Lashes

Evaluation of Eyelid Lesions

Fluid Filled Cyst Eyelid

Eyelid lesions are classified according to the anatomic structures from which they arise. These include the epidermis, dermis, and various cells and adnexal structures within these layers. Eyelid inflammations may present as a localized or diffuse erythematous area. They can be associated with ulceration, induration, eczematous changes, necrosis, edema, or loss of eyelashes. If skin contraction occurs the eyelid margins may be malpositioned manifesting as an ectropion or canthal angle dystopia. Inflammatory lesions may be painful and at times can be associated with lymphadenopathy. Infectious conditions of the eyelid result from viral, bacterial, fungal or parasitic processes and may be primary or secondary. The latter can result as extensions from head and neck foci such as the sinuses or lacrimal sac, or from hematoge-nous spread from distant sites. The cause of the infection on the eyelid is often evident, such as in a site of trauma or recent surgery. However, when the infection...

Anatomy of the Eyelids

Orbit Anatomy Orbital Septum

The eyelids serve several valuable functions. Most importantly they provide mechanical protection to the globe. They also provide vital chemical elements to the precorneal tear film, and help distribute these layers evenly over the surface of the eye. During the blink phase the eyelids propel tears to the medial canthus where they enter the puncta of the lacrimal drainage system. The eyelashes along the lid margins sweep air-borne particles from in front of the eye, and the constant voluntary and reflex movements of the eyelids protect the cornea from injury and glare. The margin of each eyelid is about 2 mm thick. Posteriorly the marginal tarsal surface is covered with conjunctival epithelium, interrupted by the meibomian gland orifices (Fig. 1). Anteriorly the margin is covered with cutaneous epidermis from which emerge the eyelashes. The gray line is a faint linear zone separating these two regions. Between the skin and conjunctiva at a level 5 mm above the tarsus are, layered from...

Evaluation of Eyelid Malpositions

Levator Disinsertion

While taking the history the surgeon should observe the patient's eyes and face. It should be noted whether the eyelid position is unilateral or bilateral, and whether there is any associated disorder affecting the brows and midface. The position of the eyelids, canthal angles, and eyelash orientation should be noted (Fig. 1). The presence of concurrent anatomical deformities, such as brow ptosis, diffuse facial laxity, skeletal abnormalities, clefting disorders, or stigmata of Down's syndrome or other genetic disorders should be recorded. Any abnormal eyelid movements with extraocular muscle contraction or with jaw movement should be carefully documented. These may sometimes be quite subtle. A head turn or tilt should lead to careful evaluation of ocular motility to rule out the presence of associated strabismus. A slit lamp examination should include a magnified evaluation of the conjunctiva and eyelid margin (Fig. 2). Thickening of the lid margin or injection of the conjunctiva may...

Eyelid Lesions and Tissues of Origin

Microcystic Adnexal Carcinoma

In addition to cutaneous layers and their included adnexal appendages eyelid lesions can arise from other eyelid structures. Most important in this group are the tarsal plate meibomian glands. These are modified holocrine sebaceous glands arranged as tubules, with about 25 to 30 in the upper eyelid and 20 in the lower lid. They are not associated with the eyelashes or a pilosebaceous unit, although they can occasionally revert to such a structure where they can be related to the development of abnormal hairs called distichiasis. An obstruction of the meibomian duct can result in an infected cyst called a chalazion. In contrast, a similar infection involving small isolated sebaceous glands (glands of Zeis) or those associated with the skin pilosebaceous units results in a more acute and superficial process called a hordeolum. Any of these sebaceous glands can also give rise to a malignant tumor, the sebaceous cell carcinoma.

