Eyelid lesions--all you need to know: this article provides an overview of benign and malignant eyelid lesions, with a guide to the appropriate referral action and detail of the secondary care management of these patients.
1 CET POINT
Patients with eyelid lesions commonly present in primary care, both to optometrists and general practitioners. They may arise from skin, its adnexal structures, meibomian glands and conjunctiva. Fortunately, most are benign and cause few functional issues, although their appearance may cause cosmetic concerns for some patients. Malignant lesions are also common and evidence predicts that rates will continue to rise significantly over the next few decades. (1)
Historically in the UK, excision of benign periocular lesions could be offered to patients, even where it was deemed unnecessary on clinical grounds; lesions were routinely subjected to histopathological analysis due to the small incidence of diagnostic error from macroscopic appearances. Unfortunately, NHS commissioning changes in many parts of the country in recent years has resulted in funding of benign lesion excision being withdrawn, unless it can be justified on functional grounds. Such extenuating circumstances include: foreign body sensation from ocular surface contact; visual field deficit; secondary conjunctivitis; and lesions in children if there is a potential risk of amblyopia from secondary astigmatism. These contractual changes place the onus on the primary care practitioner to make a definitive diagnosis in order to determine whether or not to refer into secondary care. An understanding of eyelid lesions has thus become a prerequisite for all optometrists so that patients with malignant lesions are referred in a timely manner and those with innocuous lesions without functional sequelae can be reassured and advised to seek treatment in the private sector or to make an application for individual funding to their local Clinical Commissioning Group (CCG) via their GP, should they wish to do so.
Vital clues as to the nature of an eyelid lesion are frequently apparent when the patient is asked the following key questions:
* How long has the lesion been present?
* Has it enlarged since onset?
* Has the lesion crusted or bled?
* If pigmented, has the colour or thickness of the lesion changed?
* Has there been any history of skin cancer in this site or elsewhere on the skin?
* Has there been a history of significant UV exposure, for example, residency in a hot climate (especially during childhood), outdoor occupation or recreational activities, use of sunbeds?
Benign lesions arising from the skin tend to remain static in size once they have developed and do not form adherent crusts or bleed with minor trauma. Significantly, those arising close to the lid margin do not destroy eyelash follicles; lashes may grow in a somewhat distorted fashion around or through the lesion. Therefore, the presence of lashes is a most reassuring sign in non-pigmented lesions.
Common benign lesions
Squamous papilloma is caused by the human papilloma virus (HPV), which has a fronded, irregular surface and may often be pedunculated and multiple due to viral spread in the local vicinity or from upper to lower lid or vice versa, so called kissing lesions.
Sebaceous keratoses are lesions whose pathophysiology is unclear; they consist of proliferations of epidermal cells resulting in a sessile, well circumscribed lesion, tan brown or black in colour which feel somewhat waxy to palpation. They remain fairly static in size and do not cause functional issues. Xanthelasmata appear as yellowish plaques of cholesterol within the skin of the eyelids. There is a strong association with systemic hyperlipidaemia in these patients. They cause no functional issues. Recurrences are not uncommon following removal, whether by surgical, laser or chemical means. Common cystic lesions of the skin include apocrine hydrocystoma (cyst of Moll) (see Figure 1) which contain sweat, and cysts of Zeis (see Figure 2), which contain sebaceous material. These lesions tend to inflate and deflate intermittently with gland activity and rarely cause functional issues.
Cysts arising from the meibomian glands cause swelling within the tarsal area (chalazia) (see Figure 3) and may in some cases be infective (hordeola). During the acute phase, which may last several weeks they may be warm, red and tender. Spontaneous resolution may be hastened with warm compresses and massage, although some chalazia may remain for months or years as visible or palpable painless nodules within the substance of the lid. Chronic blepharitis (often related to rosacea) is highly prevalent in association with meibomian gland cysts in adults.
