Eyelid Trauma

w/u: hx, Va, complete ocular and orbital exam Eyelid Lacerations anesthesia: local or lid block; 2% lido w/epi Lacs Not Involving Lid Margin skin, orbicularis only; 6-0 or 7-0 silk skin sutures, small bites, remove early fat in wound = septum violation, look for intra-orb FB, levator eval and careful repair

Marginal Lid Lacs tarsal approximation most important to avoid notching Rx: 1) three 6-0 silk double armed sutures thru lid margin from within lac 2 mm inf to margin, thru tarsus and out thru meibomian gland plane 2mm fom each edge; similar passes ant thru lash line and post thru gray line; pull taught to approx edges but dont tie; 2) 5-0 or 6-0 Vicryl to approximate tarsus with external approach; 3) 6-0 silk interrupteds to close skin; 4) tie the margin sutures, pull them anteriorly; incorporate ends of margin suture under the knot of the most proximal skin suture Canalicular Lacerations: see lacrimal system Canthal Angle Injuries med tendon origin @ ant, post lacrimal crests; posterior limb critical for lid/punctum position in injuries w/med canthal angle rounding/displacement, telecanthus, suspect posterior limb disruption r/o fractures of nasal or lacrimal bones, eval lacrimal system, then reduce Rx: transnasal wiring or wiring to post lacrimal crest after fracure reduction if present Burns usually seen in major body burns corneal protection w/lubrication, large tarsorrhaphies Tumors also see path sxn Color as Clue to Diagnosis

Pink or Red: increased vascularity; hamartomatous vessels in nevus flammeous, capillary hemangioma; granulation tissue in pyogenic granuloma; inflammation in chalazion, stye, cellulitis, etc. Purple: stagnant or low blood flow; hemorrhage into cystic lesions (i.e. lymphangiomas), low blood flow (deoxygenated blood) in cavernous hemangioma or varices; necrosis w/hemorrhage in malignant tumors Blue: Tyndall effect: melanin or hemosiderin in deep dermis: Nevus of Ota, blue nevus Brown or Black: from melanin in epidermis/sup dermis: more black = more superficial: junctional nevi more black than intradermal nevi; dry keratin i.e. seb keratosis and in crater of keratoacanthoma Gray or White: excess keratin; leukoplakia is descriptive only, not a disease Yellow: lipid in dermis: xanthelasma, xanthogranuloma; elastosis (i.e. pseudoxanthoma elasticum); syringoma Benign Epithelial squamous papillomaskin tag, frondlike, most common benign lid tumor; excise, cryo verruca vulgaris (wart): epidermal papovavirus infxn; cryo w/mask on to prevent spread seborrheic keratosis: common in elderly, stuckon, oily, crusty; shave bx, no malig trans inverted follicular keratosis: sk w/inflammation; wartlike keratotic nodule; cutaneous horn; recurs pseudoepitheliomatous hyperplasia (PEH): rapid growth near areas of chronic infl: burns, fungal infxn, basal cell ca, lymphoma, looks like sq cell ca on bx but grows faster keratoacanthoma: form of PEH; rapid gr, central ulcer crater w/keratin, spont resolve in 4-6 mo but can destroy tissues so excise; path may call squ cell ca, so give hx, large bx epidermal inclusion cyst: solitary, slow gr, from hair follicle, excise or currette lining Adnexal ductal cysts/sweat gland origin: sudoriferous cysts, hidrocystomas: tranlsucent cysts, +/- transillumination defect since watery center; lid margin or lateral canthus; Moll (apocrine) and eccrine glands (worse in warm weather) syringoma: most common adnexal tumor of lid, multiple, eccrine sweat structure, young F eccrine acrospiroma: single, deep, painful nodule w/erythema, mimics keratoacanthoma

