8/6/23, 2:20 PM Eyelid Disorders: Diagnosis and Management | AAFP

Eyelid Disorders: Diagnosis and Management

SUSAN R. CARTER, M.D.

info Am Fam Physician. 1998;57(11):2695-2702

Eyelid problems range from benign, self-resolving processes to malignant, possibly metastatic,
tumors. Inflammation, infection, benign and malignant tumors, and structural problems such as
ectropion, entropion and blepharoptosis may occur. Fortunately, most eyelid disorders are not
vision-threatening or life-threatening; however, many cause irritative symptoms such as
burning, foreign-body sensation or pain. Blepharitis, or eyelid inflammation, one of the most
common problems, is characterized by erythematous eyelids with accumulation of debris along
the eyelid margin. Malignant eyelid tumors may be associated with lash loss and erosion of
normal eyelid structures. Recognition and diagnosis of these problems are crucial to their
proper management. Warm compresses and antibiotics suffice for many conditions, while
excision, cryotherapy or laser treatment are required for some.

Eyelids are crucial to the health of the underlying eye. They provide coverage of the cornea and aid
in the distribution and elimination of tears. An exposed cornea will develop epithelial defects,
scarring, vascularization or infection. Resulting symptoms include ocular irritation, pain and loss
of vision. Eyelid closure distributes tears over the surface of the eye and pumps them through the
lacrimal puncta into the tear duct (Figure 1). Thus, tearing or epiphora may result from various
eyelid disorders.

FIGURE 1.

Lacrimal puncta, through which tears flow into the tear drainage system.

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Anatomically complex, the eyelids consist of an anterior layer of skin and orbicularis oculi muscle,
and a posterior layer of tarsus and conjunctiva (Figure 2). Contraction of the orbicularis muscle,
innervated by the seventh cranial nerve, closes the eyelids. The levator muscle, innervated by the
third cranial nerve, and the sympathetically innervated Müller's muscle raise the upper lid. The
orbital septum, originating from the orbital rim, inserts into the upper lid just above the tarsal
border and into the lower lid just below the tarsal border. The orbital septum limits the spread of
infection and hemorrhage from the eyelid to the posterior orbital structures.

FIGURE 2.

Anatomy of upper and lower eyelids.

Several glands along the eyelid margin contribute to the lipid component of the tear film. These
glands commonly become inflamed. The meibomian glands, approximately 30 per lid, are present
within the tarsus. The pilosebaceous glands of Zeiss and the apocrine glands of Moll are located
anterior to the meibomian glands within the distal eyelid margin.

In evaluating an eyelid problem, the physician should obtain focused but complete information
from the patient. Recognition of possible malignant lesions is essential. It is important to ask
questions about the duration of the problem, a change in size or appearance of an eyelid lesion or
the recurrence of a tumor that has been previously treated. In general, lesions that have not
changed for a long time are benign. A previous history of skin cancers should also be noted.

Examination of the eyelids should be systematic, beginning with the upper lid. A ptotic upper lid
may droop below the normal resting lid position of 2 mm below the superior corneoscleral
junction. Redundant upper lid tissue may hang into the visual axis. Eyelid retraction or inability to

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close the lid should be assessed. Eyelid lesions should be examined for size, location,
pigmentation and associated lash loss or ulceration.
Inspection of the lower lid may reveal lower lid malpositions such as entropion (inward turning) or
ectropion (outward turning). Ectropion of the inferior punctum, through which tears flow to the
lacrimal sac, may result in tearing. Misdirected eyelashes may rub on the globe.

Benign Inflammatory Eyelid Processes

Blepharitis

One of the most common eyelid problems is blepharitis, or inflammation of the eyelid margin.
Patients typically experience itching, burning, mild foreign-body sensation, tearing and crusting
around the eyes on awakening. On examination, the eyelid margins are erythematous, and
thickened with crusts and debris within the lashes (Figure 3). Conjunctival injection or a mild
mucus discharge may be present. Blepharitis occurs with chronic bacterial lid infection,
meibomian gland dysfunction, seborrhea and acne rosacea that affects the eye, known as ocular
rosacea.1 The diagnosis of rosacea is supported by the presence of dilated telangiectatic blood
vessels on the lid margins, cheeks, nose and chin.

FIGURE 3.

