The eyelids are a common site for a range of disorders affecting older adults, from simple inflammation (blepharitis) to potential life-threatening malignancies. Some problems are localized and self contained, whereas others are systemic entities that secondarily affect the eyelid tissue and function. These amazing complex structures, with many tissue layers, provide a unique and vital function in lubricating, protecting, and cleansing the underlying eyeball, which makes them essential for good vision. The ability to recognize eyelid problems is important, as they often present first to the ophthalmologist. Some eyelid disorders can be successfully treated quickly and easily by the ophthalmologist, whereas others may be chronic and more difficult to manage, requiring referral to an oculoplastic specialist.

This article gives an overview of the form and function of the eyelid complex and presents common eyelid disorders and their treatments. The information provided herein should help the ophthalmologist decide when simple in-office treatment is indicated or when surgery or referral is necessary.

The eyelid is a multipurpose, multistructured tissue that mainly provides protection and lubrication to the underlying eye. It not only furnishes some components of the tear film through the meibomian glands and conjunctival surface but also sweeps dirt, debris, and toxins away from the eye by the normal blink function. The eyelashes help keep foreign material away from the eyes, and the blink also forces tears into the tear ducts and thus circulates a clean tear film over the eye. The tear outflow system lies within the nasal eyelids; patency of this system is needed to maintain normal circulation of tears and prevent excess tearing.

The eyelid is composed of many different tissue types including skeletal (orbicularis oculi) and smooth muscle tissue (Mueller's muscle); sebaceous, mucous, and sweat glands; eyelashes; fibrous tarsal plate; skin; and a mucous membrane (the conjunctiva). The blink and tear functions are both controlled by voluntary and involuntary neurologic responses. The eyelid complex is marvelously engineered and easily taken for granted but can cause tremendous problems for patients when not working properly.

Blepharoptosis (ptosis), or a drooping upper lid, is a very common finding in the older patient. The normal lid margin sits just below the superior corneal limbus. Ptosis is classified in 5 categories, based on the underlying abnormality:¹

By far the most common type of ptosis is involutional or aponeurotic, which may be unilateral or bilateral. Eyelid excursion is good, but stretching of the lid due to aging, prior trauma, lid swelling, or cataract surgery may leave it in the drooped primary position. (A typical drooped lid due to aging that must be repaired surgically if severe is shown in Figures 1 and 2.)

Neurogenic ptosis usually is associated with ophthalmoplegia or papillary dysfunction. Most commonly, in third nerve palsy, ptosis presents with an exotropic eye, diplopia, and limitation of adduction, with or without a dilated fixed pupil. If acute, third nerve palsy may be a neurologic emergency that requires possible angiography to rule out a cerebral aneurysm.

Horner's syndrome (ptosis, miosis, and anhidrosis on the same side of the face) usually is idiopathic but may signify a compressing apical lung tumor (pancoast tumor) or neck lesion on sympathetic neural pathways. The patient with Horner's syndrome should be referred to a neurologist for possible pharmacologic testing or radiologic work-up of the chest and neck.

Trauma may cause direct injury to the levator muscle or its nerve supply and a subsequent traumatic ptosis. Tumors of the eyelid or orbit can weigh down the lid and cause a secondary mechanical ptosis. Ptosis may be the first and only finding in ocular myasthenia gravis, or it may be associated with variable ophthalmoplegia and diplopia. It is not clear why the eyelids are affected first in many patients but anyone presenting with ptosis with or without other signs of myasthenia gravis should be thoroughly evaluated by the ophthalmologist with appropriate in-office tests (ice test), blood tests, and an edrophonium (Tensilon) test.² The quick ice test to the eyelids to rule out ocular myasthenia has been reported to be very sensitive and often is diagnostic. Neurologic referral may be necessary for medical treatment using pyridostigmine or steroids and continued monitoring. Eventual surgery to lift the lids may be needed.

Surgery is indicated if the drooping lid is causing loss of superior visual field, discomfort, or significant cosmetic concern, and if medically treatable or reversible causes of ptosis have been ruled out. Redundant extra skin (dermatochalasis) often is present causing a 'heavy' sensation of the skin on the eyelashes. Usually redundant skin is excised (blepharoplasty) and some type of procedure that involves tightening the lid muscles is performed to elevate the lid.³ Eyelid surgery is typically done as an outpatient procedure under monitored local anesthesia with a 2- to 3-week recovery period.

Both the upper and lower eyelid may be retracted back, exposing more eyeball surface than usual and giving the patient the classic 'stare' appearance (Figure 3).

This may interfere with normal blinking and eye surface lubrication, leading to dry eyes and possible corneal breakdown and ulcer formation. Most often, thyroid ophthalmopathy is implicated, due to local infiltration and fibrosis of the eyelid muscles. Other frequent signs of thyroid ophthalmopathy are proptosis, edema, corneal exposure, swollen extraocular muscles with variable diplopia, and optic nerve compression and potential nerve damage. Treatment is aimed at protecting the cornea and improving the cosmetic appearance if the condition is severe. This may be accomplished with artificial tears or ointment, moist chambers, or eyelid taping. Surgical repair using lid spacers and tightening and elevating of lower lids may be needed. The elevated overacting levator muscle of the upper lid may be surgically recessed, thus lowering the lid to a more normal position.