Surgical Management of Eyelid Lesions

Cutler Beard Flap

For elevated lesions of uncertain etiology, especially those on the lid margin, the shave biopsy is a useful procedure. It provides a representative sample of tissue for the pathologist without risking lash loss, eyelid deformity or other complications. In this procedure a scalpel is used to shave off the elevated portion of the lesion flat with the surrounding eyelid (Fig. 1). Light cautery or pressure is applied, with care taken not to injure eyelash follicles. If the lesions is benign or can be treated medically, then no further surgery is necessary. However, if the results require complete excision then a more definitive wedge resection can be performed, preferably under frozen section control. by the medial and lateral palpebral arteries. Layers of the flap are advanced beneath the bridge and sutured to corresponding layers in the upper lid defect. Sclera or other material can be placed between the conjunctiva and orbicularis muscle and attached to the levator aponeurosis to...

Discoid Lupus Erythematosus

Hypertrophic Verrucous Dle

Urman et al. (Urman et al. 1978) extensively studied oral ulcerations in 47 (26 ) of 182 patients with SLE and noted no significant correlation between the oral ulcerations and cutaneous manifestations. Interestingly, an increased frequency of these mucosal lesions was associated with increased overall clinical activity, but no detectable correlation was found between oral ulcerations and serologic parameters. Oral, mainly buccal, manifestations are most common, with the palate, alveolar processes, and tongue less frequently involved, but nasal, conjuncti-val, and anogenital mucous membranes may also be affected at times. Individual lesions begin as painful, erythematous patches, later maturing to a chronic plaque that has a sharply marginated, irregularly scalloped white border with radiating white striae and telangiectasia (Fig. 6.11). The surface of these plaques overlying the palatal mucosa often have a well-defined meshwork of raised hyperkeratotic white...

Floppy Eyelid Syndrome

Floppy Eyelid Syndrome

CLINICAL CHARACTERISTICS More than 75 of patients with Floppy Eyelid Syndrome are males between the ages of 30 and 80 years. Obesity is a nearly constant finding, observed in 96 of cases. A history of sleeping on the face, especially on the involved side is typical. In most cases only the upper eyelid is involved, and in 60 of cases the condition is bilateral. Eyelash ptosis and loss of lash parallelism appear to be constant findings. Associated lower eyelid laxity is seen in 50 of affected patients, and in some a frank floppy lower eyelid will be present. Ocular symptoms include ptosis, ocular irritation, and foreign body sensation, especially upon waking up in the morning. Tear film deficiency is seen in most patients. Conjunctival injection, eyelid swelling, and a mucoid discharge are characteristics resulting from repeated nocturnal eyelid eversion. Chronic papillary conjunctivitis is typical with keratinization and epithelial thickening. Less commonly, superficial punctate...

Transcriptional Hierarchies In Invariant Lineages

One of the best examples of such an analysis is that of the specialized mechanosensory cells in nematodes studied by Martin Chalfie and his colleagues (Chalfie and Sulston, 1981 Chalfie and Au, 1989 Chalfie, 1993 Ernstrom and Chalfie, 2002). Most nematodes wiggle forward when touched lightly on the rear and backward when touched on the front. By prodding mutagenized nematodes with an eyelash hair attached to the end of a stick, Chalfie and colleagues were able to find mutants that had lost the ability to respond to touch. Many touch insensitive worms have mutations in a group of genes involved in the specification of the mechanosensory cells. Mutations in the gene unc-86 result in the failure of the mechanosensory neurons to form. Unc-86 encodes a transcription factor that is expressed transiently in many neural precursors and particularly in the lineage

Embryo Preparation

Embryos are brushed away from the main puddle of liquid toward the center of the pad using an eyelash. Typically two embryos are placed side by side this allows recording of two embryos at a time. The liquid surrounding the embryos is allowed to dry, which embeds the embryos in the agar.

Embryo Transplantation

It essential to handle the tissue delicately throughout the endoderm dissection. Alternative tools for the dissection include a very fine glass needle or tungsten needle in place of the eyelash tool. The order of dissection is not crucial and may be altered slightly to suit personal preference.

