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Alopecia areata is understood as an autoimmune disease T cell-mediated mainly involving hair follicles in humans. It is a multifactorial aetiologic disease characterised by non-scarring alopecia and asymptomatic areas, affecting approximately 2 % of dermatology patients. Recent studies suggest that the pathogenesis of AA plays an important role in the association of certain HLA groups, neuroendocrine parameters and immunogenic factors. During 3 months (March to May 2013) at Hospital Clinic de Barcelona, 22 patients with severe alopecia areata underwent ophthalmic examination to determine whether there were ocular findings in the following parameters: Best-corrected visual acuity on decimal Snellen optotype, anterior segment slit-lamp examination and photograph, intraocular pressure measurement and dilated fundoscopy. Ultra-wide-field retinal imaging with or without red-free photograph was carried out with the Optomap 200 Tx (Optos, DunFermline, UK). Forty-four eyes of 22 patients were analysed [15 females (68.2 %)]. The mean age was 38.9 (SD 13.7) and mean time of evolution was 19.9 years (SD 16.3). Alopecia areata clinical patterns were multifocal [n = 10 (45.5 %)], universalis [n = 7 (31.8 %)], totalis [n = 3 (13.6 %)] and focal [n = 2 (9.1 %)]. Best-corrected visual acuity was 1.0 in almost all patients, but only three eyes (6.8 %) had vision of 0.7. Ocular findings were as follows: madarosis [n = 7 partial loss of eyelashes (31.85 %) and n = 4 total loss (18.2 %)], lens changes [n = 4 (18.2 %)], cataract [n = 3 (13.65 %)]. Ultra-wide fundus photography examination showed peripheral drusen [n = 17 eyes (38.6 %)], white-without-pressure changes [n = 8 eyes (18.22 %)] and peripheral retinal degenerations [n = 3 eyes (6.81 %)]. Ocular findings in patients with alopecia areata are reported and discussed by dermatologic and ophthalmic evaluation.

PURPOSE: To identify the frequency of ocular changes in patients with Hansen's disease, living in a colony hospital; to confirm the predilection for the anterior segment of the eye instead of the posterior segment. METHODS: Transversal study of 115 eyes of 58 in-patients at Joao Paulo II colony, Marituba - Para, from August to October 1999. The epidemiologic data of this research were obtained from the patients' charts and from information obtained at clinical eye examination. All patients in this study were considered cured of Hansen's disease according to the Health Ministery criteria of cure. RESULTS: In 114 eyes (99.1%) ocular involvement was observed, the majority (77.2%) being the virchowian form. The most frequent ocular findings in the adnex were parcial madarosis (70.4%) and parcial eyebrow madarosis (59.1%). The most frequent ocular finding related to Hansen's disease was the decrease and/or absence of corneal sensitivity observed in 42.6% of the eyes, followed by paralytic midriasis (16.5%) found in the patients after surgery for cataract extraction; this finding was closely related to iris atrophy (8.7%), commonly found in these patients. CONCLUSION: The high prevalence of ocular involvement in Hansen patients, especially in virchowian form, indicates the need of complete assistance to these patients even after the resolution of the disease.

PURPOSE. To describe a case of congenital unilateral giant coloboma and its successful surgical repair with 33 years of follow-up. CASE REPORT. A 6-year-old boy presented with a congenital unilateral giant coloboma of the right upper eyelid associated with madarosis of the eyebrows, microphthalmos, dystopia of the hair, and coloboma of the apex of the nose. The patient underwent surgical repair of the multiple anomalies in different steps. DISCUSSION. A multiple-step, two-layer technique for the reconstruction of the right upper eyelid was performed in a 6-year-old boy with congenital unilateral giant coloboma associated with multiple ocular and facial anomalies. After 33 years of follow-up, the cosmetic results are excellent, although it has not been possible to preserve the visual function of the right eye, which had to be enucleated. (Eur J Ophthalmol 2003; 13: 714-7)

Background: Presence of physical deformities in patients with leprosy reflects the rate of disease transmission in the community; delay in detection of cases; and inadequacy or failure of treatment. Objectives: To determine the spectrum of physical deformities in patients with leprosy, to analyze the various sociodemographic factors affecting the study population, and to assess the treatment history of the selected number of patients. Materials and Methods: The study was an analytical study conducted on all leprosy patients who visited the dermatology out-patient department in a tertiary care hospital during the period of 1 year. Results: Males constituted 70.66% and females constituted 29.34%. It was found that a majority were in the age group of 21–60 years than in the extreme age groups (0–20 years and 61–80 years). Among the 92 patients studied, it was found that majority of the patients (60.86%) had WHO grade 0 or grade 1 deformity. Those with visible deformities (WHO grade 2 deformity) constituted 39.13% of the study population. Among those with visible deformities, the most common deformity was seen to be trophic ulcer (21.73%). This was followed by claw hand, foot drop, madarosis, claw toes, lagophthalmos, ear lobe deformity, facial palsy, and finally nose deformity. Conclusions: Our study found that more than one third of number of leprosy patients had deformities. It reflects the need for further efforts to curb this infectious disease and increase education among masses.

