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How to treat
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inside
Eyelid
malpositions
Twitching/spasm
Inflammation/
infection
Eyelid tumours
Trauma

The author

DR ALAN A McNAB,
ophthalmologist; director,
Orbital Plastic and Lacrimal
Clinic, Royal Victorian Eye
and Ear Hospital, Melbourne,
Victoria.

EYELID
DISORDERS
Background
THE eyelids serve an important role
in protecting the eye and maintaining
the health and optical clarity of the
anterior surface of the eye.
The eyelids have:
Very thin skin.
Muscles that open (levator) and
close (orbicularis oculi) the eye.
A mucosal lining (conjunctiva).
Tarsal plates composed of large
numbers of sebaceous glands (meibomian glands), with eyelashes and
their follicles along the margins.
Lacrimal puncta and canaliculi, in
the medial ends of the lids, which
drain tears to the nose.

Disorders of the eyelids are

common and include malpositions
(ptosis, lid retraction, entropion and
ectropion), acute and chronic inflammatory diseases, and benign and
malignant tumours. Many are easily
recognised and managed in a general
practice setting, but others require
specialist assessment and investigation and sometimes surgical treatment.
The simple classification in table
1 serves as the basis for this article. It is not an exhaustive list but
covers the vast majority of eyelid
disorders.

Table 1: Classification of eyelid disorders

Malpositions
Ptosis and excess upper-eyelid skin
(drooping upper eyelids)
Eyelid retraction
Entropion (lid margin turns inwards)
Ectropion (lid margin turns outwards)
Lagophthalmos (inability to close
the eyelids)
Facial palsy
Other causes
Eyelid twitching or spasm
Myokymia
Hemifacial spasm

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Essential blepharospasm
Eyelid inflammation and infection
Acute focal or generalised
Sub-acute or chronic focal or
generalised
Eyelid tumours
Benign
Malignant
Eyelid trauma
Blunt trauma
Lacerations
Penetrating trauma

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How to treat eyelid disorders

Eyelid malpositions
Ptosis
PTOSIS, or blepharoptosis, is a relatively common problem with a
variety of causes (table 2). The
upper eyelid normally crosses the
cornea about 2mm below the
upper junction of the cornea and
sclera (the limbus). As the corneal
diameter is normally 11mm, the
distance from where the upper
eyelid crosses the cornea to the
inferior limbus is about 9mm.
Anything lower than this can be
defined as ptosis.
The upper-lid level is maintained
by resting tone in the levator
palpebrae superioris muscle (the
levator). Its main skeletal muscle
component is innervated by the
third cranial nerve but, a small
smooth muscle component
(Mllers muscle) is innervated by
sympathetic nerve fibres from the
craniocervical sympathetic trunk.
The levator muscle attaches to
the tarsal plate of the eyelid by a
broad tendon or aponeurosis,
and this tendon may stretch or
dis-insert, leading to ptosis. This
is the most common type of
ptosis seen in clinical practice and
occurs in older patients as an
involutional process (figure 1).
Disorders of muscle (some
myopathies and myasthenia
gravis) may present with ptosis,
and some eyelid tumours may
mechanically lead to ptosis
through their bulk.
Conditions causing third-nerve
palsies may present with ptosis
(and almost always accompanying
signs of third-nerve involvement).
Disruption of the sympathetic
nerves may also present with a
mild ptosis and other features of
sympathetic disruption (Horners
syndrome [figure 2]).

Table 2: Classification of
ptosis

Figure 1 A. An elderly patient with

right involutional (age-related)
ptosis. The upper eyelid crease is
higher on the right than the left.
B: In up-gaze there is good
movement of the right upper eyelid,
indicating a healthy levator muscle.
C: In down-gaze, the right lid drops
further.

Congenital
Levator dysgenesis
Syndromic ptosis
Acquired
Neurogenic third-nerve
lesions, sympathetic denervation
(Horners syndrome)
Myogenic myopathies
(eg, myotonic dystrophy,
mitochondrial cytopathies and
myasthenia gravis)
Aponeurotic or involutional
stretching or dis-insertion of the
levator aponeurosis
Mechanical due to bulky
eyelid tumours or swelling of the
eyelid

A
Figure 4: A child with moderate left
congenital ptosis. Although only a
small part of the pupil is obscured
by the upper eyelid, there is a subtle
left strabismus, with the left eye
looking slightly downwards (a clue
to this is that the corneal light reflex
is higher on the left, almost in line
with the eyelashes, and higher on
the pupil). The left eye is amblyopic
due to the strabismus.

C
Figure 2: An adult with a right
Horners syndrome. There is mild
ptosis, a smaller pupil and the iris
is paler, indicating that the lesion
has been present from birth.

surgical intervention may be

required.
Acquired ptosis

Recognising the presence of ptosis

demands establishing a cause. Some
of the causes carry greater significance for the overall health of the
patient, for example, myasthenia
gravis, or the patient with a Horners
syndrome due to a tumour affecting
the sympathetic pathway.

Entropion and trichiasis

Excess upper eyelid skin (dermatochalasis)
Older patients may develop dermatochalasis
(figure 6), which is commonly confused with
true ptosis. The two conditions may coexist. If
the fold of excess skin is lifted away from the eye
and eyelid margin, the true level of the eyelid
may be assessed.
If the skin fold rests over the eyelashes and
the excess skin affects the patients vision, surgery
to remove the excess skin is seen as a functional
procedure, reimbursable through Medicare and
health insurance funds. If it does not reach this
level, surgery for excess upper lid skin is classified as cosmetic.
Figure 6 A: An elderly man with upper eyelid
dermatochalasis (excess skin). The skin droops
over the upper eyelid margin and lashes,
laterally more than medially. B: After surgery to
excise the excess upper eyelid skin
(blepharoplasty), the eyelid margins are visible
and in a relatively normal position, and the
patient has an improved field of vision.

26

| Australian Doctor | 25 April 2008

Figure 5 A: A 60-year-old man with

left involutional ptosis. B: After
surgery to shorten and reattach the
levator aponeurosis to the tarsal
plate of the eyelid via an incision in
the upper-eyelid crease.

