Benign nodules and cysts

Chalazion (meibomian cyst)

  • Definition: very common chronic sterile inflammation of a meibomian gland that may resolve spontaneously.

  • Diagnosis

    • Signs: (a) gradually enlarging tarsal nodule ( Fig. 1.1 ); (b) conjunctival granulomatous extension is common, and (c) secondary infection (internal hordeolum; Fig. 1.2 ) may occur.

      Fig 1.1

      Fig 1.2

    • Associations: (a) meibomian gland dysfunction, (b) acne rosacea, and (c) seborrhoeic dermatitis.

  • Treatment: (a) incision and curettage ( Fig. 1.3 ), (b) local steroid injection (0.2–2 ml of 5 mg/ml triamcinolone diacetate), and (c) prophylactic systemic tetracycline in severe recurrent disease.

    Fig 1.3


  • Cyst of Zeis: nontranslucent cyst on the anterior lid margin arising from an obstructed sebaceous gland associated with a lash follicle ( Fig. 1.4 ).

    Fig 1.4

  • Cyst of Moll: translucent, fluid-filled retention cyst on the anterior lid margin ( Fig. 1.5 ) arising from an apocrine gland.

    Fig 1.5

  • External hordeolum (stye): tender, pointing swelling in the lid margin, usually with a lash at its apex ( Fig. 1.6 ); caused by an acute staphylococcal infection of a lash follicle.

    Fig 1.6

  • Epidermal inclusion cyst: slow-growing, firm, round lesion containing keratin; located away from the lid margin ( Fig. 1.7 ); caused by implantation of epidermis into dermis following trauma or surgery.

    Fig 1.7

  • Sebaceous (pilar) cyst: may occasionally occur at the medial canthus ( Fig. 1.8 ).

    Fig 1.8

Benign tumours

Squamous cell papilloma

  • Pathogenesis: human papilloma virus.

  • Diagnosis: narrow-based pedunculated (skin tag; Fig. 1.9 ) or broad-based sessile lesion ( Fig. 1.10 ).

    Fig 1.9

    Fig 1.10

  • Treatment: simple excision.

Basal cell papilloma (seborrhoeic keratosis)

  • Diagnosis : discrete brown pedunculated or sessile lesion, often with a ‘stuck on’ appearance ( Fig. 1.11 ), in an elderly individual.

    Fig 1.11

  • Treatment: curettage or excision.

Actinic (solar, senile) keratosis

  • Predisposition: elderly fair-skinned individuals with a history of chronic sun exposure; carries low/moderate malignant potential (squamous cell carcinoma).

  • Diagnosis: hyperkeratotic plaque with a scaly surface and well-defined borders ( Fig. 1.12 ).

    Fig 1.12

  • Treatment: cryotherapy, or excision biopsy if there is suspicion of malignancy.

Acquired melanocytic naevus

  • Diagnosis:

    • Intradermal naevus: nonpigmented papilloma that may show protruding lashes ( Fig. 1.13 ), in an elderly individual. The cells are confined to the dermis and have no malignant potential.

      Fig 1.13

    • Junctional naevus: flat brown lesion ( Fig. 1.14 ) in a young individual. The cells are located at the junction of the dermis and epidermis, and they carry very low malignant potential.

      Fig 1.14

    • Compound naevus: raised papule with variable pigmentation ( Fig. 1.15 ), in a middle-aged individual. The cells extend from the epidermis into the dermis and have low malignant potential.

      Fig 1.15

  • Treatment: excision for cosmesis or suspicion of malignancy.

Strawberry naevus (capillary haemangioma)

  • Definition: common tumour of childhood with a female-to-male ratio of 3 : 1. Visceral haemangiomas may be present in patients with multiple cutaneous lesions. The vast majority present soon after birth with a rapid growth phase during infancy followed by gradual involution.

  • Diagnosis: raised, bright red lesion ( Fig. 1.16 ) that blanches on pressure and may swell on crying; orbital extension may be present (see Chapter 3 ).

    Fig 1.16

  • Treatment

    • Indications: (a) cosmesis, (b) severe ptosis ( Fig. 1.17 ), and (c) corneal distortion that may give rise to amblyopia.

      Fig 1.17

    • Options: intralesional or systemic steroid, or systemic propranolol (2 mg/kg/day).

Port-wine stain (naevus flammeus)

  • Definition: congenital lesion that is usually unilateral/dermatomal and occasionally bilateral. In some cases, it forms a component of the Sturge–Weber syndrome.

  • Diagnosis: (a) sharply demarcated, soft pink patch that does not blanch with pressure ( Fig. 1.18 ), (b) darkens with age but does not enlarge, (c) overlying skin may become hypertrophied, coarse, and nodular ( Fig. 1.19 ).

    Fig 1.18

    Fig 1.19

  • Treatment: erbium laser may decrease skin discoloration, if undertaken early; photodynamic therapy.

  • Diagnosis of Sturge–Weber syndrome (encepholotrigeminal angiomatosis)

    • Skin: unilateral naevus flammeus in the distribution of one or more branches of the trigeminal nerve.

    • Brain: ipsilateral parietal or occipital leptomeningeal haemangioma.

    • Ipsilateral ocular features: (a) glaucoma, (b) episcleral haemangioma, and (c) diffuse choroidal haemangioma (see Chapter 12 ); heterochromia iridis is uncommon.

    • Classification: (a) trisystem involves the face, leptomeninges, and eyes; (b) bisystem disease involves the face and eyes, or the face and leptomeninges.


  • Definition: common, typically bilateral lesion occurring in middle-aged and elderly individuals. It is associated with a higher risk of coronary heart disease, and in younger patients may indicate hypercholesterolaemia.

