Eyelid lesions Cysts and benign lesions EYELID cysts are very common. Like cysts and lesions elsewhere on the skin, a benign lesion is usually indicated by chronicity, maintenance of normal adnexal structures, lack of colour or pigment change, and lack of bleeding or ulceration. The loss of lashes, telangiectasia, sclerosis, ulceration, recurrent scabbing, bleeding or itch may herald a potential malignancy. When in doubt, perform a biopsy. Patients may want benign lesions removed for cosmetic appearance or irritation.
A chalazion is a specific eyelid cyst, resulting from the blockage of a meibomian gland. There are 25 meibomian glands in each upper eyelid and 20 in each lower eyelid. They traverse the tarsal plate vertically and contribute oil to the tear film.
Patients present with a localised swelling, which can be tender because of inflammation. Chalazions occur more frequently in patients with meibomian gland disease. 2 Initially, simple lid hygiene measures— including heat and vertical lid massage towards the lashes, followed by lid scrubs— may microscopically decompress the blocked gland. Incision and curettage are sometimes required to relieve a tense chalazion.
Other common benign eyelid margin lesions include xanthelasmata( figure 9), capillary haemangiomas, epidermoid cysts, cysts of Zeiss and Moll. These are all benign and can be removed if they concern the patient.
Capillary haemangiomas tend to occur in children and usually resolve without intervention, usually by the age of 10. Occasionally, intervention is required if the lesion is large, is in its growth phase and detected in infancy.
Other indications for intervention include if the lesion is inducing ptosis and risking occlusion of the visual axis or causing pressure on the upper eyelid causing astigmatism and possible amblyopia. Traditional treatment used to include surgery and intralesional steroids, but treatment today usually involves oral propranolol administered under the supervision of a paediatrician with an interest in vascular malformations. 8
Benign tumours of the eyelid can be observed or removed depending on patient desire and suspicion of sinister pathology. These include naevi, actinic keratosis, squamous papillomas and basal cell papillomas. Keratoacanthomas resemble an explosive volcano and are benign. They are known to have squamous cell carcinoma( SCC) in their base and, for this reason, should be excised with inclusion of the base. 9
Source: Bobtheowl2, bit. ly / 2j1gGKn
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Figure 9. Xanthelasma.
Figure 10. Left lower eyelid BCC.
Figure 11. Left medial canthal BCC.
Figure 12. Medial canthal BCC.
Malignant eyelid lesions Basal cell carcinomas( BCCs) account for around 90 % of eyelid malignancy. 2 Sunlight is the main risk factor for both BCCs( see figures 10, 11 and 12) and SCCs. Rarely, genetic syndromes can predispose a patient to multiple skin malignancies. 2
BCCs tend to occur most commonly
on the lower eyelid, followed by the medial canthus, upper eyelid and lastly the lateral canthus. They are slow growing and locally invasive but do not metastasise.
Because of their proximity to the orbit and sinuses, medial canthal BCCs cause more concern. Preoperative imaging may be required to
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exclude invasive disease and alter the management plan as required. Nodular histopathology subtypes carry a better prognosis than poorly defined, sclerosing or infiltrative disease.
Nodular BCCs present as an elevated, sometimes pearly nodule— often with rolled edges, surface
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telangiectasia and a central ulcer. Other forms may be less well defined and appear as an area of eyelid thickening with sclerosis and loss of lashes. Occasionally, a sclerosing BCC may be misdiagnosed as blepharitis. Biopsy any lesion with concerning features soon after presentation or review closely. Refer for biopsy if conservative measures do not yield improvement or if growth is noted.
SCCs make up approximately 5-10 % of eyelid malignancies and have a propensity for perineural spread. Enquire about formication and examine cranial nerves and lymph nodes when you suspect an eyelid malignancy. SCCs may be difficult to differentiate clinically from BCCs, but SCCs tend to grow more quickly and display more keratinisation.
