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 61
Management
Biopsy su spicious lesion s. Su rgical excision w ith free m argin s (recom m en ded 3 to 5 m m ) of h ealthy t issu e sh ould be p erform ed . Altern at ive t reat m en t m odalit ies in clu de cr yoth erapy, elect rodissect ion , cu ret t age, Moh s m icrograph ic surger y, an d radioth erapy. Th ese lesion s h ave rare m etast at ic poten t ial.
Squamous Cell Carcinoma
Squ am ous cell carcin om as com prise less th an 5%of eyelid m align an cies. Sim ilar to basal cell carcin om a, th e prim ar y cau se of m ost squam ou s cell carcin om a is cu m u - lat ive lifet im e su n exposu re, especially in fair-skin n ed in dividu als.
Presentation
Lesion s can presen t as clin ically sim ilar to basal cell carcin om as, bu t th ey com - m on ly grow rapidly w ith spread to region al lym ph n odes. Th ey can also exten d in to th e in t racran ial cavit y via perin eural spread (Fig. 2.28A,B,C). Clin ically th ese can presen t as th ree su bt ypes:
A
B
Fig. 2.28 (A) Squamous cell carci- |
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noma. (B) Squamous cell carcinom a |
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of upper eyelid. (C) Cystic squam ous |
C |
cell carcinoma. |
62 Color Atlas of Ophthalm ology
Plaquelike: Scaly, hyperkeratot ic lesion s at site of preexist ing act in ic keratosis
Nodular: Hyperkeratot ic n odu le w ith cru st ing fissu res
Ulcerat ing: Well-defin ed evert ing borders w ith an er yth em atous an d ulcerated base
Differential Diagnosis
Basal cell carcin om a, keratoacan th om a, act in ic keratosis
Management
Su rgical excision w ith free m argin s (recom m en ded 3 to 5 m m ) of h ealthy t issu e or Moh s m icrograph ic surger y sh ou ld be p erform ed . Lesion s n ot com pletely resectable can be t reated w ith adjun ct ive radiat ion or cr yoth erapy or both .
Sebaceous Cell Carcinoma
Th ese are older-grow ing lesion s frequ en tly arising from th e m eibom ian glan ds an d usually seen in th e upper eyelids. Th ey are m ore com m on ly seen in older w h ite w om en . Th ey com prise approxim ately 5%of eyelid m align an cies. Th ere is often a delay in diagn osis given its in sidiou s clin ical appearan ce.
Presentation
Can presen t eith er as a n odu lar or a pagetoid spreading m eibom ian glan d carci- n om a. Th e n odu lar t ype presen ts as a discrete n odu le th at often is m istaken for a ch alazion . Th e pagetoid sp reading su bt ype spreads in to th e derm is an d epith elium in a diffu se pat tern , often m im icking ch ron ic conju n ct ivit is (Fig. 2.29A,B).
Fig. 2.29 (A) Sebaceous cell carcinoma of eyelid margin. (B) Sebaceous cell carcinoma involving m ost of the upper tarsal conjunctiva.
A
B
2 Eyelids and Lacrimal System 63
Differential Diagnosis
Bleph arit is, ch alazion , superior lim bic keratoconju n ct ivit is, ch ron ic conju n ct ivit is, cicat ricial pem ph igoid
Management
Su rgical excision w ith w ide su rgical m argin s w ith frozen -sect ion con t rols is often n ecessar y. Conju n ct ival m apping h elps evaluate pagetoid spreading. Evalu ate local lym ph n odes (preauricular an d cer vical), an d perform a system ic evaluat ion for m etast at ic spread .
Cutaneous Malignant Melanoma
Th is is rarely seen on th e eyelids but can m anifest as potent ially lethal skin lesion s.