Scurf, or debris, found amid eyelashes in a patient with blepharitis.

Treatment of blepharitis consists initially of warm compresses, eyelid scrubs and application of
antibiotic ointment. Warm compresses should be applied for 15 minutes twice a day. This step
loosens irritating crusts in the eyelashes and melts the oil produced by the meibomian glands,
which can occlude the gland orifices. The eyelids should be scrubbed after the warm compress is
removed. Baby shampoo mixed with water produces a soapy solution. With the eyelids closed, the
eyelid margin region should be gently scrubbed with this solution, using a cotton-tipped applicator,
wash cloth or finger. Erythromycin or another antibiotic ointment should then be applied to the lid
margin. The ointment should be applied only at bedtime, because it may temporarily blur vision. If
an obvious infection is present, antibiotic eye-drops may also be used.

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If the condition is unresponsive to treatment, eyelid cultures should be obtained to rule out the
possibility of resistant organisms. Oral antibiotics may be used in such cases, or in patients with
the diagnosis of ocular rosacea. If severe, blepharitis may result in corneal infiltrates or ulcers.
Rarely, sebaceous cell carcinoma may masquerade as unilateral or bilateral intractable blepharitis.

Patients must be cautioned that blepharitis is a chronic disease and that eyelid hygiene may need
to be continued indefinitely. When the process is brought under better control, once-daily eyelid
scrubs may be sufficient to keep the problem in check.

Chalazion

Chalazia appear most commonly as chronic subcutaneous nodules within the eyelid (Figure 4).
Initially, a chalazion may be tender and erythematous before evolving into a non-tender lump.
Blepharitis is frequently associated with chalazia.

FIGURE 4.

Chalazion on left lateral upper lid.

A chalazion results from the obstruction of the meibomian gland. The blockage of the gland's duct
at the eyelid margin results in release of the contents of the gland into the surrounding eyelid soft
tissue. A lipogranulomatous reaction ensues. Occasionally, chalazia become secondarily infected.

Management includes warm compresses applied for 15 minutes four times a day. Blepharitis, if
present, should be treated. A topical antibiotic may be used if signs of infection are present. If the
lesion persists after four weeks of medical therapy, it may be incised and drained. Rarely, the
chalazion is injected with steroids; however, this may result in hypopigmentation of the overlying
skin.2

Hordeolum

A hordeolum, also known as a stye, is an acutely presenting, erythematous, tender lump within the
eyelid (Figure 5). An internal hordeolum involves infection of the meibomian gland and may evolve

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into a chalazion. An external hordeolum occurs with infection of the more anteriorly located
glands of Zeiss or Moll, present just anterior to the lash line. Hordeola usually drain spontaneously
after one week of treatment with warm compresses four times a day and topical antibiotic
ointment twice daily. Incision and drainage are required for nonresolving lesions.

FIGURE 5.

Acute external hordeolum with erythema and lump present at the lash line.

Benign Noninflammatory Eyelid Lesions

Seborrheic Keratosis

Seborrheic keratoses are pigmented, greasy hyperkeratotic lesions that appear to be stuck on the
skin (Figure 6). Commonly occurring in the elderly, these lesions may occasionally become
irritated. Surgical excision is curative.

FIGURE 6.

Hyperkeratotic seborrheic keratosis on right upper lid.

Actinic Keratosis

This flat, flaky, white, scaly lesion occurs in sun-exposed areas. Unlike seborrheic keratosis, actinic
keratosis is a premalignant condition. Excisional biopsy should be performed to discover
dysplasia or carcinoma-in-situ.

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Nevus

Nevi are well-demarcated, flat or elevated, pigmented or nonpigmented congenital lesions (Figures
7 and 8). They may become more pigmented, more elevated or cystic during adolescence or
young adulthood. Junctional nevi, occurring at the junction between epidermis and dermis, have
some malignant potential. Because of the risk for malignant transformation, pigmented lesions
that have changed in appearance should be excised.

FIGURE 7.

Pigmented nevus on the right lower lid margin.

FIGURE 8.

Nonpigmented nevus on the right lower lid margin.

Xanthelasma

Xanthelasma are soft, yellowish plaques in the medial canthal area (Figure 9).
Hypercholesterolemia or congenital disorders of cholesterol metabolism may be associated
conditions.3 Xanthelasma may be treated with excision or with a carbon dioxide laser if desired for
cosmetic reasons.

