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Absence of portion of eyelid

Usually unilateral/upper eyelid/medial to middle third

Can occur in eye - lower third

Significant corneal staining w/ corneal exposure - which is common if 30% or more missing

Cornea could become keratinized

Treatment: AT or ung for ALL/mild cases

For more severe (corneal infection risk), also use antibiotic ung: bacitracin BID-QID, polysporin(polymixin B and bacitracin zinc) IO at night or BID-QID, erythromycin(macrolide) BID-QID, gentamicin(aminoglycoside) BID-QID...or viscous antiobiotic gtt: azasite(macrolide) 1 gt BID for two days and 1 gt QD for five days, besivance(fluoroquinolone) 1 gt TID for seven days

Lid replacement if 75% missing (w/in 48 hrs of birth - if less severe wait 3-6 months b/c anesthesia

Double row of lashes that originate at Meibomian orifices

Smaller, shorter, more delicate, misdirected usually

Possible/likely corneal staining

Usually autosomal dominant if inherited

Treatment: lubricants of cornea, epilation or electorysis of lashes, cryotherapy or surgical removal if severe, antibiotic prophylactically(same as coloboma)

Epicanthal Folds
Redundant fold from upper to lower lid in medial canthus

Usually bilateral

Asian/Caucasian common

Seen in patients with flat bridges, may mimic esotropia - don't misdiagnose

NO treatment
Drooping lid - 2mm or more of superior corna covered

IF - measure at widest point, in normal patients, upper lid 1mm below superior limbus

LC - margin of lid up to the crease(where levator inserts); Epiblepharon = extra lid crease

MPD/MRD - pupillary reflex to lid margin

Levator Excursion - how well levator works; have patient look down as far as they can, then up as far as they can - measure in mm
Aquired Ptosis (Neurogenic)
Third Nerve Palsy - most commonly vascular in origin, could be hypertension

Eye could be "down and out" b/c same blood supply to superior/medial rectus and inferior oblique (diplopia)

Usually resolves w/in 90 days if benign b/c recanalization

Complete ptosis - eye shut

Neurologic Emergency if pupil involved(dilated) - intracranial aneurysm

If pupil not involved, follow patient daily to make sure

Horner's Syndrome - sympathetic interruption - ipsilater miosis, anhydrosis

LC the same b/c aponeurosis not affected

Chest X-ray if patient is smoker - tumor could compress nerve

If congenital, often associated with heterochromia
Aquired Ptosis (Mechanical)
Excess weight of lid - swelling, tumors, etc...

Conjunctival Scarring

Dermatochalasis - "pseudoptosis," loose lid folds, older patients, loss of elastin, effects of gravity, weak connective tissue...COMMON
Aquired Ptosis (Myogenic)
Aponeurotic - levater insertion pulled back or lost grip, increased LC, MOST COMMON TYPE OF AGE-RELATED PTOSIS

Myasthenia Gravis - loss of ACh receptors, ptosis varies throughout day and may alternate b/w right and left, intermittent VARIABLE diplopia

Ice Pack Test - over affected eye for 5-7 mins. and retest, delays AChe
Aquired Ptosis Treatment
Treat underlying condition

Ptosis crutch - attaches to glasses


Phenylephrine - helpful for minor Horner's
Congenital Ptosis
Developmental anomaly of levator

Have to use frontalis to look up

"Lid Lag" - in downgaze b/c levator won't stretch either (lack of tissue)

Ptotic eye in straight gaze will be higher in downgaze

Could develop amblyopia if affected certain gaze

Treatment: delay surgery till 4 months unless severe, protect cornea
Floppy Eyelid Syndrome (FES)
Soft, rubbery tarsal plate - loss of elastin

Easily everted during sleep - superior palpebral papillary response and possible PEK

Primarily obese males

Treatment: bacitracin BID-QID, gentamicin(aminoglycoside)  TID, tape lids, eye shield, follow 3-7 days till stable, surgery has variable results
Involuntary contractions of orbicular oculi