Presentation
Th ese often present as a slow ly grow ing pigm en ted lesion, but alm ost h alf of lesions can be n onpigm ented (Fig. 2.30A,B,C). Th ey are clinically seen in three t ypes:
A
B
Fig. 2.30 (A) Lentigo maligna. |
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(B) Melanoma of medial canthus. |
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(C) Melanoma of upper eyelid. |
C |
64 Color Atlas of Ophthalm ology
Lent igo m aligna (pre-m elanom a lesion): A slow -grow ing pigm en ted lesion , often affect ing elderly pat ien t s, w h ich can develop in to a m elan om a
Superficial spreading: Su perficially spreading lesion w ith an irregu lar ou tlin e, variable pigm en tat ion , an d delay in pen et rat ion in to deeper layers
Nodular: A m ore aggressive lesion th at h as a ten den cy to invade deeper layers early in it s grow th
Differential Diagnosis
Nevus, basal cell carcin om a, keratoacon th om a, seborrh eic keratosis, squ am ous cell carcin om a
Management
Excision al biopsy w ith 3- to 5-m m free m argin s is recom m en ded for th in cut a- n eou s periocular m elan om as. Melan om as th icker (u sually greater th an 2m m in th ickn ess) an d located elsew h ere m ay require 1 to 3 cm free m argin s depen ding on th eir th ickn ess. Th e exten t of surgical an d adju n ct ive th erapy is determ in ed by t u m or t ype, level, an d clin ical stage.
Distichiasis and Trichiasis
Dist ich iasis can be eith er a congen it al or an acquired con dit ion of th e eyelids an d involves th e abn orm al grow th of lash es from th e orifices of th e m eibom ian glan ds. Trich iasis is an acqu ired con dit ion of eyelash es th at are m isdirected tow ard th e globe.
Presentation
Dist ich iasis can presen t in a variet y of w ays. Th e dist ich iat ic lash es can be th in or of n orm al th ickn ess, pigm en ted or n onpigm en ted, h ave n orm al orien tat ion , or m ay be m isdirected . Acqu ired cases of dist ich iasis can be seen in longst an d - ing cicat rizat ion associated w ith t rach om a, ch em ical inju r y, Steven s-Joh n son syn - drom e, an d ocular pem p h igoid . Trich iasis can be th e result of scarring of th e lid m argin secon dar y to ch ron ic t rach om a, bleph arit is, Steven s-Joh n son syn drom e, an d h erpes zoster oph th alm icu s. In all cases, th e lash es ru b again st th e eye an d can cau se irrit at ion , tearing, an d corn eal epith eliopathy. Longst an ding cases can resu lt in corn eal u lcerat ion an d pan n us (Fig. 2.31A,B).
Differential Diagnosis
En t ropion , ep ibleph aron , bleph arit is, an d topical prostaglan din an alogue m edica- t ion s for glaucom a
Management
Num erou s approach es h ave been reported for t reat m en t . Ep ilat ion is accom plish ed by lash rem oval w ith forceps (n ot a p erm an en t solut ion ) or m ore effect ively w ith elect rocau ter y, cr yoth erapy, or argon laser to in dividu al lash es. Altern at ively, th ey can be surgically approach ed in a variet y of w ays, in cluding a com bin at ion of la- m ellar eyelid division w ith cr yoth erapy to th e aberran t lash es or direct surgical excision by w edge resect ion .
2 Eyelids and Lacrimal System 65
Fig. 2.31 (A) Distichiasis. (B) Trichiasis (of upper lid). Note the cicatricial changes of both upper and lower lids.
A
B
Lacrimal System Disorders
Canaliculitis
Can alicu lit is con sist s of eith er or both in flam m at ion an d in fect ion of th e upp er or low er can alicu lus.
Presentation
Th e can alicu lar region is er yth em atou s, in du rated, an d ten der to p alpat ion . Pa- t ien t s com plain of ep iph ora w ith ch ron ic m u copuru len t disch arge. Th e m ost com - m on bacterial path ogen is Act inom yces, w h ich produces gran ular-like con cret ion s th at are difficu lt to express from th e pun ct i (Fig. 2.32A, B).
