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From Eyelids to OrbitsPearls for the ophthalmic technician

Rao V. Chundury, MD MBA

Assistant Professor of Ophthalmology

Oculoplastic and Orbital Surgery

UNMC/NM

Objectives

• Common Eyelid Lesions• Inflammatory

• Benign

• Malignant

• Preseptal vs. Postseptal (Orbital)

• Case presentations

• Pearls along the way

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The Eyelids are Complex

Eyelid Lesions

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Chalazion vs. Hordeolum vs. Stye

• Stye = General term used by public to describe eyelid inflammation

• Hordeolum = localized inflammation/infection, +- cellulitis, 95% S. Aureus• External – Hair follicles, Zeis, Moll

• Internal – Meibomian Glands

• Chalazion = Inflammation from obstruction of MG, can arise from internal hordeolum

Chalazion or Hordeolum

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Pearls• Hordeolum = localized inflammation/infection = responds

to oral abx

• Chalazion = more posterior = warm compresses

You see an eyelid lesion, what do you ask?

• Prior skin cancer

• Sun exposure during adolescence

• Radiation therapy

• Smoking

• Immunosuppression

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It could be benign if?

• Cystic, how can you test?

• Since “forever”

• Conforms to the globe

• Soft

• Painful

It could be malignant if?

• Slow grower

• Ulcer

• Pigmentation

• Loss of eyelashes

• Overlying fine vessels

• Painless

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What are papillomas?

• Basket term to describe a variety of benign skin proliferations• Seborrheic keratosis

• Verruca

• Acrocordon (Skin tag – not a medical term)

• Squamous acanthoma

Seborrheic keratosis

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The HORN

Cutaneous horn

• Descriptive term, not a pathologic diagnosis

• Can be seen with actinic keratosis, SCC, verruca, sebK, BCC, trichilemmoma, keratoacanthoma, epidermal nevus, psoriasis, etc…

• Benign in more than 50% of patients!

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Verruca Vulgaris – AKA Warts

• HPV

• Spread via touch!

Epidermal Inclusion Cysts/Sebaceous Cyst

• Arise from hair follicle

• Filled with keratin

• Can also be infected

• Remove the entire cyst to prevent recurrence

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Epidermal Inclusion Cysts/Sebaceous Cyst

Apocrine Hydrocystoma

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Molluscum

Molluscum on Margin

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Molluscum Contagiousum

• Chronic conjunctivitis

• Waxy nodules with central holes

• Kids, immunocompromised, spread via contact

• Treatments – curettage, cryotherapy, excision

Not Basal Cell Carcinoma -> Sebaceous hyperplasia

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Xanthelasma

Not quite a SCC yet…Actinic Keratosis

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Basal Cell Carcinoma

Basal Cell Carcinoma

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Second most common eyelid malignancy

Pearls• Any lesion which changes eyelid architecture may be cancer• Cysts of the eyelid need to be completely excised or they may recur• Conjunctivitis with associated margin lesion may be molluscum

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Eyelid and Orbital Infections

Preseptal Cellulitis

• Rapid inflammatory signs and symptoms• Full motility, no proptosis, visual function

is normal, isolated to the eyelids

• From skin flora or a hordeolum

• Cephalexin, Bactrim, Clindamycin, Augmentin

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Orbital Cellulitis

• Rapid inflammatory signs and symptoms• Pain, proptosis, motility, vision

• Fever, look sick

• Majority of orbital cellulitis is extension from sinus

• Progression despite antibiotics suggests abscess or fungal

Orbital Cellulitis

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Dacryocystitis

Fractures

• Beware the white-eyed blowout fracture!

• Increased bone flexibility = “greenstick” trapdoor fractures

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Pearls• Orbital signs when present require urgent evaluation

• Be wary of pediatric orbital fractures

Cases

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Case 1

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7/1/17 – POW36/26/17 – “POW2” 7/6/17 – POW4

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Case 2

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Case 3

Arteriovenous Malformation

• Pulsatile

• CT, MRI, Ultrasound, transvenousand/or percutaneous embolization followed by excision may be needed for orbital or high-flow AV malformation

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Case 4

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Case 5

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Gorlin Syndrome

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Gorlin Syndrome

Case 6

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Case 7

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What about cosmetics?

Botulinum Toxin

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Botulinum Toxin

Fillers

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Upper eyelid blepharoplasty

Visual Field SymptomsSkin on the lashes

Lower blepharoplasty

Always cosmetic

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Droopy eyelids (ptosis)

MRD 2Visual Field Symptoms

Questions?