Congenital ptosis

Some babies are born with ptosis

that can be unilateral or bilateral.
Most of these children have a
maldevelopment or dysgenesis of
the levator muscle, usually with a
genetic basis. Some genetic syndromes may also have ptosis as
part of the constellation of features.
Babies born with ptosis should
be assessed by an ophthalmologist
very early in life because of the
risk of amblyopia, either because
of visual deprivation from the
eyelid covering some or all of the
pupil (figure 3), or more commonly because of associated
refractive errors in the eye or strabismus (figure 4).
Provided the vision is developing
normally, the ptosis can be treated
surgically at a later age, often at
about the time schooling starts. If
the vision is not developing normally
because of the ptosis itself, earlier

Figure 3: A young child with severe

right congenital ptosis. The eyelid
obscures the pupil and visual axis,
and the vision in the right eye is
severely reduced due to deprivation
amblyopia.

Turning in of the eyelid margin against the eye is called

entropion and has a variety of
causes (table 3). It may occur
as a congenital defect and is
very common in babies of eastAsian parents. In Asian babies
the condition usually affects
the lower eyelids, more medially than laterally (figure 7)
and tends to resolve gradually
over some years.
Despite eyelash contact with
the cornea, symptoms are relatively mild and include redness, watering and light sensitivity. If not resolving and
causing significant symptoms,
simple surgery is corrective.
Scarring of the conjunctival
lining of the eyelids can lead to
what is termed as cicatricial
entropion. Worldwide, one of
the leading causes of this and
the subsequent corneal ulceration, scarring and blindness is
trachoma. This is rare in
Australia but may be still seen
in Aboriginal communities and
immigrants from endemic
areas.
In urban Australians, cicatricial entropion is more commonly due to uncommon disorders
such as ocular pemphigoid
(an autoimmune mucocutaneous disorder), the sequelae of

Most patients with acquired

ptosis have a simple involutional
change as the cause, but other
causes should be excluded. A
simple history and examination
may give clues to the diagnosis
and lead to a more appropriate
referral.
Accompanying signs seen in
third-nerve palsies and Horners
syndrome and in muscle disorders
may lead to a neurological referral, whereas simple age-related
involutional ptosis can be readily
managed by an ophthalmologist
or oculoplastics sub-specialist.
Symptoms to ask for include:

Table 3: Common causes

of entropion
Congenital lower-eyelid
entropion (especially common
in Asian children)
Scarring of the
conjunctiva cicatricial
entropion (trachoma,
ocular pemphigoid,
Stevens-Johnson
syndrome)
Involutional (age-related)
lower-eyelid entropion in the
elderly

Stevens-Johnson syndrome or
chemical burns of the eye and
eyelids.
Involutional lower-eyelid
entropion occurs in older
patients and is due to laxity of
the eyelid and loss of attachment of a small structure, the
lower eyelid retractors, to the
tarsal plate of the lower eyelid
(figure 8a).
It is typically intermittent
and can be elicited by asking
the patient to forcibly close
their eyelids. If the lid is repositioned with a finger (figure
8b), it remains in position
often until the next blink or
forceful eyelid closure, but
may eventually become constant.
Eyelid surgery can be per-

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B
Onset congenital or acquired
ptosis.
Variability or fatiguability suggestive of myasthenia but commonly seen in all forms of ptosis.
Double vision suggestive of
third-nerve lesions or myopathies
and myasthenia.
Relevant examination findings
are the lid levels, eyelid movement,
eye movements and pupils.

Treatment of ptosis

The treatment of ptosis depends

on the cause, but in the vast
majority of cases, surgery can be
performed to improve the patients
eyelid level, either by shortening
the levator aponeurosis (figure 5)
and/or muscle, or, if the levator
muscle is too weak or non-functional, the lid can be suspended
from the brow and frontalis muscles using autogenous materials
such as strips of fascia lata or nonautogenous materials, performing
a so-called brow suspension procedure.

Figure 7: A young Asian boy with

congenital lower-eyelid
entropion. The medial eyelashes
point upwards, contacting the
cornea. The condition is
common, relatively
asymptomatic and often
resolves spontaneously over
some years.

Figure 8 A: An elderly patient

with right, lower-lid involutional
entropion. The eyelashes are
barely visible as the eyelid
margin has rotated inwards
against the eye. B: The eyelid is
easily repositioned by pulling it
downwards with a finger, but
after another blink or forced lid
closure, the lid usually turns in
again.

formed for all forms of eyelid

entropion, and relieves the
patient of the irritation, watering and redness of the eye as
well as the risk of the more
serious corneal sequelae of
ulceration and scarring.
Trichiasis (inward turning of
one or more eyelashes) occurs
as part of entropion but may
also occur when the lid margin
is in a normal position. The
lashes may start to grow in
abnormal directions, irritating
and abrading the cornea.
Patients with chronic blepharitis and local scars are most at
risk of developing areas of
trichiasis.
It is important to be aware
of the possibility of underlying
eyelid malignancy, especially

B
basal cell carcinoma, where
the tumour may lead to distortion of eyelash growth and
later loss of eyelashes.
Treatments available for
trichiasis include electrolysis,
cryotherapy and surgery
to remove small affected
segments of the eyelid, or
to remove more widespread
in-turned lashes and their
follicles.

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Eyelid retraction
If the upper lid sits at or above
the superior limbus, exposing
some sclera, the patient has
abnormal upper eyelid retraction.
The vast majority of such patients
will have an underlying thyroid
disorder (figure 9).
In thyrotoxicosis of any cause,
sympathetic overdrive leads to
some eyelid retraction, and in
Graves disease, the autoimmune
process may cause inflammation,
swelling and eventually fibrosis of
the levator muscle, causing lid
retraction that does not settle
when any thyrotoxicosis is controlled.
This type of lid retraction (part
of Graves eye disease) may be
unilateral or asymmetric (figure
10) and is amenable to surgery

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Figure 9: A woman with bilateral

symmetrical upper-eyelid retraction
secondary to Graves eye disease.
She also shows other features of the
disease, with proptosis (also called
exophthalmos), injection over the
medial and lateral globe and
fullness of the upper eyelids.