  • Diagnosis: white-yellow subcutaneous plaques often located medially ( Fig. 1.20 ).

    Fig 1.20

  • Treatment: (a) excision, (b) laser ablation, or (c) cryotherapy; systemic cholesterol abnormalities should be addressed to reduce risk of recurrence.


  • Plexiform: affects children with neurofibromatosis type 1 (NF1).

  • Solitary: occurs in adults, 25% of whom have NF1.

  • Diagnosis: upper lid involvement by a plexiform lesion gives rise to a characteristic S-shaped deformity ( Fig. 1.21 ).

    Fig 1.21

  • Treatment: solitary lesions can be excised, but removal of diffuse plexiform lesions may be difficult.

Malignant tumours

Basal cell carcinoma (BCC)

Table 1.1

Predisposing systemic conditions

  • Xeroderma pigmentosum

  • Gorlin–Goltz (naevoid basal cell carcinoma) syndrome

  • Dysplastic naevus (atypical mole) syndrome

  • Muir–Torre syndrome

  • Bazex syndrome

  • Albinism

  • Immunosuppression

  • Definition: common, slow-growing, and locally invasive but nonmetastasizing tumour. 90% occur on the head and neck, and 10% of these involve the eyelids, most commonly the lower.

  • Diagnosis

    • Nodular: shiny, pearly nodule with overlying fine irregular blood vessels ( Fig. 1.22 ).

      Fig 1.22

    • Noduloulcerative (rodent ulcer ): nodule with central ulceration and rolled telangiectatic edges ( Fig. 1.23 ).

      Fig 1.23

    • Sclerosing (morphoeic): indurated plaque whose margins may be impossible to delineate clinically; often associated with loss of overlying lashes ( Fig. 1.24 ).

      Fig 1.24

  • Treatment (see below).

Squamous cell carcinoma (SCC)

  • Introduction: SCC is much less common than BCC but is more aggressive, with metastasis to lymph nodes in about 20%.

    • Origin: (a) de novo, (b) in pre-existing actinic keratosis, or (c) from carcinoma in situ (Bowen disease).

    • Risk factors: (a) increasing age, (b) fair skin, (c) chronic sun exposure, and (d) immunosuppression (e.g. HIV, post-transplantation).

  • Diagnosis

    • Signs: (a) nodular ( Fig. 1.25 ), (b) noduloulcerative ( Fig. 1.26 ), and (c) associated with a cutaneous horn ( Fig. 1.27 ); it has a predilection for the lower eyelid and the lid margin.

      Fig 1.25

      Fig 1.26

      Fig 1.27

    • Differentiation from BCC: hyperkeratosis is frequent, telangiectasis is less common, and growth is usually more rapid.

  • Treatment (see below).


  • Definition: often regarded as a well-differentiated form of SCC; risk factors include chronic sun exposure and immunosuppression.

  • Diagnosis

    • Presentation: fast-growing, pink, dome-shaped hyperkeratotic lesion ( Fig. 1.28 ).

      Fig 1.28

    • Course: (a) development of a keratin-filled crater ( Fig. 1.29 ), (b) no change in size for 2 or 3 months, then (c) slow involution.

      Fig 1.29

  • Treatment: excision biopsy, radiotherapy, or chemical cauterization.

Sebaceous gland carcinoma

  • Definition: rare, slow-growing but aggressive tumour that usually arises from the meibomian glands. It most commonly affects elderly females and has a mortality of 5–10%. In contrast to BCC and SCC, it occurs more commonly on the upper eyelid.

  • Diagnosis

    • Nodular: beware mistaken diagnosis of chalazion ( Fig. 1.30 ); biopsy should be performed on any atypical chalazion or suspicious persistent eyelid thickening, particularly in an older patient.

      Fig 1.30

    • Spreading: diffuse thickening of the lid margin ( Fig. 1.31 ), which can be mistaken for chronic blepharitis.

      Fig 1.31

    • Pagetoid spread: extension of the tumour within the epithelium including the conjunctiva ( Fig. 1.32 ), which may be mistaken for chronic inflammation.

      Fig 1.32

  • Treatment (see below).

Principles of surgical treatment

  • Biopsy

    • Incisional: only part of the lesion is removed to allow histological diagnosis.

    • Excisional: entire lesion is removed.

  • Excision

    • Shave excision: for shallow epithelial tumours, such as papilloma and seborrhoeic keratosis.

    • Full-thickness skin excision: most small BCCs can be excised with a 2 to 4 mm clearance margin.

    • Radical surgical excision: for large BCCs and aggressive malignant tumours.

    • Mohs micrographic surgery: allows maximal tumour detection and is particularly useful for lesions in which extension may not be clinically detectable such as sclerosing BCC, and in difficult anatomical sites such as the medial canthus.

  • Reconstruction

    • Skin defects: closed directly or with a local flap or skin graft.

    • Small defects: (less than one-third of lid) can be closed directly, with a lateral cantholysis if necessary ( Fig. 1.33 ).

      Fig 1.33

    • Moderate defects: (up to half of lid) require a flap (e.g. Tenzel semicircular; Fig. 1.34 ).

      Fig 1.34

    • Large defects: (over half of lid) may require: (a) posterior lamellar reconstruction using hard palate graft, buccal mucous membrane graft, or a Hughes flap, or (b) anterior lamellar reconstruction may involve skin advancement, a local skin flap, or a free skin graft.

    • Laissez-faire: approximation of wound edges with residual defect left to heal spontaneously.

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Jul 11, 2019 | Posted by in OPHTHALMOLOGY | Comments Off on Eyelids
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