Ординатура / Офтальмология / Учебные материалы / Color Atlas of Ophthalmology The Quick-Reference Manual for Diagnosis and Treatment
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2 Eyelids and Lacrimal System 51
Differential Diagnosis
Ableph aron (congen it al absen ce of eyelid), t rau m a. Ru le out oth er syn drom es associated w ith colobom as such as Golden h ar syn drom e (ocu loau riculover tebral dysplasia) an d Fran cesch et t i syn drom e (m an dibulofacial dystosis).
Management
Con ser vat ive t reat m en t w ith th e u se of lubricat ing drops an d oin t m en ts if sm all an d th ere is n o risk of exposure keratopathy. How ever, defects u sually n eed to be closed by prim ar y, direct closure or, if large en ough , w ill requ ire th e use of skin graft s or rotat ion flaps or both .
Eyelid Tumors
Papilloma
Th e m ost com m on ben ign t u m or of th e eyelids.
Presentation
Th ese presen t as a pedu n culated or sessile (broad -based) lesion . Th ey are a ben ign t u m or of epith elial origin (Fig. 2.18A,B).
Differential Diagnosis
Molluscu m con tagiosum , ch alazion , squ am ous cell carcin om a, basal cell carci- n om a
Management
Man agem en t can con sist of obser vat ion or elect ive rem oval by excision . Sh ave biopsies can be perform ed if th e diagn osis is u n cer tain .
A B
Fig. 2.18 (A) Papilloma. (B) Upper eyelid margin papilloma.
52 Color Atlas of Ophthalm ology
Seborrheic Keratosis
Slow -grow ing, discrete, greasy lesion w ith a friable surface
Presentation
Th ese often ap pear to be “st u ck on ” th e skin . Th e lesion is usually brow n an d flat but can often be pedu n cu lated (Fig. 2.19A,B).
Differential Diagnosis
Nevus, m elanom a, squam ous cell carcinom a, acrochordon (skin tag), actinic keratosis
Management
Cu ret t age an d excision are cu rat ive.
Actinic Keratosis
Also term ed solar keratosis, th is is a “prem align an t” lesion seen in fair-skin n ed in dividuals w h o h ave been exposed to excessive su n ligh t .
Presentation
Lesion s can be scaly, flat , w ith hyperkeratot ic feat u res. Th ey often begin as sm all, rough m acu les or papules (Fig. 2.20).
Fig. 2.19 (A) Seborrheic keratosis.
(B) Seborrheic keratosis, lower eyelid.
A
B
2 Eyelids and Lacrimal System 53
Fig. 2.20 Actinic keratosis (arrow s depict lesions).
Differential Diagnosis
Basal cell carcinom a, cutaneous horn, squam ous cell carcinom a, seborrheic keratosis
Management
Th ese lesion s sh ou ld be biopsied for diagn osis an d t reated w ith com plete excision or cr yoth erapy.
Keratoacanthoma
Th is is an un com m on but rapidly grow ing lesion w ith a cen t ral kerat in m ass.
Presentation
Th ey are often seen in fair-skin n ed in dividuals w ith excessive su n ligh t exp osure. Th ey can often regress spon tan eously, leaving a cen t ral, su n ken scar. Th ey are h istopath ologically in clu ded in th e spect rum of squ am ou s cell carcin om as an d clin i- cally appear sim ilar to squ am ous cell carcin om as (Fig. 2.21).
Fig. 2.21 Keratoacanthoma.
54 Color Atlas of Ophthalm ology
Differential Diagnosis
Basal cell carcin om a, cu tan eous h orn , act in ic keratosis, squ am ous cell carcin om a, an d seborrh eic keratosis
Management
Biopsy su spicious lesion s. Com plete su rgical excision w ith free m argin s is recom - m en ded . Laser or cr yoth erapy can be applied to sm all lesion s.
Molluscum Contagiosum
Th ese are virally t ran sm it ted lesion s u sually seen in you nger pat ien t s (teen agers an d ch ildren ) or in im m u n ocom prom ised pat ien ts.
Presentation
Th ey are n on in flam m ator y, sm ooth , p early, dom e-sh ap ed papules w ith cen t ral depression s often fou n d n ear th e upper an d low er eyelids. Th ey are t ran sm it ted by direct con t act an d are u su ally asym ptom at ic but can be associated w ith ch ron ic conju n ct ivit is (Fig. 2.22).
Fig. 2.22 Molluscum contagiosum .
Differential Diagnosis
Basal cell carcin om a, squam ou s cell carcin om a, papillom a
Management
Lesion s can be excised by a curet or cr yoth erapy.
Nevi
Nevi are ben ign lesion s th at occu r w ith in th e epith elium an d derm is.
Presentation
Th e lesion s are derived from m elan ocyt ic cells an d can be eith er pigm en ted or n onpigm en ted . Nevi can be h istologically classified as ju n ct ion al, com pou n d, an d
2 Eyelids and Lacrimal System 55
in t raderm al. In t raderm al n evi are con fin ed w ith in th e derm al layer. Th ey are usu - ally n onpigm en ted an d elevated . Th ey h ave n o m align an t poten t ial (Fig. 2.23A).
Jun ct ion al n evi are w ell circum scribed, flat , an d u n iform ly brow n . Th ey are located at th e ju n ct ion of th e epiderm is an d derm al layers an d h ave a low poten t ial for m align an cy (Fig. 2.23B). Com poun d n evi h ave both ju n ct ion al an d in t raderm al involvem en t (Fig. 2.23C).
A
B
C
Fig. 2.23 (A) Intraderm al nevi. (B) Junctional nevus. (C) Caruncular compound nevus.
