Lesions of the eyelid

Dr Abha Gupta gives an update on diagnosing and treating the most common lid lesions presenting in primary care

Lid pathology is a common presentation to primary care. Lid lesions can be difficult to differentiate and often cause cosmetic distress to the patient. This article describes the diagnosis and management of some common lid lesions and also discusses the basic management of ectropion and entropion.

Meibomian cysts (chalazion)

Clinical recognition

These are firm, painless nodules. They are usually solitary although multiple cysts can be found. They are found more frequently on the upper lid. It is common to also find blepharitis.

Treatment

Small lesions can be left alone. Treatment involves massage and moist heat (see below). Doxycycline (100mg a day for three months) can be of use to minimise infection and to decrease inflammation, but this is reserved for severe cases.

Lid hygiene involves:

• Warm compresses – soak a pad in warm water and apply to each eye for five minutes three to four times a day.

• Lid cleansing – mix baby shampoo with water 50:50. Soak a cotton bud and run along the margin, cleaning off debris from lash base. Do not get any solution in the eye and don't clean inside the lids.

Surgery is beneficial in large or non-resolving lesions. Prophylaxis involves regular lid hygiene.

Key point

Any unilateral non-resolving or recurrent chalazion should be treated as suspicious as sebaceous cell carcinoma can present in this way.

Styes (hordeolum)

Clinical recognition

This is an acute focal infection – usually staphylococcal – involving the glands of Zeis. Styes are focal abscesses and present with a painful, warm, swollen, red lump on the eyelid. They often undergo spontaneous rupture and drainage. Patients with blepharitis or rosacea are at more risk of developing styes.

Treatment

Styes usually improve on their own in one to two weeks. Medical therapy includes eyelid hygiene, warm compresses and topical antibiotics. If a pre-septal cellulitis is present systemic antibiotics are warranted such as co-amoxiclav 375mg tds.

Key point

Surgery – incision and curettage – is only necessary if the lesion is large or resistant to medical treatment.

Xanthelasma

Clinical recognition

These are painless, soft, yellowish lesions in the inner eyelid – most commonly the upper lid.

Treatment

Medical care involves dietary advice and lipid-lowering therapy if necessary. But these measures will not affect the appearance of the xanthelasma themselves.

Surgery is the mainstay of treatment and can involve:

• excision of the lesion

• chemical cauterisation

• cryotherapy and electrodissection – these can leave scars and are not commonly done.

Key point

It is important to be aware that recurrence is common even after surgical removal.

Blepharitis

This is a common chronic inflammatory disease. Anterior blepharitis centres on lashes and follicles while posterior blepharitis involves the meibomian glands. Patients usually experience burning, itchy, erythematous lids. There may be lash changes, including loss. Blepharitis is associated with rosacea and seborrhoeic dermatitis. If left untreated it can damage the lids causing trichiasis, ectropion or entropion, or cause a variety of other problems including conjunctivitis, cysts or corneal damage.

Clinical recognition

Erythema and crusting on the lid margins is common. Additional features depending on severity are loss of lashes (madarosis), whitening of lashes (poliosis) and trichiasis. There may be corneal involvement.

Treatment

Lid hygiene is of utmost importance and must be continued after symptoms clear. Topical antibiotics such as chloramphenicol may be of use. Oral doxycycline can be used for severe or recurrent blepharitis. Artificial tears may be necessary for tear film abnormalities or corneal involvement.

Key point

Unilateral or asymmetrical blepharitis should arouse suspicion as lid carcinomas can present this way.

Entropion

Clinical recognition

This is an inversion of the eyelid, usually the lower. It can lead to ocular surface damage if left untreated.

Entropion is classified as:

• Congenital – this is rare and often resolves over time. It may be associated with other developmental abnormalities. Recurrent infections tend to be common.

• Involutional – this is the most common form and is the result of inferior retractor dysfunction and tissue laxity.

• Cicatricial – this is uncommon. It is due to scarring resulting in an inward rotation of the lid. Scarring can be secondary to burns, Stevens-Johnson syndrome, ocular cicatricial pemphigoid, infections or local response to topical medication.

The cicatrising process must be treated medically before surgery.

There are many surgical procedures for entropion – depending on the classification and patient factors. There are temporising measures that can be performed as well as more invasive surgical procedures.

Key point

Cases of entropion may require regular ocular lubrication while the patient is waiting to see an ophthalmologist. There may be an associated trichiasis.

Ectropion

Clinical recognition

This is an eversion of the eyelid, usually the lower. Again this threatens the ocular surface. Patients may complain of epiphora, recurrent infections, irritation or the sensation of a foreign body.

Clinical examination shows an everted lid. Sometimes the punctum may also be everted depending on severity.

Constant wiping because of the epiphora can exacerbate the problem and it is important to advise patients of this.

Ectropion is classified as:

• Involutional – the most common cause and a result of age-related tissue laxity.

• Cicatricial – this is uncommon and is secondary to scarring. Causes include trauma, burns, radiotherapy and dermatitis.

• Mechanical – again uncommon. It is secondary to masses displacing the lid away from the globe. Ophthalmology will identify and treat the cause, then deal with any residual ectropion.

• Paralytic – this is secondary to seventh nerve palsy. There is an associated weakness of the other facial muscles. Lagophthalmos – an inability to fully close the eyelids – and corneal exposure are likely. Patients should be told to be vigilant for any redness, pain or reduction in vision. Topical lubricants and taping the lid shut at night are helpful.

Key point

Surgery is the mainstay of treatment and depends on patient factors as well as the specific defect.

Dr Abha Gupta is a specialty registrar ophthalmologist at the Princess Alexandra Eye Pavilion, Edinburgh

Competing interests None declared