Ординатура / Офтальмология / Английские материалы / Clinical Ophthalmology A Systematic Approach 7th Edition_Kanski, Bowling_2011

kanski 7th

Chapter 1 – Eyelids

INTRODUCTION 2

Anatomy 2

Terminology 3 General considerations 3

BENIGN NODULES AND CYSTS 4 Chalazion 4

Other cysts 4

BENIGN EPIDERMAL TUMOURS 4 Squamous cell papilloma

4

Basal cell papilloma 7 Actinic keratosis 7

BENIGN PIGMENTED LESIONS 8 Freckle (ephelis) 8

Congenital melanocytic naevus 8

Acquired melanocytic naevus 9

BENIGN ADNEXAL TUMOURS 9 Syringoma 9

Pilomatricoma  10

MISCELLANEOUS BENIGN TUMOURS 10 Capillary haemangioma

 10

Port-wine stain 13 Pyogenic granuloma 14 Xanthelasma 14 Neurofibroma 15

MALIGNANT TUMOURS 15

Rare predisposing conditions 15 Basal cell carcinoma 16 Squamous cell carcinoma 18 Keratoacanthoma 19 Sebaceous gland carcinoma 20 Lentigo maligna and melanoma  21

Merkel cell carcinoma 22 Kaposi sarcoma 22

Treatment of malignant tumours  23

DISORDERS OF LASHES 27 Anatomy 27 Trichiasis 27

Congenital distichiasis  27

Acquired distichiasis 28 Eyelash ptosis 28 Trichomegaly 28 Madarosis 29

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Poliosis 29

ALLERGIC DISORDERS 29 Acute allergic oedema  29

Contact dermatitis 29 Atopic dermatitis 31

BACTERIAL INFECTIONS 31 External hordeolum

 31

Impetigo 31

Erysipelas 31 Necrotizing fasciitis  32

VIRAL INFECTIONS 32 Molluscum contagiosum 32 Herpes zoster ophthalmicus  33

Herpes simplex 33

BLEPHARITIS 34

Chronic anterior blepharitis 34 Chronic posterior blepharitis 36 Associations of chronic blepharitis 37 Phthiriasis palpebrarum 37

Angular blepharitis 38

Childhood blepharokeratoconjunctivitis  38

PTOSIS 39 Classification 39 Clinical evaluation 39

Simple congenital ptosis 41 Marcus Gunn jaw-winking syndrome  41

3rd nerve misdirection syndromes 41 Involutional ptosis 41

Mechanical ptosis 42 Surgery 42

ECTROPION 46 Involutional ectropion  46

Cicatricial ectropion 46 Paralytic ectropion 46 Mechanical ectropion  49

ENTROPION 49 Involutional entropion  49

Cicatricial entropion 50

MISCELLANEOUS ACQUIRED DISORDERS 50 Varices 50

Blepharochalasis 50 Floppy eyelid syndrome 50 Eyelid imbrication syndrome  55

Eyelid retraction 55

COSMETIC EYELID AND PERIOCULAR SURGERY 55 Involutional changes 55

Non-surgical techniques  56

Surgical techniques 57

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CONGENITAL MALFORMATIONS 58 Epicanthic folds 58 Telecanthus 58

Blepharophimosis ptosis and epicanthus inversus syndrome  58

Epiblepharon 58 Congenital entropion 59 Coloboma 59 Euryblepharon 61 Microblepharon 61 Ablepharon 62 Cryptophthalmos 62

Congenital upper lid eversion 63 Ankyloblepharon filiforme adnatum 63

Introduction

Anatomy

The skin consists of the epidermis, dermis and skin appendages (Fig. 1.1A), comprising a wide range of cell types capable of proliferation and neoplastic transformation. The range of cutaneous tumours is thus very extensive, ranging from common papillomas and basal cell carcinomas to much rarer skin appendage and soft tissue tumours in the dermis. Both benign and malignant tumours are classified according to their cell of origin as well as to their location in the epidermis, dermis or one of the skin appendages. This chapter considers only those of interest to ophthalmologists.

