Papilloma of the eyelid are benign tumours and carry little to no risk of change to any form of cancer. They can be solitary or multiple and can either have a smooth or rough (corrugated) edge surface and they are usually of a similar colour to the surrounding skin. They may cause mild irritation or may be cosmetically unacceptable to the patient. There are a few different sub types of papilloma and the most common is the squamous papilloma, otherwise known as a skin tag. This is usually soft flesh coloured smooth or pedunculated. Seborrhoeic keratosis is another benign proliferation of cells which has a ‘stuck on’ appearance and can be variably pigmentated. Their colour can vary from pink or flesh coloured to dark brown. They are usually well circumscribed and elevated often with an inflamed base (the Leser Trelat sign). The appearance of multiple separate keratoses in one area can suggest a para neoplastic process. Inverted follicular keratosis is usually a solitary lesion of the eyelid margin, which may or may not be pigmented and can be of a nodular papillary in appearance and finally the verruca vulgaris is a flesh-coloured growth caused by the human papilloma virus and this can also be found on the eyelid.
These lesions can be observed however if causing irritation or if cosmetically unacceptable they can be removed. Removal usually involves local or shave excision under local anaesthetic however verruca vulgaris often responds better to cryotherapy. Larger eyelid papillomas may require intralesional interferon therapy. If there is any suspicious characteristics, then the lesion may be sent to pathology to exclude any sinister differential diagnosis.
Chalazion and Styes
A stye is a small red painful lump that grown at the base of your eyelash and these are often caused by a bacterial infection. The eyelid is often red and tender to touch, and the eye may feel sore and scratchy. Eyelid inflammation or blepharitis can result in a predisposition to getting styes and it is worth treating these conditions to prevent recurrence.
Chalazion is a blocked oil gland or meibomian gland and may start as a stye or internal hordeolum. These tend not to be red and painful to start with and often appear as a pea size lump in the body of the eyelid. If they become large, they can press on the eye and cause your vision to become blurry.
Often both styes and chalazions can settle on their own and hot compresses are helpful as they help express the material from the glands. The heat melts away any blockage at the entrance of these glands. Hot compresses are best done by holding a clean flannel under hot water pressed firmly against the closed eye for 5 to 10 minutes, ideally 3-4 times a day. The warm compress helps to soften the contents of fluid filled swelling and the pressure helps express the contents. Antibiotic ointments are not usually of benefit for a chalazion. However, if there is an acute red tender area as in a stye, then a course of antibiotic ointment may of some benefit. Ongoing cleaning of the eyelid with a weak solution of baby shampoo and warm water or over the counter eyelid wipes such as Blephaclean or Optase helps to remove grease and dead skin cells that can predispose to cyst formation.
If the above conservative treatment has not helped, then a small operation can help to drain the contents of the cyst. This is usually done under local anaesthetic but can be done under general anaesthetic in children or in adults that may not tolerate this. A small cut is made on the inside of the eyelid and the contents of the cyst are removed with a curette. Antibiotic ointment is usually prescribed afterwards, and the results are normally excellent.
There is a chance for recurrence and hot compresses are helpful on an ongoing basis to reduce the change of recurrence.
Entropion is an eyelid condition which causes the eyelid to turn inwards resulting in the eyelashes rubbing against the surface of the eye. This can be uncomfortable, and it can lead to damage to the ocular surface. This is more common in the lower lid and it may happen all the time or after blinking or squeezing the eye shut. There are a few factors that can lead to entropion including weakening of the eye muscles and stretching of the eyelid tissues resulting in laxity of the tissues. Additionally, scarring of the conjunctive from causes such as trachoma or previous eye surgery or trauma as well as inflammation causing a spasm of the orbicularis muscle (the muscle that closes the eye) can also cause a subsequent rolling inward of the eyelid. The entropion can also be congenital and present from birth and there may be an extra fold of skin in the eyelid causing inward turning of the eyelashes but in most cases, this settles as the child grows older and the face elongates. Assessment of the patient requires an understanding of all the different anatomical and pathological causes of entropion.
There can be a wide range of symptoms causing irritation, redness, watering, discharge, crusty, blurry vision, and light sensitivity. Untreated it can cause damage to the ocular surface and this can pose a potential threat to eyesight. Entropion is therefore an important condition to treat appropriately and promptly.
Temporarily taping can be applied to the lower lid to pull the lid out, keep the skin around the eyes cleaned and a strip of medical tape is applied under the edge of the eyelid down towards the cheek and this holds the eyelid in its normal position. This helps pull the eyelashes away from the surface of the eye. The only affective long-term treatment is surgery which can usually be performed under local anaesthetic as a day case procedure. Surgery involved tightening and repositioning the lower eyelid tissues with the use of absorbable stitches. A pad is placed over the eye which is removed the following day and a course of antibiotics for one to two weeks would be used afterwards. Surgery is generally successful, without long term risks and scarring is usually minimal. There is a low risk of occurrence of the condition afterwards, in which case another surgical procedure may be required but this is uncommon.
Ectropion is an eyelid condition where the lower lid turns outwards. This can either be minimal with just the inner corner turning out by a millimetre or so or in severe condition where the entire eyelid turns out. The inside of the eyelid has a mucosal membrane which is apposed to the surface of the eye. When it is everted, it dries out and this can cause irritation and discharge. Additionally, the tears are not able to reach the tear duct (lacrimal punctum) at the nasal upper edge of the eyelid and where the lid turns out it forms a little pocket between the lower lid and the surface of the eye and tears gather here. Often when leaning forward it can lead to tears running down the cheek. Watery eyes are the most common complaint with ectropion, but it can also lead to dryness as the high portion of the eyelid is to spread the tears over the ocular surface. When it is not approximated to the surface of the eye, the cornea can dry out as it has lost its eyelid wiper function. Temporary lubricants can help but surgery is needed to correct this eyelid malposition.
Surgery is usually performed under local anaesthetic, but a general anaesthetic can be used should surgery cause anxiety or should it not be possible for the patient to keep entirely still. For a mild ectropion involving the punctum alone, punctoplasty with retropunctal cautery or medial spindle can take a matter of minutes however for a more significant ectropion eyelid tightening may be required as well. The surgery is generally safe, predictable and with low risk of complications. However, there is a small chance of recurrence of an ectropion after some time and a further procedure can be performed should this happen. If there is shortage of skin such as when ectropion happens as a result of previous surgery or trauma, a skin graft may be needed and surgery is more extensive.
The surgery would usually take place in the hospital as a day case procedure after which an eye pad would be put onto the eye. This can be removed the following day with clean hands and an antibiotic is usually applied for a week afterwards to the eyelid and eye. The stitches are usually absorbable and unless they are causing irritation they usually will not need to be removed.