acquired sebaceous hyperplasia: multiple small yellow, well-circumscribed nodules, in elderly, seen in chronic dermatitis; incr incidence of visceral ca (Muir-Torre syndrome) hair follicle tumors: trichoepithelioma: papules w/telangiectasia, can look like basal cell ca; trichofolliculoma trichilemomma: resembles verrucas pilomatrixoma: young adults, reddish subcut mass; excision curative Nevi melanocytic skin lesions junctional (deep dermis) compound (in junctional zone, dermis) intradermal (most common, benign) in kids, usually juncxl; nevus moves deeper w/age, becomes compound blue nevus: flat, blue, deep dermal melanocytes; nevus of Ota is congenital oculodermal melanocytosis w/mels in higher #s in dermis, uvea, sclera, episclera Misc Benign molluscum contagiosum: viral, seen in AIDS, central umbilication; excise, curette, cryo xanthelasma: yellow plaques of lipid-laden macs sometimes from high cholesterol; recurs Benign Vascular hemagiomas, lymphangiomas pyogenic granuloma: granulation tissue that has no pus and is not granulomatous Malignant predisposing factors include hx of: skin cancersun exposureradiation therapyred hair, fair skinEnglish, Irish, Scottish, Scandinavianblue eyeslesion hx of: growthintermittant drainage or bleedingcrustingwaxing and waning sizecolor changes exam clues include:

destruction of lid margin, lash lossulcerationpearly translucent margins, central umbilicationloss of fine wrinklesthickening of skin beyond margin of lesionActinic Keratosis chronic inflam, hard, cutaneous horn, erythematous, flat, papillary, or white flaky surface cellular atypia; 12-25% develop squamous cell CA cryo superficial lesions Basal Cell Carcinoma 90% of malignant eyelid tumors; most common; see predisp factors above rare in mucosa lower lid > upper; medial > lateral nodular: most common; firm, raised, pearly nodule, telangiectasia, central ulceration, peripheral palisading nodular ulcerative fibrosing (morpheaform): firm, sl elevated, ulcerated, indistinct borders, thin cords on path, more aggresive, may simulate inflam, madarosis cystic: w/central necrosis; looks like blue lid cyst Treatment incisional bx for suspicious excisional bx for small, grossly malig tumor away from margin; mark borders; can use 1-2 mm wide excision w/frozen sxn or Mohs micrographic surgery esp for morpheaform, deep infiltrative tumors for max retention of nl tissue; cryo only for pts unable to tolerate sugery; see reconstruction below careful of medial canthal/vertical midface, partially treated, morpheaform & neglected tumors b/c can have deep extension: need to know borders so dont use cryo or XRT, pts w/the above are majority of the 3% who die of ocular adnexal basal cell ca; may need exenteration

Basal Cell Nevus (Gorlin) Syndrome: AD; congenital or childhood; multiple basal cell CA; mental retardation, calcification of falx, tentorium; pitted skin of soles/palms; skeletal anomalies: odontogenic cysts of jaw; spina bifida occulta; cleft lip; 1/3 w/eye involvement w/early multiple lid tumors extending to orbit or brain; hypertelorism, colobomas, cataract, glaucoma, epicanthal fold Xeroderma Pigmentosum: see below Squamous Cell Carcinoma 40X less common than basal cell but more aggressive, mets thru blood, lymph, perineural arise from actinic keratosis, sun injury, worse w/immunodeficiency, HPV Treatment:

wide margin excision b/c of aggressiveness, tumor-free borders critical; recurrence may need exenteration Sebaceous Adenocarcinoma highly malignant, potentially lethal from meib or Zeiss gl of tarsal plate, lids, caruncle, face, even eyebrow F > M, > 50, younger pts w/h/o facial RT upper lid 2x > lower lid mimics chalazia, blepharitis, basal cell or squ cell ca, OCP, SLK, inclusion conjunctivitis effaces meib gl orifices, madarosis; yellow due to lipid spread to local LNs poorer prognosis with >10mm diam or symptoms >6mo if multiple sebaceous tumors (adenoma or CA) may have GI cancers Treatment: full-thickness, MAP bx; path may confuse it with CIN so check closely for foamy cytoplasm, fat stains; wide excision, possbile exenteration; Mohs not as good Miscellaneous Malignant Eyelid Lesions mucinous adenocarcinoma (sweat gland) tricolemmal ca (resembles keratoacanthoma, no mets, local excision) metastasis rhabdomyosarcoma can arise in eyelid Kaposi sarcoma: aggressive, reddish dermal mass, AIDS, conj lesions may look like FB granuloma or cavernous hemangioma; rx w/cryo, excision, radiation, intralesional chemo cutaneous melanoma: < 1% of all lid tumors, better prognosis on lid than other parts of body; lentigo maligna melanoma = 90% of all head/neck melanoma but only 10% of lid melanoma; nodular melanoma = most common lid melanoma; wide excision; node dissection if vasc/lymph involvement; met w/u for > 1.5 mm thick Lid Reconstruction upper lid:

