Eyelid Problems

Because of their close proximity to the eye, and their occasional cosmetic effect, eyelid problems can be disproportionately distressing to the patient. The differential diagnosis is wide – so the temptation to treat this presentation as a ‘quickie’ via a brief examination shouldn’t distract from the need to take a careful history.

Published: 2nd August 2022 | Updated: 15th August 2022

Differential diagnosis

Common Diagnoses

  • Stye
  • Blepharitis
  • Meibomian Cyst
  • Xanthelasma
  • Blocked Tear Duct

Occasional Diagnoses

  • Periorbital Oedema (e.g. Orbital Cellulitis, Herpes Zoster, Angio-oedema, Nephrotic Syndrome, Insect Bite)
  • Ectropion
  • Entropion (May be Secondary Trichiasis)
  • Eczema (Seborrhoeic, Allergic)
  • Ptosis (Congenital, Oculomotor Nerve Palsy, Horner’s Syndrome, Myasthenia Gravis, Senile, Myotonic Dystrophy)
  • Muscular Problems (Myokymia, Blepharospasm)

Rare Diagnoses

  • Malignant Growth (e.g. Basal Cell Carcinoma)
  • Benign Growths (e.g. Papilloma, Haemangioma)
  • Dacrocystitis
  • Alopecia
  • Molluscum Contagiosum
  • Lice

Ready reckoner

Key distinguishing features of the most common diagnoses

StyeBlepharitisMeibomian CystXanthelasmaBlocked Tear Duct
Long HistoryNoPossiblePossibleYesPossible
Visible SwellingYesNoYesYesNo
Eye WateringNoNoNoNoYes
Lids ItchyNoYesNoNoNo

Possible investigations

Likely: Lipid profile.

Possible: Urinalysis, FBC, LFT.

Small Print: Tests for ptosis, biopsy.

  • Lipid profile: If xanthelasma, as may indicate hypercholesterolaemia.
  • Urinalysis: Proteinuria in nephrotic syndrome.
  • FBC: WCC raised in infective process (e.g. cellulitis).
  • LFT: Hypoproteinaemia in nephrotic syndrome.
  • Further tests for ptosis (usually in secondary care) (e.g. CXR [Horner’s], edrophonium test [myasthenia], blood sugar and brain scan [oculomotor palsy]).
  • Biopsy – if suspicion of malignancy.

Top Tips

  • A meibomian cyst is often misdiagnosed – by patient and doctor – as a stye, particularly if it is infected.
  • Entropion with secondary trichiasis may be overlooked as a cause of a recurring sore, watering eye, especially in the elderly.
  • Myokymia: Recurrent focal twitching of the orbicularis oculi – is harmless but may distress or alarm the patient.
  • Many patients with xanthelasma will already have been ‘noted’ and so have had their cholesterol measured. Enquire about this before wasting resources on further unnecessary checks.

Red Flags

  • Orbital cellulitis requires urgent inpatient treatment.
  • Bilateral ptosis which deteriorates through the day may indicate myasthenia gravis.
  • New onset of unilateral ptosis requires investigation – possible diagnoses range from diabetes to malignancy.
  • Loss of the eyelashes is a poor prognostic sign in alopecia.
  • Unilateral eyelash loss, with or without apparent blepharitis, may be a sign of an eyelid tumour.
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Website disclaimer

Pulse Reference is based on the best-selling book Symptom Sorter.

The experts behind Pulse Reference are Dr Keith Hopcroft who is the co-author of Symptom Sorter, a GP in Essex and Pulse’s editorial advisor and Dr Poppy Freeman, a GP in Camden and also a clinical advisor to Pulse.

This website is for clinical guidance only and cannot give definitive diagnostic information. Practitioners should work within the limits of their individual professional practice, seek guidance when necessary and refer appropriately.