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FIGURE 9.

Xanthelasma on the medial upper and lower lids.

Molluscum Contagiosum

Found commonly in immunosuppressed as well as immunocompetent patients, these waxy

nodules have a central umbilication4 (Figure 10). If present on the eyelids, they may produce a
follicular conjunctivitis. These viral lesions may be treated with excision, cryotherapy or curettage,
although in many cases they are self-limited and resolve with time.

FIGURE 10.

Multiple, centrally umbilicated lesions of molluscum contagiosum.

Hydrocystoma

A hydrocystoma is a translucent cyst located near the lid margin, usually resulting from blockage
of the sweat glands of the eyelid. Complete excision may be performed.

Malignant Eyelid Lesions

Basal Cell Carcinoma

Basal cell carcinoma, the most common eyelid malignancy, usually appears in the lower lid and
medial canthal region as a firm, pearly nodule5 (Figure 11). Telangiectasia may overlie the nodule,
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or central ulceration may be present. If located along the lid margin, eyelashes may be missing in
the region of the tumor. Extension to the posterior eyelid surface may be detected by everting the
eyelid. Although basal cell carcinoma does not tend to metastasize, it may be locally invasive.

FIGURE 11.

Basal cell carcinoma of the right lateral lower eyelid, with central erosion and lash loss.

Treatment is complete surgical resection with histologic control of margins. Radiation and
cryotherapy, which have higher recurrence rates than surgical resection, are used when surgery is
not appropriate or possible.

Squamous Cell Carcinoma

Squamous cell carcinoma, although much less common than basal cell carcinoma, behaves more
aggressively.6 Erythematous, raised, scaly and centrally ulcerated, these lesions occur frequently
on the upper lid. They may arise de novo or from areas of actinic keratosis. Palpation of
preauricular and submandibular lymph nodes is crucial to detect potential metastatic spread.
Treatment is similar to that for basal cell carcinoma.

Sebaceous Carcinoma

Sebaceous carcinoma occurs in middle-aged to elderly patients and may mimic a chalazion or
chronic unilateral or bilateral blepharitis7 (Figure 12). It invades locally and spreads to regional
preauricular or submandibular lymph nodes. Distant sites of metastasis include lungs, liver and
bone. Mortality increases with increasing tumor size.8 Because of the aggressive nature of these
tumors, large or recurrent tumors may require surgical removal of the orbital contents.

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FIGURE 12.

Sebaceous carcinoma of the right upper lid, mimicking a chalazion. Seborrheic keratoses are visible above the
left brow and on the right cheek.

Melanoma

Melanoma is a rare pigmented eyelid tumor that must be differentiated from nevi and basal cell
carcinoma. During examination of the eye, the physician should always evert the eyelid to look for
conjunctival involvement. Change in the appearance of a pigmented lesion warrants excisional
biopsy of the lesion. Systemic evaluation for regional or distant metastasis is necessary with the
diagnosis of melanoma.

Mechanical Eyelid Disorders

Entropion

Entropion, or inward turning of the eyelid margin (Figure 13), causes irritation, redness and stringy
white mucoid discharge.9 Usually occurring in the lower lid, entropion causes eyelashes to rub on
the cornea and conjunctiva. Most commonly, entropion occurs in the elderly as a result of age-
related changes. Treatment is artificial tear drops and lubricating eye ointment until surgical repair
can be performed.

FIGURE 13.

Entropion, or inward turning of the lower lid.

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Ectropion

Ectropion, or outward turning of the eyelid margin, causes tearing, ocular irritation and redness10
(Figure 14). The lower eyelid is most commonly involved. Treatment is lubricating tear drops and
ointment before surgery. If the skin of the lower lid appears to pull the margin inferiorly in a
cicatricial fashion, massage of the lower lid skin with a mild steroid cream once daily for two
weeks may be beneficial.

FIGURE 14.

Ectropion, or outward turning of the lower lid.

Trichiasis

Trichiasis is a condition of misdirected eyelashes that rub on the cornea, resulting in ocular pain,
tearing and redness. Epilation or removal of the misdirected eyelashes ameliorates the
symptoms. If the offending eyelashes regrow aberrantly, they may be reepilated or treated
permanently with electrolysis or cryotherapy.

