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Home , Capillary hemangioma, Hidrocystoma, Nevus, Seborrheic keratosis, Xanthelasma

4/22/2019

Agenda

• Benign vs. Malignant • Benign Eyelid Lesions Lid Lesions: Relax or Refer – Various types – Diagnostic criteria and differentials – Treatment and management options Blair Lonsberry, MS, OD, MEd., FAAO Professor of Optometry • Malignant Eyelid Lesions Pacific University College of Optometry – Various types [email protected] – Diagnostic criteria and differentials – Treatment and management options

Eyelid Lumps and Bumps Benign Eyelid Lesions

• 15-20% of periocular lesions are malignant • Most common types of benign eyelid lesions include: • Benign vs malignant: – Squamous (skin tags)-most common – Benign lesions are: – Hordeola/chalazia • Well circumscribed and possibly multiple – Epidermal inclusion • Slow growing – Seborrheic • Less inflamed – Apocrine • Look “stuck on” instead of invasive and deep – Capillary (common vascular of childhood)

1 4/22/2019

Benign Eyelid Lesions: Squamous Benign Eyelid Lesions: Squamous Papilloma

• Most common benign • Flesh colored and maybe: lesion of the eyelid • sessile (no stalk) or pedunculated (with a stalk) – Also known as fibroepithelial polyp • Differentials: or • , • verruca vulgaris and • Single or multiple and • intradermal commonly involve • Treatment is simple eyelid margin excision at the base of the lesion.

Benign Eyelid Lesions: Seborrheic Keratosis Benign Eyelid Lesions: Seborrheic Keratosis

• Also known as senile • Color varies from tan to verruca brown and are not • Common and may occur on considered pre-malignant the face, trunk and lesions extremities • Differentials include skin • Usually affect middle-aged tags, nevus, verruca and older adults, occurring vulgaris, singly or multiple, greasy, and pigmented BCC stuck on plaques • Simple excision for or cosmesis or to prevent irritation.

2 4/22/2019

Benign Eyelid Lesions: Hordeola Benign Eyelid Lesions: Hordeola

• Acute purulent inflammation • Typically caused by Staph and often associated with – Internal occurs due to obstruction of MG • Treatment includes: – External () from • hot compresses (e.g. infection of the follicle of Bruder) a cilium and the adjacent • topical antibiotics (?) • possibly systemic of Zeiss or Moll antibiotics • Painful edema and • Treat concurrent , blepharitis

Benign Eyelid Lesions: Chalazia Benign Eyelid Lesions: Chalazia

• Focal inflammatory • May drain spontaneously or persist as a chronic lesion resulting from nodule obstruction of a • Recurrent lesions need to meibomian or Zeis exclude a sebaceous gland • Treatment varies from: • Results in a chronic • hot compresses/massage, lipogranulomatous • intralesional steroid injection or inflammation • surgical drainage.

3 4/22/2019

Benign Eyelid Lesions: Epidermal Inclusion Benign Eyelid Lesions: Epidermal Inclusion Cyst

• Appear as slow- • May become infected growing, round, firm or may rupture lesions of or • Differentials include: subcutaneous tissue – , • Eyelid lesions are – pillar cyst or usually solitary, mobile – and less than 1 cm • Treatment is • Maybe congenital or complete excision to may arise from trauma prevent recurrence.

Benign Eyelid Lesions: Eccrine Hidrocystoma Benign Eyelid Lesions: Eccrine Hidrocystoma

• Sudoriferous or sweat • Tend to increase in gland cysts size in hot, humid • Solitary or multiple, weather small nodules on the • Differentials: eyelids – apocrine • Overlying skin is hidrocystoma and smooth and shiny and – epidermal inclusion the cyst usually is cyst translucent and fluid • Treatment is complete filled excision

4 4/22/2019

Benign Eyelid Lesions: Apocrine Hidrocystoma Benign Eyelid Lesions: Apocrine Hidrocystoma

• Also known as • Do not increase in size in warm • Usually appears as a solitary, translucent weather cyst on the face and • Differential: sometimes eyelid margin – eccrine and • Usually small and filled – cystic BCC with clear or milky fluid with a shiny • Treatment is smooth overlying skin complete excision

Benign Eyelid Lesions: Benign Eyelid Lesions: Capillary Hemangioma • Classic superficial lesion • Most common vascular lesion – strawberry lesion, in childhood (5-10% of infants) appears as a red, raised, nodular mass which • Females 3:2 blanches with pressure • Periorbital may appear as a • Most common ocular superficial cutaneous lesion, complication is subcutaneous, deep orbital or combination • Because regression is • 1/3 visible at birth, remainder common, treatment is manifest by 6 months reserved for patients • 75% regress to some extent who have specific ocular, by 7 years dermatologic or systemic indications for intervention.