The eyebrows have a combined linguistic and affective function and play a key role in facial expressions. Eyebrows loss (madarosis) has various etiologies [1, 2] and may cause disfigurement and discomfort. Eyebrow transplantation is the best aesthetically acceptable procedure that is performed to improve the patient’s appearance and self-esteem. Reconstruction techniques using micrografts of various sizes usually yield good results. Transplantation methods vary from physician to physician; some use a 18-21-G needle with stick-and-place, some use implanters, and others use premade incisions with a tiny microblade, such as a 15 Sharpoint, and place the grafts afterward. The success of reconstruction depends on the surgeon’s knowledge of eyebrow anatomy and his or her ability to reproduce the angle and direction of single-hair grafts to achieve natural results [3]. Here we report our successful, easy approach, with more than 90 cases of eyebrow reconstruction by follicular unit transplant (FUT). Eyebrow design is critical [4] and has three key points: symmetry, direction, and angle. We obtained perfect symmetry by drawing the eyebrow on transparent paper, which is then used as a template for the design of a perfectly symmetrical contralateral eyebrow (Fig. 1). The donor hair is the scalp, in the occipital area, where a strip with an appropriate number of bulbs is harvested. Strip harvesting is about 45 to preserve the adjacent bulbs. Extensive dissection of at least a 1-2-cm margin to suture the donor area without tension ensures a good scar. Micrografts are prepared by means of magnification, and each hair graft is transplanted microsurgically into an incision prepared for it by using of a needle bayonet of 18/19 G (Fig. 2a). This needle is extremely handy; it simplifies and speeds up the creation of the microincision. It overcomes the main difficulty of the eyebrow transplant, reproducing the very acute angle between the hair-stem and the skin. Indeed, this needle is inserted with ease at an acute angle, virtually flat to the skin (Fig. 2b), reproducing the correct original anatomy and shortening the operative time. On average, 100-300 follicular unit grafts are transplanted microsurgically (Fig. 3). Patients who have this eyebrow transplantation for both reconstructive and aesthetic reasons (Fig. 3) are generally very satisfied. The presented technique simplifies the precise, oriented placement of single-hair grafts and has been time-tested by the senior author for the last 20 years. The bayonet needle is a novel and simple approach to FUT, with satisfactory results and a very low complication rate. It is safe, effective, minimally invasive, and very handy in allowing rapid movement. Furthermore, it has no additional costs because it is packed on the operating table by a 18/19-G needle. The results of our technique are natural, beautifully shaped, and contoured. The one problem is that the hair will continue to grow, which necessitates trimming the hair monthly. After a few years, hair transplants adapt to the recipient site by a mechanism that we call ‘‘field effect,’’ as in pubic restoration [5] and other ectopic transplants. However, this is a minor problem for most patients because the defect is caused by a disfigurement due to oncological surgery (Fig. 4), radiotherapy (Fig. 5), burns or severe Electronic supplementary material The online version of this article (doi:10.1007/s00266-011-9712-1) contains supplementary material, which is available to authorized users.

Background Collateral damage to upper eyelid margin during proton beam radiotherapy (PBR) for choroidal melanoma may cause squamous metaplasia of the tarsal conjunctiva with keratinisation, corneal irritation, discomfort and, rarely, corneal perforation. We evaluated transpalpebral PBR as a means of avoiding collateral damage to the upper eyelid margin without increasing the risk of failure of local tumour control. Methods Retrospective study of consecutive patients who underwent PBR for choroidal melanoma between 1992 and 2007 at the Royal Liverpool University Hospital and the Douglas Cyclotron at Clatterbridge Cancer Centre, UK. Results Sixty-three patients were included in this study. Mean basal tumour diameter and tumour thickness were 11.8 mm and 3.6 mm, respectively. PBR mean beam range and modulation were 26.5 mm and 16.9 mm respectively. The eyelid margin was included in the radiation field in 15 (24%) eyes. The median follow-up was 2.5 years. Local tumour recurrence developed in 2 (3.2%) patients. In these two cases that developed tumour recurrence the transpalpebral treatment did not involve the eyelid margin. Six (9.5%) patients died of metastatic disease. No eyelid or ocular surface problems developed in any of the 48 patients who were treated without eyelid rim involvement, while 7 of the 15 patients with unavoidable irradiation of the eyelid rim developed some degree of madarosis. These seven patients all received more than 26.55 proton Gy to the eyelid margin. Symptoms, such as grittiness occurred in 12% of 48 patients without eyelid margin irradiation as compared with 53% of 15 patients whose lid margin was irradiated. Conclusions Transpalpebral PBR of choroidal melanoma avoids eyelid and ocular surface complications without increasing failure of local tumour control.

The isolated absence or loss of eyelashes (madarosis) is associated with many processes including systemic and local diseases. Madarosis of dental origin has not been reported. This paper is a report of the successful treatment of unilateral eyelash loss following root canal therapy of an upper posterior tooth.

Purpose To describe eyelid abnormalities in lamellar ichthyoses (LI). Design Retrospective observational case series. Participants Eight patients with classic LI and two patients with congenital ichthyosiform erythroderma. Methods Results of eyelid and corneal examinations of 10 patients with LI were reviewed and analyzed with emphasis on the relationship between eyelid ectropion and corneal damage. Results All patients presented with cicatricial lagophthalmos. Of the eight patients with classic LI, five had ectropion of the four eyelids, one had only lower ectropion, and two had no degree of ectropion. Two patients with congenital ichthyosiform erythroderma had distinct eyelid abnormalities, including madarosis and eyelash retraction. Loss of vision caused by corneal damage was found in three patients with classic LI. Of these three patients, two did not have upper eyelid ectropion. Conclusions Severe corneal damage can occur in LI even if there is no upper or lower eyelid ectropion.

Background. Recently donor dominance has been emphasized in autologous hair transplantation while the influence of the recipient site has been considered negligible. In fact, there have been few studies that show this. Objective. This study was performed to examine the influence of the recipient site on transplanted hairs. A clinical study of 19 leprosy patients was performed. These patients had received single hair transplantation due to madarosis and were admitted to The Leprosy Mission, Jesus Hospital, Taegu, Korea, or had visited its outpatient clinic. Methods. In this study, the rate of growth, thickness of shaft, and graying rate between the transplanted eyebrow hair in the recipient site and scalp hair near the donor site were compared to observe the changes in the growth pattern of the hairs after transplantation. Results. For most of the patients, the growth rate and graying rate of transplanted hairs were lower than those of hairs in the donor site. Conclusion. It seems that the recipient site may have an influence on the transplanted hairs. Further studies are needed, including clinical, histopathologic, and molecular biological methods.

