External Eye - Lashes Eyelids and Lacrimal System

This article gives an overview of problems concerning the lashes, the lids and the lacrimal system. See separate records for more detail on:

• Allergic eye disease
• Blepharitis
• Blepharospasm
• Epiphora (watering eyes)
• Ptosis and lid lag
• Orbital cellulitis
• Congenital nasolacrimal duct obstruction
• Dacryocystitis
• Eye trauma

Trichiasis¹

This is a group of acquired conditions characterised by eyelashes making intermittent or constant contact with the ocular surface. It may arise in a number of circumstances:

• A normal lash is misdirected (for example due to scarring: a major problem following trachoma infection in developing countries) and rubs against the cornea.
• Metaplastic eyelashes grow as a result of chronic inflammation or scarring - if this growth is behind the lash line, contact with the ocular surface may occur.
• Congenital metaplastic eyelashes (distichiasis) may rarely occur where a partial or complete second row of lashes emerge behind the meibomian gland orifices. In a minority of these patients, there is an association with chronic lymphoedema, spinal arachnoid cysts and congenital heart defects (lymphoedema-trichiasis syndrome).²
• As a result of entropion (see 'lids', below).

With the exception of distichiasis, treatment is aimed at limiting any scar formation (for example through good control of meibomian gland inflammation or blepharitis) and where necessary, removing the offending lash(es). Epilation works for about 4-6 weeks but more permanent solutions include electrolysis of the problematic lashes, cryotherapy where there are many lashes involved and where there is a localised growth of lashes that are otherwise treatment resistant, a wedge resection of that part of the lid may be performed. Other than epilation, these treatments are carried out in a lid clinic or on an oculoplastics theatre list and they are associated with a ~70% success rate. Distichiasis requires more involved oculoplastic surgery.

Poliosis²

This is premature, localised whitening of the lashes and eyebrows. Ocular causes include chronic anterior blepharitis and sympathetic ophthalmitis. Systemic causes include the Vogt-Koyangi-Harada and Waardenburg syndromes. In rare cases, it has been seen as an early manifestation of conjunctival melanoma and tuberous sclerosis.

Madarosis³

This is where there is a decrease in number or loss of eyelashes altogether. Causes may be:

• Infective: chronic staphylococcal blepharitis, leprosy, parasitic infection (e.g. Demodex folliculorum) and as a result of systemic fungal infections (e.g. paracoccidioidomycosis).
• Due to autoimmune disorders: these include alopecia areata, discoid lupus erythematosus, systemic lupus erythematosus and scleroderma.
• Due to endocrine disorders: hypothyroidism, hyperthyroidism, hypopituitarism and hypoparathyroidism.
• Drugs and toxic: long-term use of Botulinum A injections (for orofacial dystonia) and drugs such as miotics, anticoagulants, cholesterol-lowering drugs, antithyroid drugs, boric acid, bromocriptine, propranolol, valproic acid and chronic epinephrine therapy have been reported to cause loss of eyelashes. Ciliary madarosis has also been reported following cocaine use. Intoxication with arsenic, bismuth, thallium, gold, quinine and vitamin A can also cause loss of eyelashes.
• From tumours: both benign and malignant - see below.
• Other problems such as those related to skin disorders (e.g. psoriasis), following removal (iatrogenic - see trichiasis above - or due to trichotillomania), a variety of metabolic diseases (e.g. mitochondriopathy, malnutrition, sickle cell anaemia, HIV infection) and congenital causes (e.g. Ehlers Danlos syndrome and lid coloboma).

Phthiriasis palpebrum⁴

Phthirus pubis infestation occurs in pubic hair but may also affect children living in poor hygienic conditions. It causes irritation and itching and is managed by trimming of the lashes, destruction of the lice and ova (e.g. yellow mercuric oxide 1%) and delousing of the patient and other family members.

Allergic disorders²

These may arise in several forms:

• Acute allergic oedema - this is usually caused by insect bites but is also seen where there is angio-oedema, urticaria and occasionally in response to drugs. There is painless pitting periorbital oedema in a well patient. Systemic anti-histamines may help.
• Contact dermatitis - this can occur in response to topical medication (due to the active component or the preservative), particularly chloramphenicol, neomycin and dorzolamide. Treatment is withdrawal of the offending agent ± a short course of mild steroid cream.
• Atopic dermatitis (eczema) - there is thickening, crusting and vertical fissuring of the lids. Treatment is with emollients ± mild topical steroid cream.

