • Verruca is a form of papilloma –Verruca plana - flat top –Verruca vulgaris - angular, raised, broad stalk –Verruca digitala - narrow stalk, cauliflower-like • Signs/symptoms – Usually asymptomatic – Growth • Viral - fairly quick • Non-viral-slow – Color • Various colors • Surface usually rough (keratinized epithelium) but may be smooth, not eroded, ulcerated • Can be slowly growing, have vascular core, do not usually erode in center. Usually near lid margins at mucocutaneous junction • Vascular core • Evaluation – Rule out neoplastic growth, if possible, by looking for the following: • Look for rapid growth, color change • If on lid margin, no cilia at the location • Bleeding highly unlikely unless papilloma is traumatized • Vascularization - not present on surface of papilloma • Surface is often rough but not eroded or ulcerated. Papilloma can occasionally outgrow blood supply resulting in keratinization or necrosis -> erosion, ulceration • Management – Generally no treatment indicated, reassure – Cosmetic treatment only if desired (excision) – Can produce local lash misdirection and resultant trichiasis – Easily excised with scissors if pedunculated. If large or flat, refer for surgical excision – Refer to dermatologist or ophthalmologist if highly suspicious or take photos and follow up in one month – If new lesion, carefully evaluate for evidence of malignant characteristics; photograph and follow-up in one to three months – If old, follow up yearly – Excision techniques • Scissors/scalpal technique –i) Scissors or scalpal –ii) If base is small, clean area with alcohol wipe –iii) Anesthetize with topical proparacaine for > 1 minute –iv) Grasp top with forceps and lift –v) Cut base with scalpal or scissors –vi) Curved scissors are best –vii) Apply pressure for bleeding –viii) Cover with antibiotic ointment (TABLE page 14) –ix) Follow up in one day • Chemical technique –i) Clean area with alcohol wipe –ii) Topical anesthetic –iii) Surround papilloma with petroleum jelly –iv) Apply bichloroacetic acid to wooden tip of cotton swab - apply to lesion –v) Should turn lesion white immediately, later darkens, scab falls off in about one week Verruca (Wart) • A papilloma in which papilloma inclusion bodies have been seen in the epith cells. Possibly all papillomas are viral in origin - caused by the human papilloma (wart) virus • Viral papillomas tend to occur in children and young adults • Transmission by direct or indirect contact and autoinoculation • Management – Spontaneous regression is likely - reassure and wait – Treat any associated conjunctivitis or keratitis with goal to prevent secondary bacterial infection – Excisional biopsy can be performed but can be followed by the spontaneous appearance of multiple viral papilloma – Cryotherapy should accompany excision if viral etiology suspected Cutaneous horn or tag • Form of papilloma probably, although may be keratinized • Management – Easily excised (see management of papilloma) Seborrheic keratosis (not actinic keratosis) • Benign, epithelial growth common in middle aged to older (some in children) • Common on trunk and head • Can occur on eyebrow and lids • Sharply defined, slightly elevated, brown, plastered on lesions, brownish color - like a "brown plaque" on the skin • Important point looks like it is tacked on or stuck onto surface of skin. Little invasion into epidermis, none into dermis • Significance – Not pre-malignant (actinic keratosis is) • Management – Excision if desired – Easily removed for cosmetic reasons Keratoacanthoma • Pseudocarcinomatous hyperplasia - benign growth • Exposed usually hairy regions (such as head, face) of skin • Middle aged or older, usually 50-70 • Usually Caucasian • Grows rapidly x 2-6 weeks then involutes in a few months or year • Maximal size usually 1-2 cm • Appearance – Raised lesion initially - dome-shaped nodule with central core like molluscum contagiosum • Has central umbilicated apical region (composed of keratin) in a crater-like excavation • Has elevated rolled borders. Mimics sq. cell ca and molluscum contagiosum – Grows rapidly to 1-2 cm with pore expanded to display keratin filled crater – Growth stops, keratin plug is discharged leaving a pit. Mimics squamous cell carcinoma • Significance – Spontaneously regresses by involution but very often mistaken for squamous