PURPOSE: To describe the clinical appearance of factitious (or self-inflicted) lesions on periocular skin and face. METHODS: All patients with factitious cutaneous disease who were examined at Mayo Clinic, Rochester, Minnesota, between 1985 and 1997 were identified. For patients with lesions on the face and periocular skin, the demographic features, clinical descriptive characteristics of their lesions, associated psychopathology, and treatments were ascertained. RESULTS: Of 38 patients with factitious dermatitis, 18 (47%) had facial lesions. Of these 18 patients, 15 (83%) were female. The mean age (± SD) of the patients with facial lesions was 35.2 ± 15.7 years (range, 9 to 66 years). Eight patients (44%) had neurotic excoriations, nine (50%) had dermatitis artefacta, and one (6%) had trichotillomania. The working diagnoses of five patients cared for initially in the Department of Ophthalmology were corneal epithelial and facial desquamation associated with severe pain of unknown cause, medial cicatricial ectropion of probable vasculitic cause, basal cell carcinoma of the nasojugal fold, recurrent preseptal cellulitis resistant to medical treatment, and madarosis of the upper eyelids of unknown cause. CONCLUSION: Cutaneous factitious disease may masquerade as numerous clinical entities and should be included in the differential diagnosis of lesions of the periocular skin.

AIM—To describe leprosy characteristics, ocular features, and type of organisms that produce infective corneal ulcers in leprosy patients. METHOD—The records of all leprosy patients admitted for treatment of corneal ulcers between 1992 and 1997 were reviewed. RESULTS—63 leprosy patients, 53 males and 10 females, are described. 16 were tuberculoid and 47 lepromatous. 25 patients had completed multidrug therapy. 10 patients had face patches, eight had type I reaction, and 10 had type II reaction. 43 (68%) patients had hand deformities. In 54% of patients pain was absent as a presenting symptom. 19 patients gave a history of trauma. In 15 patients ulcers had also occurred on the other eye, five of them having occurred during the study period and the rest before 1992. Of the 68 eyes with corneal ulcers, 28 had madarosis, 34 had lagophthalmos, nine had ectropion, three had trichiasis, six had blocked nasolacrimal ducts, and 39 decreased corneal sensation. In 14 eyes, a previous lagophthalmos surgery had been done. 16 patients were blind at presentation. 32% of ulcers were located centrally. After treatment only 18% of the eyes showed visual improvement. Five types of fungus were cultured, two of them rare ocular pathogens. CONCLUSIONS—Corneal ulcers occur more in males and in the lepromatous group of patients. Decreased corneal sensation, lagophthalmos and hand deformity are closely associated. Indigenous treatment and late presentations were notable in many patients. Visual outcome is not good. There is increased risk of developing an ulcer in the other eye. Fungal corneal ulcers are not uncommon. Keywords: infectious keratitis; corneal ulcers; leprosy

To the Editor: Leprosy (Hansen disease) is caused by Mycobacterium leprae, an extremely slow-growing, intracellular, acid-fast bacillus with a typical incubation period >2–5 years, ranging up to 20 years. Anesthetic, thickened skin lesions and granulomatous inflammation in biopsy specimens are typical findings because direct visualization of the organism from biopsy specimens is unreliable (1). The worldwide prevalence of leprosy is estimated to be

Objective To report a rare case of collision sebaceous and basal cell carcinomas of the eyelid. Design Interventional case report. Methods An 80-year-old woman presented with a nodular lesion at the center of the left lower eyelid. Small ulceration and madarosis were also present. Results The patient underwent excisional biopsy with frozen section control. Histopathology showed mixed sebaceous as well as basal cell carcinoma with uninvolved surgical margins. Oncologic survey did not disclose any other lesion. At 6-month follow-up, there was no evidence of recurrence, new lesions, or metastasis. Conclusion Sebaceous and basal cell carcinomas can coexist in the eyelid within the same clinical lesion. Because of the potential risk of metastasis of sebaceous carcinoma, close follow-up of the patients is advisable.

The purpose of this study was to determine the sensitivity of madarosis as an indicator for malignancy in eyelid lesions affecting the lid margin.A retrospective medical record review was completed for patients who were diagnosed with lesions affecting the eyelid margin which were suspicious for malignancy. Suspicion was determined by considering an array of factors, including lesion characteristics, Fitzpatrick score, sun exposure history, and history of skin cancer. Presence of madarosis was assessed by clinical examination, and presence of malignancy was determined by biopsy.The association between madarosis and malignancy was statistically significant (p ≤ 0.001). Madarosis had a sensitivity of 0.643 and a specificity of 0.882 when used as a sole indicator for malignancy. The odds of malignancy were 13.4 times higher in the presence of madarosis.Madarosis is more common in malignant eyelid margin lesions than benign lesions. If madarosis is present, there is a 69.23% chance that the lesion is malignant. Therefore, biopsy of any suspicious lesion that demonstrates madarosis is recommended. However, many malignant eyelid margin lesions do not demonstrate madarosis, and so the sensitivity of madarosis as a sole indicator for malignancy is poor. In the absence of madarosis, it is important to consider other factors when determining malignant potential of eyelid lesions.

Untreated periocular discoid lupus erythematosus (DLE), though very rare, may lead to significant morbidity with lid deformities, trichiasis, and symblepharon formation. We present the largest reported cohort of patients with biopsy-proven DLE solely affecting the periorbital region. Observational case series of patients managed over a 7-year period (2004–10). Seven patients (one male) presented to the Adnexal Service at Moorfields Eye Hospital at a median age of 47 years (range 23–71 years); median interval from symptom onset to biopsy-proven diagnosis was 38 months (range 6–86 months). Changes in peripheral skin were present in 1 patient (occurring after the initial eyelid presentation) and the presenting periocular features were dissimilar across the group, these included: chronic blepharo-conjunctivitis, madarosis, atypical chalazia, depigmentation of the eyelid margin, or marked, persistent periocular oedema with dacryoadenitis. Two cases settled spontaneously, but five required systemic hydroxychloroquine or intralesional corticosteroid injections. Periorbital DLE is rare and very varied in its presentation, the protean manifestations often resulting in significant diagnostic delay. All patients with unusual periocular skin disease and those with a refractory inflammatory dermopathy, should undergo biopsy of involved tissue(s), thus leading to earlier diagnosis and prevention of permanent cicatricial periocular changes.

