Diseases of the skin,lids and lashes

The editors of Clinical & Experimental Optometry have decided to introduce a series of reviews directed at the continuing education of clinical optometrists. These will be called Clinical Updates. They are intended as educational papers on topics that may interest the professional who graduated some time ago but who now finds difficulty in understanding the subject matter of modern optometry. They will cover areas which are new to optometry or where practitioners have expressed a desire for a better understanding of the basic concepts. As a consequence, the writers will assume an undergraduate level of understanding and we hope to encourage as many figures and pictures in these articles as is necessary to make the subject matter easy to digest and understand. We intend to produce two to three Clinical Updates a year with each spanning more than one issue of the journal. These will be written by experts in their field and it is our intent that they provide a useful armchair reference for practitioners in the future. We gladly solicit suggestions from practitioners on topics that they would like to see covered by these Clinical Update. The first of these Clinical Updates is in the area of dermatology and disorders of the lids. Dr Philip Lane is an academic associate of the Department of Optometry at the University of Melbourne, and lectures on this topic to final-year optometry students, as well as to medical students and practitioners. We hope that you find these Clinical Updates of interest and useful as part of your continuing education.     

Diseases of the skin,lids and lashes 2: Eyelid infections

In the previous section I described the anatomy and structure of the skin. In this section I will discuss the common infections that can afflict the eyelids and surrounding tissues.     

Diseases of the skin,lids and lashes 3:Inflammatory conthtions of the eyelids

Inflammation of the skin is called dermatitis or eczema depenthng upon the nature of the causative agent. If the inflammation is caused by exogenous factors, then convention is to call the condition a dermatitis, whereas inflammation produced by endogenous factors is called an eczema. An inflammatory response of the skin is probably initiated by changes to the local blood vessels which become more permeable and dilated as a consequence of the inflammation. Since the epidermis is nourished by diffusion of fluids from the capillaries of the dermis (Part 1), the increased volume of fluid leaving the dermal blood vessels enters the epidermis to cause swelling and a disruption of the skin's normal keratinising processes. This ultimately manifests as scaling and, if the fluid accumulation is severe, as blisters on the skin. The dilated vessels are responsible for a red coloration of the skin and the action of chemical mediators on the nerves produces itching. The histological term for this type of oedema of the epidermis is called spongiosis.     

Allergic diseases of the lids, conjunctiva, and cornea

Allergic ocular diseases are frequently encountered in the ophthalmologic practice. The term covers a wide array of severity, ranging from seasonal allergic conjunctivitis to the sight-threatening variant of atopic keratoconjunctivitis. The pathophysiology of these diseases is complex. Recent studies showed that nerve growth factor and interleukin IV, seem to play a role in these mechanisms.     

Cutaneous malignant melanoma metastatic to the eye, lids, and orbit

The incidence of malignant cutaneous melanoma is increasing faster than any other cancer. Thus, it will become an increasingly common source of metastatic disease to the eye, lids, and orbit. Herein, we have performed a systematic review of previously published cases including patient characteristics, clinical presentation, diagnostic techniques, current treatments, and outcomes. At the time of ocular diagnosis, nearly all reported patients had a known history of cutaneous melanoma and synchronous non-ocular metastases. Several aspects help in differentiating the tumors from primary uveal melanomas such as the presence of symptoms, rapidly growing multifocal tumors, vitreous seeding, and histopathological findings. Intraocular metastases (uvea, vitreous, retina, and anterior-segment) are more common and occur in younger patients than extraocular metastases (eyelids, orbit, and extraocular muscles). Palliative radiation therapy is often used for intraocular disease. Orbital metastases from cutaneous melanoma commonly involve the extraocular muscles resulting in diplopia and exophthalmos. The mainstays of extraocular treatment are surgical resection and radiation therapy. Unfortunately, there are few good options for systemic treatment of diffusely metastatic melanoma. Therefore, patients with ocular metastasis should be managed to prevent loss of vision or loss of the eye, and to maximize their quality of life.     

Thermal burns: the management of thermal burns of the lids and globes.