5 4/22/2019

Benign Eyelid Lesions: Capillary Hemangioma Benign Eyelid Lesions: Pyogenic • Recent evidence supports the use of oral • Most common acquired propanolol and possibly vascular lesion to topical timolol 0.25% involve the eyelids for superficial • Usually occurs after trauma or surgery as a fast growing, fleshy, red- to-pink mass which readily bleeds with minor contact

Benign Eyelid Lesions: Benign Eyelid Lesions: Xanthelasma • Differential include • Typically occurs in Kaposi’s middle-aged and older • Treatment can include adults as soft, yellow use of steroid to reduce plaques on the medial the inflammation or aspect of the eyelids surgical excision at the • is base of the lesion. reported to occur in approx 50% of patients therefore screening recommended

6 4/22/2019

Benign Eyelid Lesions: Benign Eyelid Lesions: Xanthelasma • Composed of foamy, lipid- • Common viral skin laden cells disease caused by a clustered around blood large DNA pox virus vessels and adnexal tissue • Infection usually from within the superficial direct contact in dermis children and sexually • Treatment includes: transmitted in adults – surgical excision, • Typical lesion appears as – CO2 ablation and a raised, shiny, white-to- – topical trichloroacetic acid. pink nodule with a central umbilication • Recurrence is common. filled with cheesy material

Benign Eyelid Lesions: Verruca Benign Eyelid Lesions: Molluscum Contagiosum • Eyelid lesions may Vulgaris produce a follicular • Common cutaneous conjunctival reaction caused by the epidermal • Patients with AIDS may infection of the human have a disseminated papillomavirus presentation (30-40 each • More common in children eyelid or a confluent and young adults and may mass) occur anywhere on the skin • Usually spontaneously • Lesions appear elevated resolves 3-12 months but with an irregular, maybe treated to prevent hyperkeratotic spread by excision, papillomatous surface incision and curettage, and electrodesiccation.

7 4/22/2019

Benign Eyelid Lesions: Verruca Lid Nevi Vulgaris • Lid nevi: • Lesions along lid – congenital or acquired – occur in the anterior lamella of the margin may cause eyelid and can be visualized at the papillary eyelid margin. • The congenital eyelid nevus is a special category with implications • Tend to be self for malignant transformation. limiting but if • With time, slow increased pigmentation and slight treatment required enlargement can occur. cryoptherapy or • An acquired nevus generally surgical excision. becomes apparent between the ages of 5 and 10 years as a small, flat, lightly pigmented lesion

Congenital Nevus Congenital Nevus • The nevus is generally well circumscribed and not • Most nevi of the skin are not considered to be associated with ulceration. at increased risk of malignancy. • The congenital nevus of the eyelids may present as a – However, the large congenital melanocytic "kissing nevus" in which the nevus appears to have an increased risk of are present malignant transformation of 4.6% during a symmetrically on the upper and lower eyelids. 30 year period – Presumably this nevus was present prior to eyelid separation

8 4/22/2019

Acquired Lid Nevi Pre‐Malignant Eyelid Lesions: • Appears as a solitary, • Acquired nevi are rapidly growing nodule on classified as: sun exposed areas of – junctional (involving the middle-aged and older basal /dermis individuals junction), typically flat in • Nodule is usually appearance umbilicated with a – intradermal (involving distinctive crater filled with only the dermis), tend to be dome shaped or keratin pedunculated • Lesion develops over – compound (involving weeks and undergoes both dermis and spontaneous involution epidermis) tend to be within 6 mo to leave an dome shaped atrophic

Pre‐Malignant Eyelid Lesions: Keratoacanthoma Pre‐Malignant Eyelid Lesions: Actinic Keratosis • Also known as solar or • Lesion on the eyelids may senile keratosis produce mechanical problems such as • Most common pre- or . malignant skin lesion • Differential SCC, BCC, • Develops on sun- verruca vulgaris and exposed areas and molluscum commonly affect the • Many pathologists consider face, hands and scalp it a type of low grade SCC (less commonly the • Complete excision is eyelids) recommended as there are invasive variants – Predominately white males