Many patients
with essential
blepharospasm are
initially labelled as
depressed, anxious
or emotionally
disturbed.

Figure 10 A: A young woman with

longstanding and stable left
upper-lid retraction due to Graves
eye disease. B: After surgery to
lengthen the levator muscle, the
lids are in a symmetrical position.

Eyelid twitching
or spasm
TWITCHING of the orbicularis
muscle of the eyelids is a relatively frequent symptom and is usually of no
significance, but there are some important conditions that may need further
investigation and treatment.
More common causes of eyelid
twitching or spasm are:
Myokymia (twitching of a small segment of orbicularis in one eyelid).
Hemifacial spasm.
Essential blepharospasm.

Myokymia
B
when the condition has stabilised.
In the interim the patient usually
requires additional lubrication

with drops and ointment to prevent the ocular surface drying out
and ulcerating.

Table 4: Common causes of

ectropion

Figure 13 A: A woman with complete

left facial palsy has lower-lid
ectropion due to loss of tone of the
orbicularis muscle (paralytic
ectropion) and also left brow droop
(frontalis muscle paralysis). B: On
attempted eyelid closure there is
significant lagophthalmos and also a
poor Bells phenomenon (the globe
does not rotate up under the upper
eyelid), putting the cornea at severe
risk of drying and ulceration.

Involutional (age-related)
ectropion
Cicatricial ectropion (scarring of
the eyelid and cheek skin, or
actinic skin shrinkage)
Paralytic ectropion (facial palsy)
Mechanical ectropion (large
eyelid tumours)

Figure 11: An older man with mild,

medial lower-lid ectropion. There is
a gap between the lid and the globe
and the lower lacrimal punctum sits
away from the globe, making tear
drainage less efficient and causing a
watery eye.

Figure 12 A: An elderly man with

bilateral lower-eyelid ectropion
(mild) and significant lower-eyelid
retraction (increased inferior scleral
show) due to chronic facial actinic
skin damage. B: After surgery to the
left lower eyelid to tighten the lid at
the lateral canthus and place a fullthickness skin graft below the lower
lashes, the lid is in a much
improved position.

Lagophthalmos
The term lagophthalmos (inability
to close the eye) derives from the
old Greek word for the hare
(lagos), which was believed to sleep
with its eyes open. Some normal
individuals may sleep with their
eyes partly open (physiological nocturnal lagophthalmos) and this is
rarely symptomatic.
An important cause of lagophthalmos is facial nerve palsy (figure
13). The eye closes poorly, putting
the corneal epithelium at risk of
drying, ulceration and infection. This
is the most critical aspect of the care
of a patient with facial palsy. The
risk of corneal complications
increases with increasing age, the

PM

Ectropion
Ectropion, or turning out of the
eyelid margin, is one of the most
common eyelid malpositions (table
4). It almost exclusively affects the
lower eyelid and increases in incidence with age. Age-related or involutional ectropion is very common
in the elderly (figure 11).
Other causes include scarring of
the skin of the lower eyelid and
cheek skin from any cause, especially
skin shrinkage resulting from lifelong sun exposure (figure 12). Loss
of tone in the orbicularis muscle of
the lower eyelid often occurs in facial
palsy (paralytic ectropion [figure
13]), and larger lower-eyelid tumours
can lead to a mechanical type of
ectropion.
Ectropion may initially be very
mild and not obvious (figure 11).
The patient complains of a watery
eye and the earliest sign may be that
the medial part of the eyelid, with
the lacrimal punctum on its margin,
sits away from the surface of the eye,
so that the meniscus of tears along
the lower lid margin is unable to
drain into the lacrimal punctum.
As ectropion becomes more severe
the conjunctival lining of the eyelid is
exposed to the air, becoming dry,
inflamed and thickened, often with
crusting and soreness. The symptoms
can be helped by applying ointments
such as simple paraffin lubricant or
antibiotic ointment, to the inner
aspect of the eyelid, but the main
form of treatment is surgical.
The eyelid may need to be tightened horizontally, and skin may need
to be added in the form of a fullthickness graft (figure 12) or a flap.

added presence of lower-eyelid paralytic ectropion, reduced or absent

corneal sensation, and a poor Bells
phenomenon (the upward turning of
the eye with eye closure).
Acute management of the eye in
a patient with facial palsy includes
the regular and frequent use of
lubricating ointment. One helpful
option is to place a piece of plastic
cling film over the whole eye and
tape its margins to create a moist
chamber. This can be done at night
after the insertion of ointment. If
tape is used to close the eye, it
needs to be applied very carefully
to avoid the tape itself abrading the
cornea of an incompletely closed
eye.
Surgery for the eyelids of patients
with facial palsy can be very helpful. A variety of procedures can be
performed and includes:
Correcting the lower-eyelid ectropion by tightening the eyelid.
Partial suturing of the eyelids
together in the outer corner (lateral tarsorrhaphy).
Suturing the eyelids together in the
most medial portion of the lids
(medial canthoplasty).
Lowering the upper eyelid (weakening the levator muscle, the antagonist muscle of the orbicularis
muscle).
Placing a gold weight in the tissues
of the upper eyelid (the weight
works by gravity).
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Myokymia of the eyelid is a common

symptom and consists of a small
group of muscle fibres of the orbicularis muscle of one eyelid, upper or
lower, twitching intermittently, and
often visibly, for periods of minutes,
hours or even days.
It increases with fatigue, stress and
caffeine intake and may provoke anxiety in the patient but rarely is of any
importance. The patient with simple
eyelid myokymia can be reassured and
no investigation is needed.