Fig. 1.1 Eyelid skin (A) Normal skin is composed of keratinized stratified epitheliumthat covers the surface; pilosebaceous elements are conspicuous in the dermis and a few blood vessels and sweat glands are also seen; (B) dysplasia with loss of cell polarity; (C) dyskeratosis – a non-surface epithelial cell producing keratin;

(D) parakeratosis – retention of cell nuclei into the surface keratin layer

(Courtesy of J Harry – Fig. A; J Harry & G Misson, from Clinical Ophthalmic Pathology, Butterworth-Heinemann, 2001 – Figs B, C and D)

Epidermis

The epidermis consists of four layers of keratin-producing cells (keratinocytes). It also contains melanocytes, Langerhans cells and Merkel cells. From superficial to deep, the layers of the epidermis are:

1Keratin (horny) layer is very thin and consists of flat cells devoid of nuclei.

2 Granular cell layer consists of one or two layers of diamond-shaped or flattened cells containing keratohyaline granules.

3Stratum spinosum layer is approximately five cells in thickness. The cells are polygonal and have abundant eosinophilic cytoplasm. Their free borders are united by intercellular bridges (desmosomes), hence the alternative term ‘prickle’ cell layer.

4Basal cell layer comprises a single row of columnar-shaped cells that give rise to more superficial cells. Basal cells contain melanin derived from adjacent melanocytes.

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Dermis

The dermis is much thicker than the epidermis. It is composed of connective tissue and contains blood vessels, lymphatics and nerve fibres in addition to fibroblasts, macrophages and mast cells. Upward dermal projections (papillae) interdigitate with downward epidermal projections (rete ridges). In the eyelid the dermis lies on the orbicularis muscle. Skin appendages (adnexae) lie deep in the dermis or within the tarsal plates.

1Sebaceous glands are located in the caruncle and within eyebrow hairs. Tiny sebaceous glands are associated with the thin (vellus) hairs covering periocular skin.

2Meibomian glands are modified sebaceous glands located in the tarsal plates. They empty through a single row of about 30 openings on each lid. A gland consists of a central duct with multiple acini, the cells of which synthesize lipids (meibum) that pass into the duct and form the outer layer of the precorneal tear film.

3Glands of Zeis are modified sebaceous glands that are associated with lash follicles.

4Glands of Moll are modified apocrine sweat glands which open either into a lash follicle or directly onto the anterior lid margin between the lashes. They are more numerous in the lower lid.

5 Eccrine sweat glands are distributed throughout the eyelid skin and are not confined to the lid margin, unlike glands of Moll.

6Pilosebaceous units comprise hair follicles together with their sebaceous glands.

Terminology

Clinical

1Macule: a localized area of colour change without infiltration or elevation. A macule may be pigmented (freckle), hypopigmented (vitiligo) or erythematous (capillary haemangioma).

2 Papule: a small solid elevation of skin which may be flat-topped or dome-shaped. 3 Vesicle: a small circumscribed lesion containing fluid.

4 Pustule: a collection of pus.

5Crust: a dried skin exudate.

6Nodule: a solid area of raised skin.

7 Cyst: a nodule consisting of an epithelial-lined cavity filled with fluid or semi-solid material. 8 Plaque: a palpable, shallow elevation of the skin, usually more than 2 cm in diameter.

9 Scale: thickening of the horny layer keratin in the form of readily detached fragments.

10Papilloma: a tag-like projection from the skin surface.

11Ulcer: a circumscribed area of skin loss that extends through the epidermis into the dermis.

Histological

1Hyperkeratosis is an increase in thickness of the keratin layer and appears clinically as scaly skin. Hyperkeratosis may be a feature of both benign and malignant epithelial tumours.

2Acanthosis is thickening of the squamous cell layer.

3Dysplasia is an alteration of the size, morphology and organization of cellular components of a tissue. There is disturbance of normally structured and recognized layers of tissue (e.g. loss of cell polarity; Fig. 1.1B).

4Dyskeratosis is keratinization other than on the surface (Fig. 1.1C).

5Parakeratosis is the retention of nuclei into the keratin layer (Fig. 1.1D).

6Carcinoma in situ (intraepidermal carcinoma, Bowen disease) exhibits dysplastic changes throughout the thickness of the epidermis and marked hyperkeratosis; see Fig. 1.22A).

General considerations

Benign skin lesions are much more common and varied than malignancies.

1Classification is based on the structure of origin: epidermal, adnexal or dermal.

2Diagnosis. The clinical characteristics of benign lesions are lack of induration and ulceration, uniform colour, limited growth, regular outline and preservation of normal lid margin structures. In the vast majority of cases diagnosis is straightforward although occasionally biopsy may be required if the appearance is unusual.

