Lid lumps Flashcards
What are the two broad groups into which lid lumps can be classified?
- Non-neoplastic lesions of the eyelids
- Neoplastic lesions:
- benign lid tumours
- malignant lid tumours
What are the 4 layers of the eyelid?
- Skin
- Orbicularis
- Tarsal plate
- Conjunctiva
How can the skin on the outer surface of the eyelid be described, and why is this the case?
Particularly thin to allow the eyelid to move freely
What is the orbicularis layer of the eyelid?
Second layer beneath skin; orbital part of orbicularis oculi muscle, thin layer of muscle responsible for closing the eyelids
What is the tarsal plate layer of the eyelid?
Stiff structure, third layer below skin, that acts like skeleton of eyelid giving rigidity and shape
Within which layer of the eyelid are Meibomien glands located?
The tarsal plate
What are Meibomien glands?
Oil-producing glands closely related to the sebaceous glands of the skin. Produce oily materal called Meibom
What is the role of the substance Meibom (produced by Meibomien glands)?
Plays important part in stability of the tear film
What is the conjunctiva in relation to the eyelid?
Fourth and final layer of the eyelid. Thin clear layer, lies over sclera and is reflected onto the inside of the eyelids
What are 5 types of non-neoplastic lid lumps?
- External hordeola (styes)
- Internal hordeola
- Chalazia
- Cysts of Möll and Zeiss (lid cysts)
- Xanthelasmata
What does the lid lump in the image show?
External hordeolum (stye)
What is a stye/ external hordeolum and what causes it?
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
What is the treatment of external hordeola aka styes?
Pull out the offending lash
What type of lid lump is shown in the image?
Internal hordeolum
What is the commonest acute lid lump?
Internal hordeolum
What is the cause of internal hordeola?
Blockage to the Meibomien glands or glands of Zeiss/ Möll; usually due to chronic lid inflammation e.g. blepharitis
What is the presentation of an internal hordeolum?
Acute, red, swollen, painful lid lump
What is the treatment of internal hordeola? 4 stages
- Usually self-resolve or respond to conservative treatment
- Warm compress
- Topical and/or systemic antibiotics: if frank signs of infection
- rarely, may require incision and drainage, if form an abscess
What do internal hordeola often lead to?
chalazion formation
What is the commonest lid lump (not just acute) seen in clinical practice?
Chalazion
What is a chalazion and what is it caused by?
- 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
How does a chalazion clinically appear?
As a quiet, painless eye with a hard, discrete nodule under the skin of the lid
What type of lid lump is shown in the image?
Chalazion
What are 2 management options for chalazia?
- Usually self-resolve but may take many months
- 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
What type of lid lump is shown in the image?
Cyst of Möll
What type of lid lump is shown in the image?
Cyst of Zeiss
What do cysts of Zeiss arise from and how do they appear?
Sebaceous glands. They are opaque cysts
What do cysts of Möll arise from and how do they appear?
Apocrine sweat glands. They are translucent, filled with a clear fluid
What is the treatment for both cysts of Zeiss and Möll?
Punctured or de-roofed
What are xanthelasmata?
Yellowish plaque under the skin around the eyelids, usually bilateral
What condition are xanthelasmata associated with, and what proportion of patients with them suffer with this?
Hyperlipidaemia; about half of patients
What test should be performed in patients with xanthelasmata?
Lipid profile - due to hyperlipidaemia in 50%
What can the treatment of xanthelasmata be?
May be surgically removed
What type of lid lump is shown in the image?
Xanthelasmata
What are 4 types of benign, neoplastic lid tumours?
- Papillomata
- Eyelid naevi
- Keratocanthoma
- Sebhorrheic keratosis
What is the commonest benign lid tumour?
Lid papilloma
What type of lid lump is shown in the image?
Lid papilloma
What are two ways that lid papillomata may appear?
Sessile (lie flat against skin surface) or pedunculated (proud of skin surface)
What are 3 possible causes of lid papillomata?
- Non-specific
- related to HPV infection
- can arise due to squamous hyperplasia - known as squamous papilloma
When do eyelid naevi often appear?
Often present since birth
How do eyelid naevi form?
Form when melanocytes, which migrate from neural crest cells, migrate to form nests (collection of melanocytes) within the skin (aka moles)
What are the 3 histological types of eyelid naevi, which depend on the layer of skin in which nests are located?
- Junctional naevi: found at the junction of dermis and epidermis
- Intradermal naevi: within dermis
- Compound: both at junction and within dermis
How do benign eyelid naevi appear?
Well circumscribed with a uniform colour
What should you do when someone presents with an eyelid naevus?
- 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
In which patients do seborrhoeic keratoses occur?
Elderly Caucasian, on sun-exposed areas
What lid lump is shown in the image?
Seborrhoeic keratosis
What lid lump is shown in the image?
Keratocanthoma
What lid lump is shown in the image?
Eyelid naevus
What is the apperance of seborrhoeic keratoses?
Brown, broad-based protrusion with greasy irregular surface; ‘stuck on’ appearance
When is treatment of seborrhoeic keratoses indicated?
Only required if large/ cosmetically unacceptable
What is the typical history of an eyelid keratocanthoma?
Rapid growth followed by spontaneous involution
What may be the natural progression of keratocanthomata?
Spontaneous resolution over several months, leaving no scar
How do keratocanthomata appear?
Non-pigmented, well-circumscribed solitary lesion with central craters, that may be filled with a keratin plug
What type of lesion are keratocanthomata closely related to, and therefore what can rarely occur?
Squamous cell carcinoma (keratocanthomata may truly be a low-grade malignant tumour rather than benign)
What is the treatment for a keratocanthoma?
