Benign Nodules and Cysts
Chalazion (meibomian cyst)
Definition:
very common chronic sterile inflammation of a meibomian gland that may resolve spontaneously.
Diagnosis
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Signs: (a) gradually enlarging tarsal nodule ( Fig. 2.1A ), (b) conjunctival granulomatous extension is common, (c) secondary infection (internal hordeolum) may occur ( Fig. 2.1B ).
Fig. 2.1
Meibomian cyst: (A) tarsal nodule, (B) superimposed bacterial infection, (C) conjunctival view of cyst with clamp in position, (D) after curettage.
(From Salmon JF, Kanski’s Clinical Ophthalmology: A Systematic Approach , 9th edition. Oxford, UK: Elsevier; 2020.)
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Associations: (a) meibomian gland dysfunction, (b) rosacea, (c) seborrhoeic dermatitis, (d) use of bortezomib, used in the treatment of myeloma.
Treatment:
(a) incision and curettage ( Fig. 2.1C and D ), (b) local steroid injection (0.2–1 ml of 5 mg/ml triamcinolone diacetate), (c) prophylactic systemic tetracycline in severe recurrent disease.
Miscellaneous
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Cyst of Zeis: nontranslucent cyst on the anterior lid margin arising from an obstructed sebaceous gland associated with a lash follicle ( Fig. 2.2A ).
Fig. 2.2
(A) Cyst of Zeis, (B) cyst of Moll, (C) sebaceous cyst, (D) external hordeolum.
(From Salmon JF, Kanski’s Clinical Ophthalmology: A Systematic Approach , 9th edition. Oxford, UK: Elsevier; 2020.)
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Cyst of Moll: translucent, fluid-filled retention cyst on the anterior lid margin ( Fig. 2.2B ) arising from an apocrine gland.
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Epidermal inclusion cyst: slow-growing, firm, round lesion containing keratin; located away from the lid margin. Caused by implantation of epidermis into dermis following trauma or surgery.
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Sebaceous (pilar) cyst: may occasionally occur at the medial canthus ( Fig. 2.2C ).
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External hordeolum (stye): tender, pointing swelling in the lid margin, usually with a lash at its apex ( Fig. 2.2D ). Caused by an acute staphylococcal infection of a lash follicle.
Benign Tumours
Squamous cell papilloma
Pathogenesis:
human papilloma virus.
Diagnosis:
narrow-based pedunculated (skin tag; Fig. 2.3A ) or broad-based sessile lesion ( Fig. 2.3B ).
Treatment:
simple excision.
Basal cell papilloma (seborrhoeic keratosis)
Diagnosis:
discrete brown pedunculated or sessile lesion, often with a ‘stuck on’ appearance ( Fig. 2.3C ), in an elderly individual.
Treatment:
curettage or excision.
Actinic (solar, senile) keratosis
Predisposition:
elderly fair-skinned individuals with a history of chronic sun exposure; carries low malignant potential (squamous cell carcinoma).
Diagnosis:
hyperkeratotic plaque with a scaly surface and well-defined borders ( Fig. 2.3D ).
Treatment:
cryotherapy, or excision biopsy if there is suspicion of malignancy.
Congenital melanocytic naevus
Diagnosis:
small and of uniform colour. A rare variant is a ‘kissing’ or split naevus, that involves the upper and lower eyelid and may contain hair ( Fig. 2.4A )
Treatment:
large lesions may need surgical excision, as there is a 15% risk of late malignant transformation.
Acquired melanocytic naevus
Diagnosis:
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Intradermal naevus: nonpigmented papilloma that may show protruding lashes ( Fig. 2.4B ), in an elderly individual. The cells are confined to the dermis and have no malignant potential.
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Junctional naevus: flat brown lesion ( Fig. 2.4C ) in a young individual. The cells are located at the junction of the dermis and epidermis and they carry very low malignant potential.
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Compound naevus: raised papule with variable pigmentation ( Fig. 2.4D ), in a middle-aged individual. The cells extend from the epidermis into the dermis and have low malignant potential.