Clinical manifestation

Borderline leprosy numerous, asymmetric, moderately anesthetic, red, irregularly shaped plaques less well defined than those in the tuberculoid type regional adenopa-thy sometimes present Lepromatous leprosy only infectious stage early cutaneous lesions consisting mainly of pale, small, diffuse, symmetric macules, which become infiltrated later, with little loss of sensation nerves not thickened and sweating normal alopecia of lateral eyebrows, eyelashes, and trunk, but scalp hair intact lepromatous infiltrations either diffuse nodules (lepromas) or plaques, which result in appearance of leonine facies brawny lower extremity edema neuritic lesions symmetric and slow to develop eye involvement causes pain photophobia, decreased visual acuity, glaucoma, and blindness testicular atrophy produces sterility and gynecomastia lymphadenopathy and hepatomegaly result from organ infiltration stridor and hoarseness from laryn-geal involvement nasal infiltration sometimes produces a saddle-nose...

Cicatricial Pemphigoid

Pemphigoid Eye

(diaminodiphenylsulfone) in doses of 25-50 mg daily can show early benefit, but its effect appears to diminish after one to two years. Conjunctival surgery, including cryosurgery, should be avoided because it often precipitates exacerbations, ultimately leaving the patient worse off. Marked loss of conjunctiva can be repaired with mucous membrane or amniotic membrane grafts. Eyelid surgery for trichitic lashes should avoid insults to the conjunctiva if possible, and eyelid margin rotation through an anterior approach is preferred for entropion. No matter the intervention, some patients will inexorably progress despite all therapeutic measures.

Medical Complications Direct Results of Cocaine

In terms of pulmonary effects, pneumomediastinum and cervical emphysema have been reported after smoking cocaine due to alveolar rupture with prolonged deep inspiration and Valsalva's maneuver (Aroesty, Stanley, & Crockett, 1986). Other respiratory complications of inhaling or smoking freebase cocaine include abnormal reductions in carbon monoxide diffusing capacity (Itkonen, Schnoll, & Glassroth, 1984), granulomatous pneumonitis (Cooper, Bai, Heyderman, & Lorrin, 1983), pulmonary edema (Allred & Ewer, 1981), thermal airway injury, pulmonary hemorrhage, hypersensitivity reactions, interstitial lung disease, obliterative bronchiolitis, asthma, and persistent gas-exchange abnormalities (Laposata & Mayo, 1993). Respiratory manifestations include shortness of breath, cough, wheezing, hemoptysis, and chest pains. Severe respiratory difficulties have been reported in neonates of abusing mothers. Inhalation of hot cocaine vapors may also result in bilateral loss of eyebrows...

Sebaceous Cell Carcinoma

Cutaneous Horn Formation

CLINICAL PRESENTATION The upper eyelid is the site of origin in about two thirds of all cases, presumably due to a greater number of meibomian glands on the upper eyelid. The clinical appearance is varied and sebaceous cell carcinoma is very frequently misdiagnosed as a benign process. Often it presents as a firm, yellow nodule that resembles a chalazion. It can mimic a chronic blepharo-conjunctivitis or meibomianitis that does not respond to standard therapies (the so-called masquerade syndrome). A more worrisome presentation may be as a plaque-like thickening of the tarsal plate with destruction of meibomian gland orifices and tumor invasion of eyelash follicles leading to madarosis, or loss of lashes. Tumor tends to invade the overlying epithelium which may result in the formation of nests of malignant cells. This is known as pagetoid spread. Pagetoid spread of the tumor may result in diffuse spread of the tumor that replaces the entire thickness of the conjunctiva (intraepithelial...

Kidney Capsule Grafting

Using an eyelash tool and a pair of fine forceps, remove the head and first pharyngeal arches. Carefully peel away the surface ectoderm, and then remove the heart and neural tube (see Note 6). 4. Carefully strip away the remaining mesenchyme using the eyelash tool, to leave a clean endodermal gut tube (see Note 6). Trim this down to include only the second and third pharyngeal pouches. Explants should be stored in M2 medium on ice until ready for grafting (see Note 7).