Can be functionally blind

Treatment: underlying disease, botox, sugery to remove orbicularis oculi
Seen in mentally retarded/schizophrenic patients and/or with barbiturate abuse
Lid Myokymia

Spontaneous fascicular tremor

Caused by any type of disease, stress, fatigue

Treatmeant: reassuring patient, antihistamines (increase time between APs), quinine - found in tonic water, same as antihistamine
Outward turning of eyelid

Etiology: Involutional/Age-related (senile), CNVII palsy, cicatricial, mechanical - weight (dermoid), allergic, congenital

C/O: tearing, irritation, FBS, may see PEK, injection, kertinization

Treatment: lubricants, antibiotic ung if area at risk for infection, F/U 1-2 weeks, tape lids, surgery
Inward turning

Etiology: senile, cicatricial, spastic, congenital

C/O: tearing, irritation, red eyes, may see PEK, injection

Treatment: antibiotic ung, tape lids, superglue lids, epilate lashes if trichiasis is mild, surgery, F/U as needed
Misdirected lashes

C/O: FBS, irritation, tearing, PEK, injection

Etiology: chronic bleph, entropian, distichiasis, idiopathic

Treatment: removing lashes, antibiotic ung if PEK present
Incomplete lid closure - opens normally

Etiology: orbital/proptic, nocturnal, mechanical, paralytic

C/O: FBS, morning irritation, dry eyes, PEK in exposed area - middle/lower 1/3 of cornea

Treatment: lubricating ung qhs, antibiotic PRN, soft CL as bandage, tape lids, tarsorrhapy
Cyst of Moll
Moll glands are modified sweat glands at eyelash margins (each follicle)

Excise, benign, called sudoriferous cyst
Cyst of Zeis
Zeis glands are sebaceous glands at eyelash margins (each follicle)

Excise, benign, more opaque
Sebaceous Cyst
Yellowish white, usually multiple lumps on skin

Have central punctum which looks like blackhead

Multiple lesions known as milia

Excise, benign
Cholesterol deposits and other lipids w/in skin

Investigate for hyperlipidemia in young patients

Tend to recur, benign
Molluscum Contangiosum
Viral wart - frequent in healthy children or immunocompromised adults (worry about HIV)

Small lesions w/umbilicated centers, see cheesy core that often spontaneously drains (clean with alcohol)

May be multiple

Can puncture and express in office - clean after with alcohol

Resolves w/o scars

Rule out Basal Cell Carcinoma
Verrucae Papillomata - benign overgrowth of epithelial cells

Verruca Vulgaris - pedunculated

Verruca Plana - flat

Keratin may build up and cause cutaneous horn

Rough surface - cauliflower-like

Many have viral etiology and are linked w/various subtypes of HPV
Rapidly growing epithelial lesion w/central core of keratin

Grows vigorously over 3 months and then spontaneously involutes

Excise if no resolution - small portion may progress to squamous cell carcinoma
Local/generalized mass with vascular changes from capillary system

May involute or can be surgically excised if cosmesis or visual function impaired

Worse in children while crying

Blanch with pressure - distinguishes from Sturge-Weber syndrome

40% involute by age 4, 80% by age 8
Actinic Keratosis
Yellowish rough crusty lesions that bleed easily

PRE-MALIGNANT Lesion which may lead to squamous cell carcinoma

From overexposure to sun

Excise promptly

Appears similar to sebaceous keratosis which is benign but looks greasier
Squamous Cell Carcinoma
Deeply ulcerated lesion with elevated edges

May metastisize to lymph nodes

VERY dangerous

Destroys lashes, lid tissue

Radical excision

Second most common form of skin cancer after basal
Basal Cell Carcinoma
Most common malignancy of eyelid

Mostly 40-79 years old

Highest prevalence in Australia

Uncommon in dark-skinned populations

Assiociated with UV exposure

More prevalent in lower lid

"Classic" type - pearly borders, ulcerated center, variably pigmented

"Morpheic" type - highly invasive to local tissue


Photodocument, excise, Mohs procedure, 45% of developing again w/in 5 years
Dermal - flat/raised, rarely progress

