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obvious neurologic, myogenic, and mechanical causes. Old photographs should be viewed to rule out a longstanding problem. In addition, consideration should be given to the following:

•Contact lens wear (ptosis from manipulation of eyelids or a lost lens under the eyelid, giant papillary conjunctivitis)

•Allergies, blepharochalasis, or other source of recurrent eyelid edema

•Eyelid rubbing

•Botox—ptosis is a possible side effect of treatment and is being seen more frequently owing to the rise in popularity of cosmetic treatments in younger patients. (Patients should be assured that the ptosis will not be permanent.)

•Trauma—exposure of prominent preaponeurotic fat pads may suggest levator injury; may resolve spontaneously, so most wait 6 months before operating.4

22.Describe the ice test and its use in the diagnosis of ptosis

An ice pack is held over the ptotic eyelid for 2 to 5 minutes, and the patient is then reexamined. The cold temperature inhibits acetylcholinesterase at the neuromuscular junction, therefore enhancing neuromuscular transmission and raising the ptotic eyelid in myasthenics (poor man’s Tensilon test). The test is 80 to 90% sensitive and 100% specific for MG. A positive result should prompt a further workup.9

23.How does prostaglandin-associated periorbitopathy affect eyelid position?

Prostaglandin eyedrop use (for glaucoma and possibly cosmetics) can cause atrophy of fat cells in the periorbital area after as few as 3 weeks of use, causing the upper lids to become ptotic or giving the appearance of pseudoptosis owing to deepening of the superior sulcus. In addition, there may be lengthening of the lashes and darkening of the periorbital skin.10

24.What are the features of floppy eyelid syndrome?

Floppy eyelid syndrome is caused by decreased elastin in the tarsal plate with easy and sometimes spontaneous eversion of the upper lid. The upper eyelid can become ptotic, and the lashes themselves become ptotic with the direction of lash growth vertically downward, sometimes obstructing vision. In addition to lid and lash malposition, the patient may suffer chronic conjunctivitis with discharge and keratopathy. The syndrome is strongly associated with sleep apnea. All patients with floppy eyelid syndrome should be evaluated with sleep studies.

25.Compare and contrast the two most common types of ptosis surgical correction.

The two most common types of surgical correction are the external levator resection and the Müller’s muscle resection (with or without skin resection).

The levator resection allows for the removal of skin and fat through the external incision. The contour and height of the eyelid is less predictable and is dependent on the placement of tarsal levator sutures. The reoperation rate is approximately 10 to 20%.

The Müller’s muscle resection can be done from an internal or an external approach. This allows for removal of skin and fat if necessary, or the procedure can be done without the external eyelid being touched. This can be desirable in younger patients in whom dermatochalasis does not coexist. The contour of the postoperative eyelid is generally excellent and the reoperation rate is low, approximately 3%.11

References

1.Ahmadi AJ, Sires BS: Ptosis in infants and children, Int Ophthalmol Clin 42:15–29, 2002.

2.Kersten RA: Orbit, eyelids, and lacrimal system: basic and clinical science course, San Francisco, 2006, American Academy of Ophthalmology.

3.Gausas RE, Goldstein SM: Ptosis in the elderly patient, Int Ophthalmol Clin 42:61–74, 2002.

4.Bassin RE, Putterman AM: Ptosis in young adults, Int Ophthalmol Clin 42:31–43, 2002.

5.McCord Jr CD, Tannebaum M, Nunery WR: Oculoplastic surgery, ed 3, Philadelphia, 1995, Lippincott-Raven.

6.Schaefer AJ, Schaefer DP: Classification and correction of ptosis. In Stewart WB, editor: Surgery of the eyelid, orbit, and lacrimal system, vol 2. San Francisco, 1994, American Academy of Ophthalmology, pp 128–131.

7.Chan C, Paine M, O’Day J: Carotid dissection: a common cause of Horner’s syndrome, Clin Exper Ophthalmol 29:411–415, 2001.

8.Kerrison JB, Newman NJ: Five things oculoplastic surgeons should know about neuro-ophthalmology, Ophthal Plast Reconstr Surg 15:372–377, 2002.

9.Sethi KD, Rivner MH, Swift TR: Ice pack test for myasthenia gravis, Neurology 37:1383–1385, 1987.

10.Berke SJ: PAP: new concerns for prostaglandin use, Rev Ophthalmol, October 2012.

11. Lewis K: Recognition and management of common eyelid malpositions, Audio Digest Foundation, February 21, 2013.

1.What clues are helpful in determining whether an eyelid lesion is benign or malignant?