Hemifacial spasm
Hemifacial spasm is a disorder usually seen in middle-aged adults, in
which there are involuntary paroxysmal bursts of contraction of the muscles of one side of the face, with
normal facial muscle strength and tone
between contractions. It often begins
with contractions of the orbicularis
oculi muscle and later spreads to
involve muscles of the lower face.
It is due to pressure on the facial
nerve root as it exits the brainstem,
often by normal arteries in aberrant
positions, dilated vessels or, more
rarely, aneurysms or tumours. The
spasms may be exacerbated by stress,
fatigue or coughing.
Because of the small risk of
aneurysm or tumour, imaging should
be performed. Although neurosurgical decompression of the facial nerve
may be effective, another option is to
use regular injections of botulinum
toxin into the affected muscles.

Essential blepharospasm
Essential blepharospasm is not uncommon and is often diagnosed late, as the
early symptoms may be non-specific. It
most commonly affects adults over 50,
women more than men, and begins with
increased frequency of blinking of the
eyes, especially in response to bright light
or ocular irritation or stress.
It progresses to involuntary spasms of
eyelid closure that eventually may last
seconds or even minutes, making
normal activity impossible. Untreated,
many patients become functionally
blind and housebound.
There may be other dystonic movements in the lower face and neck
(Meiges syndrome). Many patients
have concurrent dry eye problems.
There are no other neurological problems and many patients are initially
labelled as depressed, anxious or emotionally disturbed.
The diagnosis is clinical and based
on history and observation of the
spasms. Treatment has been revolutionised by the use of regular injections of botulinum toxin into the
affected muscles. Rare patients resistant to botulinum toxin may benefit
from surgery to carefully excise parts
of the orbicularis muscle (orbicularis
myectomy).
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How to treat eyelid disorders

Eyelid inflammation and infection
EYELID inflammation and
infection is common and has a
variety of causes (table 5).

Table 5: Eyelid
inflammation and
infection
Acute focal stye
(infection of an eyelash
follicle), acute meibomitis
(infection of one or more
meibomian glands)
Acute general bacterial
(eyelid cellulitis), viral
(herpes zoster, herpes
simplex), allergic
Chronic focal chalazion
(meibomian gland cyst)
Chronic general
blepharitis (often
associated with
seborrhoeic dermatitis,
staphylococcal overgrowth
or diffuse meibomian
gland dysfunction), chronic
dermatitis (eczema)

Acute focal infection

A stye is a simple infection of

the eyelash follicle, beginning
as erythema and swelling,
with focal pain and tenderness, and progressing to a
small abscess. Plucking the
offending lash may drain the
abscess or it may be lanced
with a needle. Application of
hot compresses may help
relieve symptoms. Occasionally systemic antibiotics with
cover for staphylococci may
be needed. Topical antibiotics
do not help much.

Acute meibomitis
An acute infection or inflammation centred on one or
more meibomian glands
causes swelling, redness and
pain in the more posterior
layer of the eyelid. It may be
due to infection with skin
organisms, usually staphylococci, or the inflammation
may occur as part of a more
generalised sebaceous gland
disorder such as acne rosacea.
Heat and systemic antibiotics with cover for staphylococci are helpful, and for
acne-rosacea-associated acute
lid inflammation, longer
courses of tetracyclines may
be indicated. If an abscess
occurs, it should be drained
through the conjunctival surface after everting the eyelid.

Eyelid cellulitis
A more diffuse bacterial infection of the eyelids may complicate focal infections, injuries

or infected structures such as

the lacrimal sac (dacryocystitis), or may occur with Haemophilus influenzae bacteraemia. There is diffuse
redness, swelling and pain in
the eyelid, which may be
swollen shut.
Carefully examine the eye,
by lifting the lid if possible,
looking for signs of orbital
cellulitis
(conjunctival
swelling, proptosis of the
eye, limited eye movements,
reduced vision). If these are
present, the patient should
be hospitalised.
For cellulitis confined to
the eyelids, oral antibiotics
should be started but carefully monitor for spread of
the cellulitis or poor
response to treatment, when
admission to hospital for IV
antibiotics is required.

Chalazion
A chalazion, or meibomian cyst, is the most common lump
seen on an eyelid and represents areas of granulomatous
chronic inflammation. It may start as an acute swelling with
redness and tenderness, then settle into a more chronic painless lump centred on the posterior layer of an eyelid (figures
14 and 15). They may be multiple and bilateral. Over time
they may spontaneously discharge via the conjunctiva or skin,
or may slowly disappear, but can persist for many months.
When multiple or recurrent there is a likelihood the patient
has acne rosacea. Chalazia, if small, may be left to resolve
gradually, but if symptomatic and not settling, incision and
curettage effects a rapid cure.
After injecting local anaesthetic into the eyelid (figure 15b),
the eyelid is everted, a clamp placed over the lid, and a vertical incision made in the conjunctiva over the chalazion.
Gelatinous, grey material can be curetted out of the cavity.
The eye is padded for a few hours and topical antibiotics
instilled for several days.
Kits with disposable plastic instruments (clamp, curettes
and scalpel) for this purpose can be purchased inexpensively
(see Online resources, page 32).
If the patient has acne rosacea, longer-term use of tetracyclines is often helpful in treating or preventing the appearance
of recurrent or multiple chalazia.

Viral infections

weak topical steroid creams.

Herpes zoster and simplex

may involve the eyelids, with
characteristic vesicles, pustules
and crusts. With zoster of the
ophthalmic division of the
trigeminal nerve, nasal vesicles indicate nasociliary nerve
involvement and likely eye
involvement, so referral and
early antivirals are essential.

Acute allergic blepharitis

Patients may develop an acute
allergic response to eye drops
or ointments, make up or cosmetics, with erythema,
swelling and marked itching.
Treatment consists of withdrawal of the offending cause,
cold compresses, systemic
antihistamines and sometimes

Chronic blepharitis
Chronic blepharitis is very
common and presents with
redness and scaling of the
eyelid margins and excess skin
scales or scurf accumulating
at the base of the eyelashes. It
may wax and wane and is
often associated with grittiness
of the eyes on waking.
The lid margins become
colonised with staphylococci,
and their toxins contribute to
the lid inflammation and
punctate ulceration of the
cornea, which causes the grittiness and soreness of the eyes.
Meibomian glands may
become plugged or inflamed.
Patients often have associated

Figure 14 A: A patient with a

large inflammatory mass of
the upper eyelid of several
months duration. B: Everting
the upper lid shows the
lesion, which involves the
tarsal plate, is a large
chalazion. To incise and
curette this lesion, make a
vertical incision over the
centre of the lesion and
thoroughly curette the
contents.

