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Duke Elder: Finals Ophthalmology (Alice) > Lid lumps > Flashcards

Lid lumps Flashcards

1
Q

What are the two broad groups into which lid lumps can be classified?

A
  1. Non-neoplastic lesions of the eyelids
  2. Neoplastic lesions:
  • benign lid tumours
  • malignant lid tumours
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2
Q

What are the 4 layers of the eyelid?

A
  1. Skin
  2. Orbicularis
  3. Tarsal plate
  4. Conjunctiva
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3
Q

How can the skin on the outer surface of the eyelid be described, and why is this the case?

A

Particularly thin to allow the eyelid to move freely

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4
Q

What is the orbicularis layer of the eyelid?

A

Second layer beneath skin; orbital part of orbicularis oculi muscle, thin layer of muscle responsible for closing the eyelids

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5
Q

What is the tarsal plate layer of the eyelid?

A

Stiff structure, third layer below skin, that acts like skeleton of eyelid giving rigidity and shape

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6
Q

Within which layer of the eyelid are Meibomien glands located?

A

The tarsal plate

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7
Q

What are Meibomien glands?

A

Oil-producing glands closely related to the sebaceous glands of the skin. Produce oily materal called Meibom

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8
Q

What is the role of the substance Meibom (produced by Meibomien glands)?

A

Plays important part in stability of the tear film

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9
Q

What is the conjunctiva in relation to the eyelid?

A

Fourth and final layer of the eyelid. Thin clear layer, lies over sclera and is reflected onto the inside of the eyelids

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10
Q

What are 5 types of non-neoplastic lid lumps?

A
  1. External hordeola (styes)
  2. Internal hordeola
  3. Chalazia
  4. Cysts of Möll and Zeiss (lid cysts)
  5. Xanthelasmata
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11
Q

What does the lid lump in the image show?

A

External hordeolum (stye)

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12
Q

What is a stye/ external hordeolum and what causes it?

A

common, small lid lump that occurs when there is a blockage and infection of a gland of Zeiss - one of the small glands associated with the lash follicle

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13
Q

What is the treatment of external hordeola aka styes?

A

Pull out the offending lash

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14
Q

What type of lid lump is shown in the image?

A

Internal hordeolum

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15
Q

What is the commonest acute lid lump?

A

Internal hordeolum

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16
Q

What is the cause of internal hordeola?

A

Blockage to the Meibomien glands or glands of Zeiss/ Möll; usually due to chronic lid inflammation e.g. blepharitis

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17
Q

What is the presentation of an internal hordeolum?

A

Acute, red, swollen, painful lid lump

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18
Q

What is the treatment of internal hordeola? 4 stages

A
  1. Usually self-resolve or respond to conservative treatment
  2. Warm compress
  3. Topical and/or systemic antibiotics: if frank signs of infection
  4. rarely, may require incision and drainage, if form an abscess
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19
Q

What do internal hordeola often lead to?

A

chalazion formation

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20
Q

What is the commonest lid lump (not just acute) seen in clinical practice?

A

Chalazion

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21
Q

What is a chalazion and what is it caused by?

A
  • non-infective lid lump.
  • Meibomien secretions may be secreted from gland into lid itself, these are treated as a foreign body which causes a lipo-granulomatous reaction
  • Is a consequence of a hordeolum
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22
Q

How does a chalazion clinically appear?

A

As a quiet, painless eye with a hard, discrete nodule under the skin of the lid

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23
Q

What type of lid lump is shown in the image?

A

Chalazion

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24
Q

What are 2 management options for chalazia?

A
  1. Usually self-resolve but may take many months
  2. Incision and curettage (scrape and remove with curette) may be required if persistent (as are unsightly and take too long to resolve)
  • under LA for adults, GA for children
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25
Q

What type of lid lump is shown in the image?

A

Cyst of Möll

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26
Q

What type of lid lump is shown in the image?

A

Cyst of Zeiss

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27
Q

What do cysts of Zeiss arise from and how do they appear?

A

Sebaceous glands. They are opaque cysts

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28
Q

What do cysts of Möll arise from and how do they appear?

A

Apocrine sweat glands. They are translucent, filled with a clear fluid

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29
Q

What is the treatment for both cysts of Zeiss and Möll?

A

Punctured or de-roofed

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30
Q

What are xanthelasmata?

A

Yellowish plaque under the skin around the eyelids, usually bilateral

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31
Q

What condition are xanthelasmata associated with, and what proportion of patients with them suffer with this?

A

Hyperlipidaemia; about half of patients

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32
Q

What test should be performed in patients with xanthelasmata?

A

Lipid profile - due to hyperlipidaemia in 50%

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33
Q

What can the treatment of xanthelasmata be?

A

May be surgically removed

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34
Q

What type of lid lump is shown in the image?

A

Xanthelasmata

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35
Q

What are 4 types of benign, neoplastic lid tumours?