Discoid lupus erythematosus is a common form of chronic cutaneous lupus erythematosus, an autoimmune inflammatory disease that affects most of the human organs, including the skin, kidneys, joints, heart and lungs. We describe a 45-year-old Caucasian woman with a 21-year history of eyelid redness and irritation. She had been treated with antibiotics, steroids and eyelid hygiene, a therapy that resulted to brief periods of relief of symptoms. In the last 12 months, her symptoms seemed to have exacerbated, despite the administration of a local therapy. Following biopsy, a diagnosis of discoid lupus erythematosus was confirmed and the patient was placed on a systemic therapy with hydroxychloroquine. The eyelid inflammation decreased but severe scarring of the marginal eyelids persisted, resulting in cicatricial ectropion.

Objective : This study was aimed at presenting the profile of ocular lesions observed in the in-mates on multidrug treatment, of a leprosy rehabilitation centre in Nigeria. Design : Cross-sectional. Method : One hundred patients were selected by systematic random sampling. Sixty-nine had ocular involvement and were the subjects of this study. The age range was 15 to 80 years with a mean age of 51 years. There were 57 males (82.6%) and 12 females (17.4%). The range of duration of treatment was two months to 30 years, with a mean of 15 years. Examination of the anterior and posterior segments of the globe and its adnexa was carried out using Penlight, magnifying loupe and direct ophthalmoscope. Visual acuity was recorded using the Snellen charts. Results : Lepromatous leprosy patients had the greatest incidence of ocular lesions. Ocular lesions were more in patients who have had leprosy for . 15 years. Madarosis (72.5%) and lagophthalmos (29.0%) were the commonest lesions. Corneal involvement was seen in 36.2%. Conjunctivitis in 14.5% . Trichiasis in 10.1% and ectropion in 8.7% . 17.4% were legally blind (VA.3/60) in the better eye, and 17.4% had cataract in at least one eye. There was no statistically significant difference in the incidence of ocular lesions among males and females, and between patients with Lepromatous and Tuberculoid leprosy. Conclusion : Ocular complications are common and sight threatening in leprosy patients. Regular screening and outreach by eye care providers should be incorporated into leprosy care programmes.

We report eyelid margin changes in 3 patients after docetaxel treatment for breast cancer. These patients were referred to Cincinnati Eye Institute for eyelash abnormalities and/or epiphora and all had been treated with docetaxel in the near past. The ophthalmic complaints started soon after chemotherapy. All 3 cases showed varying degrees of palpebral mucosal inflammation and cicatricial changes leading to marginal entropion. The first patient exhibited very prominent eyelid margin inflammation and diffuse trichiasis without madarosis. The second patient had extensive madarosis and abnormally curved, thin eyelashes with punctal and canalicular obstruction. Her marginal entropion was most prominent at the medial lower eyelids. The last patient showed significant lash misdirection in a scattered distribution and patchy madarosis along with pseudomembranes blocking the puncta. All of these eyelid abnormalities occurred soon after docetaxel treatment for advanced breast cancer. Such changes in the absence of questioning for previous docetaxel use in history taking.

We reviewed the adnexal and orbital findings in a large population with HIV infection followed in one medical center. Around 6% of the series had positive periocular findings. In 1% of the series, the periocular findings were the first manifestation of HIV infection or AIDS. We present the first case of basal cell carcinoma in an HIV-infected individual; the carcinoma involved the eyelid. Orbital findings included lymphoma, cellulitis, Kaposi's sarcoma, and nonspecific inflammatory disease. Adnexal findings included Kaposi's sarcoma, molluscum contagiosum, bacterial folliculitis, madarosis, psoriasis, basal cell carcinoma, and chalazion. Additional opportunistic infections and tumors involving the periocular region are expected to be reported in the future.

