Eyelid Lumps and Bumps
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Eyelid Lumps and Bumps







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Eyelid Lumps and Bumps. Acquired Tumors and Cysts with non-infectious etiology. Benign Tumors. Actinic Keratosis What is it? Slow growing keratinization of the epithelium Results from excessive sun exposure Pre-malignant: may transform into squamous cell carcinoma Appearance
Eyelid Lumps and Bumps

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Slide 1

Eyelid Lumps and Bumps

Acquired Tumors and Cysts with non-infectious etiology

Slide 2

Benign Tumors

  • Actinic Keratosis

    • What is it?

      • Slow growing keratinization of the epithelium

      • Results from excessive sun exposure

      • Pre-malignant: may transform into squamous cell carcinoma

    • Appearance

      • Rough, dry, and scaly plaque that is flat or slightly raised

      • Up to 2.5 cm diameter individually

      • Often multiple lesions in a single area that coalesce

      • Distinct boarders

      • May be skin colored to dark brown

    • Who gets it?

      • Elderly individuals with lightly pigmented skin

      • Rarely develops on the eyelid

      • Common on the scalp, ears, forehead, and backs of hands

      • The patient may notice itching or burning of the lesion

Slide 3

Benign Tumors

  • Actinic Keratosis

    • Management

      • Biopsy for definitive diagnosis

      • Usually frozen (cryotherapy) or excised

Slide 4

Benign Tumors

  • Squamous Cell Papilloma

    • What is it?

      • Outgrowth of fibrovascular connective tissue

      • Covered by irregular keratinized stratified squamous epithelium

    • Appearance

      • Variable presentations

      • “Skin tag” type: narrow base, pedunculated, skin colored

      • Board base with “raspberry like” appearance

      • May be difficult to differentiate from viral wart (human papillomavirus)

    • Who gets it?

      • No predilection to race or gender

    • Management

      • Removed by excision

Slide 5

Benign Tumors

  • Squamous Cell Papilloma

Slide 6

Benign Tumors

  • Basal Cell Papilloma

    • What is it?

      • Expansion of the squamous epithelium stemming from basal cell proliferation

      • Slow growing lesion

    • Appearance

      • Round “coin-like” lesion with “stuck-on” appearance

      • Up to 2.5 cm diameter

      • Slightly raised and crusty: often keratinized similar to actinic keratosis

      • Tan to dark brown in color

      • Variety of textures: granular to velvety

    • Who gets it?

      • Common in the elderly

      • Most people develop at least one during their lives

      • Usually develop on the head, neck, or trunk

    • Management

      • No treatment required except for cosmetic reasons or if they become irritated

      • Removed by excision

Slide 7

Benign Tumors

  • Basal Cell Papilloma

Slide 8

Benign Tumors

  • Inverted Follicular Keratosis

    • What is it?

      • Rare and often rapid growing lesion arising from a hair follicle

      • Histologically similar to basal cell papilloma, but with deeper extension into the dermis

    • Appearance

      • Non pigmented papilloma at the lid margin

      • Up to 1 cm diameter

    • Who gets it?

      • Typically older males

    • Management

      • Deep excision

      • Recurrence is common if not completely removed

Slide 9

Benign Tumors

  • Inverted Follicular Keratosis

Slide 10

Benign Tumors

  • Keratoacanthoma

    • What is it?

      • Rare and rapidly growing variant of actinic keratosis

      • Also pre-malignant, potentially transforming into squamous cell carcinoma

    • Appearance

      • Initially appears as a pink hyperkeratotic lesion usually on the lower lid

      • After a period of rapid growth, remains stable for several months

      • Then begins to involute and a keratin filled crater often forms

      • Complete involution can occur after a year leaving a residual scar

    • Who gets it?

      • Same demographic as actinic keratosis

      • Higher occurrence in patients on immunosuppressive therapy following kidney transplants

    • Management

      • Usually excised

      • Occasionally treated with cryotherapy or radiotherapy

Slide 11

Benign Tumors

  • Keratoacanthoma

Slide 12

Benign Tumors

  • Melanocytic Nevus

    • What is it?

      • Tumor composed of cells derived from either epidermal or dermal melanocytes

      • Acquired and congenital forms

      • Generally low to no malignant potential

    • Appearance

      • Junctional: Uniform brown macule or plaque

      • Compound: Uniform, light to dark brown, raised papule

      • Intradermal: Papillomatous with little to no pigment. Associated with dilated vessels and protruding lashes

    • Who gets it?