Ankyloblepharon

Herpes Eyelid Infection

CLINICAL CHARACTERISTICS In simple congenital ankyloblepharon the eyelid margins are usually fused laterally, and less commonly medially. The condition frequently accompanies other developmental anomalies such as anophthalmos, microphthalmos, ptosis, or cleft lip. In many cases the lateral canthal angle is displaced downward giving an antimongaloid slope to the palpebral fissure. The lateral canthal tendon is lax or not developed so that there is also significant laxity of the lower eyelids. In ankyloblepharon filiforme adnatum one or more narrow epithelial bands connect the central upper and lower eyelid margins. These vary from 0.5 to 5 mm in width, and may range from 1 to 10 mm in length. The zone of attachment is between the eyelashes and the meibomian gland orifices. In cases of total ankyloblepharon lacrimal secretions may accumulate beneath the lids forming a large fluid cyst. Ankyloblepahron is most commonly confused with euryblepharon since in both cases the lateral portion...

Pigmentary Changes

Antimalarial therapy can cause altered pigmentation. Premature graying of scalp hair, eyelashes, eyebrows, and beard has been detected. Also, diffuse hyperpigmenta-tion or linear horizontal bands of pigmentation can be detected in nails. A blue black patchy hyperpigmentation has also been noted on the mucous membranes and over the anterior shins. These pigmentary alterations associated with antimalarial therapy disappear with discontinuation of therapy.

Dermatochalasis

Steatoblepharon

CLINICAL PRESENTATION Dermatochalasis may be of cosmetic importance only. When more severe in the upper eyelid the anterior skin-muscle lamella can overhang the eyelid margin and obstruct superior and temporal visual fields. In some cases the skin will rotate the lid margin downward so that the eyelashes contact the cornea. When associated with steatoblepharon there will be protrusion of fat pockets within the excess folds of skin. When the lacrimal gland descends due to laxity of its suspensor ligaments it causes a bulge in the lateral upper eyelid. In the lower eyelid dermatochalasis appears as horizontal and often cascading folds of skin more prominent laterally. It is frequently associated with horizontal eyelid laxity from lateral canthal tendon and the malar suspensory ligament stretching, resulting in lateral eyelid droop or even frank ectropion. As with the upper lid, concurrent steatoblepharon causes a forward protrusion of lower lid fat pockets.

Distichiasis

Distichiasis

Distichiasis is a congenital or acquired condition in which there is an accessory row of eyelash cilia behind the normal row. The disorder may be familial with an autosomal dominant pattern of inheritance, but may also follow severe inflammatory or traumatic injury. It is believed that these abnormal lashes develop as a result of metadifferentiation of primary epithelial germ cells originally intent upon meibomian gland development. The meibomian glands are modified sebaceous glands that are not associated with the eyelashes or other hairs. In the skin sebaceous glands are usually associated with a hair follicle and an apocrine sweat gland to form a pilosebaceous unit. Under some circumstances it is believed that the meibomian gland can undergo differentiation into a primitive pilosebaceous unit producing an abnormal distichitic eyelash. CLINICAL CHARACTERISTICS The eyelid margin is typically normal with respect to the globe and the normal eyelashes are oriented appropriately. Extra,...

