tarsus, a tuberculous node, a cyst, or an adenoma of the Meibomian glands. A chalazion is roundish, nodular, sometimes though not always adherent to the skin, feels tense on palpation, but is not tender, unless it is inflamed, and is intimately attached to the tarsus, with which it is movable. An inflamed, suppurating chalazion hardly needs to be differentiated from a hordeolum, from which it differs for practical purposes only in the history of a lump of long standing. The nodule of an epithe- lioma is met with almost exclusively in old people, usually on the lower lid near the inner canthus, and is not attached to the tarsus, as a rule. We do not often see it in the stage in which it is liable to be mistaken for a chalazion, because old people are apt to think little of such a lump until its surface has become eroded. A sar- coma may be hard to differentiate clinically unless it is pigmented, or is separate from the tarsus. It is quite rare; according to Veasey only about fifty cases are on record. A melanosarcoma is likely to be recognized readily as it forms a gray, or black brown tumor, and appears gray black through the conjunctiva if it is situated deeply. This form is quite apt to start from a pigmented nevus. <Callout type="tip" title="Tip">A leuco- sarcoma may start in the tarsus, or between this and the skin, and then it may be differentiated in some cases by a growth that is more rapid than that of a chalazion, and by a necrotic destruction of its interior which may be accompanied by hemorrhages, but a histo- logical examination often is necessary to a positive diagnosis. It occurs at all ages, the round cell and the spindle cell varieties seem to be about equally common, the mixed cell form less so, while the plexiform angiosarcoma and the cylindroma are rare.</Callout> A chancre is hard, is situated in the skin, not in the tarsus, and is movable over the latter. A circumscribed gumma of the tarsus may have about the same situation as a chalazion, may be of the same shape, size, and consistency, may present the same appearance on both the inner and the outer sides of the lid, and have the same history of a slow, painless development. Fortunately it is rare. Such a tarsitis de- velops in both hereditary and acquired syphilis, and a chalazion may form readily in the lid of a person suffering from syphilis. The only way in which the differentiation can be made is through the effects produced on the growth by internal medication. Whenever THE LIDS 37 anything suggests that the growth may be syphilitic it is wise to give the patient large doses of potassic iodide for a few days; it will grow smaller if it is a gumma, but it will not be affected if it is a chalazion. A diffuse gaummatous tarsitis usually is accompanied by inflammation, but if this is absent it resembles a giant chalazion, a broad flat swelling produced by a granulating inflammation of a number of adjoining Meibomian glands; again the diagnosis can be made only by watching the effect produced by large doses of potassic iodide. A tuberculous tarsitis usually is secondary to tuberculous lesions of the skin or conjunctiva. An endogenous primary infection of a Meibomian gland is very rare, and when it occurs it is apt to cause a swelling that cannot be told from a chalazion by its appearance. A local reaction to an injection of tuberculin may make the differentiation, but sometimes the diagnosis is impossible except by a histological examination of the tissue. A cyst of a Meibomian gland appears through the conjunctiva to be more translucent than a chalazion. Adenomata of the Meibomian glands are said to cause the lid to become stiff and boardlike, and to present nodular masses which have a yellowish color on the conjunctival surface. Similar tumors have been found in Moll’s, Krause’s, and Zeiss’s glands, where they may be difficult to differ- entiate at first from commencing carcinomata, but are distinguished finally by their course, as they do not break down. When a patient has been seized suddenly with a painful feeling of tension in a diffusely red and cedematous lid, we may be able to feel by careful palpation a small, hard, exquisitely tender nodule near the margin. If it is free from the tarsus it is an external hordeolum, a staphylococcic inflammation of a sebaceous gland, or if it is quite superficial we may call it a boil or furuncle, which is a similar inflammation of a sebaceous or sweat follicle. If it is seated in the tarsus a Meibomian gland is inflamed and we have a hordeo- lum internum. All three are called styes. The nodule grows larger, the pain becomes severe, the overlying skin becomes very red and finally exhibits a yellow point which indicates that it has broken down into pus and is about to rupture. The least common variety is the hordeolum