      • Junctional type occurs in the young

      • Compound type occurs in middle age

      • Intradermal type most common overall and occurs in the elderly

    • Management

      • Removal for cosmetic reasons or if malignancy is suspected

      • Excision may need to be followed by reconstruction depending on location and size

Slide 13

Benign Tumors

  • Melanocytic Nevus

Junctional Nevus

Compound Nevus

Intradermal Nevus

Slide 14

Benign Tumors

  • Xanthelasma

    • What is it?

      • Aggregation of lipid filled macrophages at the level of the dermis

      • Common and frequently bilateral

    • Appearance

      • Yellowish subcutaneous plaque

      • Usually on the medial portion of the eyelids

      • Often multiple

    • Who gets it?

      • Middle aged and the elderly

      • May be associated with elevated cholesterol especially when occurring in younger individuals and with corneal arcus

    • Management

      • Removed for cosmetic reasons

      • Usually treated with carbon dioxide or argon laser

      • May be excised

      • Recurrence suggests persistently elevated cholesterol

Slide 15

Benign Tumors

  • Xanthelasma

Slide 16

Benign Tumors

  • Pilomatricoma

    • What is it?

      • Abnormal proliferation of the germinal matrix cells in a hair follicle

      • Frequently becomes calcified

    • Appearance

      • Deep nodule

      • Becomes hard if calcified

    • Who gets it?

      • Common in young females

    • Management

      • Excision

Slide 17

Benign Tumors

  • Pilomatricoma

Slide 18

Benign Tumors

  • Neurofibroma

    • What is it?

      • Abnormal proliferation of Schwann cells, fibroblasts, and axons

    • Appearance

      • Characteristic S shaped lesion

      • Typically located on the upper lid

    • Who gets it?

      • Solitary lesions occur in adults

      • 25% associated with neurofibromatosis-1

      • Children with neurofibromatosis-1 are affected by diffuse lesions

    • Management

      • Solitary lesions removed by excision

      • Diffuse lesions are more difficult to remove

Slide 19

Benign Tumors

  • Neurofibroma

Slide 20

Malignant Tumors

  • Basal Cell Carcinoma

    • What is it?

      • Locally invasive proliferation of pluripotent epidermal basal cells

      • Most common human malignancy and most common eyelid malignancy

      • Slow growing with no metastatic potential

    • Appearance

      • Usually on the lower eyelid

      • Non-tender ulceration

      • Irregular boarders

      • Possible keratinization

      • Destruction of eyelid architecture

      • Nodular type: pearl like appearance with dilated blood vessels on surface

      • Noduloulcerative type: central ulcer with raised pearly edges

      • Sclerosing type: lateral, hardened, infiltration beneath the epidermis. May be confused with chronic blepharitis

Slide 21

Malignant Tumors

  • Basal Cell Carcinoma

    • Who gets it?

      • Common in the elderly

      • Risk factors include fair skin and high cumulative sun exposure

    • Management

      • Diagnosis confirmed with biopsy

      • Excision is the common removal technique

      • Mohs micrographic surgery removes the tumor along with a thin layer of surrounding tissue. The surround is immediately examined for tumor cells and the procedure repeated if any are found. Highest cure rate at 98%.

      • Recurring tumors tend to be more invasive and difficult to treat

Slide 22

Malignant Tumors

  • Basal Cell Carcinoma

Nodular

Ulcerative

Sclerosing

Slide 23

Malignant Tumors

  • Squamous Cell Carcinoma

    • What is it?

      • Proliferation of invasive cells arising from the squamous cell layer of the epidermis

      • Can arise de novo or from existing actinic keratosis or keratoacanthoma

      • Less common, but more aggressive than basal cell carcinoma

      • Lymph node metastasis in 20% of cases

    • Appearance

      • Variety of appearances and may be difficult to distinguish from BCC

      • Scaly with irregular boarders

      • Absence of surface vasculature

      • Extensive keratinization usually present

      • Lesions may bleed

      • Nodular type: keratinized nodule that develops erosions and fissures

      • Ulcerating type: everted boarders with a red, well defined base

      • Cutaneous horn: invasive growth underlies keratin horn

Slide 24

Malignant Tumors

  • Squamous Cell Carcinoma

    • Who gets it?