•An incisional (shave) biopsy using a knife removes a portion of the lesion for histology and is usually employed for large superficial lesions such as seborrhoeic keratosis. In some cases the bulk of the lesion is also removed and no further treatment is required, provided histology confirms a benign lesion.

•An excision biopsy is performed on small tumours and fulfils both diagnostic and treatment objectives.

3Treatment options include:

•Excision of the entire lesion and a small surrounding portion of normal tissue.

•Marsupialization involves the removal of the top of a cyst allowing drainage of its contents and subsequent epithelialization.

•Other options include ablation with laser or cryotherapy.

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Benign nodules and cysts

Chalazion

Pathogenesis

A chalazion (meibomian cyst) is a chronic, sterile, granulomatous inflammatory lesion caused by retained sebaceous secretion leaking from the meibomian or other sebaceous glands into adjacent stroma. A chalazion secondarily infected is referred to as an internal hordeolum.

Diagnosis

1Histology shows a lipogranulomatous inflammatory reaction containing epithelioid histiocytes, multinucleated giant cells and plasma cells (Fig. 1.2A).

2Presentation is at any age with a gradually enlarging painless nodule. Very occasionally a large upper lid chalazion may press on the cornea, induce astigmatism and cause blurred vision.

3Signs

•A nodule within the tarsal plate (Fig. 1.2B) that may be tender if inflamed.

•Eversion of the lid may show an associated polypoidal granuloma if the lesion has ruptured through the tarsal conjunctiva (Fig. 1.2C).

•A ‘marginal’ chalazion is similar except that it involves a gland of Zeis and is therefore located not in the tarsal plate but on the anterior lid margin.

•Patients with meibomian gland disease or rosacea are at increased risk of chalazion formation which may be multiple (Fig. 1.2D) and/or recurrent.

•It is very important not to mistake a sebaceous gland carcinoma for a ‘recurrent chalazion’. In doubtful cases, the lesion should be biopsied and examined histologically.

Fig. 1.2 Chalazion. (A) Histology shows a lipogranuloma; the large pale cells are epithelioid cells and the well-demarcated empty space contained fat which has been dissolved out during processing; (B) chalazion involving the lower lid; (C) conjuctival granuloma; (D) multiple chalazia in a patient with acne rosacea; (E) chalazion clamp

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(Courtesy of J Harry and G Misson, from Clinical Ophthalmic Pathology, Butterworth-Heinemann 2001 – fig. A; S Tuft – fig. D; J Nerad, K Carter and M Alford, from Oculoplastic and Reconstructive Surgery, in Rapid Diagnosis in Ophthalmology, Mosby 2008 – fig. E)

Treatment

Treatment may not be required because at least a third of chalazia resolve spontaneously and an internal hordeolum may discharge and disappear. Persistent lesions may be treated as follows:

1Surgery. The eyelid is everted with a special clamp (Fig. 1.2E), the cyst is incised vertically and its contents curetted through the tarsal plate.

2Steroid injection into the lesion is preferable if close to the lacrimal punctum because of the risk of surgical damage.

•Between 0.2 and 2 mL of 5 mg/mL triamcinolone diacetate aqueous suspension diluted with lidocaine (or equivalent) to a concentration of 5 mg/mL is injected through the conjunctiva into the tissue around the lesion with a 30-gauge needle.

•The success rate following one injection is about 80%. In unresponsive cases a second injection can be given 2 weeks later. Subsequent local skin depigmentation is uncommon.

3Systemic tetracycline may be required as prophylaxis in patients with recurrent chalazia, particularly if associated with acne rosacea.

Other cysts

1Epidermal inclusion cyst is usually caused by implantation of epidermis into the dermis following trauma or surgery. It is a slowgrowing, round, firm, superficial or subcutaneous lesion containing keratin (Fig. 1.3A).

2Epidermoid cyst is uncommon and usually developmental, occurring along embryonic lines of closure. It is similar in appearance to an epidermal inclusion cyst.

3Dermoid cyst is usually subcutaneous or deeper and is typically attached to the periosteum at the lateral end of the brow (Fig. 1.3B). It is caused by skin sequestered during embryonic development.

4Sebaceous (pilar) cyst is caused by a blocked pilosebaceous follicle and contains sebaceous secretions. It is only rarely found on the eyelid although it may occasionally occur at the inner canthus (Fig. 1.3C).

5Cyst of Zeis is a small, non-translucent cyst on the anterior lid margin arising from obstructed sebaceous glands associated with the eyelash follicle (Fig. 1.3D).

