Lagophthalmos. Lagophthalmos: signs. Lagophthalmos: clinical tips. Lagophthalmos: treatment plan. Madarosis

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Moses Barrett
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Lagophthalmos Def: incomplete closure of the eyelid SX: FBS, irritation, red, burn, dry, chronic morning corneal irritation Lagophthalmos: signs 2-5 mm lid separation with slit lamp during blink can

1 Lagophthalmos Def: incomplete closure of the eyelid SX: FBS, irritation, red, burn, dry, chronic morning corneal irritation Lagophthalmos: signs 2-5 mm lid separation with slit lamp during blink can force complete closure upon demand Secondary corneal involvement SPK Epith. erosion corneal anesthesia Lagophthalmos: clinical tips R/O tear dysfunction (tbut, schirmers) Look for ABMD (anterior basement membrane dystrophy) Check Bell s phenomenon Lagophthalmos: treatment plan Lubricants- gtts and ung Tape lids at night Lateral tarsorrhaphy in severe cases with corneal threat Bandage lens Madarosis Def: loss of eyelashes Unilateral or bilateral Usually in patches Eyebrow not usually involved

Madarosis: Etiology Staphylococcus hypersensitivity most common Onset > 3 mos,

Neurotic twisting, twirling or pulling out of hair Potential sites: beards,

Cosmetic concern Poliosis Def: whitening of eyelashes, loss of pigment of

2 Madarosis: Etiology Staphylococcus hypersensitivity most common Onset > 3 mos, poorer prognosis R/O Systemic relationship, trichotillomania Trichotillomania Neurotic twisting, twirling or pulling out of hair Potential sites: beards, mustaches, long hair, eyebrows, eyelashes Potential cause of madarosis Cosmetic concern Poliosis Def: whitening of eyelashes, loss of pigment of lashes Patchy or complete Most frequent cause is staph. R/O vitiligo > 3 mos poor prognosis

asymptomatic secondary poliosis Vitiligo more prominent in dark-skinned individuals Associated ocular syndrome VKH (

3 Vitiligo def: well defined hypopigmented or depigmented patches of skin usually bilateral any body surface may be affected onset usually before age 20 Vitiligo strong family tendency (50%) slowly progressive, enlarges with age asymptomatic secondary poliosis Vitiligo more prominent in dark-skinned individuals Associated ocular syndrome VKH ( Vogt- Koyanagi-Harada) Associated systemic causes (thyroid, anemias, pituitary) Vitiligo Dermatology consult Protection from sun

Malignant tumors of the eyelid Commonly shared characteristics Asymptomatic or mildly irritating May see skin ulcerations, inflammation and distortion of the eyelid H/O extensive sun exposure, more

4 Malignant tumors of the eyelid Commonly shared characteristics Asymptomatic or mildly irritating May see skin ulcerations, inflammation and distortion of the eyelid H/O extensive sun exposure, more frequent with fair complexion. Malignant tumors of the eyelid Palpate preauricular and submaxillary nodes for metastasis Inspect for loss of lashes and destruction of meibomian orifices Photography to document as well as FAT Suspicious lesion For definitive diagnosis must biopsy Incisional surgical removal and histological eval is the treatment of choice Cryo. and radiation rarely used- distorts histopathology Basal Cell Carcinoma Most common malignant eyelid tumor (90%) Slow growing, frequently multiple sites Typical location: lower lid near medial canthus Middle aged to elderly BCC- typical appearance Firm nodule with telangiectatic vessels over the margin. Center ulcerated to varying degrees with various amts of central pigment. Pearly borders. May also present as subcutaneous firm flat poorly defined mass, but less common. Does not metastasize, but can be highly locally invasive inner canthus)

Squamous Cell Carcinoma Appearance may be

blood or lymphatics) Premalignant variant

Keratoacanthoma Sebaceous or seudoriferous

5 Squamous Cell Carcinoma Appearance may be similar to BCC Metastasis may occur (thru blood or lymphatics) Premalignant variant is Actinic keratosis often appears scaly & flat or as a cutaneous horn Benign Differentials Seborrheic keratosis Keratoacanthoma Sebaceous or seudoriferous cyst Molluscum Contagiosum Nevus Xanthelasma Verrucae Papilloma

Seborrheic keratosis middle-aged to elderly black-brown, well circumscribed crusty lesion usually slightly elevated with but not inflamed appears stuck on to epidermis Keratoacanthoma rare,

lesion begins as a erythematous papule grows to a relatively large size then spontaneously resolves Sebaceous cyst Well circumscribed, asymptomatic fatty fibrous cyst caused by the blockage

6 Seborrheic keratosis middle-aged to elderly black-brown, well circumscribed crusty lesion usually slightly elevated with but not inflamed appears stuck on to epidermis Keratoacanthoma rare, elevated, firm, pink nodule with a keratin-filled central ulceration. lesion begins as a erythematous papule grows to a relatively large size then spontaneously resolves Sebaceous cyst Well circumscribed, asymptomatic fatty fibrous cyst caused by the blockage of the sebaceous gland duct. Contains cheesy, yellowish material with a central punctum. Long term this material becomes fibrous. Common in inner and outer canthal regions Sebaceous cyst Usually 2-5 mm in size Can be superficial or subcutaneous Normal skin texture overlying Treatment is by drainage or excision

7 Sudoriferous cyst fluid filled cyst of gland of moll asymptomatic, small, round, may be multiple Tx: puncture with hypodermic or cauterize Verrucae Viral wart Slow, insidious history

Molluscum contagiosum viral etiology---->

contagious most commonly seen in children

8 Molluscum contagiosum viral etiology----> follicular conjunctivitis mildly contagious most commonly seen in children typical lesion is small, pale, umbilicated, elevated papule center contains a yellow cheesy material when active Molluscum contagiosum: treatment observation surgical excision cryotherapy expression of cheesy material

Nevus light to dark brown well circumscribed and well defined margins does not grow in size (pigmentation can

plaques in upper eyelid, most often medially, multiple and often bilateral?

seen on the mucocutaneous border epithelial overgrown with rough surface incr.

9 Nevus light to dark brown well circumscribed and well defined margins does not grow in size (pigmentation can incr.) congenital or early onset Xanthelasma collection of lipid material in the dermis presents a yellow plaques in upper eyelid, most often medially, multiple and often bilateral?lab test: serum cho, lipid profile cosmetic removal Papilloma most common benign tumor of the eyelid frequently seen on the mucocutaneous border epithelial overgrown with rough surface incr. incidence with age asymptomatic, various size and shape, cosmetic concern may have broad base or pedunculated pigment range black to amelanotic TX: snip off if base is < 2 mm otherwise refer

Hemangioma Def: Benign vascular tumor ranging in

Port-wine stain (nevus flammeus)**** Capillary Most

Flat, superficial and rapidly growing Resolve

10 Hemangioma Def: Benign vascular tumor ranging in color from pink, purple, blue, red. Usually noted at birth or early infancy Classifications Capillary (strawberry)**** Spider Port-wine stain (nevus flammeus)**** Capillary Most common. Often superior nasal. Flat, superficial and rapidly growing Resolve spontaneously??? Amblyopia threat Occlusion therapy of good eye Importance of retinoscopy Steroid injection therapy Laser

Lid Lesions: Relax or Refer

Lid Lesions: Relax or Refer Blair Lonsberry, MS, OD, MEd., FAAO Professor of Optometry Pacific University College of Optometry blonsberry@pacificu.edu Agenda Benign vs. Malignant lesions Benign Eyelid