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As eye care providers, we typically do a good job of treating lid disease. But, what about patients who present with
chronic meibomianitis who do not respond to therapy? Or, what about atypical patients who present with unilateral
blepharitis? This Pearl of the Week will provide several strategies on how to manage complex lid diseases.
First, examine the eyelid for apposition abnormalities, such as ectropion, entropion, or simple lid laxity. A patient with
poor apposition will not have proper tear flow to wash away normal bacterial flora from the eyelids.
To test for lid laxity, pull out the lower lid and note how quickly it returns to its normal position. If it is slow to return
or remains away from the globe, refer the patient to an oculoplastic surgeon who can tighten the lower lid. Without surgical
intervention, a patient with a lax eyelid will suffer from chronic ocular surface disease and blepharitis.
Additionally, be sure to check for more serious pathologies, such as skin cancers. Here are four key items to look for:
- Unilateral or very asymmetric presentations. Almost all cases of skin cancer around the eyelids, such as sebaceous
cell carcinoma, present unilaterally.
- Madarosis. Loss of eyelashes, or madarosis, is a critical red flag for potential skin cancer. Most cases of
lid cancer, including basal cell, sebaceous cell or squamous cell carcinoma, exhibit a displacement of normal tissue,
which results in eyelash loss around the lesion.
- Basal cell carcinoma. Basal cell carcinoma is the most common skin cancer diagnosed in the eyelid area. The
lesion presents with pearly, raised margins and an ulcerated center, which often crusts and bleeds.
- Sebaceous cell carcinoma. A sebaceous cell carcinoma starts in the meibomian glands and does not respond to
treatment. Typically, it manifests as unilateral or highly asymmetric chronic meibomianitis, and often causes
madarosis and significant discomfort.
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