internum, and in this the course is longer than in the others, the symptoms are more severe, the conjunctiva becomes oedematous, and the clinical picture is that of a deep seated abscess of the lid. An inflamed swelling which contains pus is an abscess. It may 38 DIAGNOSIS FROM OCULAR SYMPTOMS arise from a suppurating hordeolum, or from the entrance of pus agents into the subcutaneous tissue through a lesion in the skin, or it may originate from a cellulitis of the orbit, a periostitis of the margins of the latter, an empyema of the frontal sinus, or a purulent ethmoiditis. When the cause is not evident it should be sought for diligently. A carbuncle may be termed a conglomerate of furuncles at- tended by a severe constitutional disturbance, which includes a beat- ing headache, and is characterized by a brawny hardness and a sloughing of the tissues involved. Usually it appears in the region of the brow, and after it has ruptured it may present many per- forations. The condition is one which is quite grave as it is apt to cause not only gangrene of the affected tissues, but also a throm- bosis of the veins in the orbit, and death through a purulent menin- gitis and pyzmia. On rare occasions we may feel a circumscribed, soft, elastic, lobu- lated tumor that extends more or less back into the orbit and is usually if not always congenital; this is a lipoma. Symmetrical lipomata, situated between the orbicularis and the tarsus, sometimes produce a picture that resembles blepharochalasis, but the tumors can be felt. Much more commonly we find a more or less spherical congenital growth over which the skin is freely movable in the upper lid, either at the inner canthus, in front of the fronto-maxillary suture, or at a point in the upper outer margin of the orbit that corresponds to the fronto-malar suture, less often elsewhere, but always at a place where sutures or fissures existed during fetal life. Ordinarily such a tumor is a dermoid, but it may be a hernia cerebri, a term that includes both meningocele and encephalocele, or a cyst that has been formed by an obliteration of the pedicle of a meningocele. The differentiation of these conditions, which have several symptoms in common, is of importance. All may be attached firmly to the bone, or connected with it by a pedicle, and in all we may be able to make out by palpation an opening in the bone at the site of the suture. When the tumor is felt to pulsate, and can be made smaller by pressure, which causes at the same time such signs of increased brain pressure as nausea, vomiting, vertigo, and convulsions, it is a hernia cerebri and the brain symptoms have been caused by the return of a part of its contents to the cranial cavity. A cavernous angioma can be made smaller by pressure, but the diminution in size is not a THE LIDS 39 attended by brain symptoms, and its return to its former size when the pressure is removed is immediate, while a hernia cerebri regains its size much more slowly. When no pulsation can be felt, and the size cannot be reduced by pressure, the tumor may be a dermoid, or a cyst formed by the constriction and obliteration of the pedicle of a meningocele. Both may feel firm on palpation, but in a cyst we may be able to detect fluctuation; otherwise we are apt to remain in doubt. Little translucent tumors along the margin of the lid, perhaps as large as peas, are retention cysts due to occlusion of the excre- tory ducts of the glands of Moll. Retention cysts of the sebaceous glands form little, round, yellowish swellings, and are called milia; they are more common on the lower than on the upper lid and some- times resemble xanthoma when they are grouped. Congenital milia probably are caused by a snaring off of bits of the epidermis into the corium during fetal life. Cutaneous horns are recognized readily, and warts present the same characteristics as when on other parts of the body. The latter may give rise to carcinoma in old people. A little tumor which is attached to the skin of the lid by a pedicle and hangs down like a pouch, is a fibroma. Another name is simple molluscum, but this is not good, for it is related in no way to the much rarer molluscum contagiosum, a smooth, semiglobular, yel- lowish or pinkish tumor, that varies in size from that of a hempseed to that of a pea, and has a central depression in its top from which its soft, whitish contents can be made to exude by pressure. This tumor generally is met with in numbers along the margins of the lids of uncleanly children, where an older one frequently may be seen to be surrounded by a group of more recent, smaller ones, Whenever one appears on the margin of a lid another soon de- velops on the other, and Retzius proved it to be contagious by in- oculation. : A red or bluish, roundish tumor of the lid that is easily