Differential Diagnosis
Ch ron ic dacr yocyst it is, eth m oidal m u cocele
Management
Local an t ibiot ics sh ould be u sed according to th e path ogen s iden t ified on cult u res an d sen sit ivit y (gen erally su scept ible to pen icillin s an d ceph alosporin s). Surgical in cision (can alicu lotom y) w ith drain age an d curet tage of th e con cret ion s is often used for su ccessful t reat m en t .
66 Color Atlas of Ophthalm ology
Fig. 2.32 (A) Chronic canaliculitis.
(B) Eikenella canaliculitis.
A
B
Dacryocystitis
Th is is an in fect ion of th e n asolacrim al sac; it is often u n ilateral an d secon dar y to an acqu ired obst ru ct ion of th e n asolacrim al du ct .
Presentation
Presen tat ion can be acute or ch ron ic. A sten osis or obst ruct ion w ith in th e n asolacrim al du ct can lead to reten t ion of tear flu id w ith su bsequen t superin fect ion . An acute cou rse presen t s w ith a pain ful, localized er yth em a an d in flam m at ion arou n d th e lacrim al sac. An abscess can often develop w ith even a spon tan eous rupt ure of th e an terior skin leading to a drain ing fist ula. Neon ates can also presen t w ith dacr yocyst it is secon dar y to n asolacrim al du ct obst ru ct ion . Ch ron ic in fect ion produ ces epiph ora w ith associated conju n ct ivit is an d m in im al ten dern ess. Lacri- m al sac m assage produ ces reflu x of m ucopu rulen t m aterial from th e pu n ct i (Fig. 2.33).
Differential Diagnosis
Nasolacrim al du ct obst ruct ion , orbital cellulit is, conju n ct ivit is, h ordeolu m
2 Eyelids and Lacrimal System 67
Fig. 2.33 Dacryocystitis, left lacrim al sac with associated preseptal cellulitis.
Management
If m ild, acu te an d ch ron ic presen t at ion s can be in it ially t reated w ith local an d oral an t ibiot ics, an d on ce th e acu te sym ptom s h ave resolved, a dacr yocystorh in ostom y is often requ ired . Severe dacr yocyst it is w ith secon dar y orbital cellulit is or abscess form at ion m ay require in t raven ous an t ibiot ics. Abscess form at ion s n eed to be t reated w ith in cision an d drain age.
Nasolacrimal Duct Obstruction
Th is can be congen it al or acquired . In congen it al cases, th ere is a delay in th e can a- licu lizat ion of th e low er port ion of th e n asolacrim al du ct , w h ich is seen in up to 20% of in fan t s du ring th e first year of life bu t is sym ptom at ic in less th an 4% of th ese ch ildren . Acquired cases can be secon dar y to t rau m a or in fect ion .
Presentation
Con st an t ep iph ora an d w et t ing of th e eyelash es. Mu copuru len t m aterial is often expressed from th e low er pu n ct i after lacrim al m assage. Sym ptom s can w orsen du ring an u pper resp irator y in fect ion (Fig. 2.34).
Fig . 2.34 Left nasolacrimal duct obstruction.
68 Color Atlas of Ophthalm ology
Differential Diagnosis
Congen it al glau com a in in fan t s, eth m oidal m u coceles, lacrim al sac t u m ors (ben ign or m align an t), dacr yocyst it is, can alicu lit is
Management
Treat m en t sh ou ld be delayed in in fan t s un t il about 1 year of age becau se m ost (up to 95%) of cases self-resolve. Nasolacrim al du ct probing an d irrigat ion are usually curat ive in over 90%of in fan t s. Recu rren t failures often im ply an an atom ical problem an d m ay require silicon e in t ubat ion or balloon dilat ion . Persisten t failu res m ay n eed a dacr yocystorh in ostom y.