6Cyst of Moll (apocrine hidrocystoma) is a small retention cyst of the lid margin apocrine glands. It appears as a round, non-tender, translucent fluid-filled lesion on the anterior lid margin that may have a bluish tinge (Fig. 1.4A).

7Eccrine hidrocystoma is less common but similar in appearance to a cyst of Moll except that it is usually located along the medial or lateral aspects of the lid, and is close to but does not involve the lid margin itself (Fig. 1.4B).

8Milia are caused by occlusion of pilosebaceous units resulting in retention of keratin and represent tiny epidermal cysts. They are tiny, white, round, superficial papules which tend to occur in crops (Fig. 1.4C).

9Comedones are plugs of keratin and sebum within the dilated orifice of hair follicles that often occur in patients with acne vulgaris. They may be either open (blackheads) containing a darkened plug of oxidized material (Fig. 1.4D), or closed (whiteheads).

Fig. 1.3 (A) Epidermal inclusion cyst. (B) dermoid cyst; (C) sebaceous cysts; (D) cyst of Zeis

(Courtesy of A Pearson – fig. A)

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Fig. 1.4 (A) Cyst of Moll; (B) eccrine hidrocystomas; (C) milia; (D) comedones

(Courtesy of A Pearson – figs B and D)

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Benign epidermal tumours

Squamous cell papilloma

A squamous cell papilloma (fibroepithelial polyp) is a very common condition that has a variable clinical appearance but common histological features.

1Histology shows finger-like projections of fibrovascular connective tissue covered by irregular acanthotic and hyperkeratotic squamous epithelium (Fig. 1.5A).

2Signs

•A flesh-coloured, narrow-based, pedunculated lesion (skin tag; Fig. 1.5B).

•A broad-based (sessile) lesion which may exhibit a raspberry-like surface (Fig. 1.5C).

•A hyperkeratotic filiform lesion similar to a cutaneous horn (Fig. 1.5D).

3Treatment involves simple excision.

4 Differential diagnosis includes viral wart, seborrhoeic keratosis and intradermal naevus.

(Courtesy of J Harry – fig. A; A Pearson – fig. D)

Basal cell papilloma

Basal cell papilloma (seborrhoeic keratosis, seborrhoeic wart, senile verruca) is a common, slow-growing condition found on the face, trunk and extremities of elderly individuals.

1Histology shows expansion of the squamous epithelium of the epidermis by a proliferation of basal cells. The acanthotic epidermis may show keratin-filled cystic inclusions: either horn cysts within the mass or invaginations of surface keratin forming ‘pseudohorn’ cysts (Fig. 1.6A).

2 Signs. A discrete, greasy, brown plaque with a friable verrucous surface and a ‘stuck-on’ appearance (Fig. 1.6B). 3 Treatment involves shave excision of flat lesions and excision of pedunculated lesions.

4 Differential diagnosis includes pigmented basal cell carcinoma, naevus and melanoma.

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Fig. 1.6 Basal cell papilloma. (A) Histology shows an elevated expansion of the epidermis with proliferation frombasal cells; horn cysts and pseudohorn cysts are evident; (B) typical ‘stuck-on’ appearance

(Courtesy of J Harry – fig. A; A Pearson – fig. B)

Actinic keratosis

Actinic (solar, senile) keratosis is a common slow-growing lesion that rarely develops on the eyelids. It typically affects elderly, fair-skinned individuals who have been exposed to excessive sunlight and most frequently occurs on the forehead and backs of the hands. It has a low potential for transformation into squamous cell carcinoma.

1Histology shows irregular dysplastic epidermis with hyperkeratosis, parakeratosis and cutaneous horn formation (Fig. 1.7A).

2Signs

•Hyperkeratotic plaque with distinct borders and a scaly surface that may become fissured (Fig. 1.7B).

•Occasionally the lesion is nodular or wart-like and may give rise to a cutaneous horn.

3 Treatment involves biopsy followed by either excision or cryotherapy, especially for multiple lesions.

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Fig. 1.7 Actinic keratosis. (A) Histology shows irregular dysplastic epidermis with hyperkeratosis, parakeratosis and cutaneous horn formation; (B) clinical appearance

(Courtesy of J Harry and G Misson, from Clinical Ophthalmic Pathology, Butterworth-Heinemann 2001 – fig. A; M Jager – fig. B)

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