Skin is the most common organ in which cancer arises in humans. (2) Exposure to damaging UV rays in sunlight appears to be the most significant risk factor, (3) and as a result, fair-skinned individuals tend to be at greatest risk because of the relative lack of the protective melanin pigment in their skin. (4)
Non-melanoma skin cancer (NMSC) is very common and usually curable but may cause invasion and destruction of surrounding tissues leading to disfigurement and loss of function. Melanoma is much less common than NMSC but tends to behave aggressively and may metastasize to other parts of the body with potentially fatal consequences. Basal cell carcinoma (BCC) accounts for 80-90% of eyelid malignancies, 4-10% are squamous cell carcinoma (SCC), 5% arise from sebaceous glands and 1% are melanoma. (5) With the exception of tumours arising from adnexae, there is a strong association with UV exposure. Incidence, therefore, has been demonstrated to increase with advanced age. (1) However, in recent decades the increasing prevalence of foreign travel, outdoor pursuits and the use of sunbeds has resulted in a worrying trend of progressively younger people developing skin cancers. (6) Behaviour modification in order to reduce sunlight exposure and the daily use of a high factor sunscreen is recommended, especially for those who work outdoors, are fair skinned or have a history of skin cancer. (7)
Progressive growth, usually over a period of months, is a key feature of NMSC. Eventually the lesion may begin to crust or bleed following minor trauma.
Tumours involving the eyelids are considered particularly high risk because of their ability to spread into the orbit, which may require exenteration (surgical excision of the globe and orbital contents) and may rarely be fatal. (8)
While there are numerous methods of destruction of tumour tissue, the British Association of Dermatologists (BAD) recommends surgical excision as the treatment of choice for both melanoma and NMSC.
Basal cell carcinoma
BCCs arise from the deepest layer of the epidermis. The most common subtype is nodular. Typically this has rounded, elevated margins with dilated blood vessels (telangiectasia) and often develops a central crater where crusting and bleeding may occur (see Figure 4). Occasionally, BCCs may manifest pigmentation or cyst formation, which can introduce some diagnostic difficulty. Infiltrative BCCs behave more aggressively and can often be much more extensive than they appear macroscopically. The clinical appearances tend to be more subtle and may even mimic dermatoses such as eczema. Eyelash follicles are destroyed by tumour growth and this is a very useful sign both in terms of diagnosis and determining the extent of tumour spread along the lid margin. BCCs grow contiguously and metastasis is vanishingly rare. Referral into secondary care should be made on a routine 18-week referral to treatment (RTT) pathway.
Squamous cell carcinoma
SCCs arise from the keratinising cells of the epidermis, as such they often produce keratin, which can be helpful in distinguishing it clinically from BCC.
Patients who are immunocompromised (including those receiving immunosuppression for organ transplantation) are at greater lifetime risk of developing SCC. They are generally more aggressive and can metastasize locally and systemically. In the periocular area they are of particular concern due to their ability to utilise nerve sheaths to gain access to the orbit, particularly from the supraorbital area. Referral into secondary care should be made on a two-week wait cancer pathway.
Sebaceous cell carcinoma
Sebaceous cell carcinoma can arise from meibomian glands in the tarsus, glands of Zeis in the skin or sebaceous glands in the caruncle and eyebrow. As opposed BCC and SCC, which are most prevalent in the lower lid, sebaceous cell carcinoma presents most commonly in the upper lid. It is renowned for masquerading as other conditions--in particular as blepharitis, and can, therefore, be quite advanced by the time it is correctly diagnosed. The subtarsal, forniceal and bulbar conjunctiva may be involved and while treatment is largely surgical, topical chemotherapy is often indicated due to the multifocal, non-contiguous growth pattern resulting in difficulties in obtaining clearance of the tumour by surgical means alone. Orbital spread requiring exenteration is required in 13% of patients; death from metastasis occurs in approximately 7% of cases. (9) Referral into secondary care should be made on a two-week wait cancer pathway.