56 Color Atlas of Ophthalm ology
Differential Diagnosis
Malign an t m elan om a, basal cell carcin om a, ben ign lesion s
Management
Carefu lly docu m en t th e size of th e lesion w ith ph otograph s. Su rgically rem ove lesion s th at in crease in size.
Nevus of Ota
Congen it al oculoderm al m elan ocytosis th at involves both skin (derm is) an d eye (ep isclera, sclera, an d uveal t issu es)
Presentation
Pat ien ts presen t w ith deep, u n ilateral hyp erpigm en tat ion of th e eyelid skin an d ocu lar st ru ct u res. Th ese n evi are associated w ith iris hyperch rom ia an d fu n du s hyperpigm en t at ion . Pat ien t s are at an in creased risk of glaucom a an d, th ough rare, m elan om a (Fig. 2.24).
Differential Diagnosis
Malign an t m elan om a
Management
Follow regularly for m align an t ch ange an d glaucom a screen ing.
Fig. 2.24 Nevus of Ota. Note the relative sparing of dermal involve - ment.
2 Eyelids and Lacrimal System 57
Xanthelasma
Xan th elasm a is a com m on ly seen con dit ion th at is frequen tly bilateral an d often seen in elderly pat ien ts or th ose w ith hyperlip idem ia. How ever, m ost pat ien t s w ith xan th elasm a are n orm olipoprotein em ic. Th ese can rarely be th e presen t ing sign of xan th ogran ulom atou s disease.
Presentation
Yellow ish su bcu t an eou s plaques are often foun d aroun d th e eyelids, especially arou n d th e m edial can th al areas.
Differential Diagnosis
Am yloidosis, eccrin e hydrocystom a, at ypical lym ph oid in filt rate sarcoid
Management
Th e lesion s can be su rgically rem oved elect ively; h ow ever, recurren ces are com - m on . Altern at ively, excision or dest r uct ion by carbon dioxide, argon laser, cr yoth erapy, an d ch em ical cau terizat ion (ch lorin ated acet ic acids) can be perform ed, th ough scarring an d hyperpigm en tat ion can occu r.
Cysts—Moll/Zeis/Sebaceous
Cysts of th e glan ds can resu lt in roun d, clear, an d t ran sillum in at ing lesion s.
Presentation
Th ere are various t yp es of du ctal cysts. Cysts of Moll (ap ocrin e sw eat glan d hydrocystom a) are usually foun d on th e an terior lid m argin an d t ran sillu m in ate w ell. Th ey can be foun d in th e m edial can th al angle, an d gravit y can often result in ect ropion . Eccrin e sw eat glan ds, th ough n ot con fin ed to th e lid m argin , appear like apocrin e cyst s. Cysts of Zeis an d sebaceous cyst s con tain oily secret ion s an d th erefore do n ot t ran sillum in ate (Fig. 2.25A,B,C).
Differential Diagnosis
Ben ign an d m align an t lesion s, ch alazion , extern al h ordeolum
Management
Warm com presses an d topical an t ibiot ics are h elpfu l. Marsupializat ion of th e cyst s is usu ally curat ive. Suspiciou s lesion s sh ou ld be sen t for biopsy.
Syringoma
Syringom as are ben ign skin t u m ors of eccrin e differen t iat ion , m ore often fou n d in w om en .
Presentation
Skin -color papu les are u su ally located on th e eyelids an d can in crease in size an d qu an t it y.
58 Color Atlas of Ophthalm ology
Fig. 2.25 (A) Apocrine hydrocystoma. (B) Eccrine hydrocystoma. (C) Sebaceous hydrocystoma.
A
B
C
Differential Diagnosis
Verr uca, xan th elasm a, cylin drom a
Management
Pap ules can be elect ively rem oved by su rgical excision or elect rodissect ion an d curet tage. Th e lesion s can recur.
Neurofibroma
Neu rofibrom as are in filt rat ive n er ve cell t u m ors th at are largely com p osed of Sch w an n cells.
2 Eyelids and Lacrimal System 59
Fig. 2.26 Infiltrative neurofibroma of left orbit. (Courtesy of
Deborah Alcorn, MD).
Presentation
Th e t um ors u sually occur early in life an d can be eith er n odu lar or plexiform . Th ey can involve th e upper lid (classic-sh aped appearan ce) an d frequen tly cau se a m e- ch an ical ptosis (Fig. 2.26).
Differential Diagnosis
Cap illar y h em angiom a, lym ph om a, rh abdom yosarcom a
Management
Su rgical excision can be at tem pted, bu t th ese lesion s are ver y difficu lt to rem ove su ccessfully.
Tumors
Basal Cell Carcinoma
Th is is th e m ost com m on eyelid m align an cy. Th ere is an in creased risk in people w ith fair skin an d in in dividuals w ith in creased exposure to ult raviolet radiat ion (ch ron ic skin dam age).
Presentation
Th ese t ypically presen t as a firm lesion w ith raised m argin s. A cen t ral crater w ith su perficial vascularizat ion or u lcerat ion can often be seen . Loss of eyelash es (m ad - arosis) alm ost alw ays suggest s m align an cy. Most com m on ly seen (in decreasing order of relat ive frequ en cy) in th e low er eyelids, m edial can th u s, up per eyelid, an d lateral can th us (Fig. 2.27A,B,C,D).
Differential Diagnosis
Nevu s, papillom a, keratoacon th om a, m align an t m elan om a, squ am ous cell carci- n om a
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Fig. 2.27 (A) Basal cell carcinom a.
(B) Ulcerating basal cell carcinoma. (C) Ulcerating basal cell carcinoma with necrosis of surrounding skin. (D) Ulcerating basal cell carcinoma with umbilicated, central crater.
A
B
C
D