DISORDERS OF LASHES
Madarosis
Signs
- •
Decrease in number or complete loss of lashes.
Causes
- •
See Table 1.1 .
Table 1.1
Causes of madarosis
- 1.
Local
- •
Chronic anterior lid margin disease ( Fig. 1.1 )
- •
Infiltrative lid tumours may cause localised madarosis ( Fig. 1.2 )
- •
Burns ( Fig. 1.3 )
- •
- 2.
Following removal
- •
Iatrogenic for treatment of trichiasis or distichiasis ( Fig. 1.4 )
- •
Cryotherapy or radiotherapy of lid tumours
- •
Trichotillomania which is a psychiatric disorder of habitual hair removal
- •
- 3.
Generalised skin disease
- 4.
Systemic disease
- •
Myxoedema
- •
Systemic lupus erythematosus
- •
Syphilis
- •
Lepromatous leprosy
- •
Fig. 1.1
Fig. 1.2
Fig. 1.3
Fig. 1.4
Fig. 1.5
Fig. 1.6
- 1.
Poliosis
Signs
- •
Localised patch of grey or white hair due to lack of pigment in the epidermis ( Fig. 1.7 ).
Fig. 1.7
Causes
- •
See Table 1.2 .
Table 1.2
Causes of poliosis
- 1.
Idiopathic
- 2.
Local conditions
- •
Chronic anterior blepharitis
- •
Sympathetic ophthalmitis
- •
Lid margin tumours
- •
Herpes zoster ophthalmicus
- •
Alopecia areata
- •
- 3.
Systemic conditions
- •
Vogt–Koyanagi–Harada syndrome in which it is associated with vitiligo ( Fig. 1.8 )
- •
Waardenburg syndrome
- •
Marfan syndrome
- •
Tuberous sclerosis
- •
- 1.
Misdirection
Trichiasis
Signs
- •
Inward turning of previously normal lashes ( Fig. 1.9 ).
Fig. 1.9
Causes
- •
Idiopathic.
- •
Lid margin scarring (e.g. chronic blepharitis, herpes zoster ophthalmicus and trachoma).
Differential diagnosis
- •
Inward turning of lower lid lashes associated with entropion (pseudo-trichiasis – Fig. 1.10 ).
Fig. 1.10
Congenital distichiasis
Definition
- •
A rare, bilateral, hereditary condition.
Signs
- •
Partial or complete second row of lashes originating from or slightly behind the meibomian gland orifices ( Fig. 1.11 ).
Fig. 1.11
Look for
- •
Lymphoedema.
Acquired distichiasis (metaplastic lashes)
Definition
- •
An uncommon unilateral or bilateral condition caused by metaplasia and dedifferentiation of meibomian glands to become hair follicles in late cicatrising conjunctivitis (e.g. ocular cicatricial pemphigoid).
Signs
- •
Crops of stunted lashes originating from meibomian gland orifices ( Fig. 1.12 ).
Fig. 1.12
Eyelash ptosis
Signs
- •
Downward drooping of upper-lid lashes ( Fig. 1.13 ).
Fig. 1.13
Causes
- •
Idiopathic.
- •
Floppy eyelid syndrome.
- •
Long-standing facial palsy.
Differential diagnosis
- •
True ptosis.
- •
Upper lid entropion.
Epiblepharon
Definition
- •
A bilateral congenital condition that is common in Orientals.
Signs
- •
Extra fold of skin stretches across the anterior lid margin and the lashes are directed vertically, especially medially ( Fig. 1.14 ).
Fig. 1.14
- •
When the fold of skin is pulled down the lashes return temporarily to their normal position.
Differential diagnosis
- •
Congenital entropion is characterised by in-turning of the entire lid and lashes with absence of the lower lid crease ( Fig. 1.15 ); when downward pressure is applied to the lid the entire lid becomes pulled away from the globe.
Fig. 1.15
Trichomegaly
Signs
- •
Excessive eyelash growth ( Fig. 1.16 ).
Fig. 1.16
Causes
- •
See Table 1.3 .
Table 1.3
Causes of trichomegaly
- 1.
Congenital
- •
Oliver–McFarlane syndrome – RP, dwarfism and mental handicap
- •
Cornelia de Lange syndrome – synophrys, low hairline, and developmental and musculoskeletal anomalies
- •
Goldstein–Hutt syndrome – cataract and hereditary spherocytosis
- •
Hermansky–Pudlak syndrome – albinism and bleeding diathesis
- •
Oculocutaneous albinism type 1
- •
- 2.