Infections

A wide variety of infections can occur in the external eye:

• Herpes zoster ophthalmicus⁵ - shingles occurring in the first division of the trigeminal nerve gives rise to the characteristic unilateral maculopapular rash, often associated with marked pain and systemic malaise (may last up to 1 week prior to the development of the rash) and typically occurs in the older patient population. The eyelid, conjunctiva, episclera, sclera, cornea and anterior chamber may all be involved. Treatment is with systemic antivirals (e.g. famciclovir 750 mg o.d. for 7-10 days). Management of the lid involves cool compresses and topical lubrication ± topical antibiotics for secondary infections. The patient should be referred to the ophthalmology department the same day to rule out globe involvement - see record on Corneal Problems.
• Herpes simplex⁴ - primary infection is usually not clinically apparent unless occurring in the neonate (see Ophthalmia Neonatorum) or when associated with atopic dermatitis or immunodeficiency. Secondary infection frequently manifests itself as a dendritic corneal ulcer which needs to be further assessed in the Eye Unit to rule out deep structure involvement. Simple lid involvement in the absence of any deeper manifestation may be treated symptomatically with cool compresses ± antibiotic ointment to prevent secondary vesicle infection. Secondary disease is also managed with oral aciclovir (200 mg-400 mg 5 times a day for 7-14 days).
• Impetigo² - this superficial skin infection caused by Staph. aureus and Strep. pyogenes most commonly occurs in children and the lids will be often involved where there is infection of the face. Treatment involves both topical antibiotics and systemic flucloxacillin or erythromycin.
• Erysipelas - Strep. pyogenes causes this more unusual, acute expanding cellulitis. Lid involvement may be severe. It is treated with phenoxymethylpenicillin or erythromycin.
• Necrotising fasciitis - periocular infection is rare and may be secondary to trauma or surgery. Periorbital redness and oedema with subsequent bulla formation and black gangrenous discolouration of the skin are characteristic and prompt treatment with intravenous antibiotics as well as surgical debridement are essential.

Benign lumps²

• Chalazion - this is a chronic, sterile lipogranulomatous lesion formed within the meibomian gland when the orifice blocks off. This may be a multiple or recurrent problem which particularly (but not exclusively) affects patients with acne rosacea and seborrhoeic dermatitis. It presents as a non-tender, gradually enlarging roundish, firm lesion in either the upper or lower lid. Some chalazia disappear spontaneously or do not bother the patient but a simple minor operation carried out in the Eye Unit should correct those that trouble patients (cosmesis and, when very large, may cause slight visual difficulties).
• Internal hordeolum (infected chalazion) - the gland should be 'milked' after application of a warm compress to try and express its contents but ultimately, the patient may benefit from a short course of topical antibiotics. The lesion cannot be excised until the infection has subsided as there is a risk of spread in the acute state.
• External hordeolum (stye) - this is an acute staphylococcal abscess of a lash follicle. It tends to affect children and presents as a tender lid margin swelling pointing anteriorly (there may be multiple small lesions). Treat with lash removal, warm compresses and 'milking' (gently massage the lesion to try and express contents through the follicle) ± a short course of systemic antibiotics if it is very large (consider referring if child is unwell).
• Cysts - there are various cysts that can arise around the eye. Common ones include sebaceous cysts (as with any other part of the body), cysts of Moll (benign, non-tender translucent lesions arising from the apocrine sweat glands) and cysts of Zeiss (similar to cysts of Moll but containing oily secretions). Cysts can be removed in a simple minor operation procedure under local anaesthetic.

Benign tumours

• There are a number of lesions that can occur around the periorbital skin in a similar manner to any other part of the body, including seborrhoeic keratosis, actinic keratosis (N.B. 20% of cases may progress to squamous cell carcinoma),⁶ cutaneous horn formation, keratoxanthoma formation and melanocytic naevi.
• Pyogenic granuloma - this is a pink, vascular, often pedunculated lesion growing out from the inside of the lid which usually arises following surgery or trauma. If large or symptomatic, it can be excised.
• Capillary haemangioma (strawberry naevus) - this is rare (although one of the most common tumours of infancy) and when it occurs around the eye, tends to form on the upper lid. The tumour usually grows rapidly in the first year of life before receding. If the vision is threatened (a large tumour may close the eye or dent the cornea, so giving rise to astigmatism ± amblyopia), treatment may be warranted. This may involve laser treatment, local steroid injection (there are a number of complications) or systemic steroids if there is associated visceral involvement. Only a few cases will go on to have surgical intervention.