cell. Because of this appearance, usually excised during phase of involutional regression • Management – Reassure – Photograph if unsure and close follow-up – Excision if cosmetically desired • Excision should be strongly considered because: –Most patients prefer not to wait for regression because of the poor cosmesis of these growths –BCC and SCC can (rarely) occur along the edges –Excision and biopsy (all excised material should be biopsied) is recommended because of resemblance to SCC and BCC –BCC and SCC can (rarely) occur along the edges • Recurrence – Recurrence after excision is rare so if recurrence occurs, it was almost definitely BCC or SCC, not keratoacanthoma Dermoid Benign Cystic Lesion • Choriostomas, not neoplasms • Choriostoma arises during development from location of the lesion • Dermoids are congenital, developmental anomalies • Probably groups of surface ectodermal cells entrapped during development along lines of embryonic closure • Appearance – Tend to be cystic in nature - "dermoid cyst“ – Usually superior temporal in location; usually adherent to periosteum of orbit – Skin slides over surface easily • Evaluation – If dermoid is noted look for other congenital anomalies – Goldenhar's syndrome-dermoids on surface of globe often accompanied by lid coloboma and appendages on ears • Management – Can be removed if desired for cosmetic reasons Sebaceous gland cysts • Cysts in the glands of Zeiss (along lid margin) and/or in larger sebaceous glands (near eyebrows) • Very common • Many possible locations: scalp, face, ears, back, axillary regions • Types – Comedo (blackhead) • Keratin plaque in follicle – Milia (whitehead) • Small whitish, slight elevated, cyst of the pilosebaceous gland • On skin of lid, usually in groups • Appearance – Painless, benign, slow progression – Firm, rubbery, rounded, often moveable, yellowish or whitish color – Depth: • Superficial (epithelial) - tend to be smaller < 10 mm • Subcutaneous (epidermal) - tend to be large < 20 mm • Management – Reassure, benign but can be removed for cosmetic reasons – Excision of superficial cysts – technique a) Clean area with alcohol wipe b) Apply topical anesthetic for ~ 1 minute c) Incise with 18 to 27 gauge needle d) Express contents e) Apply pressure for bleeding f) Cover with Polysporin ung g) Follow-up in 1 day – Surgical excision for larger, deeper cysts Sudoriferous cysts • Elevated rounded lesions caused by blockage of the gland of Moll • Common • Appearance – May be < 2 mm in diameter – Localized at lid margin – Usually painless – Usually cause no problems – Cystic nature apparent in indirect/proximal illumination • Management – Reassurance, benign – Can be excised easily - technique • a) Clean area with alcohol wipe • b) Anesthetize surface for 1 minute • c) Lance with 18 to 27 gauge needle • d) Express material • e) Cover with Polysporin ung • f) Follow up in 1 day Nevus (freckle) Benign melanotic lesions • Overgrowth of melanin-containing cells in skin • Can change with time and remain benign, however change ALWAYS suggests malignancy • Flat, brownish, well defined borders • Types – Junctional nevi • a) FLAT or only slightly elevated • b) Smooth surface • c) Uniform light to medium brown • d) Symmetrical borders • e) Rarely become malignant – Compound nevi • a) Somewhat elevated, more so with age • b) Flesh colored or brown • c) Smooth or warty surface • d) Symmetric, uniformly round or oval – Dermal nevi • a) Raised, dome-shaped • b) Brown or black, lighter with age • c) Smooth or warty surface • d) May have telangiectatic vessels on surface • e) Exposed and prone to trauma from clothing • Guidelines for recognition of normal nevi • a) (A)symmetrical: symmetric, matching halves if "folded" together; round or oval • b) Borders: regular, usually quite distinct • c) Color: uniform within lesion, varies from very light brown to black d) Diameter: < 6 mm e) Elevation: fairly flat f) Remain uniform in size, shape, and color ABCDEF • Evaluation – Careful history to document onset and progression – Size it!!! – If any doubt photodocument and follow very closely or better yet dermatology consult • Management – Photograph carefully – Re-evaluate based on degree of suspicion – Only biopsy can definitely rule out melanoma. Any change demands a biopsy.
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