Eyelid Lumps and Bumps Acquired Tumors and Cysts with non-infectious etiology

Eyelid Lumps and BumpsEyelid Lumps and BumpsAcquired Tumors and Cysts with non-infectious etiology

Benign TumorsBenign TumorsActinic Keratosis

◦ What is it? Slow growing keratinization of the epithelium Results from excessive sun exposure Pre-malignant: may transform into squamous cell

carcinoma

◦ Appearance Rough, dry, and scaly plaque that is flat or slightly raised Up to 2.5 cm diameter individually Often multiple lesions in a single area that coalesce Distinct boarders May be skin colored to dark brown

◦ Who gets it? Elderly individuals with lightly pigmented skin Rarely develops on the eyelid Common on the scalp, ears, forehead, and backs of

hands The patient may notice itching or burning of the lesion

Benign TumorsBenign TumorsActinic Keratosis

◦ Management Biopsy for definitive diagnosis Usually frozen (cryotherapy) or excised

Benign TumorsBenign TumorsSquamous Cell Papilloma

◦ What is it? Outgrowth of fibrovascular connective tissue Covered by irregular keratinized stratified squamous

epithelium

◦ Appearance Variable presentations “Skin tag” type: narrow base, pedunculated, skin

colored Board base with “raspberry like” appearance May be difficult to differentiate from viral wart (human

papillomavirus)

◦ Who gets it? No predilection to race or gender

◦ Management Removed by excision

Benign TumorsBenign TumorsSquamous Cell Papilloma

Benign TumorsBenign Tumors Basal Cell Papilloma

◦ What is it? Expansion of the squamous epithelium stemming from basal cell

proliferation Slow growing lesion

◦ Appearance Round “coin-like” lesion with “stuck-on” appearance Up to 2.5 cm diameter Slightly raised and crusty: often keratinized similar to actinic

keratosis Tan to dark brown in color Variety of textures: granular to velvety

◦ Who gets it? Common in the elderly Most people develop at least one during their lives Usually develop on the head, neck, or trunk

◦ Management No treatment required except for cosmetic reasons or if they become

irritated Removed by excision

Benign TumorsBenign TumorsBasal Cell Papilloma

Benign TumorsBenign Tumors Inverted Follicular Keratosis

◦ What is it? Rare and often rapid growing lesion arising from a hair follicle Histologically similar to basal cell papilloma, but with

deeper extension into the dermis

◦ Appearance Non pigmented papilloma at the lid margin Up to 1 cm diameter

◦ Who gets it? Typically older males

◦ Management Deep excision Recurrence is common if not completely removed

Benign TumorsBenign Tumors Inverted Follicular Keratosis

Benign TumorsBenign TumorsKeratoacanthoma

◦ What is it? Rare and rapidly growing variant of actinic keratosis Also pre-malignant, potentially transforming into squamous

cell carcinoma

◦ Appearance Initially appears as a pink hyperkeratotic lesion usually on the lower lid After a period of rapid growth, remains stable for several

months Then begins to involute and a keratin filled crater often forms Complete involution can occur after a year leaving a residual

scar

◦ Who gets it? Same demographic as actinic keratosis Higher occurrence in patients on immunosuppressive therapy

following kidney transplants

◦ Management Usually excised Occasionally treated with cryotherapy or radiotherapy

Benign TumorsBenign TumorsKeratoacanthoma

Benign TumorsBenign Tumors Melanocytic Nevus

◦ What is it? Tumor composed of cells derived from either epidermal or dermal

melanocytes Acquired and congenital forms Generally low to no malignant potential

◦ Appearance Junctional: Uniform brown macule or plaque Compound: Uniform, light to dark brown, raised papule Intradermal: Papillomatous with little to no pigment. Associated with

dilated vessels and protruding lashes

◦ Who gets it? Junctional type occurs in the young Compound type occurs in middle age Intradermal type most common overall and occurs in the elderly

◦ Management Removal for cosmetic reasons or if malignancy is suspected Excision may need to be followed by reconstruction depending on

location and size

Benign TumorsBenign TumorsMelanocytic Nevus

Junctional Nevus

Compound Nevus

Intradermal Nevus

Benign TumorsBenign Tumors Xanthelasma

◦ What is it? Aggregation of lipid filled macrophages at the level of the dermis Common and frequently bilateral

◦ Appearance Yellowish subcutaneous plaque Usually on the medial portion of the eyelids Often multiple

◦ Who gets it? Middle aged and the elderly May be associated with elevated cholesterol especially when

occurring in younger individuals and with corneal arcus

◦ Management Removed for cosmetic reasons Usually treated with carbon dioxide or argon laser May be excised Recurrence suggests persistently elevated cholesterol