Junctional - flat, may progress to malignant melanoma

Hard to distinguish visually - both have distint borders and pigmentation varies
Malignant Melanoma
From pre-existing nevi or de novo

Uncommon but most deadly

Pigmentation variability w/in lesion causes suspicion
Kaposi's Sarcoma
At least 1/3 of AIDs patients

Pink to Dark Purple nodules or plaques

Surgery, Radiation, Chemotherapy

Rarely seen in non-HIV

Related to co-infection of HIV patients w/HSV
Staphylococcal Blepharitis
Hard, brittle scales - scurfs/collarettes

Hyperemia of lid margin

Chronic - madarosis, trichiasis, poliosis, tylosis ciliaris, may see ulceration when crusts removed if very severe

Can cause associated conjunctivitis, evidenced by papillary reaction

May see inferior PEK

C/O: FBS, crusting of lids especially in morning, itching, tearing, burning, plus any associated conjuncitivitis symptoms

Treatment: lid hygiene for almost all forms, azasite(macrolide) gtt BID, antibiotic ung - bacitracin BID-QID, polysporin BID-QID, erythromycin(macrolide) BID - QID, combo - tobradex(tobramycin and dexamethasone alcohol) 1 gt q 3-4 hours or ung at bedtime, if severe add orals - amoxicillin(penicillin) 250 TID, dicloxacillin(penicillin) 250 QID, erythromycin(macrolide) 250mg QID
Demodex in Staph Blepharitis
Thrives in sebaceous glands and hair follicles

Controversial as to what it does/causes

Treatment: metronidazole gel(MetroGel) - not FDA approved for ocular use - must inform, sodium sulfacetamide - high allergy rate
Seborrheic Blepharitis (MGD)
Oily flakes (epithelial cells/sebum) on eyelids and lashes

Usually associated with generalized seborrheic disorder such as acne rosacea or seborrheic dermatitis - may have oily skin, eyebrows etc...

S/S: much greasier scales/flakes, often associated w/other MGDs, complain of BURNING as primary symptom in all forms of MGD
Meibomian Seborrhea (With Seborrheic Blepharitis) (MGD)
Increase in amount of normal Meibomian secretions - almost always associated with seborrheic bleph

S/S: BURNING, itching, tearing, FBS, complaints out of proportion, FOAM in tear meniscus is biggest clue, "OIL SLICK" appearance, decreased vision
Meibomianitis (Posterior Blepharitis) (MGD)
Stagnation/Solidification of Meibomian secretions

Scattered Involvement - "secondary"

All Glands - "primary"

S/S: Thick creamy material when expressed from capped glands, thickened red lid margins w/oily texture, reduced TBUT, seborrheic bleph inevitebly present
All MGD Treatment
Lid Hygiene

AT Liberally after hygiene procedures

orals - doxycycline(tetracycline) 100mg BID first day then 50-100 QD for 21 days), use azasite(macrolide)(off-label) for pregnant women 1 gt BID could use smaller dose for maintenance of oil secretion, tetracycline 250mg QID

Co-managed with PCP for systemic disease (acne rosacea) - need topical and/or oral steroids in addition

Shampoo for seborrhea

Topical - Restasis (cyclosporine A) to treat chronic MGD as option to steroids in rosacea
Mixed Seborrheic-Staph Blepharitis
Most cases

Lid hygiene

Azasite(macrolide) gtt 1 gt BID, or ung
Angular Blepharitis
Usually caused by Moraxella or Staph

S/S: chronic hyperemia, desquamation, ulceration of lateral/medial canthal regions

C/O: redness, tenderness

Treatment: zinc sulfate ung, erythromycin(macrolide) ung BID-QID
Phthiriasis Palpebrarum
Pubic lice causing chronic bleph

Treatment: stye ung, yellow murcuric oxide, bland ointment, clean lids/head/genitalia with RID(OTC) or KWELL(Rx, avoid eyes)

Smother lice

Remove cilia with nits(waxy eggs)

