4/22/2019 Agenda • Benign vs. Malignant lesions • 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 skin lesions are malignant • Most common types of benign eyelid lesions include: • Benign vs malignant: – Squamous papillomas (skin tags)-most common – Benign lesions are: – Hordeola/chalazia • Well circumscribed and possibly multiple – Epidermal inclusion cysts • Slow growing – Seborrheic keratosis • Less inflamed – Apocrine hidrocystoma • Look “stuck on” instead of invasive and deep – Capillary hemangioma (common vascular lesion of childhood) 1 4/22/2019 Benign Eyelid Lesions: Squamous Papilloma 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 skin tag • seborrheic keratosis, • verruca vulgaris and • Single or multiple and • intradermal nevus 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, actinic keratosis singly or multiple, greasy, and pigmented BCC stuck on plaques • Simple excision for biopsy 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 blepharitis obstruction of MG • Treatment includes: – External (stye) from • hot compresses (e.g. infection of the follicle of Bruder) a cilium and the adjacent • topical antibiotics (?) • possibly systemic glands of Zeiss or Moll antibiotics • Painful edema and • Treat concurrent erythema, 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 gland carcinoma • 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 Cyst Benign Eyelid Lesions: Epidermal Inclusion Cyst • Appear as slow- • May become infected growing, round, firm or may rupture lesions of dermis or • Differentials include: subcutaneous tissue – dermoid cyst, • Eyelid lesions are – pillar cyst or usually solitary, mobile – neurofibroma 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 cystadenoma 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: Capillary Hemangioma 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 amblyopia 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 Granuloma • 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 hemangiomas • 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: Pyogenic Granuloma Xanthelasma • Differential include • Typically occurs in Kaposi’s sarcoma 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 • Hyperlipidemia 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: Molluscum Contagiosum Xanthelasma • Composed of foamy, lipid- • Common viral skin laden xanthoma 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 wart 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, cryosurgery 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 conjunctivitis 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 melanocytes 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: Keratoacanthoma • 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 epidermis/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 scar 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 ectropion • Most common pre- or ptosis. 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 papules with an malignant lesion of the adherent white scale. lids (85-90% of all • Development