Blepharospasm is the spasmodic closure of the lids from ocular irritation or other causes. There may be a neurologic or psychiatric component to this problem. Essential blepharospasm is idiopathic and involuntary, may start unilaterally and become bilateral, or may involve contraction of the face (hemifacial spasm), jaw, or neck (Meige's syndrome). Rarely, tardive dyskinesia caused by antipsychotics, Parkinson's disease, or other extrapyramidal diseases may cause blepharospasm of the lids. New blepharospasm should be evaluated by an ophthalmologist.

Blepharospasm may become debilitating and affect quality of life, although this is rare. Medications have variable success. Current treatment consists of multiple, low-dose eyelid injections of botulinum toxin to partially paralyze the orbicularis muscle, providing significant but temporary relief. This often improves the symptoms, but injections need to be repeated every 2 to 4 months.

Eyelid myokymia-or clonic blepharospasm-consists of fine, episodic undulations of the upper or lower lids. It is self-limited and attributed to fatigue, stress, or caffeine. Patients should be reassured by the ophthalmologist that this eyelid twitching is benign; no medical or surgical treatment is recommended.

Ectropion, in which the lower eyelid turns outward away from the globe, may cause tearing, conjunctivitis, and exposure of the cornea with irritation and potential corneal infections. As with ptosis and other structural lid problems, ectropion has many causes and should be evaluated by the ophthalmologist.⁴

Involutional (atonic) ectropion, the most common type, results when excessive skin, gravity, and horizontal lid laxity from age allow the floppy lid to fall away from the eye (Figure 4). Another common cause is paralysis of the orbicularis muscle from seventh nerve palsy (Bell's palsy), which may be temporary or permanent. Patients often have an associated inability to close the upper lid (lagophthalmos). This often requires diligent lubricating of the eye and, at times, taping the lids closed at night to prevent exposure complications.

Cicatricial ectropion is caused by facial burns or chemical or mechanical injury that leads to skin contraction and may pull down the lid by contraction of the scarred skin. Dermatitis from allergens or severely dry skin may cause lid and cheek thickening, which tend to pull the lid margin away from the globe in the older population with already loose tissue.

Treatment of ectropion is directed at its cause. If the cause is dermatitis or an allergy, treatment with steroid creams (e.g., hydrocortisone or betamethasone) is recommended. Other anatomic causes are treated with surgical horizontal shortening of the lid to tighten it against the globe. Cicatricial causes require excisions of scars and placement of skin grafts to replace vertical skin contraction. These full-thickness grafts usually are taken from the upper lid or the retroauricular area.

Entropion is an inversion of the upper or lower lid margin that causes rubbing of the eyelashes against the globe, often irritating the cornea.⁵ It leads to discomfort, redness, foreign body sensation, tearing, decreased vision, and possibly severe keratitis and corneal ulcers. Trichiasis, by comparison, is the occurrence of misdirected lashes causing abrasion of the cornea. It results from entropion or chronic conjunctival disease, turning in the lid from the inside surface.

There are several types of entropion.The most common, by far, is the senile (involutional) type, which is characterized by an aged, loose, floppy lid and overacting of the orbicularis muscle on closure that turns the eyelid margin toward the globe (Figure 5). Another type, cicatricial entropion, is caused by chemical, thermal, or mechanical injury to the tarsus or conjunctiva, resulting in the lid margin being pulled inward by this scarred tissue. Treatment for entropion is surgery designed to tighten the lid margin and retractors horizontally, remove overriding orbicularis muscle and skin, and prevent tarsal rotation. Misdirected lashes can be treated by epilation, electrolysis, cryotherapy, laser ablation, or surgical block resection.

Certainly, the aging skin is most susceptible to benign overgrowth of epithelial, glandular, and dermal structures. Most patients have small, usually asymptomatic, chronic lid and facial lesions that are easily seen and, at times, questioned by the patient. The face and eyelids are areas that seem most prevalent for these 'lumps and bumps.'⁶ The ophthalmologist always must be suspicious of malignancy and determine whether the lesion has functional or cosmetic significance. Any new lesions should be monitored closely or removed by an ophthalmologist if suspicious. Compared with malignancies, benign lesions typically are slow growing, less inflamed, more well circumscribed, and multiple. They tend not to be ulcerated or bleed. They often look 'stuck on' rather than invasive and deep, with attachment and destruction of surrounding structures.

Dermatochalasis, the looseness and redundancy of the eyelid skin that is seen in almost all elderly patients, occasionally produces symptoms of decreased superior visual field, brow ache, ptosis, or trichiasis. Herniation of fat often accompanies dermatochalasis, giving patients the classic bulges of the aged eyelid. Treatment consists of surgical blepharoplasty with removal of excess protruding fat and possible concomitant ptosis repair. Newer laser and cautery techniques are being used in eyelid surgery to lessen bleeding, reduce surgical time, and quicken healing.

