An overview of xanthalesma

1. AND ITS MANAGMENT
Indra PSharma
Optometrist
XANTHALESMA

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

3. Contents
1. Introduction
2. Epidemiology and pathophysiology
3. Clinical features
4. Workup and evaluation
5. Treatment
6. Conculsion
7. Reference

4. Background
Xanthoma
 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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5. 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.
So urce : Millo do t: Dictio nary o f Opto m e try and VisualScie nce , 7 th e ditio n. © 20 0 9 Butte rwo rth-He ine m a nn
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 Synonyms :
Xanthelasma
palpebrarum (XP)
 Greek xantho s (yellow)
and e lasm a (beaten
metal plate).

6. 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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7. ICD
 International Classification of Disease (ICD)
code for Xanthelesma
 ICD-10 : H02.6
 ICD-9 : 374.51
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8. Epidemiology
Frequency (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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9. 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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10. 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.Sharma IP

11. Clinical features
Symptoms
 General complain
about aesthetic
concerns.
 Once plaques are
established, they will
remain static or
increase in size.
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12. 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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13. WorkUp
 Recommended tests
1. 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)
Serumtriglyceride levels
Less than 100 mg/dL - Optimal
101-150 mg/dL - Normal
150-199 mg/dL - Borderline
200-499 mg/dL - High
500 mg/dL or higher - Very high
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14.  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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15. 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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16. 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 WilliamSharma IP

17. Treatment and management
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18. 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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19. Literature review
Disappearance 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.
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20. 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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21. Case of excision of recurrent
xanthelasma.
 4 weeks after surgery
 1 week after surgery Before surgery
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22. Carbon dioxide and argon laserablation
 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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23. FurtherOutpatient 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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24. 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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25. 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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26. Tashi Delek
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