A Summary of Eyelid Diseases and their Differentials

Omar Najim

Eyelid diseases are common presentations in both primary care and ophthalmology clinics. Although many lid conditions are benign and self-limiting, others may signal infection, inflammation, or malignancy. A structured approach to eyelid pathology is essential to arrive at the correct diagnosis and to differentiate between similar-appearing conditions.

Inflammatory conditions are among the most frequently encountered lid diseases. Blepharitis is a chronic inflammation of the lid margins, often associated with meibomian gland dysfunction or seborrhoeic dermatitis (1). Patients typically report irritation, crusting, burning, and fluctuating vision. Differentials include allergic conjunctivitis, dry eye disease, and ocular rosacea, which may coexist and exacerbate symptoms.

Hordeolum (stye) and chalazion are common focal lid lesions that are often confused. A hordeolum is an acute, painful, erythematous swelling caused by bacterial infection (usually Staphylococcus aureus) of an eyelash follicle or meibomian gland (2). In contrast, a chalazion is a chronic, painless, firm nodule resulting from granulomatous inflammation due to gland obstruction. Differentials for persistent or recurrent chalazion include sebaceous gland carcinoma, particularly in elderly patients, where lesions may be atypical, recurrent, or associated with lash loss.

Preseptal cellulitis presents with lid swelling, erythema, and warmth, often following trauma, insect bites, or local infection (3). Vision, eye movements, and pupillary responses remain normal. Its key differential is orbital cellulitis, a sight- and life-threatening condition distinguished by pain on eye movement, reduced vision, ophthalmoplegia, and proptosis. Prompt recognition and imaging are crucial to avoid serious complications.

Allergic conditions such as allergic lid dermatitis present with bilateral itching, swelling, and erythema, often with a history of allergen exposure or atopy (4). Differentials include contact dermatitis, angioedema, and infective causes. Angioedema, while dramatic in appearance, is typically painless and transient but may require urgent attention if associated with airway compromise.

Eyelid malposition is also significant. Ptosis may be congenital or acquired and can result from aponeurotic dehiscence, neurogenic causes (such as third nerve palsy or Horner syndrome), myogenic disorders, or mechanical factors like lid tumours (5). Careful assessment of pupil size, lid crease, and eye movements helps narrow the differential. Entropion and ectropion, often age-related, can cause ocular surface irritation and must be differentiated from cicatricial causes due to trauma, inflammation, or autoimmune disease (5).

Finally, eyelid tumours must always be considered, particularly in older patients. Basal cell carcinoma is the most common malignant lid tumour, typically presenting as a pearly nodule with telangiectasia or ulceration (6). Differentials include squamous cell carcinoma, sebaceous gland carcinoma, and benign lesions such as papillomas or cysts (6). Any lesion with lash loss, ulceration, bleeding, or failure to heal warrants biopsy.

In summary, eyelid diseases encompass a broad spectrum of conditions with overlapping features. A systematic approach and awareness of key differentials are essential to ensure accurate diagnosis, timely treatment, and exclusion of serious pathology.

References

  1. Eberhardt, M. et al. Blepharitis. StatPearls 2025 available at: https://www.ncbi.nlm.nih.gov/sites/books/NBK459305/
  2. Rupani SR. Hordeolum and chalazion. JAAPA. 2023;36(6):43-4. https://doi.org/10.1097/01.JAA.0000931468.68794.aa
  3. Zeppieri M, Bourget D. Periorbital Cellulitis. 2025 Feb 6. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan–. PMID: 29261970.
  4. Ashley M. Hine, Reid A. Waldman, Andrzej Grzybowski, Jane M. Grant-Kels, Allergic disorders of the eyelid, Clinics in Dermatology, 41(4) pp476-480. 2023 https://doi.org/10.1016/j.clindermatol.2023.08.002.
  5. Guthrie AJ, Kadakia P, Rosenberg J. Eyelid Malposition Repair: A Review of the Literature and Current Techniques. Semin Plast Surg. 2019 May;33(2):92-102. doi: 10.1055/s-0039-1685473.
  6. Gniesmer, S., Sonntag, S.R., Schiemenz, C. et al. Diagnosis and treatment of malignant eyelid tumors. Ophthalmologie 121 (Suppl 1), 33–39 (2024). https://doi.org/10.1007/s00347-023-01945-y

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