Malignant tumours²

• Basal cell carcinoma - accounts for >90% of all neoplastic eye lesions: look for the shiny, firm pearly, umbilicated nodule. It most frequently occurs on the lower lid (followed by the medial canthus, upper lid and lateral canthus). There is a sclerosing, non-nodular type which is less common and difficult to diagnose but look for an indurated plaque ± lid distortion and lash abnormalities. Younger patients predisposed to basal cell carcinoma include those with xeroderma pigmentosum and Gorlin-Goltz syndrome.
• Squamous cell carcinoma - this accounts for ~5% of lid malignancies and may arise from pre-existing actinic keratosis.The tumour tends to occur on the lower lid at the margin, commonly in fair-skinned elderly people with a history of sun exposure. It may be plaque-like (rough, scaly erythematous patch), nodular or ulcerating with a sharply defined base and everting borders. It can be aggressive: refer early if you suspect this.
• Sebaceous gland carcinoma - this is a rare, slow-growing but aggressive tumour usually affecting the elderly and commonly arising from the meibomian glands. In contrast to the previous two tumours, it tends to occur on the upper lid. It has a bad prognosis with an overall mortality rate of ~ 10%. A history of recurrent presumed chalazion or chronic unilateral blepharoconjunctivitis should raise suspicions.
• Other tumours - other more rare tumours occurring around the lids include melanoma (<1% of eyelid neoplasms: irregular pigmentation, inflammation, bleeding), Kaposi's sarcoma and Merckel cell carcinoma.

Ectropion⁷

• Description - this is an outward turning of the lid margin. Involutional ectropion (occurring with old age) is the most common form. Paralytic ectropion occurs following a seventh cranial nerve palsy and cicatricial ectropion can occur following burns, trauma and chronic dermatitis. Problems arise due to conjunctival and (particularly) corneal exposure.
• Presentation - it may be asymptomatic or the patient may complain of tearing (eye rubbing will make the ectropion worse) and irritation ± a red eye. Rarely, there will be complaints relating to exposure keratopathy (dry cornea).
• Assessment - examine the lids, their apposition to the globe (does the tear meniscus lie between the lid margin and the globe or somewhere down in the fornix?) and the position of the puncta with regards to the globe - the punctum should not normally be visible: if it is, there is punctal ectropion. Assess the cornea with fluorescein staining to rule out exposure keratopathy.
• Management - lubricants and artificial tears will do initially but ultimately, surgery is the only corrective measure (this can often be done under a general anaesthetic). If the ectropion is severe (assess by lying patient in supine position and asking to close the eyes), taping the lids overnight can provide a temporary solution whilst waiting for surgery.

Entropion⁸

• Description - this is an inward turning of the lid margin. As with ectropion, it may be involutional or cicatricial but it may also occur as a result of acute muscle spasm in response to ocular irritation (e.g. infectious, inflammatory or traumatic) and rarely, it may be congenital. Again, the main issue is its effect on the cornea.
• Presentation - ocular irritation, foreign body sensation, tearing and redness.
• Assessment - assess the eyelashes to distinguish entropion from trichiasis (see above) and the cornea for evidence of damage. Severe or recalcitrant cases may need a conjunctival biopsy if ocular mucous membrane pemphigoid is thought to be the underlying cause.⁶
• Management - temporising measures may include taping or, in the case of muscular spasm, botulinum injection (the effects last about 3 months) but ultimately, these patients will need corrective surgery.

Lagophthalmos

• Description - this refers to the inability to completely close the eyelids over the globe. It can occur in a number of circumstances including proptosis (exophthalmos), mechanical inability to close the lids (for example due to trauma), a paralysis of orbicularis oculi (such as may occur following a CVE or surgery) and leprosy. Occasionally, it occurs during sleep only (nocturnal lagophthalmos).⁹ Other than considerations of the underlying cause, the concern lies in the development of exposure keratopathy.
• Presentation - the patient may complain of problems associated with exposure keratopathy: discomfort, redness, (compensatory) tearing and if severe, photophobia and decreased visual acuity.
• Assessment - patients should be asked to close their eyes: look for the Bell's phenomenon (the globe should roll up when the lid closes) - if it is poor or absent, there is an increased risk of corneal damage. Examine the cornea and assess the patient for any of the underlying causes outlined above.
• Management - underlying causes should be managed (think of orbital diseases in proptosis: thyroid eye disease, orbital tumours, lacrimal gland tumours, orbital inflammatory pseudotumour) in addition to intensive lubrication ± taping at night. Irreversible causes may warrant referral for more permanent surgical intervention.