Our experience with 40 patients with eyelid and globe burns is reviewed. Initial emphasis should be placed on close monitoring, particularly of partially alert patients, debridement and treatment of corneal exposure with artificial tears and scleral shells when needed. The use of soft contact lenses in 2 patients with exposure was unsuccessful. Surgical treatment should be initiated when corneal exposure fails to respond to medical therapy. It is advisable to wait for the end stage of scarring so as to optimize chances for a single definitive correction. The use of retroauricular, supraclavicular or inner arm skin for grafting whenever possible is advised. The use of Frost sutures, tie-on dressings, and separate operations for upper and lower lids is recommended. Superficial wound sepsis is not a contraindication to grafting. Preoperative systemic or topical antibiotics do not seem to affect the outcome of the graft.     

Pseudoinflammatory metastatic breast carcinoma of the orbit and lids

A 60-year-old woman presented five years after a radical mastectomy for breast carcinoma, with vague, non-specific complaints referable to the left eye, consisting of ptosis, extraocular motility problems, and irritation, all believed initially to be due to an inflammatory causation. The indurated quality of the involved tissues, coupled with the results of computed tomographic studies, led to the suspicion of the correct diagnosis, namely, metastatic scirrhous carcinoma of the ocular adnexa. Biopsy and electron microscopic studies confirmed this diagnosis. Clinical and pathologic pitfalls in failing to distinguish scirrhous carcinoma from an inflammatory lesion are discussed.     

Management of peri-ocular skin tumours by laissez-faire technique: analysis of functional and cosmetic results

AIM: The role of wound healing by secondary intention in the treatment of peri-ocular skin tumours is not well established. The object of this retrospective analysis was to evaluate the functional and cosmetic outcome of patients treated by the Laissez-faire technique in situations where primary closure would not have been possible. METHODS: Skin defects following excision of lid and peri-ocular tumours in 24 Caucasian patients were allowed to heal by granulation. The locations included lower eyelid (n = 10), upper lid (n = 6), medial canthus (n = 5), nasojugal fold (n = 2), lateral canthus (n = 1) and brow (n = 1). Four patients had lid margin involvement. The size of the initial defect, time taken to heal, discomfort during healing, the functional and cosmetic results-both from the surgeon and patient perspective, complications, secondary intervention if any and patient satisfaction were studied. RESULTS: A good functional and cosmetic result was obtained in 23 of the 25 lesions (92%). Of these 23 patients, two patients had slightly hypertrophied scars, which responded well to massage and two patients had some degree of ectropion. Of the two patients who did not have a good cosmetic result, only one needed secondary intervention. One had an exuberant granulation tissue, which responded to topical steroids and massage, but left behind a distorted lateral canthus. CONCLUSION: Healing by secondary intention of large defects following excision of peri-ocular tumours is an effective alternative to primary or staged reconstruction in selected cases.     

Pediatric Periocular Dermoid Cysts: Incidence,Clinical Characteristics,and Surgical Outcomes

Purpose: To report the incidence, clinical findings, and surgical outcomes of periocular dermoid cysts diagnosed among children over a 20-year period.

Methods: All patients ≤5 years of age, who were diagnosed with a periocular dermoid cyst in Olmsted County, Minnesota from 1986 to 2005 were reviewed to determine the population incidence, clinical presentation, and management outcomes.

Results: A total of 54 children were diagnosed with a periocular dermoid cyst during the 20-year period, yielding a birth incidence of 1 in 638 live births. The mean age at diagnosis was 12 months (range, 1 month–60 months) and 29 (53.7%) were female. A total of 44 cysts (81.5%) occurred in the superotemporal orbital rim, 6 (11.1%) in the superonasal orbital rim, 3 (5.6%) in other periocular areas, and one (1.9%) within the orbit. A total of 34 (63%) children had an ophthalmic exam, all without amblyopia or other ocular sequelae. A total of 48 (88.9%) patients underwent surgical excision with 5 (10.4%) having documented intra-operative cyst rupture, none of whom had post-operative complications. Two (4.2%) other patients were, however, noted to have lesion recurrence following surgical intervention.

Conclusions: Periocular dermoid cysts occur in approximately 1 in 650 live births and most commonly occur in the superotemporal region of children aged 1 year or less. Ocular sequelae are rare and surgical excision often yields excellent results.     

