LIDS, LASHES, AND ADNEXA

Question 1

Lid coloboma

• Gap/notch in lid, not hereditary
• Unilateral more common than bilateral
• Upper lid: usually at jct of inner/middle third of lid
• Lower lid: usually at jct of middle/lateral third of lid

Symptoms

• Consistrent with dry eye

Answer 1

Signs

• Less irrigation of tear film, more exposure, faster evaporation
• More prone to secondary infection
• Lysozymes/lactoferrin unable to break down bacteria

Management

• Oculoplastic surgery

Question 2

DISTICHIASIS

• Meibomian orifices replaced by abnormal row of lashes
• Rare, autosomal dominant
• Usually bilateral
• Hair is misdirected twd cornea

Symptoms

• Foreign body sensation
• Redness, tearing, dryness

Answer 2

Signs

• • Fluorescein track stains
• Lack of lipid layer (Meibomian orifices occluded, xs evaporation

Management

• Bandage contact lens
• Epilation
• Electrolysis
• Cryo Treatment
• Artificial Tears

Question 3

BLEPHAROPHIMOSIS

• Narrowing of lid fissure horizontally or vertically
• Lid structures are normal
• Autosomal dominant
• Associated with epicanthal folds or ptosis

Symptoms

• Decreased quality of vision
• Dry eye symptoms

Answer 3

Signs

• Reduced VA
• Amblyopia (deprivation)

Management

• Oculoplastic surgery

NOTES

• FAS: causes
  
  • blepharophimosis,
  • abnormal RE,
  • absent philtrum,
  • elongated upper lip,
  • flared ala,
  • flat midface,
  • underdeveloped jaw,
  • ear abnormalities

Question 4

ECTROPION

• Outward eversion of lower lid
• Congenital: rare
• Paralytic: secondary to bell’s palsy/CNVII paralysis
• Spastic: secondary to lid trauma, mostly seen in younger pts
  
  • Orbicularis contracts, pulls lid down
• Cicatricial: secondary to facial burns, due to skin contraction
• Allergic: secondary to tyalosis
  
  • Mostly chronic allergies
• Mechanical: secondary to growth

Symptoms

• Xs tearing
• Redness
• Foreign body sensation

Answer 4

Signs

• Tyalosis
• Exposure keratitis
• Poor lid apposition

Management

• Horizontal shortening of lids
• Artificial tears
• Bandage contact lens: water drawn
  out of lens due to gradient – NOT
  COMMON

Question 5

ENTROPION

• Inward turning of lid margin
• Involutional: age-related
• Cicatricial: secondary to burns
• Mechanical: due to growth
• Spastic: trauma related, transient
• Can also be secondary to trachoma

Symptoms

• Tearing
• Redness
• Irritation
• Foreign body sensation

Answer 5

Signs

• Secondary trichiasis
• Xs tering
• Hyperemia
• Track staining

Management

• • Epilation
  • Electrolysis
  • Cauterization
  • Bandage contact lens
  • Artificial tears

Question 6

BLEPHAROCHALASIS

• Repeated idiopathic episodes of acute lid swelling
• Fluid accumulates, stretches skin

Symptoms

• Decreased vision
• Brow ache

Answer 6

Signs

• Redundant lid skin with wrinkled appearance
• Decreased VA
• Pseudoptosis

Management

• Blepharoplasty

Question 7

DERMATOCHALASIS

• Loosened/redundant skin on lid
• Related to age, elasticity decreases
• Common
• Usually bilateral

Symptoms

• Decreased VA
• Brow ache

Answer 7

Signs

• Decreased VA
• Pseudoptosis
• Redundant lid skin

Management

• Blepharoplasty

Question 8

PAPILLOMA

• Benign epithelial growth
• Non-infectious
• Can be pigmented or non-pigmented, singular or multiple
• Pedunculated: smaller, stalk-like base
• Sessile: flat base, dome-shaped
• Texture similar to surrounding skin
• Space between them
• Well – defined, avascular

