Eyelid malpositions
How to Treat – Eyelid and lacrimal disorders
from previous page conjunctival swelling( chemosis) or the presence of conjunctival injection. The globe may be anteriorly positioned( proptosed), possibly with dystopia( displacement horizontally or vertically)( see figure 1).
Eye movements can be reduced and painful with accompanying diplopia. Vision may be reduced if inflammation is adjacent to the optic nerve. Other signs of optic nerve dysfunction( box 1) may be present, such as a relative afferent pupillary defect on the side of concern( box 2), brightness and redness desaturation compared with the contralateral side, reduced colour vision detection as measured on colour plate determination and visual field abnormalities. The optic disc may appear swollen. 2
If any of these concerning features are present, refer urgently to an appropriate ED, preferably one with an eye service, for initiation of empiric IV antibiotics and orbital imaging.
Orbital CT scans should include coronal and axial reconstructions with fine-cut views requested. An ENT review is often requested, as sinus disease may be concomitant and the precipitating cause.
Other causes of a red, swollen eyelid include contact dermatitis, severe adenoviral conjunctivitis, eczema, allergic periorbital disease, active thyroid eye disease, idiopathic eyelid oedema( blepharochalasis), necrotising fasciitis, herpes zoster ophthalmicus and neoplastic conditions.
Complications include local abscess formation( subperiosteal or intraorbital); septicaemia; cavernous sinus thrombosis, which should be suspected if bilateral involvement is present with rapidly progressive deterioration; and meningitis. 2
Dacryocystitis Dacryocystitis may present with a red, swollen mass in the region of the medial canthus, below the level of the medial canthal tendon( see figure 2). The medial canthal tendon is a palpable, and sometimes visible, horizontal band in the medial canthus that attaches the tarsal plates of the upper and lower eyelids to the medial bony orbit.
Figure 1. Right-sided pseudoptosis due to a large mucocoele arising from the right ethmoid sinus and extending into the medial orbit and frontal sinus, with bony destruction of the medial wall of the orbit and the frontal bone. There is lateral displacement of the medial rectus muscle, and the globe is displaced anteriorly, laterally and inferiorly.
Dacryocystitis is caused by an infection of the lacrimal sac, usually caused by downstream nasolacrimal duct obstruction. Initial management is conservative, with antibiotics and warm compresses( massage).
Incision or drainage is usually not required but can be performed if it appears as though it is about to spontaneously drain( with pointing of the abscess). Incision carries the risk of fistula formation between the lacrimal sac and skin of the lower lid. 2
Following initial conservative management, an elective dacryocystorhinostomy can be performed to anastomose the lacrimal sac to the nasal mucosa, bypassing the obstruction.
Canaliculitis Canaliculitis is an uncommon condition where stones, typically precipitated by anaerobic bacteria, promote stasis and contribute to
Figure 2. Left-sided dacryocystitis with adjacent lower-eyelid preseptal cellulitis.
concretion or stone formation.
Typically a‘ pouting punctum’ is noted with pericanalicular swelling and discharge emerging on the punctum from pressure over the canaliculus. Long courses of topical antibiotics may be required or possibly a cut-down procedure onto the canaliculus to extract the concretion( s).
Allergic eyelid disease Eyelid swelling may be seen as a
Box 2. How to examine the pupils for a relative afferent pupillary defect
• During exposure to direct and indirect light( light shone on the contralateral pupil), both pupils constrict.
• With the swinging torch test, the pupil constriction should not change as the light is swung from eye to eye.
• Both pupils should maintain their constricted state.
• Any escape( dilation) when the torch approaches an eye indicates ipsilateral pupillary pathway compromise— a relative afferent pupillary defect.
• Likewise, any obvious constriction indicates contralateral visual pathway compromise( an indirect relative afferent pupillary defect) caused by interference with the previous consensual response.
response to an insect bite, topical cream, cosmetic use or in association with atopy, as a form of eczema of the eyelid. Management involves trying to ascertain the cause and remove exposure, emollient lubrication to the skin and ocular lubricant drops, which may need to be supplemented with topical ocular antihistamine use and topical steroids to the eyelids and eyes. Judicious shortterm use of steroids may be required to avoid increasing intraocular pressures, induction of cataracts and periocular skin depigmentation.
Blepharitis Blepharitis is a common cause of ocular irritation, itch, watery eyes and morning crusting. It presents with red lid margins with variable degrees of discharge, crusts or scales on the eyelid margin. It can present with lid-margin pitting and telangiectasia, but any suspicious features such as these or loss of lashes warrant consideration of malignancy.
Simple lid margin hygiene is usually very effective in the management of blepharitis. Other oral therapy may be required, such as doxycycline, if associated with rosacea, as well as flax seed or fish oil supplement intake. 3, 4
Eyelid malpositions
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MISPLACED upper or lower eyelids can create not only cosmetic grievances but functional concerns. Upper-lid retraction or lower-lid ectropion can increase exposure of the cornea, causing dry eye, irritable eyes, ocular discharge, epiphora, corneal scars, corneal vascularisation and reduced vision. 2
Droopy upper eyelids from either dermatochalasis( heavy upper eyelids often caused by extra skin) or ptosis( mechanically low-sitting eyelids) can obscure the superior field of vision, cause headaches from constant use of the frontalis muscle to clear vision and interfere with vision via direct obstruction of the visual axis. 2
Heaviness of the upper eyelids can be a feature with brow ptosis( or descent of the eyebrows below the superior orbital rim); ptosis,
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Figure 3. Bilateral dermatochalasis causing interference with superior visual field on the right and central vision on the left.
often caused by stretch in the levator aponeurosis muscle in the upper eyelid or due to dermatochalasis. Often, some of these features may
coexist, and it is important that the main aetiology( ies) are carefully assessed, such that appropriate management is offered.
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A simple blepharoplasty will not cure elements caused by brow or eyelid ptosis. A brow lift will elevate the eyebrows to a more natural and youthful location above the superior orbital rim, thus reducing the apparent excessive upper-eyelid tissue.
Excessive and unnecessary removal of upper-lid skin can create postoperative difficulties with closure and exposure keratopathy. It is essential that blepharoplasty or ptosis surgery is not overdone, as corneal protection is more important than cosmetic symmetry.
For example, in the case of a seventh nerve palsy, in addition to a lower-lid ectropion and poor eyelid closure, a patient may complain of a mechanical ptosis caused by brow ptosis.
A minimal brow lift may help
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with vision and appearance. However, assessment of closure is paramount, and a gold or platinum upper-eyelid weight may be required in addition to surgical elevation of the lower lid.
Upper lid dermatochalasis Dermatochalasis is an excessive amount of skin on the upper eyelids that can cause pseudoptosis and sit on or across the upper-eyelid margin( see box 3). This causes heaviness, irritation and loss of superior visual field, or it may cross the visual axis, causing functional blindness( see figure 3). 2
Aesthetically, patients may find it ageing or complain that they are no longer able to apply make-up. Dermatochalasis is usually a consequence of loss of skin elasticity and connective tissue strength with age cont’ d next page
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18 | Australian Doctor | 24 November 2017 www. australiandoctor. com. au