3 Orbital Infections, Inflammation, and Neoplasms
Praveen Saluja, Sw at i Ravani, Soosan Jacob, and Am ar Agarw al
Preseptal Cellulitis
Preseptal cellu lit is is defin ed as a soft t issue in fect ion an terior to th e orbit al sep - t u m . In fect ion p osterior to th is sept um , anyw h ere in th e orbit , is orbit al cellulit is. Orbit al cellu lit is is a dangerous con dit ion ow ing to th e close proxim it y to th e orbital apex, cavern ous sin us, m en inges, an d brain . Bacterial in fect ion of th e eyelid an terior to th e orbital sept um t ypically affects ch ildren , usu ally secon dar y to lid in fect ion su ch as severe acu te h ordeolu m , skin lacerat ion , an in sect bite, or th e spread of in fect ion from th e su rroun ding st ruct ures (paran asal sin uses, lacrim al sac, u pper respirator y t ract , in cluding th e m iddle ear). Th e in fect ion does n ot pen - et rate th e orbital sept um , w h ich separates th e an terior st ru ct u res from th e orbit .
Presentation
Sym ptom s in clu de eyelid edem a (w h ich m ay lead to in abilit y to op en th e eye), periorbit al sw elling, rubor, color, ten dern ess, w ith out proptosis. Un like orbit al cellulit is, th ere is n o pain w ith eye m ovem en t s. Ocu lar m ot ilit y, visu al acuit y, an d pupillar y react ion s are all n orm al (Fig. 3.1A,B,C).
Differential Diagnosis
Orbital cellulit is: Decreased visu al acu it y, decreased sen sat ion along th e first di-
vision of th e t rigem in al n er ve, eyelid edem a, proptosis, ch em osed conjun ct iva, pain w ith eye m ovem en t s, rest ricted eye m ovem en ts, sign s of ocu lar m ot ilit y disorders
Cavernous sinus throm bosis: Bilateral, decreased visual acu it y, decreased sen sa- t ion along th e first an d secon d division of th e t rigem in al n er ve, p roptosis an d paresis of cran ial n er ves III, IV, an d VI, ch em osed conju n ct iva
Chalazion: Focal, usu ally w ith ou t ten dern ess, gradu ally progressive ch ron ic in - flam m at ion of th e m eibom ian glan d
Allergic edem a of the eyelid
Contact derm at it is
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Viral conjunct ivit is associated w ith lid edem a: Watering, itch ing, st ickin ess of |
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th e eyelash es, conjun ct ival follicu lar react ion , w ith or w ith ou t disch arge an d |
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palp able preauricular lym ph n ode |
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Erysipelas: Acu te st reptococcal cellu lit is (m ostly h as a clear-cut dem arcat ion |
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lin e) w ith sign s of toxem ia, in clu ding h igh -grade fever an d ch ills |
Others: In sect bite, angioedem a, t raum a, osteom yelit is of paran asal sin u ses, especially m axillar y sin us
Management
Ch eck for a h istor y of t rau m a, rapidit y of on set , pain , fever, ch ills, can cer, diabetes, pulm on ar y diseases, an d ren al diseases. Ch ar t th e vit als (pu lse, respirat ion , tem perat u re, blood pressure). Exam in e for exoph th alm om et r y, globe displace- m en t , an d resistan ce to ret ropulsion an d exam in e th e orbital rim . Record ocular m ovem en t an d m easure deviat ion w ith a prism bar. Pup ils m u st be evalu ated for ligh t reflexes, in cluding relat ive afferen t pupillar y defect (RAPD). Color vision , in -
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70 Color Atlas of Ophthalm ology
A
B
C
Fig. 3.1 (A) Preseptal cellulitis, allergic reaction. (B) Preseptal cellulitis, bacterial infection final. (C) Preseptal cellulitis, fungal infection.
t raocu lar pressu re (in clu ding th e pressu re in variou s gazes), an d ret in al evalu at ion sh ould be recorded . Evaluate th e cran ial n er ves (especially III, IV, V1, V2, VI,). Exam - in e th e h ead an d n eck for lym p h aden it is. Gram stain ing an d cu lt u re of any open w ou n d an d disch arge sh ould be perform ed at th e earliest opport u n it y. A com plete an d differen t ial blood cou n t is perform ed if sign s of toxem ia exist .