The size, location, age of onset, rate of growth, and presence of bleeding or ulceration; any color change; and a history of malignancy or prior radiation therapy are important. A thorough examination is necessary. Malignant or inflammatory lesions may cause loss of eyelashes and distortion of meibomian gland orifices, but only malignant lesions destroy the orifices. If a lesion is near the lacrimal punctum, evaluate for invasion into the lacrimal system. Probing and irrigation may be necessary. Palpate lesions for fixation to deep tissues or bone. Regional lymph nodes also should be examined for enlargement. Restriction of extraocular motility and proptosis are clues to localized invasion. If a sebaceous adenocarcinoma or melanoma is diagnosed, systemic evaluation should target lung, liver, bones, and neurologic systems. Photographic documentation is important for any lesion to be treated or observed.

2.What is the difference between seborrheic keratosis and actinic keratosis?

Both are papillomas, an irregular frondlike projection of skin with a central vascular pedicle. These lesions are more common in elderly patients.

•Seborrheic keratosis is pigmented, oily, and hyperkeratotic. It appears stuck onto the skin (Fig. 38-1). A shaved biopsy is all that is needed to diagnose and treat. It has no increased risk for malignant change.

•Actinic keratosis is found in sun-exposed areas and appears as a flat, scaly, or papillary lesion (Fig. 38-2). This premalignant lesion may evolve into either a basal cell or a squamous cell carcinoma.

3.What eyelid lesion is associated with a chronic follicular conjunctivitis?

Molluscum contagiosum. A virus causes the multiple waxy nodules with umbilicated centers. They may resolve spontaneously but frequently require surgical excision or cautery to prevent reinfection.

4.What blood tests should you order in young patients with the lesions shown in Figure 38-3?

The appropriate tests are cholesterol level, triglyceride level, and fasting blood sugar. Xanthelasma are yellowish plaques found at the medial canthal area of the upper and lower eyelids. They are collections of lipid. In older patients, xanthelasma are common and no cause for concern. In younger patients they may be a sign of hypercholesterolemia, a congenital disorder of cholesterol metabolism, or diabetes mellitus. They may be removed for cosmetic purposes, but they can recur.

5.What is a keratoacanthoma? What malignancy does it simulate?

A keratoacanthoma is a rapidly growing lesion that appears over several weeks. It is hyperkeratotic with a central crater that often resolves spontaneously (Fig. 38-4). Clinically, the lesion simulates a “rodent ulcer” basal cell carcinoma. Microscopically, the lesion appears similar to squamous cell carcinoma. It may occur near the edge of areas of chronic inflammation, such as a burn, or on the periphery of a true malignant neoplasm. If you are sure of the diagnosis, it is reasonable to observe. However, because it may cause destruction of the eyelid margin, lesions in this area are often removed surgically. In addition, steroids may be injected into the lesion to hasten resolution.

6.What is the most common malignant eyelid tumor?

Basal cell carcinoma. It is most common in middle-aged or elderly patients.

7.What are its two clinical presentations?

It presents as a nodular (Fig. 38-5) or morpheaform (Fig. 38-6) tumor. A nodular tumor is a firm, raised, pearly, discrete mass, often with telangiectasias over the tumor margins. If the center of the lesion is ulcerated, it is called a rodent ulcer. Morpheaform tumors are firm, flat lesions with indistinct borders. They tend to be more aggressive and have a worse prognosis than the nodular variety.

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Figure 38-1.  Seborrheic keratosis is a greasy, brown, flat lesion with a verrucous surface and a “stuck-on” appearance.

(From Kanski JJ: Clinical Ophthalmology: A Synopsis. New York, Butterworth-Heinemann, 2004.)

Figure 38-2.  Actinic keratosis is a dry, scaly lesion caused by sun exposure and occurring in fair-skinned people. (From Spalton DJ, Hitchings RA, Hunter PA: Atlas of Clinical Ophthalmology, ed 2, St. Louis, Mosby, 1994.)

Figure 38-3.  Patient with xanthelasma. (From Kanski JJ: Clinical Ophthalmology: A Systematic Approach, ed 5, New York, Butterworth-Heinemann, 2003.)

Figure 38-4.  Keratoacanthoma is a fast-growing nodule with a keratin-filled crater that spontaneously involutes after several months. (From Kanski JJ: Clinical Ophthalmology: A Synopsis. New York, Butterworth-Heinemann, 2004.)

