Ординатура / Офтальмология / Английские материалы / Primary Care Ophthalmology_Palay, Krachmer_2005
.pdf
76 CHAPTER 4 • Eyelid Abnormalities
FIGURE 4–11 Xanthelasma of all four lids (boxed outlines). The patient also has an intradermal nevus on the right upper lid margin.
FIGURE 4–12 Epithelial inclusion cyst (1) of the left upper lid. |
|
1 |
|
The patient also has a seborrheic keratosis (2) of the lower lid and lateral canthus.
2
Epithelial Inclusion Cyst
Symptoms
• Patients usually are symptom free.
Signs
•The cyst is slow-growing, white, round, and firm (Fig. 4–12).
•The diameter of the cyst usually is less than 1 cm.
Etiology
• Formation of the cyst follows traumatic implantation of epidermis into the dermis.
Differential Diagnosis
Considerations in the differential diagnosis include the following:
Basal Cell Carcinoma |
77 |
|
|
•Milium (small retention cyst of a hair follicle)
•Syringoma (adenoma of an eccrine sweat gland)
•Hydrocystoma (cyst of an eccrine sweat gland)
•Trichoepithelioma (squamous cell cyst of a hair follicle)
•Basal cell carcinoma
Associated Diseases
• The disorder is rarely associated with Gardner syndrome.
Treatment
• Excision or marsupialization of the cyst is performed.
Basal Cell Carcinoma
Symptoms
• Patients usually are symptom free.
Signs
•Nodular: Most commonly, a solid, pearly lesion is covered with telangiectatic vessels and a central ulceration (Fig. 4–13).
•Infiltrative: Rarely, a superficial, erythematous patch is present.
•The most common locations are the lower lid and the medial canthus.
B
A
FIGURE 4–13 A, A relatively flat basal cell carcinoma. B, A typical nodular basal cell carcinoma.
78 CHAPTER 4 • Eyelid Abnormalities
Etiology
• The disorder results from overexposure to actinic radiation.
Differential Diagnosis
Considerations in the differential diagnosis include the following:
•Milium (small retention cyst of a hair follicle)
•Syringoma (adenoma of an eccrine sweat gland)
•Hydrocystoma (cyst of an eccrine sweat gland)
•Trichoepithelioma (squamous cell cyst of a hair follicle)
Associated Factors and Diseases
•It is the most common primary eyelid malignancy, occurring in 80% to 90% of cases.
•The disorder is more common in basal cell nevus syndrome and xeroderma pigmentosum.
•The carcinoma rarely metastasizes but is locally destructive.
Treatment
•The preferred approach is surgical removal by Mohs’ technique followed by reconstruction; use of this technique results in a high cure rate (98%) and spares as much normal tissue as possible. Surgical excision with frozen section control is an acceptable alternative with a high cure rate (95%).
•Radiation therapy (80% to 90% cure rate) usually is reserved for patients unable or unwilling to have surgery.
Follow-up
•The site is examined for recurrence.
•Sun-exposed body parts are inspected for additional lesions.
Squamous Cell Carcinoma
Symptoms
• Patients usually are symptom free.
Signs
•An infiltrative, erythematous patch, often with ulceration, is a common sign of squamous cell carcinoma (Fig. 4–14).
•A nodular, erythematous lesion, often with ulceration, is an uncommon finding.
Etiology
• The disorder results from overexposure to actinic radiation.
Blepharitis 79
A B
FIGURE 4–14 A, A typical small squamous cell carcinoma (inset). B, A large nodular squamous cell carcinoma.
Differential Diagnosis
Considerations in the differential diagnosis include the following:
•Basal cell carcinoma
•Actinic keratosis
•Verruca
Associated Factors and Diseases
•It is the second most common primary eyelid malignancy (5% to 10% of cases).
•It is more common in fair-skinned persons.
•It is more common in patients with xeroderma pigmentosum, those who have undergone radiation therapy, and immunosuppressed patients, such as those with human immunodeficiency virus (HIV) infection.
•The carcinoma may metastasize.
Treatment
•Surgery as for basal cell carcinoma is performed.
•Radiation usually is ineffective.
Follow-up
• Follow-up involves the same procedures as for basal cell carcinoma.
Blepharitis
Symptoms
•Irritation, burning, and foreign body sensation are reported by the patient.
•Excessive tearing (epiphora), photophobia, and intermittent blurred vision are other complaints.
80 CHAPTER 4 • Eyelid Abnormalities
Signs
•Erythema of the lid margin occurs.
•Dandruff-like deposits (scurf) are found on the lashes.
•Fibrinous scales surrounding individual lashes (collarettes) are seen.
•Lash loss occurs.
•Recurrent, mild conjunctivitis is present.
•Thick, cloudy secretions from the meibomian orifices result with digital pressure on the lid.
Etiology
Three distinct types of blepharitis may occur:
•Seborrhea (Fig. 4–15A) often is associated with dandruff of the brows and scalp.
•Staphylococcal infection (Fig. 4–15B) often is associated with styes (hordeola).
B
A
FIGURE 4–15 A, Seborrheic blepharitis. The typical |
|
scales (scurf) are translucent and easily removed. |
|
B, Staphylococcal blepharitis showing the typical lid |
|
margin erythema and discharge. C, Meibomian gland |
C |
dysfunction showing thick secretions. |
Stye (Hordeolum) |
81 |
|
|
•Meibomian gland dysfunction (posterior lid margin disease and meibomianitis) (Fig. 4–15C) often is associated with chalazia.
•A combination of any of the three types can cause the disorder.
