Ocular Symptoms and Conditions: Eyelid Problems
The eyelids have many functions, including protecting and lubricating the eye, producing oil secretions for the eye, and helping to drain away tears. This page includes a variety of eyelid problems ranging from lumps and bumps of the eyelid to twitching of the lid. Eyelid malpositions (in-turning and out-turning) and drooping eyelids (ptosis) are discussed as well.
Other eyelid related problems that are discussed on other pages of this Symptom and Diagnosis section are listed below with possible distinguishing features.
Conditions Discussed on this Page:
- Cellulitis of the Eyelid
- Ectropion of the Eyelid (out turning)
- Entropion of the Eyelid (inturning)
- Tumors and Growths of the Eyelid
- Twitching of the Eyelid (myokymia)
- Eyelid Drooping (ptosis)
- Other eyelid problems found on other pages
A chalazion, or stye, appears as a well defined swelling within the eyelid. The upper and lower eyelids each contain about 30 oil secreting glands that open at the edge of the lid, and travel deep within the tarsal plate of the eyelid. If one or more of these glands becomes blocked, the gland continues to make the secretion, but this is trapped within the lid and eventually forms a rounded lump within the lid. There may be mild soreness initially since the trapped material creates some inflammation in the eyelid. The swelling may protrude toward the eye, toward the outside and appear to be just under the skin, or protrude at the edge of the eyelid. Conditions such as blepharitis and rosacea may lead to chalazion formation.
In most cases, the chalazion will drain spontaneously if hot compresses are applied to the eyelid a few times a day for a few days to a week. Sometimes an antibiotic ointment or an oral antibiotic may help. In cases where the chalazion does not drain, it can be drained surgically under local anesthesia in the office or as an outpatient procedure with mild sedation. This procedure should not be overdone, since it may lead to the loss of numerous glands in the eyelid, which could lead to a dry eye problem in some people.
Sometimes a chalazion leads to the formation of a "granuloma", which is a reactive fleshy growth on the inside of the eyelid. This too can be removed if necessary. Masses in the eyelid can put pressure on the eye which can temporarily cause astigmatism, or a change in the shape of the eye.
Cellulitis of the Eyelid
Cellulitis is an infection of the eyelid, and is more severe than the more low-grade "blepharitis", which usually causes only itching or burning symptoms. Cellulitis causes diffuse swelling of the entire eyelid, which is usually tender, hot, and red. The swelling may extend onto the face, and there may be discharge present. Cellulitis of the lower eyelid can mimic infection of the tear drainage sac (dacryocystitis). It is important to distinguish infection involving only the eyelid from infection extending from behind the eye, or the orbit (orbital cellulitis), which is usually more severe and causes eye protrusion and double vision.
Eyelid cellulitis is treated with oral antibiotics, and sometimes with IV antibiotics in more severe cases. It is important to watch for extension of the infection into the orbit.
Ectropion of the Eyelid
Ectropion, or out-turning, of the eyelid usually involves the lower eyelid. The lower eyelid pulls away from the eye and visibly appears to sag down and everted. Symptoms include irritation, swelling, and redness of the eyelid, tearing, and irritation and redness of the eye. The lower eyelid is usually pressed flush against the eye and keeps the eye bathed in lubricating tears. When the eyelid sags away, so do the tears, and the eye can become severely dry. Tearing occurs if the opening in the eyelid which drains tears away becomes separated from the eye (nasally located). Thus, tears have no way to drain away except onto the face. Dryness of the cornea can lead to a scratchy sensation, redness of the eye, pain, and blurred vision. Sometimes the cornea can become infected.
Most of the time, ectropion occurs along with the general aging changes in the skin. The lower eyelid can become looser, and eventually pull away from the eye by gravity. Bell's Palsy, or a temporary paralysis of the side of the face, can suddenly make these normal aging changes much worse, and the eye can become severely dry due to ectropion. Other conditions lead to scarring of the skin under the eyelid, which pulls the eyelid away from the eye.
Treatment of ectropion in some cases is merely to lubricate the eye as best as possible, with artificial tears during the day and ointment at night. In more severe cases, or if the cornea is at risk due to severe dryness, the eyelid out-turning can be corrected surgically under local anesthesia.
Entropion of the Eyelid (Inturning)
Entropion, or inturning, of the eyelid can involve the upper or lower eyelid. Symptoms occur due to the scratching of the eye by the inwardly pointing eyelashes (trichiasis). Usually numerous eyelashes are involved, and it is impractical to pull all of them. This condition can occur due to generalized aging changing in the eyelid with a gradual rotation inward. Other cases are caused by scarring, either from trauma, infection, or an inflammatory condition such as shingles of the eyelid.
In cases where the eye is being severely scratched by the entropion, surgery can be performed emergently to reposition the lid. Other less severe cases might be able to be managed using lubricating eye drops and ointments on the eye, but usually surgery will need to be performed. It is not usually practical to treat entropion of eyelid chronically without repositioning the lid surgically. Sometimes a small piece of tape can be applied to the face to place tension on the the margin of the lower lid which can flip it out into the proper position until surgery can be performed.
Tumors and Growths of the Eyelid
This discussion of eyelid tumors includes growths present on the skin, the edge, or the inside surface of the eyelid. A chalazion, or stye, which is a lump within the eyelid, is covered in a section above.
