D/D OF LID SIGNS

Poliosis:

(White eyelashes. In the examination, poliosis may occur in the elderly as an ageing process and may have not relevance to the underlying ocular pathology. However, where it is associated with an underlying pathology the most common case is albinism. The poliosis in albinism tends to be uniform and bilateral. Other less common cases include Vogt-Koyanagi-Harada's syndrome and sympathetic ophthalmia, the poliosis tends to be patchy and may be unilateral.)

• Congenital

Waadenburg's syndrome

Albinism

• Acquired

Ageing process

inflammatory (Vogt-Koyanagi-Harada's syndrome and sympathetic ophthalmia)

Madarosis

(Loss of eyelashes. An uncommon sign in the examination but its presence should alert you to the possibility of a lid tumour or previous eyelid reconstruction.)

• Congenital: anhydrotic ectodermal dysplasia

• Idiopathic: alopecia totalis

• Neoplastic: basal cell carcinoma/sebaceous cell carcinoma

• infectious: chronic blepharitis/HZV/leprosy/syphilis

• inflammatory: OCP/Steven Johonson/ discoid SLE

• drugs: anticoagulants/hypovitaminosis A

• enocrinopathies: hypothyroidism/ panhypopituitarism

• iatrogenic from lid reconstruction

Ectropion

(You are unlikely to get simple involutional ectropion as the only clinical sign unless the centre is truly short of interesting patients. The most common case of ectropion in the examination is those due to facial nerve palsy)

Congenital as cicatricial

Acquired

Involutional

cicatricial

paralytic as in facial nerve palsy

iatrogenic due to over-correction for entropion

Entropion

(As in ectropion, this is unlikely to be a simple involutional entropion without other associated or unassociated physical signs. One common case with associated entropion is ocular cicatricial pemphigoid.)

• Congenital

• Acquired

Involutional

cicatricial such as ocular cicatricial pemphigoid or chemical burn

spastic

iatrogenic from over-correction for ectropion

Ptosis : Droopy eye lid

(This can be divided into pseudo-ptosis or true ptosis)

1. Pseudo-ptosis:

(This is uncommon if the request is to examine an eye with ptosis. It usually occurs in other examination techniques such as ocular motility or orbital examination)

• hypotropia

• enophthalmos

• small eye

• contralateral lid retraction

2. True ptosis:

• Congenital

Marcus-Gunn's jaw winking ptosis

dystrophic muscle

blepharophimosis

• Acquired

involutional (the lid crease is high and typically occur in the elderly)

mechanical (big lid tumour such as plexiform neuroma)

neurogenic (Horner's syndrome or third nerve palsy)

neuromuscular (myasthenia gravis)

myopathies (chronic progressive external ophthalmoplegia)

Lid retraction

(Lid retraction occurs if the sclera is visible between the upper lid and the superior limbus. The most common case is thyroid eye disease)

• Isolated congenital ptosis

• thyroid eye disease

• secondary to contralateral ptosis (due to increased neuromuscular stimulation to the ptotic eye)

• neurogenic (from lesion in the upper dorsal midbrain)

Collier's signs

Hydocephalus

Facial nerve palsy

• iatrogenic from over zealous ptosis operation

• directional :others where lid retraction occurs in other direction of gaze but not in primary position)

dystrophic eyelid as in some congenital ptosis

Marcus Gunn winking

aberrant third cranial nerve regeneration

Duane's syndrome

Brown's syndrome

Lid masses:

Non-pigmented lesion of the lid

Epithelial

Tumours:

• benign:

squamous papilloma

actinic keratosis

keratoacanthoma

• malignant:

basal cell carcinoma

squamous cell carcinoma

infection: molluscum contagiosum

Subepithelial

cystic

epidermoid cyst .

dermoid cyst.

Hidrocystoma.

Sebaceous cyst

solid

xanthelasma

syringoma

chalazion

sebaceous carcinoma

Neurofibroma (isolated & plexiform)

vascular

cavernous haemangioma

capillary haemangioma

ns:

schwanoma

neurofibroma

Pigmented lesion of the lid

Like pigmented lesion, it is unlikely to be the only sign in the examination. The most important lesion to exclude is melanoma.

From childhood

Flat:

naevus of Ota

blue naevus

Elevated:

melanotic naevus

First appearance in adulthood

Flat

lentigo maligna (Hutchinson's freckle)

lentigo senilis

Elevated:

seborrheic keratosis

cutaneous horn

malignant melanoma

pigmented basal cell carcinoma

Kaposi sarcoma

Ulcer of lid:

• Tumours

Sebaceous carcinoma

Basal cell carcinoma

Squamous cell carcinoma

Cutaneous lymphoma

• Infection

Leprosy

Fungal infection

Leishmaniasis

Diffuse lid swelling:

Infective:

Adenoviral conjunctvitis

Preseptal cellulitis

Orbital cellulitis

Cavernous sinus thrombosis

Erisepales

Non infective:

Allergic eye lid swelling: isolated or systemic

Thyroid eye disease

Blepherochalasis

Dermatochalasis.