A
  1. Papillomata
  2. Eyelid naevi
  3. Keratocanthoma
  4. Sebhorrheic keratosis
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36
Q

What is the commonest benign lid tumour?

A

Lid papilloma

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37
Q

What type of lid lump is shown in the image?

A

Lid papilloma

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38
Q

What are two ways that lid papillomata may appear?

A

Sessile (lie flat against skin surface) or pedunculated (proud of skin surface)

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39
Q

What are 3 possible causes of lid papillomata?

A
  1. Non-specific
  2. related to HPV infection
  3. can arise due to squamous hyperplasia - known as squamous papilloma
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40
Q

When do eyelid naevi often appear?

A

Often present since birth

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41
Q

How do eyelid naevi form?

A

Form when melanocytes, which migrate from neural crest cells, migrate to form nests (collection of melanocytes) within the skin (aka moles)

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42
Q

What are the 3 histological types of eyelid naevi, which depend on the layer of skin in which nests are located?

A
  1. Junctional naevi: found at the junction of dermis and epidermis
  2. Intradermal naevi: within dermis
  3. Compound: both at junction and within dermis
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43
Q

How do benign eyelid naevi appear?

A

Well circumscribed with a uniform colour

44
Q

What should you do when someone presents with an eyelid naevus?

A
  • Look for signs of malignancy
    • should have regular shape and uniform colour
    • no history of growth or other features of malignancy:
      • distortion of eyelid margin
      • lash loss
45
Q

In which patients do seborrhoeic keratoses occur?

A

Elderly Caucasian, on sun-exposed areas

46
Q

What lid lump is shown in the image?

A

Seborrhoeic keratosis

47
Q

What lid lump is shown in the image?

A

Keratocanthoma

48
Q

What lid lump is shown in the image?

A

Eyelid naevus

49
Q

What is the apperance of seborrhoeic keratoses?

A

Brown, broad-based protrusion with greasy irregular surface; ‘stuck on’ appearance

50
Q

When is treatment of seborrhoeic keratoses indicated?

A

Only required if large/ cosmetically unacceptable

51
Q

What is the typical history of an eyelid keratocanthoma?

A

Rapid growth followed by spontaneous involution

52
Q

What may be the natural progression of keratocanthomata?

A

Spontaneous resolution over several months, leaving no scar

53
Q

How do keratocanthomata appear?

A

Non-pigmented, well-circumscribed solitary lesion with central craters, that may be filled with a keratin plug

54
Q

What type of lesion are keratocanthomata closely related to, and therefore what can rarely occur?

A

Squamous cell carcinoma (keratocanthomata may truly be a low-grade malignant tumour rather than benign)

55
Q

What is the treatment for a keratocanthoma?

A

Complete excision, along with histological examination of the specimen

56
Q

What are the 4 key types of malignant eyelid tumours and their relative frequencies?

A
  1. Basal cell carcinoma (80%)
  2. Squamous cell carcinoma (15%)
  3. Malignant melanoma (4%)
  4. Sebaceous gland carcinoma (1%)
57
Q

What is the most common form of skin cancer and also the most common malignant eyelid tumour?

A

BCC (80-90% skin malignancies)

58
Q

When can malignant eyelid tumours be life-threatening?

A

If they metastasise

59
Q

What are the 3 different subtypes of basal cell carcinomas?

A
  1. Nodular
  2. Nodulo-ulcerative (rodent ulcer)
  3. Morpheaform or sclerosing
60
Q

Why can the clinical appearance of basal cell carcinomas be misleading?

A

Multiple subtypes may appear in one lesion

61
Q

How frequent is metastatic spread of basal cell carcinomas?

A

Extremely rare

62
Q

What is the key risk of spread associated with basal cell carcinomas?

A

Relentlessly invades locally (despite metastatic spread being rare) → if left alone will cause massive tissue destruction

63
Q

What is the classic clinical appearance of a basal cell carcinoma? 5 key features

A
  1. Painless nodule
  2. shiny and waxy (pearly)
  3. rolled border
  4. telangiectatic vessels on surface
  5. central ulceration
64
Q

How do basal cell carcinomas feel to the touch?

A

Feel firm and immobile

65
Q

What are the two most common locations for basal cell carcinomas?

A

Lower eyelid and in medial canthus

66
Q

What is the treatment of eyelid basal cell carcinomas?

A
  • Complete excision with at least 3mm margin of normal tissue excised +/- radiotherapy
  • If adequate excision can’t be performed or lesion has spread to bone, radiotherapy may be indicated
67
Q

What type of lid lump is shown in the image?

A

Basal cell carcinoma

68
Q

What type of lid lump is shown in the image?

A

BCC

69
Q

What type of lid lump is shown in the image?

A

Morpheaform BCC

70
Q

What are 2 key features of a morpheaform basal cell carcinoma?

A
  1. Indistinct borders
  2. May be central ulceration
71
Q

What is different about the management of a morpheaform BCC from other BCC types?