Madarosis

Discoid Lupus Erythematosus Eyelids

INTRODUCTION Madarosis refers to the loss of eyelashes. It may result from trauma, rubbing the eyelids, or it can follow eyelid surgery with injury to the lash follicles. Madarosis is also associated with systemic diseases such as alopecia areata, but here hair loss is usually seen in other parts of the body as well. Discoid lupus erythematosis involving the eyelids presents with erythema, scarring, and madarosis, but the latter can be the only presenting finding before any other manifestations. Lash loss is also associated with infiltrative lesions such as sarcoidosis, lymphoma, and cutaneous neoplasms. Inflammatory processes including severe blepharitis can cause lashes to fall out, and chronic infections with the mite Demodex folliculorum, found in 10 to 15 of normal individuals, can also be associated with madarosis. Loss of lashes and facial hair has been reported as a complication of botulinum toxin for oromandibular dystonia, but this is exceedingly uncommon. Iodine plaque...

Pubic Lice

But crabs have been found in armpit hair and beards and may even attach to eyelashes. The lice may also settle around the anus and in the hair on the legs and trunk. The typical infestation involves fewer than a dozen lice. Sometimes pubic lice cause no symptoms. Most often, however, they cause small red sores and itching, which becomes worse at night. If lice infest eyebrows or eyelashes, they can cause the eyes to become inflamed.

Trichiasis

Epilation Trichiasis

INTRODUCTION Trichiasis is an acquired condition in which the eyelash cilia are turned backward toward the globe. The lid margin is usually oriented normally with respect to the eye, but the lashes are directed at various angles. Trichiasis usually results from inflammation or scarring of the eyelid following eyelid surgery, trauma, chalazion, or severe blepharitis. It is frequently associated with chronic cicatricial diseases such as ocular pemphigoid, trachoma, and Stevens-Johnson syndrome. CLINICAL PRESENTATION The eyelid margin may be normal in position, or it may be associated with entropion. The trichitic lashes arise from the normal lash row, but they are oriented backward towards the cornea. Patients complain of foreign body sensation and chronic ocular surface irritation. Corneal abrasion, conjunctival injection, mucoid discharge, and reflex epiphora are typical findings. In severe cases, frank corneal ulceration may be seen. TREATMENT When only a few lashes are involved...

Atopic Dermatitis

Blepharitis Simplex

Of these types 70 result from allergic contact dermatitis, and about 9 to 10 each from irritant contact dermatitis, atopic dermatitis, and seborrheic dermatitis. Atopic dermatitis is a chronically relapsing inflammatory skin disease. It is a genetically fixed disease that remains with the patient all their lives, whether they show symptoms or not. It occurs in approximately 2 of the population. In several large series 80 to 90 of patients with eyelid dermatitis were female. Distinct infantile, juvenile, and adult stages of the disease have been reported. Associated diffuse eczematous skin changes vary with the age of the patient and often disappear during puberty or adolescence. In the infantile stages associated manifestations include facial erythema and crusting. After age two to three years erosions, lichenification, and hyper or hypopigmentaton develop particularly on the face and flexural surface of the extremities. In adults the rash may be bright red, edematous and oozing or...

Ichthyosis

Epidermolytic Hyperkeratosis

INTRODUCTION Ichthyosis represents a heterogeneous group of disorders of skin keratinization. Four major classes of ichthyosis are recognized. The most common type is ichthyosis vulgaris, an autosomal dominant disease with onset prior to age five years. Fine, light scales with flexural sparing is present. The eyelids and eyelashes are often involved. In X-linked ichthyosis affected males manifest large, dark scales with flexural involvement during the first year of life due to a deficiency of microsomal enzyme cholesterol sulfatase. Lamellar ichthyosis is an autosomal recessive condition present at birth. The infant is invested in a thick collodion membrane that is usually shed in 10 to 12 days. Large, thick uniform scales with generalized involvement is characteristic. Epidermolytic hyperkeratosis, a rare autosomal dominant disorder, presents at birth with red, moist skin and blisters. Thick scales form within several days. Facial involvement is usually mild. Associated corneal...