A 75-year-old man presented with a peculiar facial appearance, having a diffuse yellowish hue, atrophic skin, and deep wrinkles and furrows involving the entire face, most prominently the forehead, zygomatic, and malar areas [Figure 1]. Multiple large comedones and numerous 2-6 mm sized yellow-to-brown colored papules and nodules were present, clustered in the periocular region and over the dorsum of a patulous nose. The lesions had been present for at least 15 years with gradual coarsening of facial features. Lateral madarosis of both eyebrows was evident, but leprosy was clinically ruled out based on absence of history suggestive of any sensory or motor impairment and lack of cutaneous lesions suggestive of leprosy, Hypoesthesia, thickening of peripheral nerves, any motor deficit or deformity on examination. He also had depigmentation of lower lips but was not bothered by it and did not seek any treatment for the same. The patient was a farmer by occupation with history of significant daily sun exposure and had never followed any specific sun-protection measures or used sunscreens. He had been a chronic heavy smoker with 50 smoking pack years (25 cigarettes per day for 40 years). The patient was totally unconcerned about the facial disfigurement and wanted to consult regarding itching in his groin region, which on examination revealed tinea cruris. Histopathology from the cheek revealed grossly solar damaged epidermis with abundant grey-blue ribbon-like elastotic fibers in upper- and mid-dermis, agglomerating to form elastic globules at places. The upper dermis shows an increased number of thin-walled capillaries and sparse superficial perivascular lymphohistiocytic infiltrate with thinning of reticular dermis [Figure 2]. We diagnosed him as a case of Favre-Racouchot syndrome (FRS) with tinea cruris. Special stains were not done as the histopathology on hematoxylin and eosin staining was characteristic of this syndrome. He was prescribed a 2-week course of twice daily terbinafine cream that completely cleared the fungal infection when examined on follow-up. He refused any treatment for the facial skin. Figure 1 Deeply wrinkled, furrowed, and atrophic facial skin with multiple comedones, papules, and nodules over the nose, cheeks, and forehead Figure 2 Histopathology from the cheek revealing sparse superficial perivascular lymphohistiocytic infiltrate with abundant grey blue ribbon like elastotic fibers in upper- and middermis, agglomerating to from elastic globules at places. Overlying epidermis is ... FRS, also referred to as senile comedones, solar comedones, and nodular elastosis with cysts and comedones, was originally described in 1932 by Favre and later reviewed in detail by Favre and Racouchot in 1951.[1] Though mostly reported in Caucasian men (with an estimated prevalence of 6% in adults older than 50 years), cases have also been reported in dark-skinned people including Indians, albeit rarely.[2] Cases occurring as early as the second decade of life have also been documented.[3] Males clearly outnumber females, presumably due to more sun-exposure and the effect of smoking. Clinically, this peculiar syndrome is characterized by a diffuse yellowish hue with the presence of large, open, black comedones symmetrically distributed on the temporal and periorbital areas, and deep wrinkles and furrows over a background of actinically damaged and atrophic skin.[3] In severely affected patients, multiple small papules, nodules and cystic lesions develop, especially involving the periocular region and the nose. Uncommonly, the lateral neck, retroauricular areas, earlobes, and forearms may also be involved. The eruption is usually bilaterally symmetrical. The differential diagnosis includes acne comedones, milia, colloid milium, syringomas, trichoepitheliomas, and sebaceous hyperplasia.[3] Conditions closely linked to FRS include cutis rhomboidalis nuchae which it often accompanies and the actinic comedonal plaque, which is considered to be a variant of FRS.[3] Other conditions reported to be associated with FRS include cutaneous myxoma, actinic keratosis, basal and squamous cell carcinoma, trichostasis spinulosa, keratoacanthoma, and eyelid papilloma.[4] Diagnosis is primarily clinical and histopathology is rarely required. However, the histologic features of FRS are very characteristic with presence of dilated pilosebaceous openings, atrophic sebaceous glands and large, round cyst-like spaces lined by a flattened epithelium and filled with layered horny material.[5] Evidence of significant solar elastosis is often present with presence of epidermal atrophy and massive basophilic degeneration of the upper dermis.[3] Vellus hair shafts, copious amounts of bacteria, sebum, and eosinophilic laminated horny material have been demonstrated within the cyst-like spaces, suggesting that they actually represent oblique histologic cuts of closed comedones rather than true infundibular cysts.[3,5] The comedones are colonized with Propionibacterium acnes, Corynebacterium acnes, Staphylococcus albus, and Malassezia yeasts. Inflammation is conspicuously absent. Though the precise pathogenesis of FRS remains unclear, implicated factors include chonic exposure to ultraviolet radiation and heavy smoking, which may act synergistically. Additionally, radiation therapy has been linked to development of FRS in at least three reported cases till now.[3,5] Measures to halt the progression of the disease include meticulous sun-protective measures like avoiding outdoors activities during peak hours of sun-exposure and the use of broad spectrum sunscreens.[4] Cessation of smoking is strongly advised. Isolated use of pharmacologic treatments or surgical techniques has so far resulted in unsatisfactory results. For best therapeutic outcome, one needs to target the solar elastosis, nodulocystic lesions, and the small as well as large comedones that require mechanical removal. Thus, combining medical and surgical treatments seems to be the best approach at present. Owing to their exfoliative and collagen remodeling properties, topical retinoids constitute the mainstay of medical treatment. Their regular use results in expulsion of small comedones and improvement in photodamaged skin. Daily oral Isotretinoin (0.05-0.1 mg/kg/day) used in conjunction with topical tretinoin has also been found effective.[3] Surgical techniques include comedone extraction, curettage, simple or multiple-stage excision, dermabrasion, and laser resurfacing.[4] The most recent addition to the therapeutic armamentarium of FRS is the combination of superpulsed carbon dioxide laser to vaporize the epidermis followed by extraction of cystic and comedonic material with a pair of forceps, with the entire procedure performed without anesthesia. After an initial encouraging outcome observed in two cases of unilateral FRS, Mavilia et al.,[6] reported excellent cosmetic results, rapid recovery, and good safety profile of this combination therapy in 50 patients of FRS with Fitzpatrick skin type III, and have suggested that it may become the treatment of choice for FRS in future. The prognosis of this condition is excellent if the patient is properly counseled and treated.

A 28-year-old woman presented with a 2-year history of idiopathic, chronic blepharitis unresponsive to several courses treatment of corticosteroid eye drops. Physical examination was notable for edematous, erythematous plaques of the lower eyelids with madarosis in the absence of preceding skin scarring. Biopsy specimen was obtained and diagnosis of discoid lupus erythematosus (DLE) was made. DLE is a chronic, cutaneous disease that is clinically characterized by a malar rash, acute erythema, and discoid lesions. Localized DLE occurs when the head and neck only are affected, while widespread DLE occurs when other areas are affected, regardless of whether disease of the head and neck is seen. Patients with widespread involvement often have hematologic and serologic abnormalities, are more likely to develop systemic lupus erythematosus, and are more difficult to treat. A number of skin diseases may be confused with DLE, such as psoriasis, seborrheic dermatitis, acne, rosacea, lupus vulgaris, sarcoidosis, Bowen's disease, polymorphous light eruption, lichen planopilaris, dermatomyositis, granuloma annulare, and granuloma faciale. Palpebral lesions may rarely be the presenting or sole manifestation of the disease and lower eyelid involvement is seen in 6% of patients with chronic, cutaneous lupus erythematosus. DLE should therefore be considered as a differential diagnosis in chronic blepharitis or madarosis that persists despite usual medical management and eyelid hygiene. The patient was treated successfully with hydroxychloroquine. The skin lesions resolved with minimal scarring.