Skin cancer of the eyelid appears usually as a slowly enlarging lump usually on the lower eyelid. The most common type is "basal cell" cancer, which usually is a firm, pearly nodule which is non-tender. If present at the edge of the eyelid, there may be a loss of eyelashes. Basal cell cancers are not malignant but can be locally destructive. Sebaceous carcinoma, another type of skin cancer of the eyelid, resembles a chronic infection of the lid, or blepharitis, with redness of the lid. Melanoma can involve the outside or inside of the eyelid, and usually is a changing, darkly pigmented growth. Sometimes melanomas have no pigment.
Treatment of suspicious growths of the eyelid is by excisional biopsy with examination in the laboratory to determine if the growth is cancerous, and if it has been removed completely.
Non-cancerous growths of the eyelid include:
- Skin tags or cutaneous horns, which are fleshy growths or hornlike growths of skin on a stalk. These can be removed if necessary.
- Seborrheic keratoses are "stuck-on appearing" growths on the skin. These are more of a cosmetic problem and rarely have to be removed, but they are extremely common and can appear anywhere on the body, especially on the face and neck.
- Inclusion cysts are round, bubble-like swellings on the eyelid which may come and go. If simply drained, they usually recur. Excision usually is done as an outpatient procedure using an operating microscope due to the meticulous dissection required to remove the cyst in its entirety to prevent recurrence.
- Viral papillomas, or wart-like growths, are fleshy growths usually on the edge of the eyelid. These can be removed if the become bothersome, irritated, or large.
- Granulomas are inflammatory growths on the inside or outside of the eyelid, and can occur after a stye, or chalazion.
- Molluscum contagiousum is a small viral growth of the eyelid or skin which can spread. Usually it is a tiny, round, white lump on the lid. Viral particles shed from this can irritate the eye and lead to itching and redness. Treatment is by excision.
Calcifications, or "concretions" can occur on the inside of the eyelids. If the eyelid is flipped over, a small, very white particle or cluster of particles may be seen on the inside surface. Usually these are covered over by a transparent membrane that lines the inside of the eyelid. Rarely they can erode through the conjunctival surface and scratch the eye, and in those cases they can be removed.
Twitching of the Eyelid (myokymia)
Twitching of the eyelid is a common and annoying problem. Usually a tiny section of muscle beneath the skin of the upper or lower eyelid seems to rhythmically, sporadically and uncontrollably twitch. Often it is barely visible to other people observing the eyes, but can be very annoying to the patient. The muscle fibers beneath the skin of the eyelid run in a circle around the eye, so the twitch seems to also pull toward the inside or outside.
Causes include local eye irritation such as dry eye and blepharitis, and artificial tears may help. Fatigue, stress, and lack of sleep are other known causes. Stimulants such as caffeine and decongestants may also lead to twitching. Rarely, pulsation of an artery on a nerve controlling the muscle causes twitching.
Usually the eyelid twitching will resolve with time spontaneously. A more severe version of this, called blepharospasm, leads to severe, uncontrollable squeezing of the eyelids closed. This problem can be treated if necessary by medication such as Botox injections. This problem usually needs evaluation by an ophthalmologist.
Drooping of the Eyelid (ptosis)
Several problems can lead to drooping of the upper eyelids, called ptosis (toe-sis). Some people are born with this condition, and live their lives with no complaints or symptoms. The Asian eyelid often has the appearance of ptosis as a normal variation. This may not be even a cosmetic problem for many individuals, especially if it is symmetrical between the two eyes (as in some photos of Marilyn Monroe). However, for people who develop worsening ptosis in one eye or the other, it can become a battle to keep the eyes open. Significant ptosis of the upper lids can block the upper field of vision. Causes include:
- Aging changes - in some people the muscle that lifts the upper eyelid slips back with time and the eyelid droops.
- Trauma - a blow to the eye or a laceration can damage or disinsert the muscle controlling the height of the eyelid.
- Eye surgery - for an unknown reason, some people will develop ptosis after cataract surgery, or other eye surgeries.
- Myasthenia gravis - this unusual disorder leads to a temporary, often severe, drooping of one or both eyelids. This drooping is often worse as the day goes on, or with fatigue. At other times, the height of the lids can be completely normal. This may be associated with muscle weakness and fatigue, as well as a variable double vision. It is treatable with medication.
- Nerve paralysis - one of the nerves that control eye movement also controls the muscle which lifts the eyelid. If the affected eyelid is raised, usually the person will have double vision. This is discussed more in the section on nerve paralysis. Another condition called "Horner's syndrome" can cause this also, although usually with less severe ptosis, and the pupil on the affected side is smaller. Both of these conditions need prompt evaluation by a ophthalmologist as they can be associated with life-threatening complications.
- Brow ptosis - in this condition, especially common in men, the entire brow area drops down. If folds of skin then block the vision, surgical correction can be done.
- Some people develop loose overhanging skin of the eyelids, or develop pockets of fat which protrude and bulge in the eyelids called dermatochalasis. This can be corrected surgically if necessary or desired.
Ptosis which encroaches on the pupil and is blocking the upper field of vision can be surgically corrected. Less severe ptosis can be corrected with cosmetic surgery.
Other eyelid problems found on other pages:
A link to each condition is listed along with other hallmark features of the condition.
- Thyroid eye disease - can cause eyelid swelling and "retraction" (a wide-open eye appearance)
- Myasthenia Gravis - can cause drooping of one or both upper eyelids, often worse at the end of the day or when tired.
- Dacryocystitis - infection of the tear drainage system can cause eyelid swelling and pain.
- Trichiasis (inturned eyelashes) - an eyelid problem leading to a scratchy eye sensation, redness, and tearing.
- Orbital infection - infection behind the eye can lead to eye swelling.
- Ocular cicatricial pemphigoid - an autoimmune disorder that leads to conjunctival scarring with inturning of the eyelids and lashes.