Benign TumorsBenign TumorsXanthelasma

Benign TumorsBenign TumorsPilomatricoma

◦ What is it? Abnormal proliferation of the germinal matrix cells in a hair

follicle Frequently becomes calcified

◦ Appearance Deep nodule Becomes hard if calcified

◦ Who gets it? Common in young females

◦ Management Excision

Benign TumorsBenign TumorsPilomatricoma

Benign TumorsBenign TumorsNeurofibroma

◦ What is it? Abnormal proliferation of Schwann cells, fibroblasts, and axons

◦ Appearance Characteristic S shaped lesion Typically located on the upper lid

◦ Who gets it? Solitary lesions occur in adults 25% associated with neurofibromatosis-1 Children with neurofibromatosis-1 are affected by diffuse

lesions

◦ Management Solitary lesions removed by excision Diffuse lesions are more difficult to remove

Benign TumorsBenign TumorsNeurofibroma

Malignant TumorsMalignant TumorsBasal Cell Carcinoma

◦ What is it? Locally invasive proliferation of pluripotent epidermal basal cells Most common human malignancy and most common eyelid

malignancy Slow growing with no metastatic potential

◦ Appearance Usually on the lower eyelid Non-tender ulceration Irregular boarders Possible keratinization Destruction of eyelid architecture Nodular type: pearl like appearance with dilated blood vessels on

surface Noduloulcerative type: central ulcer with raised pearly edges Sclerosing type: lateral, hardened, infiltration beneath the

epidermis. May be confused with chronic blepharitis


◦ Who gets it? Common in the elderly Risk factors include fair skin and high cumulative sun exposure

◦ Management Diagnosis confirmed with biopsy Excision is the common removal technique Mohs micrographic surgery removes the tumor along with a

thin layer of surrounding tissue. The surround is immediately examined for tumor cells and the procedure repeated if any are found. Highest cure rate at 98%.

Recurring tumors tend to be more invasive and difficult to treat


Nodular Ulcerative

Sclerosing

Malignant TumorsMalignant TumorsSquamous Cell Carcinoma

◦ What is it? Proliferation of invasive cells arising from the squamous cell layer

of the epidermis Can arise de novo or from existing actinic keratosis or

keratoacanthoma Less common, but more aggressive than basal cell carcinoma Lymph node metastasis in 20% of cases

◦ Appearance Variety of appearances and may be difficult to distinguish from

BCC Scaly with irregular boarders Absence of surface vasculature Extensive keratinization usually present Lesions may bleed Nodular type: keratinized nodule that develops erosions and

fissures Ulcerating type: everted boarders with a red, well defined base Cutaneous horn: invasive growth underlies keratin horn


◦ Who gets it? Most common occurrence is in the elderly Risk factors include fair skin, sun exposure, and immune

suppression

◦ Management Can be fatal if left untreated (2,500 annual deaths in USA) Confirmed with biopsy Mohs micrographic surgery: highest cure rate 94-99% Other options include standard scalpel excision, cryotherapy,

and radiotherapy


Nodular Ulcerative

Cutaneous horn Large ulcerative

Malignant TumorsMalignant TumorsSebaceous Gland Carcinoma

◦ What is it? Slow growing tumor Arises from the meibomian glands, glands of Zeis, or

sebaceous glands in the caruncle More likely to occur on the upper lid where glands are more

numerous

◦ Appearance No pathognomonic presentation Initially can appear similar to chalazion or chronic blepharitis Yellowish material may be seen within the tumor Nodular type: hard, painless, immobile nodule similar to

chalazion Spreading type: thickened lid margin, loss of lashes, similar to

chronic blepharitis


◦ Who gets it? Females in their 60's and 70's most commonly affected Youngest reported case was in a 3 year old

◦ Management Because of appearance, diagnosis is often delayed Mortality rate is 5-10% Large (1cm) and non-resolving chalazion should be suspected Cryotherapy and surgical excision are the standard treatments Recurrence is as high as 33% Little documentation for Mohs, but possibly lower recurrence

rate


Nodular Spreading

Conjunctival involvement

Malignant TumorsMalignant TumorsMelanoma

◦ What is it? Epidermal and dermal proliferation of transformed and invasive

melanocytes Arises from existing nevus, lentigo maligna (pre-malignancy), or

de novo High potential for metastasis Potentially fatal (represents greater than 2/3 of all skin cancer

deaths)

◦ Appearance Rarely develops on the eyelid (1% of all eyelid lesions) Half of those that do are non-pigmented Asymmetric plaque or nodule Irregular and indistinct boarders Variable colors in the lesion (blue and black) Diameter larger than ~6mm Associated with destruction of local anatomy and loss of lashes


◦ Who gets it? Most common in elderly individuals with light skin History of sun damaged skin