Brauers syndrome

Hereditary, focal pigmented nevi of the forehead and chin associated with either the absence of eyelashes or double rows of eyelashes and absence of sweat glands in the lesions Hereditary, focal pigmented nevi, similar to forceps marks located on the forehead and chin absence of eyelashes or double rows of eyelashes and aplasia of the sweat glands in the lesions protuberant nose

Blepharitis

Seborrheic Blepharitis Pictures

CLINICAL PRESENTATION Blepharitis is characterized by small brittle scales and collarettes at the base of the lashes, and moderate erythema along the eyelid margin. A more severe ulcerative form has larger mottled crusts surrounding the base of the lashes, which upon removal result in small ulcers and even bleeding. With time the lid margins develop telangiectasias and become permanently thickened, roughened, and keratinized on the inner surface. The orifices of the meibomian glands may be dilated and inflamed, and become capped by a dome of inspisated oil or it may take on a pouting appearance. The tear film may appear foamy with suspended particulate debris over the surface of the cornea. Recurrent hordeola and loss of lashes are often seen. Angular blepharitis represents a distinct form of blepharitis characterized by a subacute or chronic inflammation of the skin of the lateral canthal region associated with a low-grade conjunctivitis. Symptoms of blepharitis include burning,...

Herpes Simplex

Herpes Zoster Lamina Histologica

CLINICAL PRESENTATION Following a 2 to 14 day incubation period there develops a mild fever with moderately painful, usually unilateral, edema and erythema of the eyelid region. This is soon followed by the development of multiple discrete 2 to 3 mm vesicles that generally have a central umblilication. These break, crust over, and most often resolve without bacterial infection or scarring over the ensuing few weeks. There is a mildly tender preauricular lymphadenopa-thy, and often vesicular lesions are found elsewhere on the face or mucous membranes. Atypical dermal manifestations include the development of a black eschar early on, or edema without obvious vesicles. A careful search often reveals a few minute vesicles sometimes hidden at the base of the lashes. Following resolution the herpes virus retreats to the trigeminal ganglion where it can later reactivate and incite recurrent infections. Recurrent herpetic infections frequently follow a fever, head cold, sun exposure, or some...

Eyelids Palpebrae

Eyelids are skin folds, which can be actively moved. They consist of a tough connective tissue skeleton H (tarsus superior and tarsus inferior). Toward the outside, it is covered by the musculus orbicularis oculi (pars palpebralis) 2. The surface covering of the eyelid is a multilayered keratinizing squamous epithelium with only a few velum hairs. The outer lid is about 2 mm wide and consists of a dull anterior 4 and a sharp-edged posterior palpebral limb O. This tissue continues in the multilayered nonkeratinizing squamous epithelium of the palpebral part of the conjunctiva (conjunctiva tarsi) 0 .A multi-layered columnar epithelium with goblet cells is only found beyond the level of the fornix of the conjunctiva. Long cilia (eyelashes) C3 protrude from the anterior rim of the lid. They are rooted in the lid plate (see Fig. 626). The sebaceous glands (Zeis glands), apocrine scent glands and the sweat glands of the cilia (Mollglands) end in the hair follicle of the eyelashes. The right...

Rosacea

Papulopustular Rosacea

CLINICAL PRESENTATION Skin lesions consisting of variable combinations of patchy erythema, telangiectasia, small papules, pustules, and hypertrophic sebaceous glands occur on the brow, eyelids, and midface. Heat, sunlight and possibly gastrointestinal stimuli may induce physiologic flushing. Capillary proliferation and dilatation may lead to dermal lymphatic stasis and a sterile cellulitis. Common ocular symptoms include burning, redness, itching, foreign body sensation, tearing, dryness, photophobia, and eyelid swelling. Inflammation of the meibomian glands with dilation and plugging of the gland orifices is seen along the lid margins and pressure on the tarsus results in expression of abnormally thick secretions. Greasy scales (scurf) may be present on the eyelashes. With chronic disease there is often loss of lashes and recurrent chalazia. Gland dropout and abnormally low lipid levels result in excessive evaporation of tears and a subsequent dry eye state. An associated...