Figure 15 A: A young patient

with a small, left upper-lid
chalazion. B: To anaesthetise,
inject 2mL local anaesthetic
using a 25-gauge needle.
Insert the needle from the
lateral side about 1cm above
the lash line, where the
injection is less painful. The
needle should be tangential to
the globe (the eyelid is quite
thin) and the local is injected
slowly then left for at least 10
minutes to make sure it is
working. The lid can then be
everted with a clamp and the
chalazion incised and curetted.

B
seborrhoeic dermatitis.
This is often a lifelong condition but can be managed to
reduce the symptoms and
complications. Simple cleansing of the eyelids removes skin
scales and reduces the numbers of staphylococci while
helping to keep meibomian
glands functional and not
obstructed or plugged. Using a
weak solution of baby shampoo in warm water, the lid
margins can be cleansed with
cotton-tipped applicators several times a week. There are
also proprietary preparations
available (LidCare, Steri-Lid).
For more severe cases, antibiotic ointment applied to the lid
margins at night, especially after
cleansing, will further reduce

the bacterial overgrowth. Oral

tetracycline given over 2-3
months will also often dramatically reduce symptoms and also
have a specific positive effect on
meibomian gland function.
Treatment of underlying seborrhoea may also be helpful.

Chronic eyelid dermatitis

(eczema)
Eczema commonly affects the
eyelids as part of generalised
eczema, or on the eyelids
alone, in susceptible atopic
individuals. The eyelid skin
shows the characteristic
changes of eczema. Treatment
is as for eczema elsewhere, but
any topical steroid creams
need to be used sparingly on
the very thin eyelid skin.

Eyelid tumours
TUMOURS of the eyelids are not
uncommon. The more common
and more important lesions are
listed in table 6.

Benign eyelid tumours

Seborrhoeic keratoses have the same
appearance as elsewhere on the body
(figure 16). On the eyelid margin,
lashes tend to grow through them
rather than being absent.
Squamous papillomas on the eyelids have a variable appearance. Multiple papillomas associated with HPV
are usually relatively small, elevated,
pinkish papillary lesions occurring
on the upper and lower eyelid skin
and sometimes in the line of the eyelashes, which grow through them.
They are sometimes called skin tags.
Patients with these lesions often have
similar multiple papillomas or skin
tags over their upper trunk, neck and
in the axillae.
Melanocytic naevi can occur on
the eyelid skin or on the eyelid
margin and have similar appearances to such lesions elsewhere (figures 17 and 18). If on the eyelid
margin, the lashes tend to grow
through them.
Cysts of Moll, or sweat gland
cysts (hidrocystadenomas), are relatively common eyelid lesions that
occur most frequently at the medial

28

| Australian Doctor | 25 April 2008

Table 6: Common and more

important eyelid tumours
Benign
Epidermal seborrhoeic
keratosis, squamous papilloma
Melanocytic compound
naevus, junctional naevus
Cystic cysts of Moll (sweat
gland cysts)
Xanthelasma
Malignant
Basal cell carcinoma
Squamous cell carcinoma in situ
(Bowens disease)
Invasive squamous cell carcinoma
Melanoma (in situ [lentigo
maligna], invasive)
Sebaceous cell carcinoma
(meibomian gland carcinoma)

Figure 16: A seborrhoeic keratosis

(seborrhoeic wart) of the lower lid.
As elsewhere, they are variably
pigmented. The lashes continue to
grow through the lesion if the lash
line is affected, in keeping with its
benign nature.

Figure 18: A longstanding, bulky,

upper-lid-margin compound naevus.
The lashes are still growing through
the lesion.

Figure 20: A typical small nodular

BCC of the lower-lid margin. It is
pearly, has telangiectatic vessels on
its surface, and there is associated
loss of the eyelashes, indicating
deeper destruction of the lash
follicles by the malignant process.

Figure 17: A relatively flat

melanocytic naevus of the lower lid
margin. It has been present for
many years and has changed only
minimally over time.

Figure 19: A medial, lower-lid

sweat-gland cyst
(hidrocystadenoma or cyst of Moll).
It is smooth and filled with clear
fluid.

Figure 21: A nodulo-ulcerative BCC

of the medial canthus, involving the
medial canthal skin and a small part
of the medial conjunctiva. Such a
lesion is a high-risk BCC for later
recurrence and deeper invasion.

(figure 20) and nodulo-ulcerative

types (figure 21) being most
common. Less obvious types such
as infiltrative (figure 22, page 30)
and sclerosing BCCs (figure 23,

page 30) may be more difficult to

diagnose. A useful clinical sign is
the loss of eyelashes (figure 22, page
30). Initially lashes may grow in

or lateral ends of the eyelids (figure

19). They may be multiple, are usually small (up to 3-4mm in diameter)
and filled with clear fluid. The main
differential diagnosis is cystic BCC.

Malignant eyelid tumours

Basal cell carcinoma

BCC is the most common malignant

eyelid tumour, representing 80-90%
of eyelid malignancies. It has the
same subtypes and appearances as
elsewhere in the skin, with nodular
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How to treat eyelid disorders

from page 28

aberrant directions before disappearing.

Some BCCs, particularly those
of the medial canthus, are at higher
Figure 22: A very extensive but not
very obvious infiltrative BCC
affecting the entire length of the
lower eyelid, and also a small part of
the lateral upper-eyelid margin,
where there is loss of eyelashes. It
had grown slowly over many years,
causing problems with ingrown
lashes, which gradually disappeared.