Acquired
- •
Drug-induced – phenytoin, ciclosporin and topical prostaglandin analogues ( Fig. 1.17 )
- •
Malnutrition
- •
AIDS
- •
Porphyria
- •
Familial
- •
Fig. 1.17
- 1.
INFLAMMATORY LID MARGIN DISEASE
Staphylococcal blepharitis
Signs
- •
Lashes – soft scales around lash roots ( Fig. 1.18 ), madarosis, poliosis and trichiasis.
Fig. 1.18
- •
Anterior lid margin – ulceration, notching and microabscesses.
- •
Cysts – acute external hordeolum (stye – see Fig. 1.102 ).
Fig. 1.102
- •
Tear film – dry.
- •
Conjunctiva – papillae and phlyctens.
- •
Cornea – punctate erosions and marginal infiltrates.
- •
Associated dermatitis – atopic (see Fig. 15.1 ).
Seborrhoeic blepharitis
Signs
- •
Lashes – soft greasy scales in between the lash roots and oily lashes stuck together ( Fig. 1.19 ).
Fig. 1.19
- •
Anterior lid margin – shiny.
- •
Tear film – dry.
- •
Conjunctiva – unremarkable.
- •
Cornea – punctate erosions and peripheral infiltrates.
- •
Associated dermatitis – seborrhoeic.
Posterior blepharitis
Signs
- •
Lashes – unremarkable.
- •
Posterior lid margin – notching, oily capping or occlusion of meibomian gland orifices ( Fig. 1.20 ), expressed meibomian secretions may be turbid and toothpaste-like.
Fig. 1.20
- •
Cysts – meibomian (see Fig. 1.100 ).
Fig. 1.100
- •
Tear film – dry and frothy.
- •
Conjunctiva – unremarkable.
- •
Cornea – punctate erosions and infiltrates.
- •
Associated dermatitis – acne rosacea (see Fig. 15.2 ).
| Anterior blepharitis | ||||
|---|---|---|---|---|
| Sign | Staphylococcal | Seborrhoeic | Posterior blepharitis | |
| Lashes | Deposit | Hard | Soft | |
| Loss | ++ | + | ||
| Distorted or trichiasis | ++ | + | ||
| Lid margin | Ulceration | + | ||
| Notching | + | ++ | ||
| Cyst | Acute hordeolum | ++ | ||
| Meibomian | ++ | |||
| Conjunctiva | Phlycten | + | ||
| Tear film | Foaming | ++ | ||
| Dry eye | + | + | ++ | |
| Cornea | Punctate erosions | + | + | ++ |
| Vascularisation | + | + | ++ | |
| Infiltrates | + | + | ++ | |
| Associated dermatitis | Atopic | Seborrhoeic | Acne rosacea | |
Childhood blepharokeratoconjunctivitis
Signs
- •
Lashes – crusty.
- •
Lid margin – chronic anterior and posterior blepharitis.
- •
Cysts – styes and meibomian, often multiple ( Fig. 1.21 ).
Fig. 1.21
- •
Tear film – dry.
- •
Conjunctiva – phlyctens, and follicular or papillary hypertrophy.
- •
Cornea – punctate erosions, axial subepithelial haze, and peripheral infiltrates and vascularisation.
- •
Associated dermatitis – absent.
Angular blepharitis
Signs
- •
Lashes – unremarkable.
- •
Lids – erythema, scaling and fissuring of skin at one or both canthi ( Fig. 1.22 ).
Fig. 1.22
- •
Cysts – absent.
- •
Tear film – unremarkable.
- •
Conjunctiva – follicular conjunctivitis.
- •
Cornea – marginal infiltrates and phlyctens.
- •
Associated dermatitis – atopic.
Phthiriasis palpebrarum
Definition
- •
Infestation of the lashes with the crab louse ( Phthirus pubis ).
Signs
- •
Lashes – adherent lice and ova ( Fig. 1.23 ).
Fig. 1.23
- •
Lids – erythematous.
SUPERFICIAL INFLAMMATION
Allergic
Contact dermatitis
Definition
- •
A common, unilateral or bilateral condition, frequently caused by sensitivity to topical medication.
Signs
- •
Initially there is erythema and oedema associated with ipsilateral conjunctivitis ( Fig. 1.24 ).
Fig. 1.24
- •
Thickening and crusting develops in long-standing cases ( Fig. 1.25 ).
Fig. 1.25
Atopic dermatitis
Definition
- •
An uncommon, bilateral condition which may occur in patients with more generalised skin involvement.