Dermatochalasis

Dermatochalasis, or redundant eyelid skin and fat, may result in functional loss of superior vision
if the tissue hangs over the eyelid margin into the visual axis. Surgical repair of this age-related
problem is termed blepharoplasty.

Blepharoptosis

Drooping of the margin of the eyelid, or blepharoptosis, may also cause functional vision loss,
depending on the severity of the condition (Figure 15). Etiology includes age-related dehiscence of
the levator muscle, Horner's syndrome, third cranial nerve palsy, myasthenia gravis and trauma.11
Treatment is usually surgical, depending on the etiology.
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FIGURE 15.

Blepharoptosis, or drooping of the left upper lid, obstructing vision of the left eye.

Eyelid Retraction

The normal resting position of the upper lid is 2 mm below the junction of the superior cornea with
the sclera, and that of the lower lid is at the junction of the inferior cornea with the sclera (Figure
1). Because the most common cause of eyelid retraction is thyroid ophthalmopathy (Figure 16),
the thyroid status of the patient should be evaluated.12 Other causes include midbrain disease,
such as tumors or infarcts, or blepharoptosis with compensatory contralateral eyelid retraction.
Treatment depends on the underlying etiology.

FIGURE 16.

Retraction of the right upper lid due to thyroid ophthalmopathy.

Facial Palsy

Facial palsy results in an inability to close the upper lid and laxity of the lower lid. A frank paralytic
ectropion may occur as well (Figure 17, top and bottom). A thorough work-up for the etiology of the
facial palsy must be performed.

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FIGURE 17.

(Top and bottom) Patient with left facial palsy, with inability to close left upper lid and paralytic ectropion of the
left lower lid.

Treatment of the eyelid problems includes vigorous lubrication of the eye with artificial tear drops
and lubricating ointment.13 Plastic wrap, fixed to the skin with ointment, may be placed over the
orbital region during the night to create a moisture chamber for the eye. For temporary facial
palsies such as Bell's palsy, small external tantalum eyelid weights (manufactured by MedDev,
Palo Alto, Calif.; telephone: 650-494-1153) may be easily fixed to the skin with double-sided tape
(Figure 18, top and bottom). The weight passively closes the upper lid, protecting the cornea.14
Surgical procedures are performed in patients with permanent palsies.

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FIGURE 18.

Patient with left facial palsy (top), with skin colored weight adhered to left upper lid, enabling closure of lid
(bottom).

Blepharospasm

Spasm of the eyelids may be unilateral or bilateral. Unilateral lid spasm may occur in conjunction
with unilateral or hemifacial spasm. Hemifacial spasm results most commonly from irritation of
the seventh nerve roots by a dilated or tortuous vascular structure (Figure 19). Because tumor is
the etiology in up to 1 percent of patients, all patients with hemifacial spasm should receive a
magnetic resonance imaging scan of the brain.15

FIGURE 19.

Patient with right hemifacial spasm, with resultant obstruction of vision by eyelids.

Bilateral blepharospasm is most commonly the result of dry eyes, corneal irritation or benign
essential blepharospasm. Brain imaging is not required. Benign essential blepharospasm may be

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caused by an overexcitatory drive of the basal ganglia. Initial treatment is artificial tear drops and
injections of botulinum toxin to weaken the affected muscles.16

Author Information
SUSAN R. CARTER, M.D., is assistant professor of ophthalmology at the University of California,
San Francisco (UCSF), School of Medicine. She is co-director of the Ophthalmic Plastic and
Reconstructive Service at UCSF, as well as chief of the Oculoplastics Service at the San Francisco
Veterans Affairs Medical Center. Dr. Carter graduated from Yale University School of Medicine,
New Haven, Conn., and completed both a residency in ophthalmology and a fellowship in
ophthalmic plastic and reconstructive surgery at UCSF.

The author was supported in part by That Man May See, Inc., San Francisco, Calif., and by an
unrestricted departmental grant from the Research to Prevent Blindness, Inc.

Address correspondence to Susan R. Carter, M.D., Department of Ophthalmology, University of

California, San Francisco, 400 Parnassus Ave., Suite A-750, San Francisco, CA 94143. Reprints are not
available from the author.

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