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)?
• 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
     • Differential diagnosis includes:
        –Globe displaced forward (retrobulbar
          mass, thyroid disease)
     • Larger than normal axial length
     • Shallow orbit (rare)
– Neurogenic
   • Stimulation of retractors (Mueller's
   • Hyperthyroidism (Grave's disease) is
     most common cause
– Mechanical
   • Scarring
   • Active lid disease
– Physiological or nocturnal
• Signs and symptoms
  – During sleep lids not in apposition ->
    tear film evaporation - epithelial
  – 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
– 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
     • 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
– 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.
• Involuntary contraction of
• 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
• 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,
– Various neurological disorders
– Functional (hysterical)
• Treatment
  – Counseling since patient is quite self-
  – Counseling for depression since many
    activities of daily life and work are
  – 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
     – 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
  • 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
• 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
• 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
• 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,
  – 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;
 women, since increases risk of abortion
• Oral antihistamine
  – Benadryl
• Dirty water = tonic water with lime
• Drink prn
• 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
  – May traumatize the epithelium
     • corneal epithelial defects - infections,
     • damage and scarring of conj or cornea
  – Can cause vision loss due to corneal
• 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
     • 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
– If > 1/3 of lashes are turned in,
  surgery is warranted rather than
  •Argon laser photocoagulation
– Regular use of ocular lubricants
  Q1H to QID
– Prophylactic broad spectrum
  antibiotic coverage
•   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
• Lash loss
• Causes
  – Very common cause is staph
  – Trichotellomania (neurotic pulling of
• Evaluation
  – Look for any evidence of staph
  – 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
 – 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
     – may have foreign body
•   Look for more than a single
    ingrown cilia
•   Look for cause, lid trauma and
• Management
 – Cut lash near follicle
 – Remove distal portion of lash
 – Epilate remainder of lash
 – Prophylaxis with antibiotic

• 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
•   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
• Surgery - blepharoplasty remember VF
    necessary with and without lid held to
    obtain insurance funding
•   Referral to oculoplastic specialist or
    cosmetic surgeon
• 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
• 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
• 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

• Management
  – Reassure patient
  – Cosmetic surgery, if desired
  – Excision of orbital fat plus
    blepharoplasty for dermatochalaisis if
        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
•   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,
• 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
•   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,
• Management
  – Generally no treatment indicated,
  – Cosmetic treatment only if desired
  – 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
–v)      Cut base with scalpal or
–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
  –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
         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
• 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
  – Grows rapidly to 1-2 cm with pore
    expanded to display keratin filled
  – 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
  – 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
       Benign Cystic Lesion
• Choriostomas, not neoplasms
• Choriostoma arises during development
    from location of the lesion
•   Dermoids are congenital, developmental
•   Probably groups of surface ectodermal
    cells entrapped during development
    along lines of embryonic closure
• Appearance
  – Tend to be cystic in nature - "dermoid
  – Usually superior temporal in location;
    usually adherent to periosteum of
  – 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

• 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
     • On skin of lid, usually in
• 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 –
           a) Clean area with alcohol
           b) Apply topical anesthetic
                for ~ 1 minute
           c) Incise with 18 to 27 gauge
        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
•          b) Anesthetize surface for 1
•          c)    Lance with 18 to 27 gauge
•          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
•           b) Smooth surface
•           c)   Uniform light to medium
•           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
•          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
d) Diameter: < 6 mm
e) Elevation: fairly flat
f) Remain uniform in size,
    shape, and color
• 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
    – Only biopsy can definitely rule out
      melanoma. Any change demands a

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