Sebaceous gland carcinomas arise from sebaceous glands and are slowly-growing lesions. They typically arise in elderly patients and are difficult to diagnose in their early stage. They may present as a nodule( similar to the appearance of a chalazion) or may masquerade as blepharitis, diffuse eyelid thickening or cicatricial pemphigoid.
The presence of yellow material within the lesion is highly suggestive. Delays in diagnosis are common, and this can give rise to a poor prognosis. Sebaceous gland carcinomas display intraepithelial pagetoid spread, with skip lesions to the adjacent palpebral conjunctiva( conjunctiva underlying the eyelid) and the bulbar conjunctiva( conjunctiva overlying the globe), and they can spread to local lymph nodes and distant organs.
Sebaceous gland carcinomas can be associated with colorectal malignancy, which may be undiagnosed and already present or yet to develop. 10 Immunochemical staining of excised specimens can help determine which patients may need systemic surveillance. 10
Melanoma can occur on the eyelids, but is rare.
Incisional biopsies are typically performed for all types of eyelid malignancy so that the diagnosis can be established and appropriate counselling and surgical planning can occur.
Surgical excision is carried out with histological margin control. This can be with the use of an onsite pathologist performing frozen sections via formal laboratorybased rapid paraffin sections or a Mohs-trained dermatologist who carries out the excision. Frozen section cannot be undertaken for sebaceous gland carcinomas or melanoma.
Following margin clearance, surgical reconstruction of the defect can be undertaken. Reconstruction by an oculoplastic surgeon is advised because of the specialised eyelid structures. If intraepithelial spread is found on mapping biopsies of sebaceous gland carcinomas, management is controversial and can include exenteration for orbital spread with adjunctive cryotherapy or topical mitomycin C. 11 Wider surgical excision margins are required for melanoma than for BCC / SCC and sebaceous cell carcinoma. 12
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Disorders of eyelashes TRICHIASIS, or inversion / ingrowing of the eyelashes, is a common acquired condition. 2 It may be idiopathic or may result from cicatricial changes of the lid margin, including blepharitis, trachoma and zoster. Exclude the presence of entropion.
If lashes are causing corneal staining seen with fluorescein( corneal abrasions) or corneal scarring( not usually visible without a slit lamp), deal with the lashes by epilation, electrolysis, lash laser or hyfrication. Treatments may need to be repeated because ablation techniques tend to be effective during the growth phase of lashes.
Distichiasis, or a second row of lashes behind the meibomian gland orifices, is less common. It is often inherited. The abnormal lashes may be soft, fine lashes that do not cause symptoms, or they may need to be dealt with in the same way as trichiasis.
Lacrimal system THE lacrimal system comprises the inflow glands, which create tears( lacrimal gland, meibomian gland and accessory eyelid glands), as well as the outflow drainage system.
The outflow system starts at the punctae and continues into the superior and inferior canaliculae. These join to form a common canaliculus, which then enters the lacrimal sac. The lacrimal sac sits in the bony lacrimal fossa in the medial orbit. The outflow of the sac is into the nasal mucosa via the intraosseous nasolacrimal duct.
A watery eye may result from irritation, causing overflow, or due to obstruction along the path of its outflow. An assessment of the system includes looking for retention of fluorescein dye placed on the eye; examining the ocular surface and the internal aspects of the eyelids for inflammation or a foreign body, and the eyelid margin for blepharitis, trichiasis or malposition; as well as syringing the lacrimal system to ensure patency.
Punctal stenosis is a common and easily corrected cause of epiphora. After syringing the lacrimal system to ensure outflow patency, the lower punctum( usually) can be widened by a punctal snip.
Canalicular narrowing or stenosis can be caused by topical drops, infection, chemotherapy drugs or irradiation. 2 Treatment may include placement of silicone stents or combining stenting with downstream procedures. For blockage of the nasolacrimal duct, a dacrocystorhinostomy is performed to anastomose the lacrimal sac directly to the nasal mucosa by creation of a bony rhinostomy.
Silicone stents are usually left cont’ d page 24
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