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23 July 2020

Eyelid lumps – who to refer

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Eyelid lumps - who to refer

Miss Susan Sarangapani FRCOphth

Consultant Oculoplastics, Lacrimal and Orbital Surgeon

AOP WEBINAR 23rd July 2020

LEARNING OBJECTIVES

• Benign vs Malignant Eyelid lesions

• Features of suspicious Eyelid lesions

• Local CCG referral guidelines

• Rapid referral pathways

AREAS FOR DISCUSSION AND REFLECTION

• Diagnostic challenges – discrepancies between signsand symptoms

• Symptomatic vs Asymptomatic Disease

• Associated ocular signs

• Key Mechanisms of Eyelid Cancers

Benign Nodules and Cysts: Chalazion

• Lipogranulomatous inflammatory lesion• Blockage of meibomian gland orifices• Stagnation of sebaceous secretions• Risk Factors – Acne Rosacea, Seborrhoeic Dermatitis, Blepharitis

Chalazion: Clinical Features

Chalazion: Treatment• Treat underlying cause

• Warm Compresses

• Steroid Injection – Triamcinolone

• Surgery - Incision & Curettage

• Systemic Tetracycline

• Systemic Antibiotics

Chalazion: Incision & CurettageLocal AnaesthesiaEyelid ClampIncise & curettage through tarsal plate

N.B RECURRENT CHALAZIA AT SAME TIME (BIOPSY AS RISK MEIBOMIAN GLAND CARCINOMA CAN MASQUERADE AS RECURRENT CHALAZIA)

Chalazion: CCG Treatment Guidelines

Benign Nodules and Cysts

• INTERNAL HORDEOLUM

• Abscess • Caused by acute Staphylococcus infection of meibomian gland

Internal Hordeolum: Clinical Features and Treatment

• Warm Compresses

• Incise & Drain

• Systemic antibiotics

Benign Nodules & Cysts

• EXTERNAL HORDEOLUM (Stye)

• Acute Staphylococcal abscess of lash follicle• Usually affects children• Multiple lesions may be present• Can lead to pre-septal cellulitis

External Hordeolum: Clinical Features and Treatment

• Warm Compresses

• Epilate infected lash

• Systemic antibiotics

Benign Nodules and Cysts

• MOLLUSCUM CONTAGIOSUM

• Pox virus• Usually affects children• Multiple lesions• Can lead to chronic conjunctivitis/ red eye

Molluscum Contagiosum: Clinical Features and Treatment

• Pale, waxy umbilicated nodule

• Curette lesions

• Systemic antibiotics

Benign Nodules and Cysts

•XANTHELASMA

•Common, frequently bilateral•Usually affects middle-aged/ elderly•Check hyperlipidaemia

Xanthelasma: Clinical Features and Treatment

• Yellow subcutaneous plaques of lipid and cholesterol

• Cosmetic Excision

Benign Nodules and Cysts

• CYST OF MOLL

• Sweat gland hidrocystoma• Small, round and non-tender• Anterior lid margin

Cyst of Moll: Clinical Features and Treatment

• Translucent/ fluid filled lesion

• Cosmetic Excision

Benign Nodules and Cysts

• CYST OF ZEIS

• Oil filled lesion• Small, round and non-tender• Anterior lid margin

Cyst of Zeis: Clinical Features and Treatment

• Oily secretion filled lesion

• Cosmetic Excision

Benign Nodules and Cysts

• SEBACEOUS CYST

• Arises from sebaceous gland• Rarely found on eyelid• May occur at medial or lateral canthus

Sebaceous Cyst: Clinical Features and Treatment

• Central punctum

• Thick “cheesy” like secretions

• Cosmetic Excision

Benign Nodules and Cysts

• MILIA

• Arises from hair follicles or sebaceous glands• Tend to occur in crops• Round superficial lesions

Milia: Clinical Features and Treatment

• Tiny white superficial cysts

• Cosmetic Excision

Benign Eyelid Lesions: CCG Treatment Guidelines

Benign Eyelid Lesions: CCG Treatment Guidelines

Benign Tumours

• SQUAMOUS CELL PAPILLOMA (Viral Wart)

• Most common benign tumour of eyelids• Usually found in adults• Pedunculated, sessile or mixed

Squamous Papilloma: Clinical Features and Treatment

• Characteristic “raspberry” like surface

• Cosmetic Excision

Benign Tumours

• BASAL CELL PAPILLOMA (Seborrhoeic Keratosis)

• Common slow growing tumour of eyelids• Usually found in elderly• Occasionally pedunculated

Basal Cell Papilloma: Clinical Features and Treatment

• Greasy brown flat lesion

• “Stuck on” appearance

• Friable, verruca like surface

Benign Tumours

• DERMATOSIS PAPULOSA NIGRA (DPN)