毛囊破坏术治疗双行睫及乱生睫的临床疗效

目的观察睑缘灰线切开法破坏睫毛毛囊术治疗双行睫及乱生睫的临床效果。方法 36例（65只眼）双行睫和乱生睫患者,施行眼睑睑缘灰线切开法烧灼毛囊根部,无阻力拔出破坏的睫毛,以治疗双行睫及乱生睫,所有患者术后随访3个月以上观察临床效果。结果 49只眼双行睫及乱生睫术后效果满意,7只眼效果良好,9只眼术后有部分睫毛再次生长触及角膜,3个月后同样方法行二次手术,随访未复发。结论眼睑睑缘灰线切开毛囊破坏术矫正双行睫及乱生睫简单易行,创伤小,手术效果好恢复快,可保持外观并重复进行。     

Capillary hemangioma of the lids and orbit: an analysis of the clinical features and therapeutic results in 101 cases

The clinical records of 101 patients (biopsies done on 48) with capillary hemangiomas of the orbit, orbit and lids, and lids were analyzed. Lesions predominated in females and typically appeared at birth or within the first two months of life. The superior orbit and lids were definite sites of predilection. Telltale periocular cutaneous involvement occurred in one third of the cases. Pure proptosis caused by a deep orbital tumor without an anterior component was found in seven cases. Proptosis in general was mild, but in two cases was severe enough to cause corneal exposure. Findings suprortive of a diagnosis of an orbital or periorbital hemangioma include (1) change in tumor size on crying (46%); (2) a dark vascular coloration to the subcutaneous tissue (80%); and (3) the existence of nonperiocular strawberry marks (25). Diagnostic tests of most value were plain radiography, ultrasonography, computed axial tomography, and arteriography. The complication rate in the 50 patients followed up over five years was 80% (60% with amblyopia). Present treatment modalities do not appear to be achieving the desired goals of a good cosmetic and functional outcome. Radiotherapy and corticosteroids are both effective in individual cases, but many lesions are resistant to all forms of present treatment. Amblyopia therapy is difficult and often unsuccessful in these patients.     

Efficacy of incisional vs punch biopsy in the histological diagnosis of periocular skin tumours

AIMS: The aim of this study was to compare the accuracy of incisional and punch biopsy techniques in obtaining correct histological diagnosis of periorbital eyelid tumours. The technique of punch biopsy is presented and described in detail. METHODS: A retrospective analysis was made of 20 consecutive incisional biopsies and 20 consecutive punch biopsies. In each case, the histology obtained at biopsy was compared with that identified at the time of tumour excision. RESULTS: A total of 40 consecutive biopsies on 38 patients were analysed. The first 20 were incisional; the second 20 were punch biopsies. Of the 20 incisional biopsy specimens, 19 were confirmed accurate at the time of excision of the lesion. Of the 20 punch biopsies, 17 were confirmed accurate at the time of excision. These correspond to accuracy rates of 95 and 85%, respectively. CONCLUSIONS: Both incisional and punch biopsy techniques have relatively high accuracy rates and there is a high concordance between tissue diagnoses made by each of these techniques. Incisional techniques should preferably be performed on any atypical lesion. Punch biopsy is a quick and simple procedure. It is easy to perform in an outpatient environment and requires a minimum of surgical equipment and no specific surgical skills. If the site of biopsy is carefully chosen, this simple technique provides tissue specimens of adequate size and quality for accurate histology and is a most useful adjunct in the management of periocular tumours.     

Mechanical manipulation of the lids and tear break-up time measurements in Hong Kong Chinese

We measured tear break-up time (TBUT) after lid-rubbing in a single masked experiment, and found that TBUT was unaltered. A further single masked experiment in which non-invasive tear break-up Lime (NITBUT) was measured after the lids were raised as if to apply fluorescent also showed no effect of this interference with the lids. An experiment in which fluorescent was applied either with the lid raised or not raised during fluorescein application, again with the experimenter masked with respect to treatment, also produced no significant difference in TBUT. When we measured TBUT with the lid raised so that it was not in contact with the cornea, there was no difference in TBUT for the group between the "lifted" and 'non-lifted' eye; some subjects showed substantially shorter TBUT values, while others showed substantially longer TBUT values. These findings are surprising in view of the concerns expressed in the literature regarding the sensitivity of the tear film to mechanical interference, and suggest that the tear film is more resistant to disruption than has previously been thought.