Differential Diagnosis
Considerations in the differential diagnosis include the following:
•Infiltrative lid neoplasm (e.g., squamous cell carcinoma, sebaceous cell carcinoma)
•Discoid lupus erythematosus
Treatment
•The lid margins are scrubbed daily with a cotton-tipped applicator dipped in dilute baby shampoo to remove scurf, collarettes, and bacteria. Massage of the lid margins may help express the abnormal meibomian secretions.
•Antibiotic treatment consists of the following:
A topical antibiotic ointment such as erythromycin or polymyxin B/bacitracin (e.g., Polysporin) is applied to the lid margins at night if lid scrubs are ineffective.
A 4 to 6 week course of doxycycline (50 to 200 mg/day) is added to improve meibomian gland function. Doxycycline is contraindicated in children, pregnant women, and breastfeeding mothers.
Follow-up
• The disorder frequently recurs and sometimes is recalcitrant to treatment.
Stye (Hordeolum)
Symptoms
•The subacute onset of a painful nodule or pustule of the eyelid is reported by the patient.
Signs
•A painful, erythematous, often pointed nodule is present on the skin surface (external stye) (Fig. 4–16) or conjunctival surface (internal stye).
Etiology
•Usually the disorder is caused by a staphylococcal infection of a sebaceous gland of the lid.
Differential Diagnosis
Considerations in the differential diagnosis include the following:
•Chalazion
•Inclusion cyst
•Lid tumor
82 CHAPTER 4 • Eyelid Abnormalities
FIGURE 4–16 External stye.
Treatment
•Warm compresses and topical antibiotic drops such as fluoroquinolones (e.g., Vigamox, Zymar) or polymyxin B/trimethoprim (Polytrim) are applied three to four times a day.
•Incision and drainage are performed if improvement is not obtained with use of compresses and antibiotics or if the patient wants rapid relief of symptoms.
Follow-up
• The focus of follow-up evaluation is to ensure that preseptal cellulitis does not occur.
Chalazion
Symptoms
• Patients usually are symptom free or report a minimally tender nodule of the lid.
Signs
•A firm, well-demarcated nodule is present just below the lid margin (Fig. 4–17A).
•Usually a grayish discoloration is visible on the conjunctival surface (Fig. 4–17B).
Etiology
•A chronic, lipogranulomatous inflammation of a meibomian gland is present.
•The disorder is more common with meibomian gland dysfunction.
Differential Diagnosis
Considerations in the differential diagnosis include the following:
•Hordeolum
•Inclusion cyst
•Lid tumor
Molluscum Contagiosum |
83 |
|
|
A B
FIGURE 4–17 A, A typical chalazion appearing as a pea-sized nodule. B, The conjunctival appearance of the same chalazion.
Treatment
•Early treatment (during the first 5 days) consists of application of frequent, warm compresses to open the inflamed gland.
•Intermediate treatment (for first 2 to 3 weeks) consists of injection of triamcinolone. Steroid injections can result in depigmentation and are contraindicated in darkly pigmented individuals.
•Late treatment (after 1 month) entails marsupialization of the encysted meibomian gland using a conjunctival approach.
Molluscum Contagiosum
Symptoms
•Irritated skin, conjunctivitis, and keratitis secondary to viral shedding into the tear film are typical ophthalmic symptoms.
Signs
•Round, umbilicated, pearly-white lesions of the skin are present (Fig. 4–18).
•Lesions usually are multiple.
Etiology
• The disorder is caused by a poxvirus.
Differential Diagnosis
Considerations in the differential diagnosis include the following:
•Verruca
•Herpes zoster
•Herpes simplex
84 CHAPTER 4 • Eyelid Abnormalities
FIGURE 4–18 Multiple lesions of molluscum contagiosum.
Associated Factors and Diseases
•It is more common in children, sexually active adults, and patients with HIV infection.
Treatment
• The lesion is destroyed using excision, curettage, electrocautery, or cryotherapy.
Herpes Simplex Dermatitis
Symptoms
• Mild to moderately painful blepharitis occurs.
Signs
•Vesicular eruption on the skin of the lids or lid margin is present (Fig. 4–19).
•The eruption progresses to an ulcerative lesion with escharification.
Etiology
•The disorder commonly is caused by infection with herpes simplex virus 1 (human herpesvirus 1).
•Infection with herpes simplex virus 2 is uncommon.
Differential Diagnosis
Considerations in the differential diagnosis include the following:
•Molluscum
•Verruca
•Herpes zoster
Workup
• A viral culture is performed if necessary.
Contact Dermatitis |
85 |
|
|
A
FIGURE 4–19 Herpes simplex dermatitis. |
A, |
Involvement of the eyelids. B, In this patient, the der- |
|
matitis affects the face and eyelids. |
B |
Treatment
•In mild cases, good hygiene is encouraged to prevent secondary bacterial infection.
•In moderate to severe cases, the following regimen is recommended:
Topical polymyxin B/bacitricin (e.g., Polysporin) ointment to prevent secondary bacterial infection
Trifluridine (Viroptic) drops to prevent secondary herpetic keratitis
Oral acyclovir (Zovirax) or famciclovir (Famvir) or valacyclovir (Valtrex)
Follow-up
•The patient is referred to an ophthalmologist, who monitors for subtle signs of herpetic keratitis.
Contact Dermatitis
Symptoms
• Generalized pruritic or painful eyelid occurs.
Signs
•In acute cases, erythema and edema of the eyelid occur (Fig. 4–20).
•In chronic cases, manifestations of the acute disorder as well as scaling and lichenification are present.
•Generally, the inflammation has a well-demarcated border.