Figure 23: This older man has a

deeply invasive medial canthal
sclerosing BCC, recurrent after
incomplete excision some years
earlier. There is drawing in of the
tissues at the medial canthus,
including the eyebrow, and the
patient also had limited left eye
movements due to deep orbital
invasion. He required radical surgery
that included removal of the eye and
orbital contents (orbital exenteration).

risk of incomplete excision, later

recurrence and deeper invasion
(figures 21 [page 28] and 23).
Orbital invasion by BCC is one of
the most common indications for
orbital exenteration, and preventing this outcome is critical in the
management of periocular BCC.

Figure 26: A bulky, elevated, fairly

rapidly growing lesion of the medial,
right lower lid in an older patient.
There is hyperkeratosis of the
surface, which often turns white
(leucoplakia) in the moist
environment of the eye. This is an
invasive SCC.

Figure 24: An elderly man with an

area of red scaling skin of the
medial right lower lid. There is some
associated patchy lash loss. A
punch biopsy led to a diagnosis of
SCC in situ (Bowens disease).

Squamous cell carcinoma

SCC is the second most common

eyelid malignancy. When it occurs
as in-situ disease (Bowens disease), its appearance may mimic
chronic blepharitis, with red scaling skin associated with eyelash
loss (figures 24 and 25). The clue
to the diagnosis is that only one
eyelid is affected, and the patient
often has other sun-related skin
tumours.
Invasive SCC of the eyelids presents with bulkier, often ulcerated,
lesions, sometimes with a hyperkeratotic surface which, when moistened by tears, becomes whitened
(leucoplakia; figure 26).
SCC of the face, forehead or
scalp may spread via nerves (perineural spread), and such patients
may present with ocular symptoms.
Initially altered sensation and
dysaesthesia occurs in the distribution of the sensory nerve(s)
affected. As tumour spreads to the
cavernous sinus, oculomotor nerves
are affected and the patient develops double vision. If the facial
nerve is involved, gradually increas-

ing local anaesthetic under the skin

of the eyelid (figure 15b, page 28),
a small incisional biopsy or punch
biopsy can be obtained.
When diagnosed or suspected,
malignant eyelid lesions should be
referred on for usually surgical
excision and eyelid reconstruction,
which is most commonly performed by oculoplastics specialists.
Melanoma

Figure 25: A longstanding area of

red, scaling and greasy skin of the
upper-eyelid margin and skin,
misdiagnosed as blepharitis. The
patient history of other nonmelanoma skin cancers elsewhere
and the loss of eyelashes were
important clues to the diagnosis of
SCC in situ (Bowens disease).

invasion, but in the early stages

clinical symptoms and signs may
predate detectable MRI changes.
Sebaceous gland carcinoma

Sebaceous gland carcinoma, an

adenocarcinoma arising in the
sebaceous glands, occurs more
commonly in the eyelids than elsewhere in the body. These often
highly malignant lesions, while
rare, occur more commonly in
patients of Asian background.
They may mimic chalazia or masquerade as a chronic blepharitis.
Any recurrent chalazion should be
suspected of malignancy, and tissue
sent for pathological examination.
If eyelid lesions are suspected of
malignancy, obtaining biopsy specimens is relatively easy. After inject-

ing facial weakness occurs.

Contrast MRI is the most sensitive way of imaging such perineural

Melanoma of the eyelids is rare.

In-situ melanoma (lentigo maligna)
may involve eyelids and wider
areas of the face (figure 27), and
invasive melanoma can arise within
these lesions and spread to involve
the conjunctiva. Nodular and
superficial spreading melanomas
may rarely arise on the eyelids.
Figure 27: An area of lentigo
maligna (Hutchinsons melanotic
freckle) affecting the lower lateral
eyelid and lid margin. Such a lesion
may spread slowly over time to
affect more skin and also the
conjunctiva, and may develop areas
of invasive melanoma (lentigo
maligna melanoma).

Eyelid trauma
THE eyelids may be traumatised by blunt, sharp or penetrating trauma.
Blunt trauma to the eye region often results in significant bruising and
swelling. It is critical to open the lids and examine the eye to check
vision and exclude globe trauma.
Eyelid lacerations may be partial or full thickness. It is important to
establish the mechanism of injury to ascertain the risk of deeper penetrating trauma. Blunt injuries may cause tractional tearing of the eyelids;
the lid is weakest in the medial portion, where the lacrimal canaliculus
lies. Any medial tear or laceration should be suspected of lacrimal
trauma and referred appropriately (figure 28).
Full-thickness lacerations (figure 29) need to be repaired in layers,
taking care to align the lid margin to avoid notching or misalignment of
the lashes. All knots need to be tied away from the conjunctival surface.
In a severely traumatised eyelid, identifying normal structures may be
challenging, and specialist referral is advised.
Penetrating injuries by projectiles, sticks, etc, may penetrate deeply,
well beyond the eyelids and into the orbit or cranial cavity. Any penetrating orbital injury should be suspected of possible cranial penetration
and appropriate scans performed.

Figure 28 A: A young child with a dog-bite injury to the right eyelids. There is a small
puncture wound of the upper eyelid and an apparently small wound of the medial lower
eyelid. B: Under anaesthetic the lower lid wound is explored and found to involve the full
thickness of the lid and lower lacrimal canaliculus, which has a probe in it. All patients
with lid injuries should have a thorough eye assessment to exclude globe injuries.

Figure 29: A young man with

complex full-thickness
lacerations of the left upper
and lower eyelids due to an
assault with a broken glass.

Authors case studies

A chronically red and scaly
right upper eyelid
A 60-YEAR-old man presented with redness and scaling of his right upper eyelid of
more than two years duration
(figure 25). He had consulted
several other doctors and been
treated with several courses of
topical antibiotic ointment,
with some temporary improvement, but overall the
area of redness had gradually
enlarged.
One doctor diagnosed blepharitis and treated the patient
with a three-month course of
oral doxycycline, again with
only some mild temporary
improvement. There were no
other ocular problems and the
other eyelids were normal.
The patient had worked as a
roof tiler from the age of 18

30

and had been treated for several non-melanoma skin cancers on his face, neck, arms
and upper trunk over at least
15 years.
There was an area of erythema involving the central
part of the right upper
eyelid, the line of the eyelashes and the skin about
1cm above the eyelashes.
Some eyelashes in the
affected area were missing.
Because of the chronicity
of the lesion, the lack of
involvement of other eyelids,
and the history of other sunrelated skin lesions, it was
felt this was unlikely to be
chronic blepharitis. A punch
biopsy of the upper eyelid
skin was performed and
SCC in situ (Bowens disease) was diagnosed. The

| Australian Doctor | 25 April 2008

patient referred to an oculoplastics sub-specialist.