A 10-year-old white male presented with a recurrent painful nodule of the left lateral lower eyelid margin with associated madarosis. The initial pathologic diagnosis at an outside institution was reported as chalazion. The lesion was re-excised, and histopathologic examination with immunohistochemical evaluation confirmed the diagnosis of leiomyoma. This is the first reported case of primary leiomyoma originating in the eyelid.

A 72-year-old woman presented with a 3 × 2 × 1-mm right lower eyelid micronodular, whitish solid lesion at the nasal eyelid margin that had caused madarosis. Local excision led to the microscopic discovery of 2 epidermoid cysts, one of which harbored a basal cell carcinoma arising from its orthokeratinizing squamous cell lining. Poral openings indicated that the cysts represented follicular infundibular ectasias. BER-EP4-positive immunostaining confirmed the basal cell nature of the neoplasm. This is the first example in the eyelid of an epidermoid cyst displaying malignant transformation. No matter how innocent they may appear, all small cystic or noncystic eyelid lesions should be submitted for pathologic evaluation.

Blepharitis is an inflammation of the eyelid margins which sometimes leads to secondary changes in the conjunctiva and cornea. Symptoms of blepharitis tend to be longstanding, thus, blepharitis is more of a chronic condition than being acute and both eyes are usually affected, however, the symptoms can easily be eased.Once symptoms have eased, daily'eyelidhygiene' canusuallykeepthe symptoms toa minimum. Vision is rarely affected. This case report reviewed themanagement of blepharitis in a 25-year old girl the clinical findings andtreatment optionswerealsodiscussed. Keywords: Blepharitis,Madarosis, Conjunctivitis,Keratitis, Staphylococcus auerus

Diseases of the periocular hair range from localized disease to systemic processes and may present challenging diagnostic questions. We present a comprehensive clinical guide to the evaluation and diagnosis of these disorders. Deficiencies in growth, excess production, changes in pigmentation, aberrant position, or abnormalities in form may affect this region's hair. These range from benign to sight-, and even life-, threatening pathologies.

Traumatic eyelid avulsion is reported infrequently. We cared for an 18-year-old man who lost > 75% of his right upper eyelid. The tissue was recovered 10 h following the initial trauma. Successful surgical reimplantation resulted in a functional upper eyelid with extensive madarosis. An experimental study was undertaken to attempt to determine the optimal method for preservation of avulsed eyelid tissue. Experimental surgery was performed to simulate repair of eyelid avulsion. The postoperative changes in experimentally reimplanted eyelids parallel those noted in the clinical example of eyelid avulsion. This clinical example and experimental study suggested the following management principles for handling avulsed eyelid tissue: eyelid tissues should not be immersed in saline; avulsed eyelid tissues should be stored at 4 degrees C; if reimplantation time is < 6 h, storage in a cold moist environment is adequate.

espanolCasos clinicos: Mujer de 94 anos que consulta por chalazion de 8 meses de evolucion. Presenta engrosamiento palpebral con necrosis y madarosis, y una adenopatia preauricular. Mujer de 67 anos operada de un carcinoma de glandulas sebaceas que acude por enrojecimiento conjuntival y palpebral. La biomicroscopia manifestaba inflamacion del parpado y presencia de una conjuntiva bulbar superior irregular y muy eritematosa con desestructuracion de la arquitectura limbar. Discusion: El carcinoma de glandulas sebaceas es un tumor de diagnostico y manejo dificil ya que puede presentarse de manera parcheada y tiene tendencia a la diseminacion pagetoide. Para su diagnostico se debe realizar biopsia escisional y mapa de biopsias de conjuntiva palpebral y bulbar. El tratamiento posterior dependera de la extension del tumor, bien escision simple, Mitomicina C topica, radioterapia o exenteracion orbitaria EnglishClinical cases: A 94-year-old woman, who had had a chalazion for a period of 8 months, presented because of thickening of the eyelid with necrosis, madarosis and adenopathy. A 67-year-old woman, previously operated on for a sebaceous carcinoma, presented because of reddening of the conjunctiva and eyelid. Clinical evaluation revealed inflammation of the eyelid and an irregular and erythematous superior bulbar conjunctiva with disruption of the limbal architecture. Discussion: A sebaceous carcinoma is a tumour which is difficult to diagnose and treat, because it can be patchy and has a tendency to pagetoid dissemination. Diagnosis requires a biopsy of the lesion and mapping of biopsies from the conjunctiva of the eyelid and eyebrow. The subsequent treatment depends on the extent of the tumour, and may involve simple cleavage, topical mitomycin C, radiotherapy or exenteration of the eyebrow

The objective of this study was to detect ocular lesions of newly diagnosed leprosy cases admitted to Istanbul Leprosy Hospital. The patients were categorized according to sex, age, type of leprosy and duration of the disease. Their eyes were categorized as with or without ocular findings due to leprosy. The total number of patients was 21. The mean age was 22+/-4.6 years, the duration of the disease was 36.3+/-19.6 months. Madarosis was the most common finding in this group. It was found in 15 patients (71.4%, 95% confidence interval (CI) 47.8-88.7%). As a second common finding related to corneal alterations, 13 patients had nerve thickening (61.9%, 95% CI 38.4-81.8%). None of our patients had trichiasis, episcleritis, scleritis, cataract, iris atrophy, iris pearl, abnormal vitreous or retinal findings.

To determine the ocular morbidity, visual disability and potential for blindness in leprosy patients recently released from treatment. In-patients from Eku leprosy settlement were interviewed and examined for ocular disease from leprosy and other causes. They were examined using the Snellen's chart, pentorch, Kowa portable slit-lamp, direct ophthalmoscope and the pulsair non-contact tonometer. The patients were also refracted. In all, 60 inpatients who were recently released from treatment, comprising 39 men (65%) and 21 women (35%), were examined. Fifty-eight patients (96.67%) had ocular symptoms, the most common being blurred vision in 23 patients (38.33%). Nine patients (15%) were blind. Cataract was the most common cause of blindness occurring in three of the nine patients (33.33%). The most common types of ocular lesions were madarosis (31.67%), lagophthalmos (16.67%) and cataract (16.67%). Potentially blinding conditions due to leprosy were seen in 42 patients (70%). The incidence of ocular involvement, blindness and potentially blinding conditions are high in leprosy patients recently released from treatment. Regular ophthalmic evaluation and integration into Vision 2020 programmes are recommended.

