5/24/17 ¨ Eyelid anatomy review ¨ Eyelid lesions ¡ Review ¡ Benign vs. Precursors vs. Cancer ¡ How it relates to the anatomy ¨ Eyelid surgery clinical tips Nate Lighthizer, O.D., F.A.A.O. ¨ Lesion removal techniques/terms ¨ Radiofrequency surgery (Ellman Unit) ¡ Indications ¡ Contraindications ¡ Techniques for removal of lesions ¡ Videos ¨ Chalazion management ¨ Most eyelid lesions ¨ Very thin (4 – 5 cell layers are benign thick) ¨ Benign lesions ¨ Uniform depth originate in the skin ¨ Fastest turnover (5 – 7 (epidermis) and grow days) outward ¨ No dermal papilla present ¨ The skin of the eyelid (absent rete ridges & rete pegs) is ideally suited for ¨ Potential space between office surgery epidermis & dermis accommodates local anesthetic well ¨ Lid Margin: Stay 2 mm from margin is possible ¨ Benign ¨ Eyelid proper: Skin is only 4 ¡ Hyperkeratoses: eg, – 5 cell layers thick squamous papilloma ¨ Inner canthus: Beware lacrimal apparatus, angular ¡ Pseudoepitheliomas: vein, etc… eg, seborrheic keratosis ¨ Outer Canthus: Beware ¡ moving outer canthus up or Cysts: eg, chalazion down as this significantly ¡ Nevi: eg, Clark nevus changes individuals appearance ¨ The Gray Zone (pre- ¨ Lid Crease: Can be altered malignant): eg, actinic ¨ Brow: Stay 2 mm below the keratosis brow if possible. ¨ Malignant: eg, squamous cell carcinoma 1 5/24/17 ¨ Benign Lid Lesions ¨ Precursors To Cancer ¡ Chalazion ¡ Actinic Keratosis ü H: loss of hair bearing structures? ¡ Skin tag/papilloma ¡ Keratoacanthoma q A: asymmetrical? ¡ Verrucae ¨ Cancer q A: abnormal blood ¡ Seborrheic Keratosis ¡ Basal Cell Carcinoma vessels (telangectasia’s)? ¡ Cyst of Moll & Zeiss ¡ Squamous Cell Carcinoma q B: boarders irregular? ü B: bleeding reported? ¡ Sebaceous Cyst ¡ Malignant Melanoma q C: multicolored? ¡ Freckle/nevus ¡ Sebaceous Gland ü C: change in the size or Carcinoma color of the lesion? ü D: overall diameter > 5 mm? ¨ Lesion work-up ¨ AKA papilloma or Skin Tag ¡ How long has that been there? ¨ Squamous papillomas are the most common ¡ Is it changing/enlarging? benign neoplasms of the eyelid and conj** ¡ Is it bothersome? ¡ Is it bleeding? ¨ Usually not bothersome to patient other than ¡ Personal history of cancer? cosmetic concerns ¨ Often been there for many years ¡ Is it ulcerated? ¨ More likely seen in overweight people ¡ Is there hair loss? ¡ Is there destruction of tissue? ¨ Signs: ¨ AKA Viral Warts or Common Warts ¡ Flesh-colored, avascular ¨ Caused by epidermal infection with the HPV pedunculated lesion ¡ Spread by direct contact and fomites ¡ Often seen at areas of skin rubbing ¡ Contagious*** ¡ May be one or several ¨ ¨ DDx: More common in children and young adults ¡ Verruca vulgaris ¨ May occur anywhere on the skin ¡ Seborrheic keratosis ¡ Occasionally on the eyelids ¡ Intradermal nevus ¨ Tx: ¡ Simple excision at the base of the lesion 2 5/24/17 ¨ Signs: ¨ AKA Basal cell papilloma ¡ Single or multiple elevated flesh-colored lesions with ¨ Common, slow growing benign epithelial an irregular, hyperkeratotic papillomatous surface neoplasm most often found on the face, trunk, ¡ If on lid margin can shed viral particles into the tear and extremities of older individuals film -> mild viral conjunctivitis ¨ Signs: ¨ DDx: ¡ Single or multiple discrete, greasy brown plaque ¡ Skin tags with a “stuck on” appearance ¨ Treatment: ¡ Observation ¡ Simple excision ¨ DDx: ¨ Small, non-translucent cyst on the anterior lid ¡ Pigmented basal cell margin arising from obstructed sebaceous carcinoma glands associated with the eyelash follicle ¡ Skin nevus ¨ Only problem may be a cosmetic concern for pt ¡ Malignant melanoma ¨ Basically is a type of sebaceous cyst ¡ Verruca vulgaris ¨ Tx: ¡ Skin tag ¡ Surgical excision/drainage ¡ Pt ed they may recur ¨ Tx: ¡ ¡ Shave excision of flat lesions ¡ Excision of pedunculated lesions Elman unit Seborrheic keratosis removal ¨ Benign cyst filled with cheesy sebum from a ¨ Cyst of Moll (AKA apocrine hydrocystoma) = small retention cyst of the lid margin apocrine sebaceous gland in the skin glands. ¨ Caused by a blocked sebaceous gland/follicle ¨ Appears as a round, non-tender, translucent ¨ May be found on the eyelid or ocular adnexa fluid-filled lesion on the anterior lid margin. ¨ Only problem may be a cosmetic concern for pt ¨ Only problem may be a cosmetic concern for pt ¨ Tx: ¨ Tx: ¡ Surgical excision/drainage ¡ Surgical excision/drainage ¡ Pt ed they can recur ¡ Pt ed they may recur 3 5/24/17 • 2nd most common benign lesion after the epithlial ¨ Freckle = brown macule due to increased hyperplasias melanin in the epidermal basal layer, usually in • develop from epidermal sunlight exposed areas cells trapped within the hair follicle, allowing ¨ Nevus = sharply demarcated lesion of the skin keratin to accumulate ¡ AKA