small (<1/3 lid): direct closure +/- cutting sup crus of lat canthal tendon for 3-5 extra mm of give moderate (1/3-1/2): advance lat segment by cutting lat canthal tendon, semicirc skin flap from below lat eyebrow, may also try full-thickness composite graft from opposite lid large (>50%): advance adjacent tissue w/full thickness lower lid flap, free tarsoconj graft from opposite upper lid w/skin-muscle flap, or adjacent fornix-based tarsoconj flap transposed w/full thickness skin placed anteriorly over it lower lid: small (<1/3): direct closure +/- cut inf crus of lat canthal tendon moderate (1/3-1/2): semicirc advancement flap, tarsoconjunctival flap/graft w/skin graft large (>1/2): tarsoconj graft from upper to lower lid for post lamellae w/ant skin graft most often from behind ear (Hughes); possibly rotating cheek (Mustarde) flap VI. Systemic Necrobiotic Xanthogranuloma xanthomatous firm lid nodules that ulcerate and progress associated w/conjunctival hyperemia, uveitis, episcleral plaques infiltrative orbital masses w/restrictive motility 80% show paraproteinemia, usually multiple myeloma IgG monoclonal gammopathy, hyperlipidemia, neutropenia Dx: bx w/granulomas in all layers of skin with Touton/FB giant cells Rx: excision, local steroid inj, phasmapheresis, immunosuppressives Acanthosis Nigricans benign pigmented papillomas of epithelium brown velvety hyperkeratotic plaques, symmetric and rarely generalized most commonly in axilla, neck, genitalia, but can be hands, mouth, and eyes no increase in melanin benign: AD, childhood, puberty, without CA pseudo form: w/obesity, endocrine abnl incl insulin resistance, polycystic ovaries

malignant form: w/adenoca of GI, >20 yo, eye involvement demands systemic w/u, usually lid plaques that can block meibomian glands, even NLDO; no local therapy Xeroderma Pigmentosa rare, AR, defective DNA repair mech, UV damage cutaneous problems by 2 yo w/freckling, dry skin, telang, actinic keratoses 50% w/cancer by 15 yo w/95% involving head/neck

most commonly progressive LL atrophy starting at lid margin w/ectropion, exposure, loss of lashes, photophobia, conjunctival injection, exposure keratitis frequency of ocular neoplasms increased about 2000x esp limbal squamous cell CA Porphyria congenital (no hypertension, neurologic dysfunction, overproduction), variegate (neurological, hepatic) cicatricial ectropion, loss of lashes/brows, bilateral exophth chorioretinitis, ON atrophy, conjunctivitis with shrinkage, scleromalacia, corneal pannus no specific ocular therapy Ichthyosis thickened scaly skin vulgaris (AD), epidermolytic hyperkeratosis (AD), and sex linked ichthyosis associated w/dot shaped deep corneal opacities not affecting Va lamellar (AR) w/cicatricial lower lid ectropion Ehlors Danlos AD elastic skin w/hyperextensibility, gaping wounds after mild trauma w/irregular scars classic, varicose, arterial, scoliosis forms epicanthal folds most commonly, angiod streaks, strabismus, blue sclera, keratoconus, microcornea, ectopia lentis, familial RD Dego's syndrome malignant atrophic papulosis is rare vasculitis in young M>F multiple red papules 2-10 mm progressing to porcelain white atrophic depressed center w/surround telang on trunk/limbs eyelid lesions, conjunctival telang/MA, conjunctival plaques, focal retinal vasculitis

fatal from peritonitis no RX, bowel resection is temporizing Amyloidosis orbital/adnexal involvement, usually painless, more often 1o amyloidosis w/systemic signs most typical is ptosis followed by ophthamoplegia by restrictive infiltration proptosis from orbital mass or fatty infiltration lacrimal involvement w/either mass or sicca optic nerve sheath or other cranial nerve involvement lid involvement (hemorrhagic waxy papules) has high likelihood of systemic involvement

can be nodular or diffuse, unilateral or bilateral