• Black spots in patients with pigmented skin• Occasionally pedunculated – “black skin tags”• Face, eyelid, neck, skin, back• Develop from keratin (not pigment) cells• Unknown aetiology, but some hereditary

Dermatosis Papulosa Nigra: Clinical Features and Treatment

• Cosmetic excision

• Recurrence

• Hereditary competent

Benign Tumours

• ACTINIC KERATOSIS

• *MOST COMMON PRE-MALIGNANT SKIN CONDITON*• Usually found in elderly with history of sun exposure

Actinic Keratosis: Clinical Features and Treatment

• Flat, Scaly, Hyper-keratotic lesion

• May be associated with cutaneous horn

• BIOPSY + SURGICAL EXCISION OR EFUDIX

Benign Tumours

• CUTANEOUS HORN

• Uncommon• Can be associated with underlying actinic keratosis or

squamous cell carcinoma

Cutaneous Horn: Clinical Features and Treatment

• 10% associated squamous cell carcinoma/ dysplasia in base of lesion

• BIOPSY + SURGICAL EXCISION

Benign Tumours

• PYOGENIC GRANULOMA

• Fast growing vascularised granuloma• History of surgery, trauma or infection• Can be idiopathic

Pyogenic Granuloma: Clinical Features and Treatment

• Pedunculated or sessile

• May bleed with trivial trauma

• SURGICAL EXCISION

Benign Tumours

• MELANOCYTIC NAEVUS

• 3 main types• Intradermal• Junctional • Compound

Melanocytic Naevus: Clinical Features and Treatment

• Low malignant potential

• If in doubt, biopsy +/-surgical excision

Benign Tumours

• KERATOACANTHOMA

• Uncommon but fast growing• Typically found in fair skinned individuals with history of chronic

sun exposure• More common in immune suppressed individuals following renal

transplants

Keratoacanthoma: Clinical Features and Treatment

• Usually stops growing after 2-3 months then involutes spontaneously

• CAN evolve into SCC. If in doubt, biopsy +/-surgical excision

Benign Tumours

• STRAWBERRY NAEVUS (capillary haemangioma)

• Rare. • Upper eyelid +/- orbital extension• Blanches with pressure/ swells when crying• Can cause mechanical ptosis/ lead to amblyopia

Benign Tumours

• STRAWBERRY NAEVUS (capillary haemangioma)

• Rapid growth in first year of life • Stops growing in year 2• 40% complete resolution by age 4• 70% complete resolution by age 7• Systemic associations eg Kasabach-Merritt & Maffuci Syndromes

Strawberry Naevus: Clinical Features and Treatment

• Treat only if visual development threatened

• Laser, Steroid injection, Systemic steroids, Interferon injection, surgical resection

Benign Tumours

• PORT WINE STAIN (cavernous haemangioma)

• Rare, usually unilateral subcutaneous lesion • DOES NOT blanch with pressure• Darkens with age and overlying skin hypertrophies• 30% association with ipsilateral glaucoma • 5% Sturge Weber Syndrome

Cavernous Haemangioma: Clinical Features and Treatment

• Sturge Weber Syndrome

• Glaucoma, seizures, developmental delay

• Early laser to decrease skin discolouration

Malignant Tumours

• BASAL CELL CARCINOMA (BCC)

• Most common malignancy in humans• 90% affect head and neck• Fair skin and chronic sun/ UV exposure main risk• Slow growing, locally invasive and non metastasizing• NB MEDIAL canthal BCC

Malignant Tumours

• BASAL CELL CARCINOMA (BCC)

• 3 main types• Nodular• Ulcerative• Sclerosing (morphoic)

Basal Cell Carcinoma: Clinical Features and Treatment

Nodular BCC Ulcerative BCC Sclerosing BCCNodular BCC Ulcerative BCC Sclerosing BCC

Malignant Tumours

• SQUAMOUS CELL CARCINOMA (SCC)

• Less common but more aggressive than BCC• Eventually metastasizes to regional lymph nodes• Perineural spread to intracranial cavity• Fast growing

Malignant Tumours

• SQUAMOUS CELL CARCINOMA (SCC)

• 3 main types• Nodular• Ulcerative• Plaque like

Squamous Cell Carcinoma: Clinical Features and Treatment

Nodular SCC Ulcerative SCC Plaque SCC

Sebaceous Gland Carcinoma: Clinical Features and Treatment

• Rare, slow growing

• Can be difficult to diagnose in early stages

• BIOPSY

Melanoma: Clinical Features and Treatment• Potentially lethal

• ½ of eyelid melanomas are non-pigmented

• Nodular, superficial spreading, arising from lentigo maligna

• BIOPSY

Merkel Cell Gland Carcinoma: Clinical Features and Treatment

• Rare, fast growing

• HIGHLY MALIGNANT

• Can be difficult to diagnose in early stages

• > ½ have mets at presentation

Thank you

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