Answer 8

Management

• document,
• monitor,
• excise,
• cauterize w/bichloroacetic
  acid

Question 9

XANTHELASMA

• Multiple soft yellow deposits under skin on
  inner aspect of upper/lower lids
• Associated with elevated cholesterol

Answer 9

Management

• excision,
• laser,
• cauterize (uncommon)

Question 10

BASAL CELL CARCINOMA

• Most common lid malignancy – 90% prevalence
• Derived from epithelial cells
• Non-metastatic – will get bigger, but won’t migrate
• Initially grows laterally, then deeper, creates
  central indentation. Grows slowly.
• Can recur
• Begins insidiously
• Progresses more rapidly laterally than posteriorly
• Extensive local destruction

Answer 10

​Risk Factors

• Age over 60
• UV exposure
• Outdoor vocation

Question 11

BASAL CELL CARCINOMA

NODULAR TYPE

Answer 11

• Localized, raised
• Most common
• Center is depressed, houses visible, fine, telangetic blood vessels
• Edges appear pearly/translucent
• 5-10 mm in size

Question 12

BASAL CELL CARCINOMA

ULCERATIVE TYPE

Answer 12

• Skin loses its fine lines
• Center is ulcerated
• Distinct borders
• Telangetic vessels
  visible

Question 13

BASAL CELL CARCINOMA

SCLEROSING TYPE

Answer 13

• Pale yellow
• Flatter
• Firm texture
• Indistinct borders
• Could be a bit red from vascularization, but
  usually yellow
• Less common

Question 14

BASAL CELL CARCINOMA

MULTI-CENTRIC TYPE

Answer 14

• Multi-lobulated tumor
• Found more on truncal area
• Less common

Question 15

Management of basal cell carcinoma

Answer 15

• Refer for removal
• Biopsy for confirmation
• Moh’s technique
• Surgeries:
  
  • Excision
  • Frozen section
  • Radiotherapy
  • Cryo-surgery

Question 16

STAPHYLOCOCCAL BLEPHARITIS

• Most common lid disorder
• 75% of cases affect conj
• G+ bacteria (staph aureus or
  epidermidis)
• Acute, sudden onset
• Worsens between 24-48 hours
• Dissipates in ~1 wk

Symptoms

• Highly variable in presentation and severity
• Sticky/crusty lids, difficulty opening eyes in AM
• Burning
• Foreign body sensation

Answer 16

Signs

• Lid margins, conj hyperemic
• Collarettes at lash base
• SPK on cornea

Management

• Warm compress to soften collarettes (min BID)
• Lid scrubs to reduce bacterial population (min BID)
  
  • Non commercial: 1:9 dilution of bb shampoo
  • Commercial: lyses bacteria (see addendum)
• Artificial tears for SPK (6x/day)
• Topical ABs: broad spectrum/G+
  
  • Polytrim: TID 1 wk
  • Polysporin: ung hs

Question 17

CHRONIC STAPH BLEPHARITIS

• Can develop form acute, esp in immunocompromised pop
• Usually bilateral
• Persistent with bacterial resistance

Symptoms

• Highly variable
• Sticky/crusty lids, difficulty opening in AM
• Burning
• Foreign body sensation
• Lumpz n bumpz along lid
  margin

Answer 17

Signs

• Hyperemia
• Madarosis
• Irregular lid margin
• Poliosis
• Tyalosis
• Collarettes at lash base
• Rosettes
• Hordeolums, chalazions
• Secondary dry eye
• Corneal staining/SPK

Management

• Warm compress TID/QID 1-2wks, taper w/recovery
• Lid scrub following warm compress
• Artificial tears up to 6x/day, taper w/recovery
• ABs: ung hs, combine with steroid for 1 wk only (can lead to high IOP)
• Maintain lid hygiene for long term health
• BlephEx: in office tx, cleans lids
• If topical tx doesn’t work, use oral ABs
  