Signs
- •
Erythema, thickening, vertical fissuring, often associated with madarosis and staphylococcal blepharitis ( Fig. 1.26 ).
Fig. 1.26
Look for
- •
See Table 1.5 .
Table 1.5
Ocular associations of atopic dermatitis
- •
Chronic staphylococcal blepharitis
- •
Angular blepharitis
- •
Vernal conjunctivitis in children
- •
Atopic keratoconjunctivitis in adults
- •
Keratoconus
- •
Anterior shield-like cataract
- •
Retinal detachment
- •
Infectious
Herpes zoster ophthalmicus
Definition
- •
A common unilateral infection with varicella-zoster virus that typically affects the elderly.
Signs
- •
Painful maculopapular rash involving the first division of the trigeminal nerve followed by vesicles, pustules and crusting ulceration ( Fig. 1.27 ).
Fig. 1.27
Look for
- •
Hutchinson sign (involvement of the side of the nose).
- •
Anterior uveitis.
- •
Keratitis.
- •
Scleritis.
- •
Neurological complications.
- •
AIDS in young patients.
Impetigo
Definition
- •
A bilateral infection with staphylococci or beta-haemolytic streptococci that typically affects children.
Signs
- •
Small vesicles and bullae which on rupturing produce crusts composed of golden-yellow crystals ( Fig. 1.28 ).
Fig. 1.28
Erysipelas
Definition
- •
A unilateral subcutaneous cellulitis caused by entry of beta-haemolytic streptococci at a site of minor skin trauma.
Signs
- •
Well-defined, erythematous, tender subcutaneous plaque, often with a butterfly configuration ( Fig. 1.29 ).
Fig. 1.29
Necrotising fasciitis
Definition
- •
A rare bilateral but life-threatening necrosis of subcutaneous soft tissues caused by S. pyogenes or S. aureus .
Signs
- •
Black discoloration due to gangrene secondary to underlying thrombosis ( Fig. 1.30 ).
Fig. 1.30
DIFFUSE EYELID SWELLING
Inflammatory causes
Associated with conjunctivitis
Signs
- •
Adenoviral infection in particular ( Fig. 1.31 ).
Fig. 1.31
Associated with dacryoadenitis
Signs
- •
Unilateral tender erythema and oedema involving the upper outer part of the lid causing a characteristic S-shaped deformity ( Fig. 1.32 ).
Fig. 1.32
- •
Injection of the lacrimal gland and conjunctiva may occur ( Fig. 1.33 ).
Fig. 1.33
Associated with dacryocystitis
Signs
- •
Very tender erythema and oedema at the inner canthus with spread to the lids ( Fig. 1.34 ).
Fig. 1.34
Inflammatory orbital disease
Signs
- •
Unilateral or bilateral tender erythema and oedema, and mechanical ptosis ( Fig. 1.35 ).
Fig. 1.35
Angioedema
Signs
- •
Transient painless pitting oedema ( Fig. 1.36 ) that may be associated with oedema of the tongue or lips.
Fig. 1.36
Local non-inflammatory causes
Orbital fat herniation
Definition
- •
A common, usually bilateral, age-related condition.
Signs
- •
Asymmetrical periorbital swelling ( Fig. 1.37 ).
Fig. 1.37
Blunt trauma
Signs
- •
Painful oedema and ecchymosis ( Fig. 1.38 ).
Fig. 1.38
- •
Subcutaneous emphysema caused by medial orbital floor blow-out fracture ( Fig. 1.39 ).
Fig. 1.39
Blepharochalasis
Definition
- •
An uncommon, usually bilateral condition which typically affects young individuals characterised by recurrent attacks of non-pitting oedema of the upper and occasionally the lower lid.
Direct carotid–cavernous fistula
Definition
- •
A high-flow shunt in which carotid artery blood passes directly into the cavernous sinus.
Signs
- •
Severe lid swelling and haemorrhagic chemosis ( Fig. 1.40 ).
Fig. 1.40
Look for
- •
Pulsatile proptosis associated with a bruit.
- •
Anterior segment ischaemia.
- •
Raised intraocular pressure.
- •
Ocular motor nerve palsies.
Rapidly growing tumours
Signs
- •
In rhabdomyosarcoma the swollen lid is frequently red but not warm ( Fig. 1.41 ).
Fig. 1.41
Systemic causes
Myxoedema
Signs
- •
Swelling typically involves the lower lids ( Fig. 1.42 ).