com- pressible, but regains its size as soon as pressure is removed, and swells when the blood is driven into the face, whether by position or by the emotions, is an angioma. It is a mass of enlarged blood vessels which grows slowly and may reach an enormous size. Usu- ally it is congenital and may form simply a red spot, which com- monly is called a birthmark, a little blue growth, or a large lobed tumor. When it contains large spaces it is called a cavernous angioma. A congenital, elastic, diffuse swelling that resembles a 40 DIAGNOSIS FROM OCULAR SYMPTOMS venous angioma but is pale and bears more resemblance to a cyst, is a lymphangioma, which consists of hollow spaces lined with epithelium. Very large lobulated tumors of similar nature are known as congenital elephantiasis lymphangiectatica. Quite rarely we meet with a rather soft congenital tumor in the upper lid from which hard cords may be traced by palpation; it is not painful, as a rule, but may be tender in places. This is a neurofibroma, and generally is associated with a hypertrophy of the skin that causes ptosis, frequently with buphthalmos. Sometimes the lids are pressed out by tumors beneath them, or perhaps invading their tissues to some extent, as in affections of the lacrimal gland, and in leucocythemia. The former are described under diseases of the lacrimal organs, and the lymphomata of the latter disease will be discussed under tumors of the orbit. BLEPHAROPHIMOSIS When the palpebral fissure is shortened by an adhesion along a part of the margins of the upper and lower lids the condition is known as blepharophimosis. The adhesion itself is called an anky- loblepharon. This condition is congenital in rare cases, in which it may have been caused by an epithelial adhesion, or by the union of the lids through connective tissue for a greater or less distance from the outer canthus, but more often it is due to a cicatricial con- traction of the conjunctiva, or to the adhesion of the margins of lids which have been made raw by ulcers or burns. A severe burn may cause the lids to agglutinate throughout their entire extent and produce acquired cryptophthalmos, which usually is associated with an extensive symblepharon. Congenital cryptophthalmos, produced by a total ankyloblepharon, generally epithelial, is common in many animals, but is rare in man. The growth of the lids is restricted together with that of the neighboring tissues after enucleation or atrophy of the eye in child- hood, and this is likely to result in a blepharophimosis in the adult. Sometimes we need to determine whether a blepharophimosis is real or not, for atony of the external palpebral ligament may counterfeit a stenosis of the palpebral fissure, and the latter may seem to be shortened by a vertical fold of skin that covers the outer canthus. Usually such a fold can be drawn back and the fissure revealed to be of its normal size, but its skin may become irritated by constant THE LIDS 41 wetting in a conjunctivitis so as to be hard and contracted hori- zontally, while a blepharospasm may be excited, and we be led to think the fissure too short until the seeming blepharophimosis passes away with the recovery from the conjunctivitis. LAGOPHTHALMOS When the lids lie wide apart and can be closed with difficulty, if at all, we say that the patient has lagophthalmos. In very rare cases this condition may result from a congenitally too short uppér lid, or from a spasm of the levator palpebre, but much more com- monly it is due to a paresis of the orbicularis, to ectropion, to exophthalmos, to an enlargement of the eyeball, to a tumor that separates the lids, or to a very grave general disease in which the sensorium is so benumbed, or the sensitiveness of the cornea so im- paired that the patient no longer winks. The differentiation of these conditions ordinarily can be made at a glance. Sometimes the eye- ball protrudes so much in high myopia that the presence of lagoph- thalmos is suggested, but this can always be excluded if there is no circumscribed patch of redness of the bulbar conjunctiva on each side of the cornea, which will always form at the place habitually left uncovered by the lids. The consequences of this condition will be discussed under keratitis e lagophthalmo. ECTROPION Eversion of the lids is ectropion. It may be very slight, so great that the entire inner surface of the lid lies exposed to view, or of any intermediate degree. The diagnosis is made readily except in very slight cases, when attention may need to be drawn to it by an epiphora and a slight thickening of the conjunctiva near the mar- gin of the lid. Differentiation deals mainly with the causes, which are diverse. A cicatrix that makes traction on the anterior part of the lid is a sufficient explanation; so is a cicatricial fistula