Complains of same symptoms as bleph
Internal Hordeolum
Bacterial infection of meibomian glands

Almost always staph

Hurts b/c rigic tarsal plate has to conform

May be associated with preceptal cellulitis

More common in upper lid

C/O: pain, warm sensation, may have PAN

Treatment: hot compress alone BID - QID for mild - watch for spread b/c of heat, orals - dicloxacillin(penicillin) 250mg QID, amoxicillin(penicillin) 250mg TID, or erythromycin(macrolide) 250 QID (topicals don't reach lesion), surgery for resistant cases (done after lesion is quiet)
External Hordeolum (Stye)
Acute staph infection of Zeis or Moll glands, at lid margin, may have yellow point on it

C/O: acute and recent onset

Treatment: usually drain w/o assistance within 3-4 days of "pointing," hot compress may hasten, can punture and drain then apply gentamicin(aminoglycoside), plucking infected lash could clear it out
Sterile, chronic, lipogranulomatous inflammation of meibomiam gland due to abnormal retention of normal secretions, spontaneous or after internal hordeolum infection

Hard, immobile, nontender lump, can point to external lid surface or inwards

Treatment: 25% resolve over 6 months, for new small lesions hot compress QID for 4-6 weeks, steroid injection - Kenalog-10(injected on inner lid b/c of scarring and discoloration), resistant lanced and drained, antibiotics dont work

Recurrent could be sebaceous cell carcinoma
Preseptal Cellulitis
Anterior eyelid infection, in front of orbital septum

Usually Strep or H.Flu (especially kids)
Staph more common in adults

Arises from pre-existing infection such as dacryocystitis, conjunctivitis, internal/external hordeolum

Penetrating lid injury is another route

S/S: lid is red, swollen, painful, warm, may have PAN, fever with H.flu

Treatment: staph - amoxicillin(penicillin) 250mg to 500mg TID, dicloxacillin(penicillin) 125mg to 250mg QID, H.flu - 3rd gen. cephalosporin, warm compress once antibiotics start, hospitalized if meningitis suspected(high fever, stiff neck), blood cultures

**MUST differentiate from orbital cellulitis - life threatening and arises from sinusitis...orbital ALSO has proptosis, limited EOM, extreme pain, obliteration of LC, decreased VA, APD
Acute Bacterial Conjunctivitis
Red eye, tearing, FBS, mucopurulent discharge in lower fornix, papillae, usually one eye first then spreads to other

Usually diffuse injection, chemosis present but not profound, usually uncomfortable (NOT painful)

Lids may be "matted shut" in morning(single-most accurate predictor)

Most infectious material drains through nasolacrimal duct so PAN usually not present (too big for blood/lymph system)

Acute bacterial keratoconjunctivitis more painful

Treatment: if mild combo, tobradex gt q 3-4 hours or zylet gt q 4-6 hours, w/significant corneal staining use broad spectrum QID, polytrim(trimethroprim and polymixin B) 1 gt q 3 hours, ciloxan(fluoroquinolone), ocuflox(fluorquinolone), zymar(fluorquinolone), vigamox(fluoroquinolone) TID, azasite(macrolide) BID for 2 days then QD for 5 days,

If cornea at risk, DO NOT use steroid on first day, wait and see if antibiotic improves
Chronic Bacterial Conjunctivitis
Four or more weeks

Staph Aureus most common

May have additional chronic infectious/inflammatory signs(phylctenules usually at 4 and 8 or 10 and 2, infiltrates, bleph)

If significant corneal involvement - chronic bacterial keratoconjunctivitis (causes more discomfort/pain)

Treatment: treat associated disorders (especially bleph), antibiotic with good gram+ coverage, polytrim(trimethoprim and polymixin B) 1 gt q 3 hours, bacitracin ung q BID-QID
Hyperacute Conjunctivitis
Almost always caused by Neisseria
Gonorrheae (gram-diplococcus)