Because of the involvement
of the eyelid margin and lash
follicles, the in-situ disease
extended deeply into the
epithelium of the meibomian
glands, the lash follicles and
their associated glandular
structures, making cryotherapy or topical therapies much
less likely to eradicate the disease. The involved area of
eyelid was resected using
frozen-section control. A complex reconstructive procedure
was performed, leaving the
patient with a functional
upper lid and reasonable
cosmesis.
SCC in situ of the eyelid is
not that rare, and looks like
Bowens disease elsewhere.
The clues in this man were the

chronicity of the lesion, the

involvement of only one eyelid
(blepharitis usually involves all
eyelids) and the presence of
other non-melanoma skin
cancers. If there is any suspicion of a neoplasm, a biopsy
is a simple procedure. It is
better to have a low threshold for biopsy than to miss
such a lesion and allow it to
spread more widely, making
surgical excision and repair
more difficult.

A dog-bite injury of the

right eyelids
A seven-year old girl presented
several hours after being
attacked by a friends pet dog
while playing with him. There
were two small wounds, one
in the upper eyelid, well away
from the eyelid margin, and

www.australiandoctor.com.au

the other producing a small

abrasion or laceration of the
medial lower eyelid (figure
28a). The lower eyelid injury
involved the medial most portion of the eyelid and there
was a concern it may have
involved the lower lacrimal
canaliculus.
The patient was referred to
an ophthalmologist and the
apparently shallow laceration
of the lower lid was found to
be a full-thickness tear of the
lid, with the tear involving the
lower lacrimal canaliculus
(figure 28b). The canaliculus
was intubated with fine silicone tubing, and the canaliculus and eyelid repaired by
direct closure in layers. The
silicone stent was removed
after 12 weeks, with a good
cosmetic and functional result.

Dog-bite injuries to the eyelids are more usually tractional tearing injuries in which
the animals tooth presumably
gets behind the lid, the victim
pulls away and the eyelid tears
at its weakest point, which is
the medial portion of the lid
with the lacrimal canaliculus.
Other mechanisms such as a
finger caught behind the lid,
or a tractional injury to the
lid and cheek by a punch, may
cause similar tearing or avulsion injuries of the lid, with
tearing of the canaliculus.
The tear or laceration may
be inconspicuous, and even an
apparently shallow wound in
the medial eyelid should be
suspected to involve the
lacrimal canaliculus and
referred for assessment and
treatment.

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How to treat eyelid disorders

GPs contribution

Online resources

DR MARG TAIT
Picnic Point, NSW

Case study
AM, 64, gave a 12-month
history of palpitations,
lethargy, heat intolerance
and faecal urgency. On
examination, she had a
normal thyroid on palpation
and there were no thyroid
eye signs.
Pathology demonstrated a
T3 toxicosis. A test for thyroid antibodies was negative.
Thyroid nuclear scan
showed an autonomously
functioning nodule occupying the right lower lobe. A
benign follicular pattern was
shown on biopsy.
AM was given carbimazole and, after two months,
I-131. The T3 toxicosis did
not resolve and a second
dose of I-131 was given. She
developed persistent symp-

tomatic periorbital swelling

of the upper eyelids bilaterally in the absence of other
signs of thyroid eye disease.
TSH-receptor antibodies
were strongly positive, which
raised the prospect that this
was an atypical manifestation of autoimmune thyroid
disease. An empirical trial of
prednisone was started with
little benefit.
An ophthalmologist confirmed thyroid eye disease,
with oedematous upper and
lower eyelids and raised
intraocular pressures that
increased by 15% with
upward gaze. There was no
evidence of compressive
optic neuropathy.
AM was given hydrocortisone ointment 1% tds to the
lids, and advised to elevate
the bed head and use cold
compresses.
CT confirmed thyroid eye
disease. AM saw an ocular
plastic surgeon regarding
management. As there was
no optic neuropathy, a conservative approach was
taken and within six months
the inflammatory phase had
resolved without intervention.

AM presented with a
history of palpitations
and heat intolerance.

Questions for the author

What are the indications for
orbital radiotherapy/surgery
for thyroid eye disease?
The evidence base for any
benefit for low-dose orbital
radiotherapy (20cGy) in thyroid eye disease is slim.
There is good evidence from
several randomised controlled trials of minimal benefit (mild improvement in
ocular motility) or no effect
(on soft tissue swelling, lid
retraction or proptosis).
Despite this, some specialists
still recommend radiother-

How to Treat Quiz

2. Which TWO statements regarding eyelid

malpositions are correct?
a) Most cases of acquired ptosis are due to
simple involutional change, but other causes
should be excluded.
b) Babies with congenital ptosis should be
assessed by an ophthalmologist very early
in life
c) Lid retraction in Graves disease always
resolves with correction of thyrotoxicosis
d) Lid retraction due to Graves eye disease is
always bilateral.
3. Which TWO statements regarding
entropion and trichiasis are correct?
a) Congenital lower-lid entropion in Asian
babies always requires surgical correction
b) Involutional lower-eyelid entropion in older

How common is thyroid eye

disease?
Incidence data are not
available for our community
but are likely to be similar
in all communities. A study
in Minnesota showed an
incidence of 16.0 cases per
100,000 women a year, and
2.9 per 100,000 men a year,
so in a city of 5 million there
would be an expected new
case load of 800 women and
145 men a year. Most however, have mild disease and
only 5% have severe disease
with optic neuropathy.