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Figure 38-5.  Nodular basal cell carcinoma of the eyelid. A firm, pink-colored basal cell carcinoma of the left upper eyelid with raised border, superficial telangiectatic vessels, and characteristic central ulceration. These lesions are more commonly seen on the lower eyelid. (From Wojno TH: Eyelid Abnormalities. In Palay DA and Krachmer JH (eds): Primary Care Ophthalmology, ed 2, Philadelphia: Mosby, 2005. Fig. 4-13, B.)

Figure 38-6.  Unlike nodular basal cell tumors, morpheaform basal call carcinomas have less clearly defined surgical margins. (From Spalton DJ, Hitchings RA, Hunter PA: Atlas of Clinical Ophthalmology, ed 2, St. Louis, Mosby, 1994.)

8.In order of frequency, where do basal cell carcinomas present?

The most common location is the lower eyelid, followed by the medial canthus, lateral canthus, and upper eyelid.

9.Do basal cell carcinomas metastasize?

Lesions grow only by local extension.

10.If basal cell carcinomas do not metastasize, why be concerned with them?

Ocular adnexal basal cell carcinomas have a 3% mortality rate. The vast majority of these patients have canthal area disease, prior radiation therapy, or clinically neglected tumors. Tumors near the medial canthus may invade the orbit via the lacrimal drainage system. Rarely, extension can occur to the brain. Removal of the tumor can be quite disfiguring.

11.How do you treat tumors with a suspicious lesion?

First, do an incisional biopsy of the lesion to confirm the diagnosis. Permanent sections must be done, not merely frozen sections. If a basal cell lesion is found, there are several possibilities for treatment.

•Large surgical resection: A large surgical resection with frozen sections is performed to confirm the entire tumor has been removed. If the lacrimal system must be removed, do not perform a dacryocystorhinostomy at the same time as the primary surgery. Wait at least 1 year to prevent iatrogenic seeding of the nose.

•Mohs’ lamellar resection: The complete tumor is removed, sparing as much healthy tissue as possible. The excised bits of tissue are sent to pathology during the procedure to confirm the presence or absence of tumor and therefore direct the subsequent course of the surgery. This procedure preserves a larger amount of normal tissue, allowing improved function and cosmesis. Sometimes it even saves the globe, whereas conventional surgery may require exenteration. This time-consuming procedure is not available everywhere. After the tumor is completely removed and confirmed by pathology, the patient is sent to a plastic surgeon for reconstruction the same or the next day.

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Figure 38-7.  Squamous cell carcinoma of the upper eyelid. (From Kanski JJ: Clinical Ophthalmology: A Synopsis. New York, Butterworth-Heinemann, 2004.)

•Radiation: Basal cell carcinoma is radiosensitive, but treatment is not curative, only palliative (see question 10). Radiation should be reserved for elderly patients who are unable to undergo surgery.

•Cryotherapy: This treatment is not curative and should be used only palliatively.

•Topical treatments: Newer FDA-approved treatments for superficial basal cell include imiquimod and 5-fluorouracil. Trials are under way for their use in more invasive basal cell carcinomas.

12.How do you treat a recurrent tumor that has limited the extraocular motility from invasion of the orbit?

It is treated with exenteration.

13.Describe basal cell nevus syndrome.

This autosomal dominant disease is characterized by development of multiple basal cell carcinomas at an early age. Patients also have skeletal, endocrine, and neurologic abnormalities.

14.What are the complications of radiation to the area around the eye?

Keratitis sicca, cataracts, radiation retinopathy (if more than 3000 rads are used), optic neuropathy, entropion, lacrimal stenosis, and dermatitis. In young children the bones of the orbit may not grow normally, causing a significant cosmetic deformity.

KEY POINTS: COMPLICATIONS OF RADIATION TREATMENT AROUND THE OCULAR AREA

1.Keratitis sicca

2.Cataracts

3.Radiation retinopathy

4.Optic neuropathy

5.Entropion

6.Lacrimal stenosis

7.Dermatitis

8. Cosmetic deformity in children (orbital bones may not develop normally)

15.Where do squamous cell carcinomas usually present around the eye?

They usually present on the upper eyelid (Fig. 38-7). However, basal cell carcinomas are 40 times more common.

16.How are patients with squamous cell carcinomas treated?

They are treated similar to patients with basal cell carcinomas. However, squamous cell carcinomas are more aggressive locally and metastasize via the blood or lymph system. Neuronal spread is described and can be fatal. Exenteration is suggested for recurrences.

17.A 60-year-old man has had a chalazion removed from his left upper eyelid three times. It has recurred yet again. How do you treat it?

A sebaceous gland carcinoma must be suspected. Such lesions arise from the meibomian glands in the tarsal plate, Zeis’ glands near the lashes, and sebaceous glands in the caruncle and brow. Any