Complete excision, along with histological examination of the specimen
What are the 4 key types of malignant eyelid tumours and their relative frequencies?
- Basal cell carcinoma (80%)
- Squamous cell carcinoma (15%)
- Malignant melanoma (4%)
- Sebaceous gland carcinoma (1%)
What is the most common form of skin cancer and also the most common malignant eyelid tumour?
BCC (80-90% skin malignancies)
When can malignant eyelid tumours be life-threatening?
If they metastasise
What are the 3 different subtypes of basal cell carcinomas?
- Nodular
- Nodulo-ulcerative (rodent ulcer)
- Morpheaform or sclerosing
Why can the clinical appearance of basal cell carcinomas be misleading?
Multiple subtypes may appear in one lesion
How frequent is metastatic spread of basal cell carcinomas?
Extremely rare
What is the key risk of spread associated with basal cell carcinomas?
Relentlessly invades locally (despite metastatic spread being rare) → if left alone will cause massive tissue destruction
What is the classic clinical appearance of a basal cell carcinoma? 5 key features
- Painless nodule
- shiny and waxy (pearly)
- rolled border
- telangiectatic vessels on surface
- central ulceration
How do basal cell carcinomas feel to the touch?
Feel firm and immobile
What are the two most common locations for basal cell carcinomas?
Lower eyelid and in medial canthus
What is the treatment of eyelid basal cell carcinomas?
- 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
What type of lid lump is shown in the image?
Basal cell carcinoma
What type of lid lump is shown in the image?
BCC
What type of lid lump is shown in the image?
Morpheaform BCC
What are 2 key features of a morpheaform basal cell carcinoma?
- Indistinct borders
- May be central ulceration
What is different about the management of a morpheaform BCC from other BCC types?
Larger margin of normal tissue should be removed during excision: 4-5mm
What type of tumour is a squamous cell carcinoma?
A rare, malignant epithelial tumour
Why can squamous cell carcinomas be difficult to diagnose?
can present with varied clinical appearance
What should be done if there is doubt about the diagnosis of squamous cell carcinoma?
Biopsy
What are 3 risk factors for squamous cell carcinomas?
- Increased age
- Fair skin
- Sun exposure (e.g. solar keratosis)
Why might squamous cell carcinomas have a crust over the lesion?
Due to the squamous origin they have a tendency to overproduce keratin
Via which 2 routes does metastasis occur from an eyelid squamous cell carcinoma?
- Lymphatic (pre-auricular, cervical, submandibular nodes)
- Perineural (into orbit)
In which eyelid region are squamous cell carcinomas more common?
Lower eyelid
How might squamous cell carcinomas physically appear?
As plaques or nodules with variable degrees of scale, crust or ulceration
What are 2 key features suggestive of malignancy in SCC?
- loss of lashes
- destruction of normal eyelid architecture
What can the need for adjuvant therapy in squamous cell carcinoma be assessed based upon? 2 key things
- Evaluation of subcutaneous tissues (depth of lesion, bony involvement)
- Conjunctival involvement (hyperaemia, dyskeratosis)
What is the treatment for eyelid squamous cell carcinoma?
- Treatment: wide local excision
- Adjuvant therapy: radiation, cryotherapy
What type of lid lump is shown in the image?
Squamous cell carcinoma
What type of lid lump is shown in the image?
Squamous cell carcinoma
What type of lid lump is shown in the image below?
Malignant melanoma
How common is malignant melanoma on the periocular skin?
Very rare
Despite malignant melanomas rarely occurring on the periocular skin, why is there a high risk associated with them?
High mortality: any growing pigmented lesion on the eylid should be treated with suspicion
What proportion of all skin cancer cases are malignant melanomas?
4%
What proportion of all skin cancer deaths are malignant melanomas?
75%
What is the physical appearance of an eyelid malignant melanoma?
Irregular pigmented lesion with irregular border
What are 3 suspicious features in malignant eyelid melanoma?
- Irregular border
- Lesion asymmetry
- Varying colour
What is the treatment of malignant eyelid melanoma?
Excision with 5-10mm margin of normal tissue
What can be done to improve early detection of lymph node involvement in eyelid malignant melanoma?
Sentinel node biopsy
What is the treatment for lymph node involvement due to malignant eyelid melanoma?
Direct adjuvant radiotherapy or chemotherapy
What is another name for sebaceous cell carcinoma?
Sebaceous gland carcinoma
How common are sebaceous cell carcinomas of the eylid?
Very rare lid malignancy (but easily misdiagnosed)
What might a sebaceous cell carcinoma of the eyelid mimic?
Benign lid problems
How might sebaceous cell carcinomas of the eyelid be misdiagnosed and why?
Meibomienitis, meibomien cysts; can present in a variety of ways
How can sebaceous cell carcinomas of the eyelid present?
Can cause lid distortion, may cause ectropion or entropion
What are recurrence and metastasis of sebaceous cell carcinomas like?
High rates of both recurrence and metastasis
What is the mortality rate of sebaceous cell carcinomas of the eyelids and why?
22%: high rates of metastasis
What is the treatment for sebaceous cell carcinomas of the eyelid? 2 key elements
- Surgical resection: 2-3mm margins ± lymph node sampling, with careful histology to check if lesion and adequate margin excised
- Plus: local cryotherapy, local chemotherapy and radiotherapy may be considered
What treatment may be required if a sebaceous cell carcinoma has diffused/ there is significant pagetoid spread into orbit?
May require removal of entire orbital contents
What is the definition of pategoid spread?
individual cell proliferation in the upper levels of the epidermis, similar to the pattern of epidermal involvement by Paget’s disease of the breast
What type of lid lesion is shown in the image?
Sebaceous cell carcinoma
What type of lid lesion is shown in the image?
Sebaceous cell carcinoma