Australian and New

Zealand Society of
Ophthalmic Plastic
Surgeons ANZSOPS,
a recognised craft group
within the Royal
Australian and New
Zealand College of
Ophthalmologists:
www.anzsops.org
The American Society of
Ophthalmic Plastic and
Reconstructive Surgeons
(contains patient
information):
www.asoprs.org
Eyeplastics a
commercial web site with
some patient information:
www.eyeplastics.com
Kits for curetting chalazia.
Austramedex, Scoresby,
Victoria. E-mail
austramedex@bigpond.com

General question for the

author
Is there any indication for
treatment of acute meibomitis with topical antibiotics?
Probably not. Acute meibomitis is a relatively deepseated infection, and topical
antibiotics are unlikely to
reach the centre of the infection. They may help reduce
bacterial flora on the eyelid
and ocular surface.

INSTRUCTIONS
Complete this quiz online and fill in the GP evaluation form to earn 2 CPD or PDP points. We no longer accept quizzes
by post or fax.
The mark required to obtain points is 80%. Please note that some questions have more than one correct
answer.

Eyelid disorders
25 April 2008
1. Which TWO statements regarding eyelid
malpositions are correct?
a) The upper-lid level is maintained by resting
tone in the levator muscle, which is
innervated by the seventh cranial nerve
b) Conditions causing sixth-nerve palsies may
present with ptosis
c) Disruption of sympathetic nerve fibres from
the craniocervical sympathetic trunk may
also present with a mild ptosis and other
features of sympathetic disruption
d) Double vision in patients with ptosis is
suggestive of third-nerve lesions or
myopathies and myasthenia gravis

apy in the early inflammatory phase of the disease in

more severe cases.
Surgery has a role in the
management of severe thyroid eye disease when there
is compressive optic neuropathy (ie, orbital decompression surgery, which is
very effective for optic neuropathy). It is also useful in
stable, burnt out disease,
when orbital decompression
is useful for reducing proptosis and exophthalmos.
Eyelid surgery can also be
used to treat lid retraction

and lid puffiness and has a

role in treating established
and stable strabismus in thyroid eye disease.

ONLINE ONLY
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people may be intermittent

c) Trachoma is one of the leading causes of
cicatricial entropion worldwide, but it is no
longer seen in Australia
d) In patients with chronic blepharitis and
trichiasis, it is important to be aware of the
possibility of an underlying eyelid
malignancy
4. Which TWO statements about ectropion
and lagophthalmos are correct?
a) Ectropion almost exclusively affects the
lower eyelid
b) Causes of ectropion include ocular
pemphigoid and the sequelae of StevensJohnson syndrome
c) The main form of treatment of ectropion is
surgical
d) Lagophthalmos due to facial nerve palsy is
rarely symptomatic and does not lead to
any significant complications
5. Which TWO statements about eyelid
twitching or spasm are correct?
a) Myokymia (twitching of a small segment of
orbicularis in one eyelid) increases with
caffeine intake
b) Hemifacial spasm often begins with
contractions of the orbicularis oculi muscle
and later spreads to involve muscles of the
lower face
c) The patient with hemifacial spasm can be
reassured, and no investigation is needed

d) Essential blepharospasm is more common

in men than in women
6. Trudy, 26, presents with an acute red,
diffusely swollen upper right eyelid. You are
concerned that she may have orbital
cellulitis. Which THREE symptoms and
signs would suggest this?
a) Reduced vision
b) Enophthalmos
c) Limited eye movements
d) Conjunctival swelling
7. Julie, 50, has a chronic history of redness
and scaling of the lid margins, and a gritty
feeling of both eyes on waking. Which TWO
statements about chronic blepharitis are
correct?
a) Chronic blepharitis is due to streptococcal
infection of the lid margins
b) Patients with chronic blepharitis often have
associated eczema elsewhere on the body
c) Lid margins can be cleaned using a weak
solution of baby shampoo in water
d) More severe cases may require antibiotic
ointment or oral tetracycline
8. Robert, 70, presents with a nodular basal
cell carcinoma (BCC), of the left lower
eyelid. Which TWO statements about BCC
of the eyelid are correct?
a) BCC is the second most common malignant
eyelid tumour

b) The most common types of BCC on the

eyelid are the infiltrating and sclerosing
types
c) Loss of eyelashes may be a useful clinical
sign to assist with diagnosis
d) BCCs at the medial canthus are at higher
risk of deeper invasion
9. Which TWO statements about
eyelid tumours are correct?
a) Unilateral involvement is an important clue
in distinguishing Bowens disease of the
eyelid from chronic blepharitis
b) Melanoma does not occur on the eyelids
c) Sebaceous gland carcinoma occurs more
commonly in Asian patients
d) Most suspected malignancies of the eyelid
can be managed by simple excisional
biopsy, without requiring specialist
referral
10. Which TWO statements about eyelid
trauma are correct?
a) Even if there is significant bruising and
swelling from blunt trauma, examination
must include opening the eyelids
b) The eyelid is weakest and most susceptible
to tractional tearing in the lateral portion
c) Cranial penetration must be suspected with
any penetrating orbital injury, and
appropriate scans performed
d) Full-thickness lacerations can be repaired in
a single layer

CPD QUIZ UPDATE

The RACGP now requires that a brief GP evaluation form be completed with every quiz to obtain category 2 CPD or PDP points for the 2008-10 triennium. You
can complete this online along with the quiz at www.australiandoctor.com.au. Because this is a requirement, we are no longer able to accept the quiz by fax.
However, we have included the quiz questions here for those who like to prepare the answers before completing the quiz online.

HOW TO TREAT Editor: Dr Martine Walker

Co-ordinator: Julian McAllan
Quiz: Dr Wendy Morgan

NEXT WEEK The next How to Treat discusses inguinal and scrotal problems in men, a common problem in general practice and often an incidental finding on routine physical examination and on imaging.
The authors are Dr Jyotsna Jayarajan, urology registrar, Austin Hospital, Heidelberg, Victoria; and Dr Shomik Sengupta, urology consultant, Austin Hospital, Heidelberg, Victoria.

32

| Australian Doctor | 25 April 2008

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