The study was carried out in Meshed, Islamic Republic of Iran, from 1998 to 2000 to explore the visual outcome of eye surgery with extracapsular cataract extraction and intraocular lens replacement on 18 leprosy patients [20 eyes]. The most common complications of leprosy were madarosis [90%] and partial or total corneal opacity [90%]. Visual acuity before surgery ranged from ‘light perception’ to 1/10, and this improved after surgery to 5/10-8/10 for 55% of patients. Postoperative infection leading to endophthalmitis occurred in only 1 patient and was treated with drugs; this patient’s visual acuity remained at 10 cm finger count. Posterior synechia due to chronic uveitis in leprosy was diagnosed in 70% of eyes, obstructed iris in 25%, keratic precipitates in 25% and moderate iris atrophia in 10%

Purpose : Botulinum neurotoxins are considered relatively safe therapy for treatment of inappropriate muscle spasms. As seen in this report, undesirable consequences may result. Methods : The author conducted a clinical interview and examination of the patient. Results : Unilateral left-sided madarosis and facial alopecia were observed in a patient undergoing botulinum A toxin injections for the treatment of left oromandibular dystonia. The patient had started treatment 18 months previously. He received injections every 3 months in the left masseter and left temporalis muscles. He first noted loss of his left sideburn 8 months into treatment. After 10 months of treatment, he noted that he no longer needed to shave on the left side of his face. Eighteen months after receiving his first botulinum toxin injection, madarosis of the temporal aspect of the left lower lid was observed. Conclusions : This is the first case report documenting an idiosyncratic unilateral madarosis and facial alopecia as adverse side effects presumed secondary to botulinum A toxin injections.

Purpose To recognize discoid lupus erythematosus (DLE) as a treatable cause of chronic blepharoconjunctivitis. Design Retrospective observational case series. Participants Records of 5 patients with biopsy-proven DLE were reviewed. Methods Clinical and pathology records were examined. Main Outcome Measures Patients' clinical and histopathological characteristics and response to treatment were assessed. Results Clinical features included meibomian gland dysfunction, blepharitis, chalazia, trichiasis, madarosis, conjunctivitis, chronic eyelid edema, and eyelid plaques. Histopathology showed hyperkeratotic epithelium, degeneration of the basal cell layer, and a perivascular lymphocytic infiltrate. There was delayed diagnosis in all cases, ranging from 4 months to 25 years. All of the patients responded to systemic hydroxychloroquine therapy. Conclusions Heightened awareness of eyelid DLE may lead to earlier detection and specific therapy for this chronic disorder.

Objective To describe the clinical outcomes of patients treated by proton beam irradiation for choroidal metastatic tumors. Design Noncomparative case series. Participants A retrospective chart review was performed on a series of 63 patients (76 eyes) with choroidal metastases treated with proton beam therapy between December 1989 and September 2000. Methods Patients were treated with 2 fractions of 14 cobalt gray equivalents (CGEs) (CGE = proton Gy × relative biological effectiveness 1.1), each using a nonoperative "light-field" technique. Ophthalmologic follow-up was available for 46 patients (55 eyes), with a mean follow-up time of 10 months. The medical record or the Social Security Death Index was used to obtain survival status, which was available in 94% of cases. Main outcome measures Tumor regression, recurrence, treatment-associated complications, and visual acuity were evaluated by ophthalmologic examination and ultrasonography. Eye retention and length of survival also were assessed. Results At the time of ocular diagnosis, 49 patients reported a history of a primary cancer. Median survival time after ocular diagnosis was 16 months through May 2003. Most choroidal metastases were dome shaped (62%) and located at the posterior pole (95%). Mean tumor height was approximately 3.5 mm, and serous retinal detachment was seen in 63% of cases. Eighty-four percent of treated tumors regressed completely within 5 months of treatment, and none of these recurred. Retinal detachment resolved in 82% of patients within 3.8 months after treatment, and visual acuity was preserved or improved in 47% of the patients. Complications occurred in 56% of cases and included madarosis, keratitis, dry eye syndrome, cataract, neovascular glaucoma, chorioretinal atrophy, radiation papillopathy, and radiation maculopathy. None of the treated eyes required enucleation. Conclusions Proton beam irradiation is a useful therapeutic approach for choroidal metastases; it allows retention of the globe, achieves a high probability of local tumor control, and helps to avoid pain and visual loss. Although complications occur in most cases, many of these are minor and are not associated with a change in function. This modality is accurate and efficient, because it only entails 2 treatment fractions and does not require surgery for tumor localization.

OBJETIVO: Determinar a prevalência das alterações oculares em pacientes de hanseníase ativa ou inativa, acompanhados em serviço de referência. MÉTODOS: O estudo transversal constou de exame ocular e levantamento de dados demográficos e clínico-epidemiológicos, em serviço de referência da cidade de Rio Branco (Acre), no período de outubro de 2001 a abril de 2002. RESULTADOS: Foram examinados 254 pacientes, com média de idade de 41,9 anos; 70,1% do sexo masculino e 29,9% do feminino; 73,6% residentes da área urbana e 76,8% de formas multi e 23,2% de paucibacilares. Anormalidades de anexos oculares foram descritas em 49,6% (n=126) dos casos e do globo ocular em 39,4% (n=100) dos casos, sendo as mais freqüentes: hipoestesia corneana, catarata, madarose, manchas hipercrômicas, hipolacrimejamento e ceratite ponteada. As lesões oculares (74,4%) tiveram freqüências desiguais (r

Madarosis is window of diagnosis to various diseases and disorders. Though the patient presents to the dermatologist or the ophthalmologist for the treatment of this disease, a consultation with various other departments is necessary for the accurate diagnosis and treatment of this condition. Madarosis occurs in leprosy frequently but its occurrence as a presenting manifestation of leprosy has seldom been reported. Here, we are presenting a case of lepromatous leprosy who presented with bilateral madarosis only with no obvious skin lesions of leprosy.

