AND ITS MANAGMENT

Indra P SharmaOptometrist

XANTHALESMA

Objective To have a better understanding about xanthelesma with regard to its pathophysiology, etiology, clinical manifestation and management.

Contents1. Introduction

2. Epidemiology and pathophysiology

3. Clinical features

4. Workup and evaluation

5. Treatment

6. Conculsion

7. Reference

BackgroundXanthoma Fatty deposits form beneath the skin ranging

from very small to 3 inches. Not painful or dangerous, but cosmetically

disfiguring. Appears anywhere but commonly on the elbows,

joints, tendons, knees, hands, feet, and buttocks.

Xanthelasma : A form of xanthoma appearing on eyelids.

Most common type of xanthoma.

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Introduction

A cutaneous deposition of lipid material that appears in the skin of the eyelids, most commonly in the inner canthus. It appears as a yellowish slightly elevated area. It is a benign and chronic condition that occur primarily in the elderly.

Source :Millodot: Dictionary of Optometry and Visual Science, 7th edition. © 2009 Butterworth-Heinemann

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Synonyms : Xanthelasma palpebrarum (XP)

Greek xanthos (yellow) and elasma (beaten metal plate).

Xanthelesma- Characteristics

Yellow plaques Most common - inner canthus and upper lid. Frequently bilateral Can be soft, semisolid, or calcareous. Have a tendency to progress, coalesce, and

become permanent. Frequently symmetrical; often 4 lids involved. Once plaques are established, they will remain

static or increase in size.

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ICD International Classification of Disease

(ICD) code for Xanthelesma

ICD-10 : H02.6

ICD-9 : 374.51

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EpidemiologyFrequency (International) Rare in the general population.

Mortality/Morbidity Reported no premalignant potential.

Sex In case studies of patients, a predominance of

xanthelasma in women has been seen; women, 32%, and men, 17.4%.

Age Onset between 15-73 years, with peak in the

fourth and fifth decades.

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Literature review A study by Christoffersen et al (2013) finds that

xanthelasmata can be a predictor of risk for myocardial infarction, ischemic heart disease, severe atherosclerosis, and death in the general population, independent of well known cardiovascular risk factors (eg, plasma cholesterol, triglyceride concentrations). On the other hand, they found that cornel arcus is not an important independent predictor of risk.

If one has xanthalesma, he/she has the chances of getting an heart attack.

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Pathophysiology 50 % lesions - associated with elevated

plasma lipid levels. Frequently in type II hyperlipidemia and in the

type IV phenotype. Primary genetic causes- familial

dyslipoproteinemia, familial hypertriglyceridemia, and familial lipoprotein lipase deficiency.

Common in normolipemic with low HDL cholesterol levels or other lipoprotein abnormalities.

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Clinical features

Symptoms General complain

about aesthetic concerns.

Once plaques are established, they will remain static or increase in size.

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Signs Lesions are yellowish and soft, and they

form plaques. Usually are located on the medial side of

the upper eyelids. Generally, these lesions do not affect the

function of the eyelids, but ptosis has been known to occur.

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Work Up Recommended tests1. lipid levels (triglyceride)

2. LDL cholesterol - Normal <100 mg/dL (below 2.6 mmol/L)

3. HDL cholesterol levels -Normal 40–59mg/dL(1.03–1.55 mmol/L)

Serum triglyceride levels Less than 100 mg/dL - Optimal101-150 mg/dL - Normal150-199 mg/dL - Borderline200-499 mg/dL - High500 mg/dL or higher - Very high

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Usually an obvious clinical diagnosis but rarely can mimic other malignant lesion.

In doubt, surgical excision and pathologic analysis should be performed.

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Histologic Findings Composed of xanthoma cells. Foamy histiocytes laden with

intracellular fat deposits mainly in the upper reticular dermis.

The main lipid stored is esterified cholesterol.

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A. Clinical photograph of xanthelasma showing typical distribution of the xanthomatous nodules on the eyelids. 

B. High-power photomicrograph of many multinucleated foamy xanthoma cells (hematoxylin and eosin stain). (Photos courtesy of William Morris, M.D.)

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Treatment and management

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Medical Care

Dietary restriction and pharmacologic reduction of serum lipids - important in the overall care of a patient with abnormal lipids

Limited response in the treatment of xanthelasma.

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Literature reviewDisappearance of eyelid xanthelasma

following oral simvastatin (Zocor) CL Sheilds et all (2005) reported: In 1992, a 68 year old male smoker with a history of hypertension and

elevated serum cholesterol was referred for evaluation of a newly diagnosed iris mass. On examination, the visual acuity was 20/20 in both eyes. The mass was diagnosed as a benign iris naevus and observation was advised. Coincidental bilateral medial canthal and upper and lower eyelid xanthelasma were detected The largest xanthelasma measured 16 mm in diameter. Observation was advised with tentative plan for surgical excision in the future. The patient was advised to continue his antihypertensive medications and anticholesterol medication (oral simvastatin (Zocor) 20 mg once daily). At the 6 month follow up the iris nevus was stable and the xanthelasma persisted. Yearly examinations were advised. The patient did not return for 10 years. Surprisingly, the xanthelasma had completely resolved, leaving no clinical trace of subcutaneous lipid. He continued on his medications and serum cholesterol was normal.

Source: http://bjo.bmj.com/cgi/pmidlookup?view=long&pmid=15834100 retrived 16/1/2015

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Surgical Treatment

Incorporated into cosmetic surgery For small linear lesions, excision is recommended, as

scarring should blend in with the surrounding eyelid tissue. Smaller bulging lesions can be "uncapped" and removed; then, the flap can be replaced and sutured.

In full-thickness excisions, the lower lid is more prone to prominent scarring, as the tissue tends to be thicker.

Simple excision of larger lesions risks eyelid retraction, ectropion, or the need for more complicated reconstructive procedures.

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Case of excision of recurrent xanthelasma.

4 weeks after surgery

1 week after surgery Before surgery

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Carbon dioxide and argon laser ablation Enhanced hemostasis, better visualization, lack of

suturing, and speed have been cited as reasons to use this technique; however, scarring and pigmentary changes can occur.

Chemical cauterization The use of chlorinated acetic acids found effective. These agents precipitate and coagulate proteins

and dissolve lipids. Electrodesiccation and cryotherapy Can destroy superficial xanthalesma but may

require repeated treatments. Cryotherapy may cause scarring and hypopigmentation.

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Further Outpatient Care Patients should receive follow-up care

for medical and surgical treatment. Referral to Medical specialist for

systemic association of high cholestrol.

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Prognosis Recurrence is common. Studies show - Recurrence in up to 40%

of patients after surgical excision. This percentage is higher with secondary excisions.

Of these failures, 26% occurred within the first year and were more likely to occur in patients with hyperlipidemia syndromes and in those with all 4 eyelids affected.

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Conclusion Patient Education on Lifestyle Cholesterol

Management, and Cholesterol Lowering Medications is important.

Educate patient on different treatment modalities.

Optometrist can help by referring patients to medical doctors to rule out cholesterol related systemic problems at earlier stages.

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Tashi Delek

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