Diagnosis of Periocular Lid Lesions, Seeing the Forest Through the Trees- instructional Course Using Case Studies Jill Melicher, M. D. Minnesota Eye Consultants, P. A. Ophthalmic Plastics, Orbit and Reconstructive Surgery Introduction



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Diagnosis of Periocular Lid Lesions, Seeing the Forest Through the Trees- Instructional Course Using Case Studies

Jill Melicher, M.D.

Minnesota Eye Consultants, P.A.

Ophthalmic Plastics, Orbit and Reconstructive Surgery
Introduction:

  • 15-20% of periocular lesions are malignant

  • Kersten et al. showed that differential diagnosis between benign and malignant eyelid tumors based on clinical evaluation carries a 2% risk of error

  • It is important to recognize the characteristics of malignancy rather than spend the time trying to learn all the names of each benign lesion-

    • “Don’t lose sight of the forest, while trying to learn the names of all the trees”


Eyelid anatomy:

  • Periocular skin

  • Lash follicle

  • Sebaceous glands

    • Meibomian glands- tarsal plate

    • Zeiss glands- associated with lash follicles

    • Sebaceous glands of the caruncle

  • Sweat glands

    • Apocrine glands of Moll- associated with lash follicles

    • Eccrine glands


Sorting out the origin of the neoplasm:


Factors predisposing to malignancy:

  • >4th decade

  • Celtic or Scandinavian ancestry

  • Fair skin, red hair and blue eyes

  • Excessive sun exposure (1+ episodes of blistering sunburn during adolescence)

  • Previous radiation

  • Smoking

  • History of cancerous lesion


Characteristics of benign eyelid neoplasms:

  • Important to remember the big picture…recognize benign vs. malignant characteristics


Characteristics of eyelid neoplasms suggesting malignancy:

  • Important to remember the big picture…recognize benign vs. malignant characteristics

    • Ulceration

    • Painless

    • Irregular “pearly” borders

    • Induration

    • Telangiectasias

    • Alteration of normal eyelid anatomy (i.e. lash loss, lid margin notching)

    • Asymmetry

    • Variable coloration


Benign neoplasms:

  • Epithelial/dermal origin:

    • Acrochordon/Fibroepithelioma- skin tag

      • Often referred to as papillomas- this is a descriptive clinical term…not a diagnosis

    • Xanthelasma- upper eyelids, can be associated with metabolic disorder

    • Epidermal inclusion cyst- round, contain keratin, frequently see and pore on top of cyst

      • Milia

    • Seborrheic keratosis- waxy, stuck on, often non-pigmented in the eyelid

      • At slit lamp will see keratin pits

    • Cutaneous horn

    • Nevi

  • Sebaceous gland origin:

    • Chalazion

    • Hordeolum

  • Sweat gland:

    • Apocrine hidrocystoma- translucent or bluish in coloration, often occur at canthi, more common in African Americans

    • Syringoma

    • Cylindroma- turban tumor


Pre-malignant neoplasms:

  • Actinic keratosis

  • Bowen’s Disease

  • Keratoacanthoma

  • Lentigo maligna


Malignant neoplasms:

  • Epithelial origin:

    • Basal cell carcinoma-

      • Most common periocular malignancy

      • Lower eyelid > medial canthus > upper eyelid > lateral canthus

      • Locally aggressive

      • Treated with Mohs excision and reconstruction

    • Squamous cell carcinoma

      • May arise de novo from areas of AK or actinic damage

      • Risk of metastatic spread

      • Treated with Mohs excision and reconstruction

    • Malignant melanoma

  • Sebaceous gland origin:

    • Sebaceous gland carcinoma-

      • Highly malignant

      • Potentially lethal

      • Originate from MG, Zeiss glands or sebaceous glands of caruncle, eyebrow or skin

      • Upper eyelid

      • Tigroid appearance of conjunctiva secondary to lipid within neoplastic cells

      • Mimics unilateral blepharitis, recurrent chalazion, SLK

      • Loss of cilia, disruption of normal architecture

      • Unique characteristic- intradermal or “pagetoid” spread

      • May be associated with other visceral malignancies

      • Risk of metastasis

      • Treated with wide local excision and sentinel node biopsy

  • Other:

    • Dermal metastasis


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