birthmarks or moles beneath the cutaneous ¡ Benign by definition surface ¡ Correct term is melanocytic nevus for most lesions ¡ 4 main types: ú Junctional nevus ú Compound nevus ú Intradermal nevus ú Dysplastic nevus ¨ Junctional nevus – occurs more often in young individuals. Usually brown macule. Nevus cells are located at the junction ¨ Signs: of the epidermis and dermis and have low potential for ¡ Usually pigmented, flat or slightly elevated skin lesion malignant transformation (although higher than the next 2). ¡ Located anywhere on the body ¨ Compound nevus – occurs more often in middle aged ú Frequently at the lid margin individuals. Usually light tan-dark brown slightly raised papular lesion. Nevus cells extend from the epidermis into the ¨ DDx: dermis. It has low malignant potential. ¡ Melanoma ¨ Intradermal nevus – most common nevus. Typically occurs in ¨ Diagnosis: old age. Usually papillomatous lesion and flesh-colored (not ¡ A pigmented). Nevus cells are confined to the dermis. No ¡ malignancy potential. B ¡ C ¨ Dysplastic nevus – usually a compound nevus with cellular and architectural dysplasia. Can be flat or raised. Typically ¡ D larger than normal nevi and tend to have irregular borders and ¡ E coloration. More likely to transform into melanoma. ¨ Tx: ¨ AKA strawberry hemangioma or nevus ¡ Photodocument q3-6 months for any changes ¨ One of the most common tumors of infancy ¡ Biopsy if suspicious*** ¡ Usually present shortly after birth ¨ Female: male ratio is 3:1 ¡ If you cut on a melanoma in OK = malpractice*** ¡ Be darn sure that is not a melanoma*** ¨ May present as a small isolated lesion of minimal clinical significance or as a large disfiguring mass that can cause visual impairment and systemic complications 4 5/24/17 ¨ Tx: ¨ Signs: ¡ Usually just leave it alone and it will go away ¡ Unilateral, raised bright red lesion which blanches with pressure ú 30% of lesions resolve by 3 years of age ú May appear dark blue or purple if below the skin ú 70% of lesions resolve by 7 years of age ¡ ¡ Large lesion may cause a mechanical ptosis Steroid injections – primary treatment ¡ Large orbital tumors may give rise to proptosis ¡ Surgical excision/resection ¡ Biggest ocular concern???? ¡ Refer to a PCP for any treatment ¨ Most common acquired vascular ¨ AKA Solar Keratosis lesion to involve the eyelids/conj ¨ Most common pre-cancerous lesion** ¨ Usually occurs after surgery or trauma to area ¡ 60% of predisposed people over the age of 40 will ¨ Symptoms: have one of these in their lifetime ¡ Asymptomatic ¨ Elderly, fair-skinned individuals with excessive ¡ Cosmetic concerns sunlight exposure ¨ Signs: ¨ Most often seen on the forehead, face, and ¡ Fast growing, fleshy, backs of the hands pinkish red mass ¨ ¨ Treatment: Low potential for conversion to SCC*** ¡ Steroid QID X 1-2 weeks ¡ 1 in 1000 ¡ Surgical excision ¨ Signs: ¨ Tx: ¡ Hyperkeratotic plaque with distinct borders and a ¡ Precancerous so referral to dermatologist scaly surface ¡ Biopsy & excision ¡ Dry, rough area when running your fingers over it ¡ Cryotherapy – liquid N2 to freeze of the AK ¡ Usually minimally elevated ¡ 5-FU – chemotherapy agent which causes the area to ¨ DDx: become red and inflamed and the lesion will then ¡ SCC fall off ¡ Seborrheic keratosis ¡ PDT – injecting dye into the bloodstream which makes AK more sensitive to light therapy 5 5/24/17 ¨ Rare tumor usually occurring in fair skinned ¨ Signs: (in order) individuals ¡ Pink, rapidly growing hyperkeratotic ¨ Often a history of chronic sun exposure lesion, often on the lower lid ¡ ¨ More likely seen on the face, neck, May double or triple in size in weeks hands/forearms ¡ Growth ceases for 2-3 months, after ¨ Histopathologically, it is regarded as part of which spontaneous involution occurs the spectrum of SCC ¡ During the period of regression, a ¨ Symptoms: keratin-filled crater may develop ¡ Lesion that comes about fairly rapidly ¡ Resolution may take up to a year and (within weeks to months) often leaves a nasty scar ¨ Benign Lid Lesions ¨ Precursors To Cancer ¨ DDx: ¡ Chalazion ¡ Actinic Keratosis ¡ SCC** ¡ Skin tag/papilloma ¡ Keratoacanthoma ¨ Tx: ¡ Verrucae ¨ Cancer ¡ Derm consult ¡ Seborrheic Keratosis ¡ Basal Cell Carcinoma ¡ Complete surgical excision/biopsy ¡ Cyst of Moll & Zeiss ¡ Squamous Cell Carcinoma ú Removal with RFP ¡ Sebaceous Cyst ¡ Malignant Melanoma ú Cryotherapy ¡ Freckle/nevus ¡ Sebaceous Gland ¡ Topical or intralesional 5-FU Carcinoma ¨ Lesion work-up ¨ Slow-growing, locally invasive, non-metastatic ¡ How long has that been there? tumor ¡ Is it changing/enlarging? ¨ Most common malignant lid tumor*** ¡ Is it bothersome? ¡ 90% of cases ¡ Is it bleeding? ¨ 90% of cases occur on the head and neck ¡ Personal history of cancer? ¡ 10% of these are