The purpose of the present study is to describe a case of severe, psoriasiform blepharitis by means of a case report and literature review. A 44-year-old man developed chronic blepharitis and tearing months after bilateral cataract surgery. Exam showed diffuse quad-eyelid erythema, discharge, edema, madarosis, and scale. He also had insufficient tear drainage due to bilateral upper eyelid cicatricial punctal atresia with bilateral lower eyelid punctal stenosis. Biopsy of the lower eyelids exhibited psoriasiform hyperplasia. Topical 0.1% tacrolimus achieved improvement but caused some subjective eye irritation. Psoriasiform dermatitis manifesting on the eyelids is rare, may be associated with insufficient tear drainage, and may respond favorably to 0.1% tacrolimus.

A 65 year old roofer presents to his GP with a slow growing lower lid lump of several months duration. It is not tender but there is involvement of his lid margin. Eyelid lumps have a variety of causes, ranging from innocuous cysts to malignant lesions. Although sinister pathology is rare, early identification and referral are essential to ensure a good outcome. ### History Is it chronic? —Chronic lesions include papillomas (viral warts), naevi, sebaceous cysts, and molluscum contagiosum. These all have the same appearance as elsewhere on the body. Molluscum near the lid margin can cause a persistent follicular conjunctivitis. Chalazia (figure 1⇓) are the commonest chronic eyelid lumps. They are caused by a blocked meibomian gland. Chalazia are entirely benign; however, it is important to be suspicious of a recurrent chalazion in the same position as this might represent a malignancy. Fig 1 Lower lid chalazion of the left eye. The lid margin is not distorted and there is no madarosis (loss of eyelashes), suggesting a non-sinister lesion Is it tender?— Tender eyelid lumps and lesions are often acute and associated with infection. Hordeolum externum (a stye) arises from a staphylococcal infection of a lash follicle, presenting as a tender, erythematous, pus filled lesion near the eyelid margin. Hordeolum internum (an infected chalazion, figure 2⇓) presents similarly, but is located away from the lid margin. Fig 2 Left upper lid internal hordeolum with limited cellulitis Dacryocystitis (figure 3⇓), an infection of the lacrimal sac caused by a blocked nasolacrimal duct, is another periocular tender swelling. It is located beneath …

In a 77-year-old man with a history of arterial hypertension, coronary heart disease, dilative cardiomyopathy, mitral and tricuspid insufficiency, arteriovenous block III, implantation of a pacemaker, atrial fibrillation, and heart failure, left ventricular hypertrabeculation (LVHT) was detected on transthoracic echocardiography during hospitalization for worsening heart failure. Revision of previous echocardiography did not show LVHT in any of the previous investigations why LVHT was interpreted as acquired. The additional presentation with bilateral ptosis, madarosis (absent eyelashes), bilateral hypoacusis, sore neck muscles, absent tendon reflexes, weakness for foot extension, ataxic stance, and recurrently elevated creatine kinase with normal troponin-T suggested a metabolic myopathy. Autopsy after death resulting from intractable heart failure, 17 months later, confirmed severe coronary heart disease and LVHT in the apex. The case confirms that LVHT may be acquired in single cases with neuromuscular disease and may represent an adaptive mechanism of an impaired myocardium.

To the Editors: There are some reports of scalp and axillary hair alopecia after immunizations, mostly related to hepatitis B vaccine.1 To the best of our knowledge, eyelash loss after measles-mumps-rubella (MMR) vaccination has not been reported yet. We describe a case of bilateral acute-onset madarosis following MMR vaccination.

Cetuximab is a monoclonal antibody that binds to the epidermal growth factor receptor (EGFR) of cancer cells expressing EGFR and prevents dimerization and downstream cell signaling pathways. It has been shown to prolong survival in patients with metastatic colorectal cancer. Cutaneous toxicity is relatively common because of the inhibition of EGFR of normal epidermal cells. We present a 49-year-old man with metastatic colon cancer who had development of periocular skin toxicity, madarosis, and cicatricial ectropion after the addition of weekly cetuximab infusions to his baseline chemotherapy. His findings resolved within weeks of the discontinuation of the drug. Cicatricial ectropion is a potential sequela of EGFR inhibition by cetuximab and can resolve without surgical intervention with the discontinuation of this drug.

We report familial acanthosis nigricans affecting a 35-year-old woman, her 7-year-old son and 5-year-old daughter. Absence of the eyebrows and eyelashes was noted in this family. The mother had no axillary hair and her pubic hair was sparse. The boy also suffered from congenital heart disease and a congenital cataract in the left eye. The combination of acanthosis nigricans and ectodermal defects in this family may represent a distinct nosological entity.

Purpose Discoid lupus erythematosus (DLE) is an autoimmune disorder that usually affects the sun–exposed skin. Periocular involvement occurs uncommonly and may progress from eyelid erythema to scarring and madarosis. Method Observational case report. Result A case of DLE that presented with madarosis alone in the absence of preceding skin erythema and scarring. Conclusion Our case demonstrates that DLE may present with madarosis alone in the absence of a history of preceding erythema and scarring. Discoid lupus erythematosus should therefore be considered as a differential diagnosis in chronic blepharitis that persists despite usual medical management and eyelid hygiene. Biopsy should be considered in the presence of clinical features such as erythematous scale on the face and alopecia and sent for direct immunofluorescence staining.

A 47-year-old man presented with a 1-year history of left lower eyelid erythematous scaly plaque-like lesion with madarosis (Figure 1) accompanied by pain and redness. Conservative treatment (topical antibiotics and anti-allergy medications) had failed. He had no systemic symptoms except for fatigue. Subsequently, a left eyelid biopsy was performed and was consistent with …