Acquired disorders of the lid

• Dermatochalasis - this is a condition which largely affects elderly patients and is characterised by (usually bilateral) herniation of fat through the orbital septum giving rise to a saggy appearance of the skin under the eyebrow, overlying the lids. If it is severe, a simple surgical procedure can go some way towards correcting it.
• Blepharochalasis - this rare condition involves repeated episodes of painless non-pitting oedema of both upper lids which spontaneously resolves. Episodes tend to start during puberty and decrease in frequency with age. There may be an end-result of sagging eyelid skin.
• Floppy eyelid syndrome - this self-describing problem tends to occur in obese men and is often associated with sleep apnoea and snoring. The loose lids tend to part during sleep so resulting in an exposed cornea and chronic papillary conjunctivitis. Treatment is with lubricants and in severe cases, surgery. Patients manifesting other symptoms and signs relating to sleep apnoea may need to be referred to a respiratory physician.⁶
• Lid retraction - this describes the situation where the upper lid margin rests above the superior corneal limbus (where the cornea meets the sclera) and can arise from a number of causes:
  • Thyroid eye disease
  • Neurogenic causes (e.g. facial nerve palsy, hydrocephalus, sympathomimetic drops)
  • Mechanical causes (e.g. over correction of ptosis, scarring of upper lid skin)
  • Congenital causes (e.g. Down's syndrome)

Congenital disorders of the lid

• Epicanthic folds - these are bilateral vertical folds of skin at the medial canthi which may give rise to the impression that the baby has an esotropia (inward turning squint). This can be ruled out by looking at the position of the light reflection of a pen torch with respect to the position of the pupil. Orthoptist assessment can confirm or refute this.
• Epiblepharon - this is the phenomenon where there is an extra fold of skin on the anterior lid margin which causes the lashes to be directed vertically rather than out. Manual correction restores the normal position. The majority of cases resolve with age.
• Coloboma - this is the uncommon condition of a partial or full thickness defect of the lid and is associated with systemic conditions such as Treacher Collins' syndrome. Treatment is surgical.

Blocked lacrimal ducts

• Description - obstruction may occur at any level of the drainage system from the puncta to further down the nasolacrimal duct. Idiopathic stenosis is by far the most common cause but other aetiology includes trauma, Wegener's granulomatosis, infiltrating nasopharyngeal tumours and stones (dacryoliths). Congenital nasolacrimal obstruction usually refers to delayed canalisation (which occurs in at least 20% of infants in the first year of life) which often resolves spontaneously.
• Presentation - infants present with a sticky non-infected and non-red eye. They are well with it. Both sides may be affected. Later on, presentation is with epiphora (excess tearing) and there may sometimes be an associated ectropion due to constant rubbing away of the tears.
• Assessment - babies are left alone until at least two years of age. Adults and older children can undergo canal probing: this is carried out in the lid clinic (adults) or under anaesthetic (children). If this is inconclusive, a dacryocystography (DCG) may be carried out. This involves taking plain film images after injection of radiopaque contrast into the system.
• Management - if the symptoms are really problematic, surgical correction can be performed (this needs to be done under a general anaesthetic). Traditionally, an external approach involving a few sutures over the position of the sac is used but increasingly, an endoscopic procedure is favoured, often carried out jointly by the ENT and oculoplastic surgeons.

Dacryocystitis⁴

• Description - this is an inflammation of the nasolacrimal sac which is almost always related to nasolacrimal duct obstruction. Less commonly, it may be due to local diverticula, dacryoliths and nasal or sinus surgery/trauma.
• Presentation - there is pain, erythema and swelling over the sac (look for it in the innermost aspect of the lower lid) associated with tearing and discharge which can be expressed from the punctum when pressure is applied on the sac. The swelling may extend around the periorbital area nasally. The patient may be pyrexial. Rarely, there is an associated orbital cellulitis.
• Assessment - palpate the lesion and see if pus can be expressed to confirm the diagnosis. A further assessment should be made to help exclude orbital cellulitis (is there pain or restriction on ocular motility? Is vision impaired? Is there proptosis?).
• Management - well children can be managed at home with augmentin (20-40 mg/kg/day in 3 divided doses) but febrile or otherwise acutely unwell children need admitting for intravenous antibiotics. Well adults can be managed with oral cephalexin 500 mg q.d.s. or amoxicillin 500 mg t.d.s. Acutely unwell or febrile patients benefit from hospital admission and intravenous antibiotics. If the cause is obstructive, episodes of dacryocystitis are likely to recur in which case, these patients benefit from surgical correction (see above). This can only be carried out once the acute episode has resolved.

See record on Dacryocystitis and Canaliculitis for more detail on this condition.