- 1.
What clues are helpful in determining whether an eyelid lesion is benign or malignant?
The size, location, age of onset, rate of growth, and presence of bleeding or ulceration; any color change; and a history of malignancy or prior radiation therapy are important. A thorough examination is necessary. Malignant or inflammatory lesions may cause loss of eyelashes and distortion of meibomian gland orifices, but only malignant lesions destroy the orifices. If a lesion is near the lacrimal punctum, evaluate for invasion into the lacrimal system. Probing and irrigation may be necessary. Palpate lesions for fixation to deep tissues or bone. Regional lymph nodes also should be examined for enlargement. Restriction of extraocular motility and proptosis are clues to localized invasion. If a sebaceous adenocarcinoma or melanoma is diagnosed, systemic evaluation should target lung, liver, bones, and neurologic systems. Photographic documentation is important for any lesion to be treated or observed.
- 2.
What is the difference between seborrheic keratosis and actinic keratosis?
Both are papillomas, an irregular frondlike projection of skin with a central vascular pedicle. These lesions are more common in elderly patients.
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Seborrheic keratosis is pigmented, oily, and hyperkeratotic. It appears stuck onto the skin ( Fig. 38-1 ). A shaved biopsy is all that is needed to diagnose and treat. It has no increased risk for malignant change.
Figure 38-1
Seborrheic keratosis is a greasy, brown, flat lesion with a verrucous surface and a “stuck-on” appearance.
(From Kanski JJ: Clinical Ophthalmology: A Synopsis. New York, Butterworth-Heinemann, 2004.)
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Actinic keratosis is found in sun-exposed areas and appears as a flat, scaly, or papillary lesion ( Fig. 38-2 ). This premalignant lesion may evolve into either a basal cell or a squamous cell carcinoma.
Figure 38-2
Actinic keratosis is a dry, scaly lesion caused by sun exposure and occurring in fair-skinned people.
(From Spalton DJ, Hitchings RA, Hunter PA: Atlas of Clinical Ophthalmology, ed 2, St. Louis, Mosby, 1994.)
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- 3.
What eyelid lesion is associated with a chronic follicular conjunctivitis?
Molluscum contagiosum. A virus causes the multiple waxy nodules with umbilicated centers. They may resolve spontaneously but frequently require surgical excision or cautery to prevent reinfection.
- 4.
What blood tests should you order in young patients with the lesions shown in Figure 38-3 ?
The appropriate tests are cholesterol level, triglyceride level, and fasting blood sugar. Xanthelasma are yellowish plaques found at the medial canthal area of the upper and lower eyelids. They are collections of lipid. In older patients, xanthelasma are common and no cause for concern. In younger patients they may be a sign of hypercholesterolemia, a congenital disorder of cholesterol metabolism, or diabetes mellitus. They may be removed for cosmetic purposes, but they can recur.
Figure 38-3
Patient with xanthelasma.
(From Kanski JJ: Clinical Ophthalmology: A Systematic Approach, ed 5, New York, Butterworth-Heinemann, 2003.)
- 5.
What is a keratoacanthoma? What malignancy does it simulate?
A keratoacanthoma is a rapidly growing lesion that appears over several weeks. It is hyperkeratotic with a central crater that often resolves spontaneously ( Fig. 38-4 ). Clinically, the lesion simulates a “rodent ulcer” basal cell carcinoma. Microscopically, the lesion appears similar to squamous cell carcinoma. It may occur near the edge of areas of chronic inflammation, such as a burn, or on the periphery of a true malignant neoplasm. If you are sure of the diagnosis, it is reasonable to observe. However, because it may cause destruction of the eyelid margin, lesions in this area are often removed surgically. In addition, steroids may be injected into the lesion to hasten resolution.
Figure 38-4
Keratoacanthoma is a fast-growing nodule with a keratin-filled crater that spontaneously involutes after several months.
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