Treatment:
excision for cosmesis or suspicion of malignancy.
Capillary haemangioma (strawberry naevus)
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. Most present soon after birth with a rapid growth phase during infancy, followed by gradual involution.
Diagnosis:
raised, bright red lesion ( Fig. 2.5A ) that blanches on pressure and may swell on crying; orbital extension may be present (see Chapter 4 ).
Treatment
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Indications: (a) cosmesis, (b) severe ptosis, (c) corneal distortion that may give rise to amblyopia.
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Treatment: topical timolol or systemic propranolol (2 mg/kg/day in two divided doses).
Port-wine stain (naevus flammeus)
Definition:
congenital lesion that is usually unilateral and occasionally bilateral. In some cases, it forms a component of Sturge–Weber syndrome.
Diagnosis:
(a) sharply demarcated, soft pink patch that does not blanch with pressure ( Fig. 2.5B ), (b) darkens with age, but does not enlarge, (c) overlying skin may become hypertrophied, coarse and nodular.
Treatment:
erbium laser may decrease skin discoloration if undertaken early; photodynamic therapy. Topical imiquimod and rapamycin alone or with adjunctive laser may be considered.
Diagnosis of Sturge–Weber syndrome (encephalotrigeminal angiomatosis)
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Skin: unilateral naevus flammeus in the distribution of one or more branches of the trigeminal nerve.
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Brain: ipsilateral parietal or occipital leptomeningeal haemangioma.
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Ipsilateral ocular features: (a) glaucoma, (b) episcleral haemangioma, (c) diffuse choroidal haemangioma (see Chapter 20 ), (d) heterochromia iridis is uncommon.
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Classification: (a) trisystem involves the face, leptomeninges, and eyes, (b) bisystem disease involves the face and eyes or the face and leptomeninges.
Xanthelasma
Definition:
common, typically bilateral lesion occurring in middle-aged and elderly individuals. It is associated with increased risk of coronary heart disease. In younger patients xanthelasma may indicate hypercholesterolaemia.
Diagnosis:
white-yellow subcutaneous plaques usually located medially ( Fig. 2.6A ).
Treatment:
(a) excision, (b) laser ablation, (c) cryotherapy, (d) systemic cholesterol abnormalities should be addressed to reduce risk of recurrence.
Neurofibroma
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Plexiform: affects children with neurofibromatosis type 1 (NF1).
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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. 2.6B ).
Treatment:
solitary lesions can be excised, but removal of diffuse plexiform lesions may be difficult.
Malignant Tumours
Rare predisposing conditions
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Xeroderma pigmentosa: AR inheritance. Skin damage on exposure to sunlight. Predisposes to BCC, squamous carcinoma, melanoma. 90% have ocular or periocular involvement ( Fig. 2.7A )
Fig. 2.7
Basal cell carcinoma: (A) xeroderma pigmentosa, (B) nodular, (c) nodulo-ulcerative, (D) sclerosing.
(From Salmon JF, Kanski’s Clinical Ophthalmology: A Systematic Approach , 9th edition. Oxford, UK: Elsevier; 2020.)
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Gorlin–Goltz syndrome: AD inheritance. Extensive congenital deformities of eye, face, CNS, developing BCC in the second decade of life.
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Immunosuppression
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Other: albinism, Muir–Torre syndrome, Bazex syndrome, dysplastic naevus syndrome.
Basal cell carcinoma (BCC)
Definition:
common, slow-growing, and locally invasive but non-metastasizing tumour. 90% occur on the head and neck and 10% of these involve the eyelids; most commonly the lower.
Diagnosis
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Nodular: shiny, pearly nodule with overlying fine irregular blood vessels ( Fig. 2.7B ).
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Nodulo-ulcerative (rodent ulcer ): nodule with central ulceration and rolled telangiectatic edges ( Fig. 2.7C ).