Nevi and papillomas are common benign eyelid tumors that may appear flat, pedunculated, or papillomatous (Figure 6). They may be pigmented or nonpigmented. Papillomas show

hyperkeratoses and proliferation of dermal papillae beneath the epithelium. Some nevi may be premalignant and may lead to melanomas. Treatment consists of excisional biopsy.

Seborrheic keratoses and xanthelasma are two very common benign lid tumors seen in older patients. Seborrheic keratosis is usually an elevated, brownish, soft, oily, well-defined, lobulated lesion that appears 'stuck on' the underlying surface (Figure 7). Histologically, this is a 'button' of hyperkeratosis and proliferation of benign basaloid cells. Xanthelasma are yellowish plaques that occur in the medial canthal area both superiorly and inferiorly. They represent clusters of lipid-laden foam cells in the superficial dermis and, although usually idiopathic, they may be associated with

elevated serum cholesterol, especially in younger individuals.

Malignant lid tumors arise from the epithelial tissues and are more frequently found on the lower lid than the upper lid or canthus due to chronic direct sun exposure.7 These tumors can cause severe eyelid destruction and rarely invade the eye or metastasize.7 Basal cell carcinomas are most prevalent (40:1) (Figure 9), but squamous cell carcinoma (Figure 10) and melanoma can occur. Sebaceous cell carcinoma is rarer but can be devastating. Cancers of the tear duct system, lacrimal gland, and orbital tissues also can spread to the eyelids. Malignancy should be suspected based on rate of growth (i.e, slow enlargement

over months), vascularity, loss of lashes or distorted anatomy, and ulceration with bleeding. The ophthalmologist should be suspicious of any potentially malignant ocular lesions and refer the patient for appropriate management.

In patient evaluation, the possibility of local or metastatic spread always should be considered. Referral to an ophthalmologist is needed to evaluate and biopsy these suspicious lesions. Surgical repair involves full thickness eyelid excisions with sliding flaps, skin grafts or, if severe enough, lid sharing procedures. Frozen sections or Mohs technique is necessary to define tumor margins and ensure complete excisions.

The ophthalmologist sees many cases of eyelid inflammation.⁸ Inflammation and infection of the eyelid may be primary or may be secondary to underlying conjunctivitis or ocular irritation. The clinical response usually is redness, scaling, ulcerated lid margins, and crusts or sleeves around the lashes. Symptoms include itching, mattering, pain, blurred vision, and irritation. Staphylococcal infection is the most common cause of blepharitis and if seen in the outer canthal area is called angular blepharitis.⁹

Seborrheic blepharitis is a common type of inflammation in older patients with associated skin seborrhea and dandruff. Excessive greasy or dry scales form on the lid and lashes with variable symptoms.

Contact dermatitis arises from an irritant or allergen contacting the skin (Figure 11). The skin of the lids is highly vascularized and is particularly prone to involvement with itching, edema, hyperemia, and an associated conjunctivitis and eye irritation.

Almost all cases of blepharitis can be treated well by the ophthalmoligist with lid cleansing using scrubs with mild detergent or shampoo, warm compresses, and the judicious administration of an antibiotic/steroid ointment (e.g., tobramycin/dexamethasone, dexamethasone/ neomycin, sulfacetamide/prednisolone. Often these are chronic, recurring problems that require intermittent treatment. Recurring or nonresolving blepharitis is suspicious and may mimic sebaceous cell carcinoma of the eyelid, and thus requires referral to an ophthalmologist.

The stye (external hordeolum) and chalazions (internal hordeolum) are common inflammatory lid margin infections (Figure 12). Both are blocked sebaceous glands-either Zeis's gland at the lash base or meibomian glands opening onto the margin itself. Both

may cause a red, inflamed, very tender, localized lid margin lump, and tend to be recurrent or recalcitrant. They may point to the skin or conjunctival side and may be associated with staphylococcal infection.

Treatment consists of hot compresses and topical antibiotics and/or steroids. Low-dose oral doxycycline may be tried to control severe blepharitis and recurring chalazion. If a concomitant periorbital or preseptal cellulitis develops, systemic antibiotics (eg, cephalexin monohydrate, penicillin V potassium, or erythromycin) may be used for 10 to 14 days. If the lesion is large enough or symptomatic after the initial topical treatment, surgical drainage by the ophthalmologist may be required.

The eyelids serve a vital function in protecting and cleansing the eye. They are a wondrous mixture of function and form with multiple tissue types playing their parts. They also can be the source of numerous disorders and complaints in the older patients, some benign and some most serious. Clinically, the most important problems are suspicious lid lesions that may harbor malignancy, neurologic disorders, and structural malpositions that cause poor lid function and may lead to globe damage and visual impairment. Some simple inflammations or infections can be treated by the ophthalmologist; however, many more serious problems require prompt evaluation and often referral for further medical or surgical management by the ophthalmologist or oculoplastic surgeon.