Ординатура / Офтальмология / Английские материалы / Rapid Diagnosis in Ophthalmology Series Oculoplastic and Reconstructive Surgery_Nerad, Carter, Alford_2008
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Fig. 2.5 Chalazion of right lower eyelid. Note absence of infl ammation.
Hordeolum and Chalazion
Fig. 2.6 Hordeolum of left lower eyelid. Lesion is erythematous and tender.
Fig. 2.7 Everted eyelid with chalazion clamp in place.
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Lesions• 2 SECTIONEyelid: the of Disorders
Chalazion and Hordeolum (Continued)
•Surgical
•Drainage and curettage if medical therapy fails
•Best performed via conjunctival surface with a chalazion clamp in place (Fig. 2.7): use a no. 11 blade to open chalazion with a vertical incision; scoop out contents with a curette (Fig. 2.8)
•Intralesional injection of steroid can be effective
•Complications:
•gland dropout
•eyelash loss
•eyelid margin changes
•ptosis
•conjunctival scar
Prognosis
•Most cases respond to medical and/or surgical treatment with no long-term complications
• Patients with rosacea may have recurrent disease
•Recurrence rate high if underlying blepharitis or meibomianitis not treated with chronic eyelid hygiene (see above)
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Fig. 2.8 Lipogranulomatous contents of a chalazion during excision.
Fig. 2.9 Hordeolum at eyelid margin.
(continued) Hordeolum and Chalazion
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Lesions• 2 SECTIONEyelid: the of Disorders
Seborrheic Keratosis
Key Facts
•Most common skin lesion, common in periocular area
•Benign neoplasm
•Middle-aged to older patients
Clinical Findings
•Lesions are brown to dark brown warty plaques
•Lesion has a greasy, stuck-on appearance, especially away from the thin eyelid skin (Fig. 2.10)
•Eyelid skin lesions tend to appear pedunculated or papillary rather than flat (Fig. 2.11)
Ancillary Testing
• None
Differential Diagnosis
•Malignant melanoma if darkly or asymmetrically pigmented
•Epidermal nevus
•Verruca vulgaris
•Acrochordon (skin tag)
Treatment
•Observation if sure of diagnosis
•Biopsy if lesion is symptomatic, catching clothing
•Shave biopsy works well
• Cryotherapy can be effective
Prognosis
• Excellent, low recurrence rate
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Fig. 2.10 Brown, warty-looking lesion with classic stuck-on appearance of seborrheic keratosis.
Keratosis Seborrheic
Fig. 2.11 Brownish black pedunculated papillary lesion of the right lower eyelid.
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Lesions• 2 SECTIONEyelid: the of Disorders
Epidermal Inclusion Cyst
Key Facts
•Occurs when epithelial cells are turned inward, buried within the skin
•The epidermal wall sheds keratin
•Usually the result of entrapment of epithelial cells of the infundibulum of the hair follicle
•May occur after trauma if the skin surface is interrupted
•Common benign lesion in periocular area
Clinical Findings
•Lesion appears smooth (Fig. 2.12), and a central pore may be present
•Slowly enlarges as the cyst wall produces keratin (not sebaceous material)
•Can be associated with minor skin trauma
Ancillary Testing
• None
Differential Diagnosis
• Neurofibroma
Treatment
• Observation
•Marsupialization of cyst is simple and effective
•If complete excision of cyst is attempted, the entire cyst wall must be removed to prevent recurrence
Prognosis
• Excellent with marsupialization or complete cyst excision
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Fig. 2.12 Smooth, elevated, whitish lesion in the right medial canthus.
Cyst Inclusion Epidermal
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Lesions• 2 SECTIONEyelid: the of Disorders
Xanthelasma
Key Facts
•Common skin lesion of the medial aspect of upper and lower eyelids
•Middle-aged to older patients
•Usually bilateral
•Usually not associated with hyperlipidemic condition
Clinical Findings
•Yellowish dermal plaques of the eyelids (Fig. 2.13)
•Lesion is composed of lipid-laden macrophages
•Upper lids more common location
Ancillary Testing
• Serum lipid levels if suspected metabolic disorder
Differential Diagnosis
•Usually no other lesions look like this, but some other xanthematous lesions may appear yellow
Treatment
•Full-thickness excision of lesion
•Must be careful not to remove too much of the anterior lamella of the eyelid
•Must avoid lagophthalmos and ectropion with skin closure
•Carbon dioxide laser ablation or trichloroacetic acid is less likely to be effective, because the lesion extends deep into the dermis
•Full-thickness skin grating may be required after excision of larger lesions
Prognosis
•Excellent with surgical excision
•Recurrence possible
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Fig. 2.13 A 49-year-old woman with yellowish plaques in all four eyelids.
Xanthelasma
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Lesions• 2 SECTIONEyelid: the of Disorders
Nevus
Key Facts
•Common lesion of the eyelid
•Appearance depends on skin level where nevus resides
•Nevus cells arise from undifferentiated melanocytes
•Nevi not normally present at birth
•Nevi usually appear and can increase in size and change in pigmentation during puberty
•Three stages of a nevus
1.Junctional: at junction of epidermis and dermis
2.Compound: in epidermis extending deeper into dermis
3.Dermal: solely in dermis
Clinical Findings
•Children: nevi usually flat pigmented macules
• This stage is junctional, usually appearing in adolescence
•Middle-aged adults: elevated lesion, pigmented lesion compound stage. The pigment is slowly lost as the nevus ages (Fig. 2.14)
•Older patients:
•dermal stage
•pigment usually lost
•lesion appears elevated in a dome shape
•A common location is the eyelid margin
•Eyelid margin structures are not destroyed, as with carcinomas
•Eyelashes grow out through the nevus but may lose their parallel orientation (Fig. 2.15)
Ancillary Testing
• None. See below for indications for biopsy
Differential Diagnosis
•Pigmented seborrheic keratosis
•Melanoma (see below)
Treatment
•Observation
•Simple shave biopsy removes any elevated portion (may mean slowly)
•Wedge resection of the eyelid margin or excisional biopsy at full thickness eyelid skin for complete removal
Prognosis
•Excellent
•If only superficial portion is removed, the nevus may recur over time
•Biopsy recommended if melanoma suspected:
•large lesions (>6 mm)
•bleeding
•highly irregular borders
•change in pigmentation
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