that leads down to carious bone in the vicinity, if similar traction is exerted. This is cicatricial ectropion, the degree and extent of which varies accord- ing to the size and position of the scar. The highest possible degree may be produced by an extensive burn of the face. I have seen the upper lid everted until its lower margin coincided with the line of the A2 DIAGNOSIS FROM OCULAR SYMPTOMS eyebrow, and the margin of the lower drawn down nearly to the level of the ala of the nose, in a child that had fallen into a fire and burned the entire side of the face. The cicatricial contraction that follows lupus can produce almost if not quite an equal degree. Smaller cicatrices may evert only a portion of the lid, when the ectropion is said to be partial. That which is produced by fistule is partial and usually is about the outer canthus. When there is no explanatory cicatrix we look for other causes. The weight of a tumor may cause a lower lid to turn out. A re- laxation of the margin which allows the lower lid to droop is seen occasionally in facial palsy; this is due to paralysis of the orbicularis, is known as paralytic ectropion, and is differentiated through a paresis of other muscles on the same side of the face. The strength of the orbicularis fails along with that of other muscles in old people, while at the same time the skin of the lids becomes relaxed. ‘This relaxation may pass the point at which the lower, lid is supported against the eyeball, or the weight of the lid may be increased by a chronic conjunctivitis sufficiently to allow the margin to fall away a little and produce a senile ectropion. All forms tend to grow worse and many points in the course of the senile variety are com- mon to all. As soon as the palpebral conjunctiva is allowed to re- main in contact with the air it becomes hyperemic, swollen and in- flamed, presses the lid out still farther, increases its weight, and so renders the ectropion worse. The lacrimal punctum is turned out- ward, the tears overflow and cause a dermatitis which makes the skin of the lid heavier, and this helps to drag it down. The con- junctiva hypertrophies, dark red elevations appear in it, and, if the condition persists long enough, its surface becomes dry, lusterless, covered with scabs, and the epithelium becomes almost horny. The ectropion sometimes met with in a chronic blepharoconjunctivitis admits of a similar explanation; the tissues of the lid become relaxed from some cause, perhaps ill health, and then the conditions present are favorable for its development. When we try to open
Key Takeaways
- Chalazions can be differentiated from hordeolums based on their history and location.
- Syphilitic growths may require specific treatments like large doses of potassic iodide to differentiate them from chalazions.
- Various tumors and cysts can affect the eyelids, each with distinct characteristics that aid in diagnosis.
Practical Tips
- Always examine the patient's medical history for signs of syphilis before diagnosing a growth on the eyelid.
- Use palpation to differentiate between chalazions and hordeolums; chalazions are more adherent to the tarsus, while hordeolums are often superficial and tender.
- For suspected tumors or cysts, consider performing a histological examination for accurate diagnosis.
Warnings & Risks
- Be cautious when diagnosing syphilitic growths; incorrect treatment can lead to complications.
- Avoid applying pressure to tumors that may be associated with increased brain pressure, as this could exacerbate symptoms.
- Do not attempt to treat suspected malignancies without proper diagnosis and medical supervision.
Modern Application
While the techniques described in this chapter are historical, they provide a foundation for understanding various eye conditions. Modern ophthalmology has advanced significantly, but recognizing these growths is still crucial for initial triage and treatment planning. The knowledge of specific diagnostic methods can help prevent misdiagnosis and ensure appropriate care.
Frequently Asked Questions
Q: How can you differentiate a chalazion from a hordeolum?
A chalazion is usually round, nodular, and adherent to the tarsus, while a hordeolum is often superficial and tender. Chalazions are not typically painful unless inflamed.
Q: What should be done if a patient has a suspected syphilitic growth on their eyelid?
Administer large doses of potassic iodide for a few days to observe the growth's response. If it shrinks, it is likely a gumma; otherwise, it may be a chalazion.
Q: Can you differentiate between different types of tumors based on their appearance?
Yes, some tumors like dermoid cysts or lipomas can be identified by their location and characteristics. However, histological examination is often necessary for accurate diagnosis.