A

Larger margin of normal tissue should be removed during excision: 4-5mm

72
Q

What type of tumour is a squamous cell carcinoma?

A

A rare, malignant epithelial tumour

73
Q

Why can squamous cell carcinomas be difficult to diagnose?

A

can present with varied clinical appearance

74
Q

What should be done if there is doubt about the diagnosis of squamous cell carcinoma?

A

Biopsy

75
Q

What are 3 risk factors for squamous cell carcinomas?

A
  1. Increased age
  2. Fair skin
  3. Sun exposure (e.g. solar keratosis)
76
Q

Why might squamous cell carcinomas have a crust over the lesion?

A

Due to the squamous origin they have a tendency to overproduce keratin

77
Q

Via which 2 routes does metastasis occur from an eyelid squamous cell carcinoma?

A
  1. Lymphatic (pre-auricular, cervical, submandibular nodes)
  2. Perineural (into orbit)
78
Q

In which eyelid region are squamous cell carcinomas more common?

A

Lower eyelid

79
Q

How might squamous cell carcinomas physically appear?

A

As plaques or nodules with variable degrees of scale, crust or ulceration

80
Q

What are 2 key features suggestive of malignancy in SCC?

A
  1. loss of lashes
  2. destruction of normal eyelid architecture
81
Q

What can the need for adjuvant therapy in squamous cell carcinoma be assessed based upon? 2 key things

A
  1. Evaluation of subcutaneous tissues (depth of lesion, bony involvement)
  2. Conjunctival involvement (hyperaemia, dyskeratosis)
82
Q

What is the treatment for eyelid squamous cell carcinoma?

A
  • Treatment: wide local excision
  • Adjuvant therapy: radiation, cryotherapy
83
Q

What type of lid lump is shown in the image?

A

Squamous cell carcinoma

84
Q

What type of lid lump is shown in the image?

A

Squamous cell carcinoma

85
Q

What type of lid lump is shown in the image below?

A

Malignant melanoma

86
Q

How common is malignant melanoma on the periocular skin?

A

Very rare

87
Q

Despite malignant melanomas rarely occurring on the periocular skin, why is there a high risk associated with them?

A

High mortality: any growing pigmented lesion on the eylid should be treated with suspicion

88
Q

What proportion of all skin cancer cases are malignant melanomas?

A

4%

89
Q

What proportion of all skin cancer deaths are malignant melanomas?

A

75%

90
Q

What is the physical appearance of an eyelid malignant melanoma?

A

Irregular pigmented lesion with irregular border

91
Q

What are 3 suspicious features in malignant eyelid melanoma?

A
  1. Irregular border
  2. Lesion asymmetry
  3. Varying colour
92
Q

What is the treatment of malignant eyelid melanoma?

A

Excision with 5-10mm margin of normal tissue

93
Q

What can be done to improve early detection of lymph node involvement in eyelid malignant melanoma?

A

Sentinel node biopsy

94
Q

What is the treatment for lymph node involvement due to malignant eyelid melanoma?

A

Direct adjuvant radiotherapy or chemotherapy

95
Q

What is another name for sebaceous cell carcinoma?

A

Sebaceous gland carcinoma

96
Q

How common are sebaceous cell carcinomas of the eylid?

A

Very rare lid malignancy (but easily misdiagnosed)

97
Q

What might a sebaceous cell carcinoma of the eyelid mimic?

A

Benign lid problems

98
Q

How might sebaceous cell carcinomas of the eyelid be misdiagnosed and why?

A

Meibomienitis, meibomien cysts; can present in a variety of ways

99
Q

How can sebaceous cell carcinomas of the eyelid present?

A

Can cause lid distortion, may cause ectropion or entropion

100
Q

What are recurrence and metastasis of sebaceous cell carcinomas like?

A

High rates of both recurrence and metastasis

101
Q

What is the mortality rate of sebaceous cell carcinomas of the eyelids and why?

A

22%: high rates of metastasis

102
Q

What is the treatment for sebaceous cell carcinomas of the eyelid? 2 key elements

A
  1. Surgical resection: 2-3mm margins ± lymph node sampling, with careful histology to check if lesion and adequate margin excised
  2. Plus: local cryotherapy, local chemotherapy and radiotherapy may be considered
103
Q

What treatment may be required if a sebaceous cell carcinoma has diffused/ there is significant pagetoid spread into orbit?

A

May require removal of entire orbital contents

104
Q

What is the definition of pategoid spread?

A

individual cell proliferation in the upper levels of the epidermis, similar to the pattern of epidermal involvement by Paget’s disease of the breast

105
Q

What type of lid lesion is shown in the image?

A

Sebaceous cell carcinoma

106
Q

What type of lid lesion is shown in the image?

A

Sebaceous cell carcinoma

Duke Elder: Finals Ophthalmology (Alice) (20 decks)

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