  • Doxycycline: 2wks, can also use as pulse tx (1x mo/1 wk)
  • Can cause photophobia, GI symptoms,
    but usually everything’s fine

Question 18

SEBORRHEIC
BLEPHARITIS

• Common, involves scalp, face, brow
• Hormones, nutrition, stress play a role
• Often underlying staph bleph

Symptoms

• Highly variable
  • Burning
  • Foreign body sensation
  • Bilateral

Answer 18

Signs

• Mild lid hyperemia, can be subtle
• Dry to oily dandruff-like particles on lashes
• No ulcerations – smooth lids

Management

• Hot compresses/lid scrubs
• Discontinue makeup
• RTC 2-4 wks
• Scalp tx w/selenium sulfide (contains zinc),
  let it run down onto lids/lashes, don’t apply directly to eyes

Question 19

ANGULAR
BLEPHARITIS

• Common in elderly, alcoholics,
  dry/warm climates
• Cause:
  o Staph aureus in old ppl
  o Moraxella in alcoholics

Symptoms

• Redness on one part of eye
• Skin changes/irritation
• Itchiness (from bacterial metabolic products)

Answer 19

Signs

• Hyperemia in lateral
  canthus
• Excoriation
• Maceration

Management

• Topical ABs: target staph (G+) if present
  
  • If Moraxella: use ZnSO4 soln
• Disco makeup

Question 20

MEIBOMIANITIS

• AKA: MGD
• Excess lipid secretion, leads to
  blockage of meibomian orifices

Symptoms

• Unspecific
• Burning
• Increasing prevalence in younger pop due to usage
  of screens (less blinking at near)

Answer 20

Signs

• Inflammation of lid margins
• Irritation
• Excess lipid secretion
• No expression when press on glands or thick
  yellow sebum secreted

Management

• Expression of glands
• Oral ABs: helpful in getting tx down to tarsal plate
  
  • Doxycycline: low dose, 2-4 wks
• NO UNG – will clog more
• Artificial tears

Question 21

EXTERNAL HORDEOLUM

• Staph infection – gland of Zeiss
• Acute presentation
• Worsens on day 2-3, resolves in ~1 wk
• Focal swelling on lid margin
• Red, elevated lesion
• Core pointing out
• Commonly called a STYE

Symptoms

• sudden onset, progressively getting worse
• red bump on lid margin
• tender to touch
• warm to touch

Answer 21

Signs

• dome shaped focal elevation
• pus point facing out
• tenderness/warmth

Management

• hot compress: accelerates problem, but also makes it go away sooner. BID-TID
• once burst, tell pt not to wipe shit into eye
• lid scrubs BID/TID for underlying bleph
• ABs: use with repeated occurrences
• Disco makeup

Question 22

INTERNAL HORDEOLUM

• Staph infection of MB glands
• Acute onset
• Will involve more tarsal surface area, typically bigger than
  external hordeolum
• Can lead to pre-septal cellulitis
• Rarely can lead to orbital cellulitis in injured or
  immunocompromised pt
  
  • Refer immediately

Symptoms

• Progressive worsening, esp over days 3-4
• Pain/warm to touch
• Focal elevation along lid margin

Answer 22

Signs

• Redness to focal elevation and surrounding area
• Peak faces internally
• Tender/warm to touch

Management

• Hot compresses BID/TID 1 wk
• Lid scrubs for underlying bleph BID/TID 1wk
• Topical broad spectrum ABs: 1 wk
• If pre-septal cellulitis: add oral AB
• Disco makeup

Question 23

CHALAZION

• Chronic lipo granulomatosis of mb gland caused by retention of granulomatous tissue
• mb gland clogs, swells, becomes inflamed
• can recur
• can progress from an unresolved internal hordeolum
• non-infectious

Symptoms

• enlarges over a long period of time
• slow onset, sterile swelling
• cosmetic concern

