ocular disease lecture

7/28/2019 ocular disease lecture

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DISORDERS OF THEEYELIDS 2

Dr Russell J Watkins



Entropion

Types

Involutional

Cicatricial

Acute spastic



Involutional Entropion

Affects lower lid

Possible pathological mechanisms are:

Preseptal portion overrides pretarsal portionof orbicularis oculi

Horizontal lid laxity due to stretched canthaltendons, orbital fat atrophy

Weakened tarsus allowing flexure Vertical instability due to dehiscence of

retractors



Involutional Entropion

Treatment of involutional entropion

Taping

Botulinum toxin if unfit for surgery

Surgery



Cicatricial Entropion

Affects upper or lower lid

Scarring shortens posterior lamella

Causes include trachoma, radiation, chemicalinjury, topical rx, previous surgery, trauma, SJS& mucous membrane pemphigoid

Treatment is usually surgical



Acute Spastic Entropion

Orbicularis oculi spasm due to ocular irritation oressential blepharospasm

Usually associated with involutional entropion

Management is by removal of irritant, treatmentof associated involutional entropion, botulinumtoxin



Ectropion

Types of ectropion

Involutional

Cictatricial

Paralytic



Involutional Ectropion

Usually lower lid

Tarsal stretching ± orbicularis weakness

Treatment is by cicatrising cautery or surgery



Cicatricial Ectropion

Upper or lower lid

Causes include trauma [lacerations, burns,surgery], tumours, infections

Optometric management - refer

Pay attention to prevention of exposurekeratopathy

Surgical management aimed at release of scarring including skin grafts



Paralytic Ectropion

Lower lid ±lagophthalmos

Causes: myopathy; CN VII disorders

Optometric management – refer

Pay attention to prevention of exposurekeratopathy

Botulinum toxin induced ptosis; tarsorrhaphy

Various other surgical techniques including nervetransposition



Blepharospasm

Involuntary tonic, spasmodic, bilateral eyelidclosure

F>M

More common in older individuals (60+ yrs)

Causes - idiopathic, Parkinson’s disease,psychogenic, post-encephalitic, tetany, drugse.g. psychotropics

Treatment - botulinum toxin injections intoorbicularis oculi



Floppy Lid Syndrome

Generalised laxity of eyelid tissues

Can be unilateral or bilateral

Symptoms - ocular irritation, redness

Signs - SPK, easy distraction of lid from globe,easy upper lid eversion, lower lid ectropion,ptosis

Treatment - wedge excision, canthal tendonrepair



Orbicularis Myokymia

Involuntary contraction producing an annoyingtwitching sensation

Related to fatigue - a very common presentation

in optometric practice Rarely due to a sinister cause

Hemifacial spasm

Multiple sclerosis



Benign Eyelid Tumours

Xanthelasma

Fatty plaques (foam cells in epidermis),usually medial, usually bilateral

Associated with 1° hyperlipidaemic states,DM, hypothyroidism, primary biliary cirrhosis

Optometric management - refer to GP forexclusion of underlying cause

Surgical management - excision (60% recur),laser ablation, chemical cautery




Basal cell papilloma

Also known as seborrhoeic keratosis

Common

Sessile




Squamous cell papilloma

Common

Sessile or pedunculated

Histopathology - excessive convolutedepithelium with central fibrovascular core;may form keratin horn




Solar keratosis

Flat, multiple, scaly lesions

Occasionally papillomatous with keratin hornformation

NB: premalignant

Histopathology - epithelial dysplasia withkeratosis BUT no invasion




Keratoacanthoma

Rapidly enlarges (months), then regresses

Volcano shaped with keratin plug

Visually, often difficult to distinguish fromBCC, whereas:

Histopathology - difficult to differentiate fromSCC unless whole lesion examined; noinvasion, but basal inflammation




Haemangioma

Strawberry naevus: evident in neonatal period

Grows then usually regresses by 5yrs

May be cutaneous, orbital or mixed

Histopathology - capillary proliferation, someof which are uncanalised




Neurofibroma

Associated with neurofibromatosis

Histopathology - Schwann cell & fibroblastproliferation




Naevi

Congenital collections of naevus cells

Pigmented or non-pigmented

May become pigmented post-puberty




Naevi are classified according to location

Epidermal - slightly thickened epithelium withnaevus cells forming cysts

Junctional - activity at epidermal/dermal junction, occuring at puberty

Dermal - collections of naevus cells within thedermis; Can be associated with choroidal

melanomas Compound - malignant




Cyst of Moll

Retention cyst

Clear & fluid filled

Cyst of Zeis

Retention cyst

White cheesy (sebaceous) material



Miscellaneous BenignLumps

Milia

Cutaneous horn

Meibomian cyst

Naevus flammeus

Dermoid cyst



Malignant Eyelid Tumours

Basal cell carcinoma

Most common malignant carcinoma

Lower lid most common site

Do NOT metastasise but invade locally Types

• Noduloulcerative - well defined; Ulcerated & inflamed lesion

• Sclerosing (morphoea) - tends to be multifocal

Optometric management - refer for cryo, RT or surgery




Carcinoma in situ (Bowen’s disease)

5% of eyelid tumours

Upper lid most common site

Histopathology - dedifferentiation of epithelialcells; localised to epidermis; premalignant forSCC




Squamous cell carcinoma

Arise de novo from premalignant states suchas solar keratoses & xeroderma pigmentosum

Lymphatogenous spread May evoke inflammatory response

Histopathology can be from well differentiatedto anaplastic

Optometric management - refer (radicalexcision)




Malignant melanoma

Very rare (of the eyelid)

Can arise de novo or as a malignant

transformation of a junctional naevus Signs include itching, bleeding, pigmentary

changes, increase in size




Types of malignant melanoma

Lentigo maligna - superficial, premalignant(seen in the elderly)

Superficial spreading melanoma Nodular - occurs only on covered areas not on

face

Optometric management - refer

Prognosis depends on site, depth of invasion(poor if >1.5mm) & degree of inflammation




Meibomian gland carcinoma

Rare

Localised

May present as recurrent chalazion

Optometric management - refer (radicalexcision & RT)



Miscellaneous Malignant



Miscellaneous MalignantLumps

Metastatic deposit

Lymphomatous infiltrate

Sebaceous gland carcinoma

Kaposi sarcoma

ocular disease lecture

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