Melanoma may arise de novo or within a pre-existing naevus. Individuals with pre-existing large numbers of naevi (moles) are at increased risk from melanoma, and sunburn, particularly early in life, is also a risk factor. Sinister signs in a pre-existing naevus include change in size, shape or colour; itching or bleeding of the lesion and reddening of adjacent skin. (10)
Lentigo maligna is a form of melanoma which is non-invasive, that is to say, within the epidermis only. It develops as a slowly growing patch of discolouration or freckling in sun-damaged skin rather than from existing naevi (see Figure 5). Surgical excision with wide margins is indicated due to the risk of developing into invasive melanoma. Referral into secondary care should be made on a two-week wait cancer pathway.
The vast majority of tumours can be diagnosed by clinical examination, augmented by the use of a dermatoscope or slit lamp. Where diagnostic uncertainty exists, incisional biopsy may be undertaken where a small sample of tumour tissue is sent for histopathological analysis.
This is also undertaken in patients for whom Mohs micrographic surgery is planned. It aims to obtain a representative sample of the tumour without disturbing its macroscopic appearances in order to not compromise later definitive surgery. There has historically been controversy about its use where melanoma is suspected due to concerns that it may adversely affect prognosis. (11)
Conventional excisional biopsy
In this technique, the tumour is excised with peripheral and deep margins of macroscopically normal tissue in order to clear subclinical tumour extension. A nodular BCC is usually excised with closer margins (up to 5mm) to reflect its tendency to local contiguous growth, as compared with melanoma where peripheral margins of up to 30mm may be indicated due to the propensity towards intravascular and lymphovascular spread. Histopathological processing of the specimen involves fixing the excised tissue in paraffin wax then slicing it perpendicularly from the surface to the deep margin, a technique known as 'bread slicing.' Not all of these slices will be analysed by the pathologist. An assumption is made that the slides assessed are representative and that if no tumour is detected at the margins of the slides examined, then no residual tumour remains in situ. This may, in some instances, not be the case and recurrences may still occur where there had been reported complete histopathological clearance.
Recurrences where they occur may be multifocal and a more aggressive histological subtype than the primary lesion, (5) and are, therefore, much more challenging to successfully excise. The risk of further recurrences and of the need for exenteration is also correspondingly higher. (8,12)
Mohs micrographic surgery
Mohs micrographic surgery (MMS) is a technique developed in the US for the treatment of certain types of skin cancer and is now practised in specialist centres worldwide (see Figure 6, page 68). It offers the highest chance of complete cure for basal cell carcinoma (BCC), squamous cell carcimona (SCC) and some types of cancers of skin adnexal structures. Its use in melanoma remains controversial. It differs from conventional excision because the peripheral margins of macroscopically normal tissue excised at skin level are narrower (around 2mm); and the skin incision is bevelled at 45 degrees (compared with 90 degrees in conventional excision) resulting in a tissue specimen with a smooth, rounded deep contour. The specimen can then be mounted with its entire undersurface flattened and processed in such a manner that the histopathological slides allow examination of the entire surface area of the excised tissue, thereby eliminating the potential processing errors of the conventional 'bread slicing' technique. Specialist training is required to interpret MMS histopathological slides due to the different appearances of tissue oriented in this manner. If an area of the biopsy specimen suggests that there may be residual tumour present, a further section of tissue is excised only from the area of positivity, thereby reducing, in many cases the loss of normal tissue and vital structures, particularly pertinent in the periocular location. Although this technique offers advantages of higher complete excision rates and reduced normal tissue loss, the disadvantages are that it is much more time consuming, requires specific equipment and appropriately trained specialist clinicians and technicians. It is, therefore, an expensive resource which tends to be reserved for patients with tumours which are large, recurrent, have poorly defined clinical margins, are located in anatomically high risk locations (including the periocular area) and / or manifest histological features associated with poorer outcomes.
