Differential Diagnosis 
of 
Common Physical Signs
in the Eyelids

 
Poliosis
(White eyelashes. In the examination, poliosis may occur in the elderly as an ageing process and may have not relevance to the underlying ocular pathology. However, where it is associated with an underlying pathology the most common case is albinism. The poliosis in albinism tends to be uniform and bilateral. Other less common cases include Vogt-Koyanagi-Harada's syndrome and sympathetic ophthalmia, the poliosis tends to be patchy and may be unilateral.)

Congenital

  • Waadenburg's syndrome
  • albinism
  • Acquired
  • ageing process
  • inflammatory (Vogt-Koyanagi-Harada's syndrome and sympathetic ophthalmia)

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    Madarosis
    (Loss of eyelashes. An uncommon sign in the examination but its presence should alert you to the possibility of a lid tumour or previous eyelid reconstruction.)

    Congenital

  • anhydrotic ectodermal dysplasia
  • Acquired
    • idiopathic as in alopecia totalis
    • neoplastic as in basal cell carcinoma or sebaceous cell carcinoma
    • infectious such as leprosy and secondary syphilis
    • iatrogenic from lid reconstruction
    • trauma

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    Ectropion
    (You are unlikely to get simple involutional ectropion as the only clinical sign unless the centre is truly short of interesting patients. The most common case of ectropion in the examination is those due to facial nerve palsy)

    Congenital

    Acquired

  • involutional
  • traumatic including cicatricial
  • paralytic as in facial nerve palsy
  • iatrogenic due to over-correction for entropion

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    Entropion
    (As in ectropion, this is unlikely to be a simple involutional entropion without other associated or unassociated physical signs. One common case with associated entropion is ocular cicatricial pemphigoid.)

    Congenital

    Acquired

  • involutional
  • cicatricial such as ocular cicatricial pemphigoid or chemical burnt
  • iatrogenic from over-correction for ectropion

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    Ptosis
    (This can be divided into pseudo-ptosis or true ptosis)

    1.Pseudo-ptosis
    (This is uncommon if the request is to examine an eye with ptosis. It usually occurs in other examination techniques such as ocular motility or orbital examination)

  • hypotropia
  • enophthalmos
  • contralateral lid retraction
  • 2. True ptosis

    Congenital

  • Marcus-Gunn's jaw winking ptosis
  • dystrophic muscle
  • blepharophimosis
  • Acquired
    • involutional (the lid crease is high and typically occur in the elderly)
    • mechanical (big lid tumour such as plexiform neuroma)
    • neurogenic (Horner's syndrome or third nerve palsy)
    • neuromuscular (myasthenia gravis)
    • myopathies (chronic progressive external ophthalmoplegia)

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    Lid retraction
    (Lid retraction occurs if the sclera is visible between the upper lid and the superior limbus. The most common case is thyroid eye disease. )

    Congenital
     

    Acquired

  • thyroid eye disease
  • secondary to contralateral ptosis (due to increased neuromuscular stimulation to the ptotic eye)
  • iatrogenic from over zealous ptosis operation
  • neurogenic (from lesion in the upper dorsal midbrain, Collier's signs and can occurs with Parinaud's syndrome)
  • other (where lid retraction occurs in other direction of gaze but not in primary position)
  • dystrophic eyelid as in some congenital ptosis
    aberrant third cranial nerve regeneration
    Duane's syndrome
    Brown's syndrome
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    Non-pigmented lesion of the lid
    (The differential diagnosis is huge. However, in the examination it is unlikely to be the only sign. Always look for associated or unassociated signs. A common case is plexiform neuroma in neurofibromatosis. For ease of classification, the lesion is divided into epithelial and subepithelial.)

    Epithelial

    • tumours
      • benign such as keratoacanthoma or actinic keratosis and squamous papilloma
        malignant such as basal cell carcinoma and squamous cell carcinoma
    • infection as in molluscum contagiosum
    Subepithelial
    (nearly any structures can enter the differential diagnosis but for simplicity, it is classified as follow)
    • cystic
      • epidermoid cyst
        dermoid cyst
        hidrocystoma
    • solid
      • chalazion
        syringoma
        sebaceous carcinoma
        xanthelasma
    • vascular
      • cavernous haemangioma
        capillary haemangioma


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    Pigmented lesion of the lid
    (The most important lesion to exclude is melanoma. Like pigmented lesion, it is unlikely to be the only sign in the examination. However, it is common question in the oral examination especially in the pathology section. The following classification is based on time of onset.)

    From childhood

  • flat lesion (naevus of Ota, blue naevus)
  • elevated (melanotic naevus)
  • First appearance in adulthood
  • elevated
  • malignant melanoma
  • pigmented basal cell carcinoma
  • seborrheic keratosis
  • flat
  • lentigo maligna (Hutchinson's freckle)
  • lentigo senilis

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