      • Most common occurrence is in the elderly

      • Risk factors include fair skin, sun exposure, and immune suppression

    • Management

      • Can be fatal if left untreated (2,500 annual deaths in USA)

      • Confirmed with biopsy

      • Mohs micrographic surgery: highest cure rate 94-99%

      • Other options include standard scalpel excision, cryotherapy, and radiotherapy

Slide 25

Malignant Tumors

  • Squamous Cell Carcinoma

Nodular

Ulcerative

Cutaneous horn

Large ulcerative

Slide 26

Malignant Tumors

  • Sebaceous Gland Carcinoma

    • What is it?

      • Slow growing tumor

      • Arises from the meibomian glands, glands of Zeis, or sebaceous glands in the caruncle

      • More likely to occur on the upper lid where glands are more numerous

    • Appearance

      • No pathognomonic presentation

      • Initially can appear similar to chalazion or chronic blepharitis

      • Yellowish material may be seen within the tumor

      • Nodular type: hard, painless, immobile nodule similar to chalazion

      • Spreading type: thickened lid margin, loss of lashes, similar to chronic blepharitis

Slide 27

Malignant Tumors

  • Sebaceous Gland Carcinoma

    • Who gets it?

      • Females in their 60's and 70's most commonly affected

      • Youngest reported case was in a 3 year old

    • Management

      • Because of appearance, diagnosis is often delayed

      • Mortality rate is 5-10%

      • Large (1cm) and non-resolving chalazion should be suspected

      • Cryotherapy and surgical excision are the standard treatments

      • Recurrence is as high as 33%

      • Little documentation for Mohs, but possibly lower recurrence rate

Slide 28

Malignant Tumors

  • Sebaceous Gland Carcinoma

Nodular

Spreading

Conjunctival involvement

Slide 29

Malignant Tumors

  • Melanoma

    • What is it?

      • Epidermal and dermal proliferation of transformed and invasive melanocytes

      • Arises from existing nevus, lentigo maligna (pre-malignancy), or de novo

      • High potential for metastasis

      • Potentially fatal (represents greater than 2/3 of all skin cancer deaths)

    • Appearance

      • Rarely develops on the eyelid (1% of all eyelid lesions)

      • Half of those that do are non-pigmented

      • Asymmetric plaque or nodule

      • Irregular and indistinct boarders

      • Variable colors in the lesion (blue and black)

      • Diameter larger than ~6mm

      • Associated with destruction of local anatomy and loss of lashes

Slide 30

Malignant Tumors

  • Melanoma

    • Who gets it?

      • Most common in elderly individuals with light skin

      • History of sun damaged skin

    • Management

      • Question any new, changing, or irregular appearing lesions

      • Melanoma confirmed with biopsy

      • Wide surgical excision with up to a 1 cm margin for confirmed malignancy

      • Local lymph node dissection if malignancy is more than 1.5 mm deep

      • Prognosis and recurrence is tied to size and any metastasis of original lesion

      • Patients should be followed closely following surgery

Slide 31

Malignant Tumors

  • Melanoma

Slide 32

Malignant Tumors

  • Merkel Cell Carcinoma

    • What is it?

      • Very rare and fast growing form of skin cancer

      • Highly malignant and potentially fatal

      • Arises from Merkel cells located in the basal layer of the epidermis

      • Normal cells thought to play a regulatory role in epidermal growth

    • Appearance

      • Frequently involves the upper eyelid

      • Red, purple, or violet colored, well defined nodule

      • Wide variation in size, from less that 2cm to larger than 15cm

      • Overlying skin is intact

Slide 33

Malignant Tumors

  • Merkel Cell Carcinoma

    • Who gets it?

      • Average age of diagnosis is 75

      • 20x more likely to occur in whites than blacks

      • No gender predilection

      • Risk factors include sun exposure and immune suppression

    • Management

      • Many have metastasized by the time they are diagnosed

      • CT and/or MRI imaging used to evaluate systemic spread

      • Primary tumor removed with a wide excision (margins up to 3cm if possible)

      • Chemotherapy and/or radiotherapy depending on spread

      • 2 year mortality rate of 30-50%

Slide 34

Malignant Tumors

  • Merkel Cell Carcinoma

Slide 35

Cysts

  • Chalazion

    • What is it?