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Sclerosing (morphoeic): indurated plaque whose margins may be impossible to delineate clinically; often associated with loss of overlying lashes. This can mimic a localized area of chronic blepharitis ( Fig. 2.7D ).
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%. Perineural spread into the orbit may occur.
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Origin: (a) de novo , (b) in pre-existing actinic keratosis or (c) from carcinoma in situ (Bowen disease). ( Fig. 2.8A )
Fig. 2.8
Squamous cell carcinoma: (A) carcinoma in situ , (B) nodular, (C) nodulo-ulcerative, (D) associated with a cutaneous horn.
( Figure 2.8B from Singh AD, Damato BE, Pe’er J, Murphree AL, Perry JD. Clinical Ophthalmic Oncology , Saunders 2007.)
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Risk factors: (a) increasing age, (b) fair skin, (c) chronic sun exposure, (d) immunosuppression (e.g. HIV, post-transplantation).
Diagnosis
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Signs: (a) nodular ( Fig. 2.8B ), (b) nodulo-ulcerative ( Fig. 2.8C ), (c) associated with a cutaneous horn ( Fig. 2.8D ). It has a predilection for the lower eyelid and the lid margin.
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Differentiation from BCC: hyperkeratosis is frequent; telangiectasis is less common and growth is usually more rapid.
Treatment
(see below).
Keratoacanthoma
Definition:
often regarded as a well-differentiated form of SCC. Risk factors include chronic sun exposure and immunosuppression.
Diagnosis
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Presentation: fast-growing, pink, dome-shaped hyperkeratotic lesion ( Fig. 2.9A ).
Fig. 2.9
Keratoacanthoma: (A) dome-shaped, hyperkeratotic lesion, (B) keratin-filled crater.
(From Salmon JF, Kanski’s Clinical Ophthalmology: A Systematic Approach , 9th edition. Oxford, UK: Elsevier; 2020.)
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Course: (a) development of a keratin-filled crater ( Fig. 2.9B ), (b) no change in size for 2 or 3 months, then (c) slow involution.
Treatment:
excision biopsy, radiotherapy or cryotherapy if less than 0.5 cm.
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
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Nodular: beware mistaken diagnosis of chalazion. Biopsy should be performed on any atypical chalazion or suspicious persistent eyelid thickening, particularly in an older individual.
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Spreading: diffuse thickening of the lid margin ( Fig. 2.10A ), which can be mistaken for chronic blepharitis.
Fig. 2.10
(A) Sebaceous gland carcinoma, (B) malignant melanoma.
(From Salmon JF, Kanski’s Clinical Ophthalmology: A Systematic Approach , 9th edition. Oxford, UK: Elsevier; 2020.)
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Pagetoid spread: extension of the tumour within the epithelium including the conjunctiva, which may be mistaken for chronic inflammation.
Malignant melanoma
Diagnosis
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Nodular: blue-black nodule ( Fig. 2.10B )
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Superficial spreading: plaque with irregular outline and variable pigmentation.
Treatment
(see below).
Principles of surgical treatment
Biopsy
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Incisional: only part of the lesion is removed to allow histological diagnosis.
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Excisional: entire lesion is removed.
Excision
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Shave excision: for shallow epithelial tumours, such as papilloma and seborrhoeic keratosis.
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Full-thickness skin excision: most small BCCs can be excised with a 2 to 4 mm clearance margin.
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Radical surgical excision: for large BCCs and aggressive malignant tumours.
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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
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Skin defects: closed directly or with a local flap or skin graft.
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Small defects: (less than one-third of lid) can be closed directly, with a lateral cantholysis if necessary ( Fig. 2.11A and B )
Fig. 2.11
(A and B) Reconstruction, showing incisions, direct closure and lateral cantholysis.
(From Salmon JF, Kanski’s Clinical Ophthalmology: A Systematic Approach , 9th edition. Oxford, UK: Elsevier; 2020.)
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Moderate defects: (up to half of lid) require a flap (e.g. Tenzel semicircular; Fig. 2.12A and B )