Answer 23

Signs

• elevated focal lesion
• dome shaped
• not tender to touch
• not warm to touch
• pebble-like nodule

Management

• warm compress 6x/day for 1-2 wks
• excision/biopsy if super big
• steroid injections with ABs
• if recurrent in same location = sebaceous cell carcinoma L

Question 24

DEMODEX

• Common 8-legged mite
• Affects all age groups
  
  • 90% of adults
  • 50% of kids
• bilateral
• Life cycle:
  
  • ~14 days
  • Adult mite lives 5-6 days in follicle
  • Migration 1 cm/hr
  • Most active at night
• Avg size 0.1 - 0.4 mm
• Human manifestation = Demodicosis
• Demodex Folliculorum:
  
  • Lives in hair follicle
  • Larger, round abdomen
• Eggs more arrow shaped, 0.1 mm dia
• Demodex Brevis
  
  • Lives in sebaceous gland
  • Smaller, pointed abdomen
  • Eggs more oval shaped, 0.06mm dia

Symptoms

• Sore lids
• Redness
• Burning/itching mostly in AM
• Crusty lids
• Bilateral
• Chronic

Answer 24

Signs

• Bilateral
• Inflamed lid margins
• Collarettes wrapped tightly around lash base

Management

• Ung hs to suffocate mites
• Topical steroids to control inflammation
• ABs to accompany steroids bc theyre bffs
• Hot compresses, scrubs
• Tea tree oil with 4-terpinol:
  
  • Use 50% or lower dilution
  • BID 10 days, then QD 10 days
  • Some solns also include buckthorn seed

Question 25

**PHTHIRIASIS PALPEBRUM** * Pediculus Humanus: head/body lice * Phthiris Pubis: crab lice, found on lids, likes spacing/density of lashes * 6 legs, longer/darker than humanus, 1-1.5 mm long * found in areas of close proximity **Symptoms** * sore, red lids * Intense itching, burning * Crusty ass lids * Bilateral

Answer 25

**Signs** * Bilateral * Inflamed margins * Secondary signs of bacterial bleph * Red/black deposits on lids (literal bug shit) * Nits (eggs) wrapped around cilia, baloney appearance * React upon exposure to bright light, hard to see * Blue marks on lids = bites **Management** * Ung hs to suffocate * Seek total elimination: pull eggs off, RTC in a few days * Kids: literally just chop off their lashes if they’re too squirmy lol * Topical steroids for inflammation * Hot compresses, lid scrubs * ABs to control bacteria * Clean bedding, towels @ 140° 20-30 mins, dry on high heat * Contact PCP

Question 26

**MOLLUSCUM CONTAGIOSUM** * Often seen in children, HIV/AIDS population * Epidermal infection of DNA pox virus * Insidious onset * Painless, wart-like lesions * Transmitted by contact, autoinoculation * Usually 2-10mm, round, central umbilication * Multiple lesions together, **core is yellow/”cheesy”** (ddx from basal cell) * Can cause secondary follicular conjunctivitis if virus travels into eye

Answer 26

**Management** * excision and cauterization only when virus no longer active! * self-limiting

Question 27

**VERRUCA** * Caused by HPV – **infectious** (ddx from papilloma) * Can affect upper or lower lid adnexa * Frondular growth (comes out at you?) * Multiple, lobulated, crowded together * Cauliflower-ish presentation

Answer 27

**Management** * May regress with time * Cauterize when no longer active

Question 28

**CONTACT DERMATITIS** * Allergic reaction * Exogenous source * Can affect othwer parts of the face * Unilateral or bilateral **Symptoms** * Itching * Red adnex * Increased tearing * Swollen adnexa

Answer 28

**Sign** * Reddened skin * Edema * Bilateral or unilateral * Xs tearing * Flaky skin as it progresses **Management** * Cold compress for itching/swelling * Topical steroids for inflammation * Anti-histamine