      • AKA meibomian cyst

      • Fatty secretions of a meibomian gland are retained

      • Causes a chronic, painless inflammation

      • Patients with rosacea or meibomian gland dysfunction are more prone to developing multiple and recurrent chalazion

    • Appearance

      • Nodule that has enlarged gradually

      • May enlarge up to nearly 1 cm

      • If large enough, may induce astigmatism by pressing on the cornea

Slide 36

Cysts

  • Chalazion

    • Treatment

      • About one third drain and resolve spontaneously

      • Standard therapy aimed at stimulating and speeding draining by using warm compress and massage

      • Steroid injection through the palpebral conjunctiva

        • 0.1-0.2 ml Kenalog (triamcinolone)

        • 80% success rate

        • May cause local depigmentation of the skin

      • Oral tetracycline/doxycycline useful in patients with chronic lid inflammation

        • Do not use in children or pregnant/nursing women!

        • 250mg PO qid tetracycline

        • 100mg PO bid doxycycline

        • 1-2 week course

      • Incision and drainage through the palpebral conjunctiva and tarsal plate

      • Biopsy a recurrent chalazion - it may be sebaceous cell carcinoma

Slide 37

Cysts

  • Cyst of Zeis

    • What is it?

      • Variation of chalazion

      • Non-translucent retention cyst involving the anterior lid margin

      • Gland of Zeis produces oil for eye lashes

Slide 38

Cysts

  • Cyst of Moll

    • What is it?

      • Variation of chalazion

      • AKA Sudoriferous cyst

      • Translucent retention cyst involving the anterior lid margin

      • Variation of chalazion

      • Gland of Moll is a modified sweat gland also emptying to the lashes

Slide 39

Cysts

  • Epidermoid Cyst

    • What is it?

      • AKA sebaceous cyst

      • Cyst lined by stratified squamous epithelium and containing keratin and sebaceous material

      • Result from ingrowth of surface epidermis after trauma or surgery

    • Appearance

      • Round, well defined, non-tender mass

      • Ruptured cysts cause an acute inflammatory response and possible secondary infection

    • Treatment

      • Complete surgical excision

Slide 40

Cysts

  • Eccrine Hidrocystoma

    • What is it?

      • Rare cyst that forms from retained sweat in a blocked and dilated sweat duct

      • More common in females

    • Appearance

      • Similar to Cyst of Moll with the exception that it does not involve the lid margin

      • Painless and usually asymptomatic

      • May grow up to 6mm

    • Treatment

      • Monitor or needle puncture if desired

Slide 41

Cysts

  • Syringoma

    • What is it?

      • Benign and asymptomatic proliferation of sweat gland duct epithelium

      • Relatively common

      • Most common in adult females

    • Appearance

      • Multiple small (3mm or less) papules

      • May be skin color or yellowish

    • Treatment

      • Removed for cosmetic reasons only

      • No set recommended removal technique

      • Options include excision, cryotherapy, dermabrasion, electrocautery and more

Slide 42

Cysts

  • Milia

    • What is it?

      • Tiny epidermoid cysts that tend to occur in clusters

      • Result from a blocked vellus hair follicles that retain the keratin

      • Very common – occurs in half of all infants

      • May also occur following dermabrasion or damage to the follicle

    • Appearance

      • Small pearly white to yellowish papules

    • Treatment

      • No treatment necessary

      • Needle puncture and expression may be performed if desired

Slide 43

Resources

  • Kanski, Jack J. Clinical Ophthalmology a Systemic Approach. 6th ed. Edinburgh, UK: Elsevier, 2007.

  • http://www.mayoclinic.com/health/actinic-keratosis/DS00568

  • http://www.consultantlive.com/photoclinic/article/10162/1265743

  • http://www.skincancer.org/Basal-Cell-Carcinoma/

  • http://www.skincancer.org/squamous-cell-carcinoma.html

  • http://emedicine.medscape.com/article/1101433-overview

  • http://emedicine.medscape.com/article/1213671-overview

  • http://emedicine.medscape.com/article/1100917-overview

  • http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1781304/

  • http://emedicine.medscape.com/article/1058063-overview

  • http://emedicine.medscape.com/article/1059871-overview


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