Genital-hand-eye contact

SEVERE copious mucopurulent discharge, lid edema, A/C reaction, PAN, HOT eye

Treatment: 1 dose IM ceftriaxone 125mg(cephalosporin), 1 dose IM 1g Spectinomycin, co-treat for chlamydia(zithromax - macrolide -  1g), topical prophylaxis (good opportunity for fungal infection)
Neonatal Conjunctivitis
Treatment: erythromycin oral(macrolide) BID-QID, bacitracin BID-QID, polysporin BID-QID, polytrim 1 gt q 3 hours
Bacterial Keratitis w/Ulceration
Most of all cases are bacterial

Epithelial defect over thick stromal infiltrate w/edema surrounding, A/C reaction, pain, photophobia, blurred vision, tearing, PLUS all other keratoconjunctivitis findings

Mostly CL wearers, predominantly extended wear
(hypoxia -> infiltrates -> epithelial breakdown -> opportunity for bacteria - pseudomonas usually)

Cornea swells more overnight in CL wearers

Contaminated CL solutions/medications, decreased immune response from other diseases, dry eye syndrome, recurrent eye disease(HSV), chronic desease(dacryocystitis, canaliculitis, bleph), prior surgery/trauma, trichiasis, corneal exposure, corneal edema/bullous keratopathy, collagen-vascular disease, other mucous membrane disorders, VITAMIN A DEFICIENCY, hospitals can all be risk factors

Treatment: remove CL till cleared, lavage purulent material, broad-spectrum, 4th gen. fluoroquinolones - vigamox LOADING DOSE - 1 gt q 5 mins. for one hour, then 1 gt q hr for 24 hours then q 2 hours, same for zymar, besivance LOADING DOSE 1 gt q15min. for 1 hr, 1 gt q hour hour, 2 gtt overnight (NOT FDA approved for ulcers but approved for conjunctivitis - must inform), 2nd gen. fluoroquinolones (FDA approved for ulcers) - ciloxan, 2 gtt q 15 min for 6 hours then 2 gtt q 30 min for 18 hours, ocuflox 1 gt q 30 min while awake and twice overnight, can alternate; tobramycin 1 gt q hour and cefazolin 1 gt q hour (drop every 30 min around the clock), reduce inflammation w/COLD compress BID-QID no more than 15 min at a time, cycloplege to reduce pain and seal up leaky vessels and also reduce potential for iris-lens adherence(posterior synechiae), doxycycline (use azasite for females on birth control) optional - reduces collagenase, could use corticosteroids if improvement DEFINITE, NEVER used first day

Could taper treatment given the right signs...blunting of perimeter etc..

Stain every day and do VA and pupils first(vision often worse next day but will feel better)

Fungal Eye Infections
Higher in southeast, vegetative debris, CL wear, topical steroid use, immunosupression, corneal surgery, chronic keratitis

Most worldwide: Aspergillis, southern US: Fusarium, Northern: Candida, Aspergillis

C/O: FBS, pain, reduced vision, photophobia, injection, chemosis
(INDOLENT presentation so get worse gradually - 5 to 7 days)

Signs: epi defect, purulent discharge, dense stromal infiltrate, A/C reaction, hypopyon, FEATHERY BORDERS, SATELLITE LESIONS, rough textured, brown pigmentation, "dry" infiltrate

Treatment: Polyenes; natamycin 1 gt q 1-2 hours (drug of choice - otc), amphotericin B(must be prepared), and/or Azoles; oral intraconazole - candida and aspergillis, oral ketoconazole 200mg QD - fusarium, miconazole
and/or Pyrimidines; topical/oral voriconazole - fusarium, flucytosine - adjunctive with other agents, can add antibiotic; neomycin, vigamox TID (kill bacteria that fungi feed off of), sub-conj injections, cold compress, cycloplege, topical steroids ONLY if vision threatened and ONLY after two weeks of care(b/c antifungals aren't strong and indolence of fungi)...require about 12 weeks of treatment

Mechanical debridement of lesion allows better penetration of topical drugs

1/3 require PKP to be done within 4 weeks of infection when no response

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