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Symptom sorter - eyelid problems

GPs Dr Keith Hopcroft and Dr Vincent Forte continue their series on how to make sense of common presentations

GPs Dr Keith Hopcroft and Dr Vincent Forte continue their series on how to make sense of common presentations

The GP overview

Because of their close proximity to the eye, and their occasional cosmetic effect, eyelid problems can be disproportionately distressing to the patient. The differential diagnosis is wide – and it is tempting to treat this presentation as a ‘quickie' but a careful history should be taken.

Differential diagnosis

Common

• Stye

• Blepharitis

• Meibomian cyst

• Xanthelasma

• Blocked tear duct

Occasional

• Periorbital oedema, for example orbital cellulitis, herpes zoster, angio-oedema, nephrotic syndrome, insect bite

• Ectropion

• Entropion (may be secondary trichiasis)

• Eczema (seborrhoeic, allergic)

• Ptosis (congenital, oculomotor nerve palsy, Horner's syndrome, myasthenia gravis, senile, myotonic dystrophy)

• Muscular problems (myokymia, blepharospasm)

Rare

• Malignant growth, for instance BCC

• Benign growths, such as papilloma, haemangioma

• Dacrocystitis

• Alopecia

• Molluscum contagiosum

• Lice

Possible investigations

Likely: Lipid profile

Possible: Urinalysis, FBC, LFT

Small print: Tests for ptosis, biopsy

• Lipid profile If xanthelasma, as may indicate hypercholesterolaemia

• Urinalysis Proteinuria in nephrotic syndrome

• FBC White cell count raised in infective process, such as cellulitis

• LFT Hypoproteinaemia in nephrotic syndrome.

• Further tests for ptosis Usually in secondary care – for example CXR (Horner's), edrophonium test (myasthenia), blood sugar and brain scan (oculomotor palsy)

• Biopsy If malignancy suspected

Top tips

• A Meibomian cyst is often misdiagnosed – by patient and doctor – as a stye, particularly if it is infected.

• Entropion with secondary trichiasis may be overlooked as a cause of a recurring sore, watering eye, especially in the elderly.

• Myokymia – recurrent focal twitching of the orbicularis oculi – is harmless but may distress or alarm the patient.

• Many patients with xanthelasma will already have this in their notes and so have had their cholesterol measured. Enquire about this before wasting resources on further unnecessary checks.

Dr Keith Hopcroft is a GP in Basildon, Essex

Dr Vincent Forte is a GP in Gorleston, Norfolk

Red flags

• Orbital cellulitis requires urgent in-patient treatment
• Bilateral ptosis that deteriorates through the day may indicate myasthenia gravis
• New onset of unilateral ptosis requires investigation – possible diagnoses range from diabetes to malignancy
• Loss of the eyelashes is a poor prognostic sign in alopecia

Eyelid problems

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