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.
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
| Stye | Blepharitis | Meibomian Cyst | Xanthelasma | Blocked Tear Duct | |
|---|---|---|---|---|---|
| Painful | Yes | No | Possible | No | No |
| Long History | No | Possible | Possible | Yes | Possible |
| Visible Swelling | Yes | No | Yes | Yes | No |
| Eye Watering | No | No | No | No | Yes |
| Lids Itchy | No | Yes | No | No | No |
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.