◦ Management Question any new, changing, or irregular appearing lesions Melanoma confirmed with biopsy Wide surgical excision with up to a 1 cm margin for confirmed

malignancy Local lymph node dissection if malignancy is more than 1.5

mm deep Prognosis and recurrence is tied to size and any metastasis of

original lesion Patients should be followed closely following surgery


Malignant TumorsMalignant TumorsMerkel Cell Carcinoma

◦ What is it? Very rare and fast growing form of skin cancer Highly malignant and potentially fatal Arises from Merkel cells located in the basal layer of the

epidermis Normal cells thought to play a regulatory role in epidermal

growth

◦ Appearance Frequently involves the upper eyelid Red, purple, or violet colored, well defined nodule Wide variation in size, from less that 2cm to larger than 15cm Overlying skin is intact


◦ Who gets it? Average age of diagnosis is 75 20x more likely to occur in whites than blacks No gender predilection Risk factors include sun exposure and immune suppression

◦ Management Many have metastasized by the time they are diagnosed CT and/or MRI imaging used to evaluate systemic spread Primary tumor removed with a wide excision (margins up to

3cm if possible) Chemotherapy and/or radiotherapy depending on spread 2 year mortality rate of 30-50%


CystsCystsChalazion

◦ What is it? AKA meibomian cyst Fatty secretions of a meibomian gland are retained Causes a chronic, painless inflammation Patients with rosacea or meibomian gland dysfunction are

more prone to developing multiple and recurrent chalazion

◦ Appearance Nodule that has enlarged gradually May enlarge up to nearly 1 cm If large enough, may induce astigmatism by pressing on the

cornea

CystsCystsChalazion

◦ Treatment About one third drain and resolve spontaneously Standard therapy aimed at stimulating and speeding draining by

using warm compress and massage Steroid injection through the palpebral conjunctiva

0.1-0.2 ml Kenalog (triamcinolone) 80% success rate May cause local depigmentation of the skin

Oral tetracycline/doxycycline useful in patients with chronic lid inflammation Do not use in children or pregnant/nursing women! 250mg PO qid tetracycline 100mg PO bid doxycycline 1-2 week course

Incision and drainage through the palpebral conjunctiva and tarsal plate

Biopsy a recurrent chalazion - it may be sebaceous cell carcinoma

CystsCystsCyst of Zeis

◦ What is it? Variation of chalazion Non-translucent retention cyst involving the anterior lid

margin Gland of Zeis produces oil for eye lashes

CystsCystsCyst of Moll

◦ What is it? Variation of chalazion AKA Sudoriferous cyst Translucent retention cyst involving the anterior lid margin Variation of chalazion Gland of Moll is a modified sweat gland also emptying to the

lashes

CystsCystsEpidermoid Cyst

◦ What is it? AKA sebaceous cyst Cyst lined by stratified squamous epithelium and containing

keratin and sebaceous material Result from ingrowth of surface epidermis after trauma or

surgery

◦ Appearance Round, well defined, non-tender mass Ruptured cysts cause an acute inflammatory response and

possible secondary infection

◦ Treatment Complete surgical excision

CystsCystsEccrine Hidrocystoma

◦ What is it? Rare cyst that forms from retained sweat in a blocked and

dilated sweat duct More common in females

◦ Appearance Similar to Cyst of Moll with the exception that it does not

involve the lid margin Painless and usually asymptomatic May grow up to 6mm

◦ Treatment Monitor or needle puncture if desired

CystsCystsSyringoma

◦ What is it? Benign and asymptomatic proliferation of sweat gland duct

epithelium Relatively common Most common in adult females

◦ Appearance Multiple small (3mm or less) papules May be skin color or yellowish

◦ Treatment Removed for cosmetic reasons only No set recommended removal technique Options include excision, cryotherapy, dermabrasion,

electrocautery and more

CystsCystsMilia

◦ What is it? Tiny epidermoid cysts that tend to occur in clusters Result from a blocked vellus hair follicles that retain the

keratin Very common – occurs in half of all infants May also occur following dermabrasion or damage to the

follicle

◦ Appearance Small pearly white to yellowish papules

◦ Treatment No treatment necessary Needle puncture and expression may be performed if desired

ResourcesResources Kanski, Jack J. Clinical Ophthalmology a Systemic Approach. 6th ed. Edinburgh, UK:

Elsevier, 2007.

http://www.mayoclinic.com/health/actinic-keratosis/DS00568

http://www.consultantlive.com/photoclinic/article/10162/1265743

http://www.skincancer.org/Basal-Cell-Carcinoma/

http://www.skincancer.org/squamous-cell-carcinoma.html

http://emedicine.medscape.com/article/1101433-overview



http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1781304/



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Eyelid Lumps and Bumps Acquired Tumors and Cysts with non-infectious etiology