Formal surgical repair of the area is not always necessary to restore functional integrity and provide a cosmetically acceptable outcome; the 'laissez-faire' approach, where no attempt to surgically close the defect may be acceptable for smaller defects, particularly those at the lateral canthus. The wound will usually heal within a few weeks with minimal sequelae but, used injudiciously, it may result in cicatricial ectropion (scar-induced everted eyelid) resulting in a watering eye, lagophthalmos, corneal exposure or medial canthal 'webbing.' Formal surgical reconstruction is, therefore, frequently required, utilising flaps of mobilised healthy tissue adjacent to the area of excision to repair the defect. Autologous tissue grafts (tissue from a remote site from the same patient) consisting, where appropriate, of bone, cartilage, muscle, fascia, skin, tarsus, conjunctiva or a combination of these may be utilised adjunctively or as an alternative to flaps. Damage to the proximal lacrimal outflow system occurring in patients with lesions involving the medial canthus may result in epiphora. Further surgery can be undertaken to address this once the wounds from the tumour surgery have healed. This usually involves the placement of a permanent canalicular bypass tube feeding tears from the preplical tear lake directly into the nasal cavity.
Patients rarely anticipate the scale of the post-excision surgical defect and the measures necessary to repair it and its secondary sequelae when they present with their periocular lesions. It is, therefore, advisable that the patient has the opportunity to meet their reconstructive surgeon prior to commencement of treatment in order that pre-operative counselling is undertaken and fully informed consent obtained before any treatment. In some cases where facial tumours are extensive, reconstruction may involve multidisciplinary teams of surgeons from a variety of specialties including oculoplastics, maxillofacial, ENT and plastic surgery.
The management of skin cancer in the UK is now organised within regional multidisciplinary teams (MDT) consisting of dermatologists, oncologists, pathologists, reconstructive surgeons and cancer nurses. This ensures that patients receive the highest standards of care provided by the most appropriate specialists both in the NHS and private sectors. All specialists treating skin cancers are required to report cases through their local MDT.
Eyelid lesions are common and may be benign or malignant. Benign lesions are now generally only eligible for NHS treatment in extenuating circumstances so it is important to identify lesions that may be malignant and to refer appropriately.
Patients may not always be aware or concerned about lesions arising on their skin. Eye care practitioners working close to their patients are ideally placed to detect lesions of concern, even as incidental findings where patients themselves may not have highlighted their presence. The increasing use of telephone consultations and reliance on allied health professionals for provision of healthcare in the community may ultimately mean that such lesions are less likely to be diagnosed by GPs in the future and the role of the optometrist in this aspect of patient care is likely to become increasingly important.
Under the enhanced CET rules of the GOC, MCQs for this exam appear online at www.optometry.co.uk. Please complete online by midnight on 16 December 2016. You will be unable to submit exams after this date.
CET points will be uploaded to the GOC within 10 working days. You will then need to log into your CET portfolio by clicking on 'MyGOC' on the GOC website (www.optical.org) to confirm your points.
Visit www.optometry.co.uk, and click on the 'Related CET article' title to view the article and accompanying 'references' in full.
Course code: C-52747 Deadline: 16 December 2016
General Optical Council
[check] Approved CET For Optometrists
* Be able to explain to patients about the management options for a range of eyelid lesions (Group 1.2.4)
* Be able to recognise and manage patients presenting with eyelid lesions (Group 6.1.4)
General Optical Council
[check] Approved CET For Optometrists
* Understand the natural progress and severity of different eyelid lesions (Group 1.1.1)
* Be able to identify the nature, severity and significance of different types of eyelid lesions (Group 2.1.3)
General Optical Council
[check] Approved CET For Dispensing Opticians
* Be able to explain to patients about the management options for a range of eyelid lesions (Group 1.2.4)
* Be able to recognise a range of different eyelid lesions and manage the patient accordingly (Group 8.1.1)
Julia Sen is a consultant ophthalmologist and Mohs surgeon, specialising in oculoplastic, periocular skin cancer, reconstructive and aesthetic surgery. She has a subspecialist practice in periocular skin cancer and reconstruction surgery having completed fellowships in Newcastle-upon-Tyne and Moorfields Eye Hospital. Ms Sen represents the British Oculoplastic Surgeons' Society on the NHS England Skin Cancer Commissioning Reference Group.
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|Title Annotation:||Eyelid lesions|
|Date:||Nov 1, 2016|
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