Eyelid Problems

Differential Diagnosis

Common Diagnoses

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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