9 4/22/2019

Pre‐Malignant Eyelid Lesions: Actinic Keratosis Malignant Eyelid Lesions: Basal Cell Carcinoma (BCC)

• Appear as multiple, flat- • Most common topped with an malignant lesion of the adherent white scale. lids (85-90% of all • Development of SCC in malignant epi eyelid untreated lesions as tumors) high as 20% • 50-60% of BCC affect the lower lid followed • Management is surgical by medial canthus 25- excision or 30% and upper lid (following biopsy) 15%

Malignant Eyelid Lesions: Basal Cell Carcinoma (BCC) Malignant Eyelid Lesions: Basal Cell Carcinoma

• Etiology is linked to • Diagnosis is initially made from excessive UV its clinical appearance, especially with the exposure in fair- noduloulcerative type with its skinned, ionizing raised pearly borders and radiation, arsenic central ulcerated crater exposure and – categorized into two basic types: noduloulcerative and • Metastases is rare but morpheaform local invasion is – The morpheaform variant is common and can be typically diffuse, relatively flat with indistinct borders. This variant is very destructive more aggressive and can be invasive despite showing less obvious features.

10 4/22/2019

Malignant Eyelid Lesions: Malignant Eyelid Lesions: Basal Cell Carcinoma (SCC)

• Definitive diagnosis made on • Much less common histopathological examination than BCC on the of biopsy specimens eyelid but has much – loss of adjacent cilia is strongly higher potential for suggestive of malignancy and metastatic spread occurs commonly with basal cell carcinoma of the eyelid • Typically affects • Surgery is generally accepted as elderly, fair-skinned treatment of choice and usually found on – Mohs’ surgery technique the lower lid

Malignant Eyelid Lesions: Squamous Cell Carcinoma Malignant Eyelid Lesions: Squamous Cell Carcinoma (SCC) (SCC)

• Environmental and • Presents as a intrinsic factors erythematous, indurated, initiate cell growth hyperkeratotic plaque – Many SCC arise or nodule with irregular from actinic lesions margins • Lesions have a high tendency towards ulceration and tend to affect lid margin and medial canthus

11 4/22/2019

Malignant Eyelid Lesions: Squamous Cell Carcinoma Malignant Eyelid Lesions: (SCC) Carcinoma • Highly malignant that • Diagnosis requires arises from the meibomian glands, Zeis and the sebaceous biopsy glands of the caruncle and • Surgical excision is eyebrow recommended • Aggressive tumor with a high recurrence rate, significant – Mohs’ technique metastatic potential and notable mortality rate • rates of misdiagnosis have been reported as high as 50%

Malignant Eyelid Lesions: Sebaceous Gland Malignant Eyelid Lesions: Sebaceous Gland Carcinoma Carcinoma

• Relatively rare, 1/3 most • Upper lid origin in common eyelid malignancy about 2/3 of all cases • Uncommon in the Caucasian • Typically affects older population and represents only individuals, women 3% of eyelid malignancies, more so than men – most common eyelid • has also been reported malignancy in Asian Indian in younger individuals population, where it who are represents approximately immunosuppressed or 40% or more of eyelid who have received malignancies radiation treatment.

12 4/22/2019

Malignant Eyelid Lesions: Sebaceous Gland Malignant Eyelid Lesions: Sebaceous Gland Carcinoma Carcinoma

• Presents as a firm, • Diagnosis is by biopsy yellow nodule that • Treatment is surgical resembles a . excision with • May mimic: microscopic monitoring – chronic of the margins blepharoconjunctivitis, – meibomianitis or – chalazion that does not respond to standard therapies

Malignant Eyelid Lesions: Malignant Malignant Eyelid Lesions: Malignant Melanoma • MM of the eyelid • Risk factors include accounts for about 1% congenital and dysplastic nevi, changing cutaneous of all eyelid moles, excessive sun malignancies exposure and sun • Incidence been sensitivity, family history, age greater than 20 and increasing and it causes white. about 2/3 of all tumor • History of severe related deaths from sunburns rather than cutaneous cumulative actinic • Incidence increases exposure thought to be a with age major risk factor

13 4/22/2019

Malignant Eyelid Lesions: Malignant Malignant Eyelid Lesions: Malignant Melanoma Melanoma • Flat lesion with irregular • Prognosis and borders and variable metastatic potential are pigmentation typically linked to the depth of occurring in sun invasion and thickness exposed areas of the tumor • Confirmed diagnosis by • Treatment is wide biopsy surgical excision confirmed with histological monitoring

Thank You! [email protected]

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