Benign Ey lid Lesions

Dr.Mohammad Khabbaz

eoculofacial plastic and reconstructive surgery

Eyelid Anatomy

-Local examination of an eyelid mass includes the following steps: Look (shape – site – extension – color – texture – loss of lashs) Feel (tempreature – tenderness – surface…..) Edge (well defined – indistinct) Consistency (hard – soft – spongy…..) Press (pulsation – fluctuation – compression) Move (mobility – fixation….) listen (bruit) for AV malformations transillumination Measure Draining group of lymph nodes Photographic documentation

Technique for Local Examination of theEyelid Mass

I. Epidermis Tumors II. Sebaceous gland TumorsIII. Sweat gland TumorsIV. Hair follicle TumorsV. Melanocytic TumorsVI. Neural TumorsVII.Vascular TumorsVIII.Cystic lesionsIX. Inflammatory lesionsX. Miscellaneous lesions

Benign Eyelid Lesions

Squamous papilloma:the most common benign eyelid lesions

middle or elderly age

slow grow

sessile or pedunculatedsolitary or multiplepigmented or siamilar to skin colorirregular surface with keratinized crust formation common

Excision or laser

Epidermis Tumors

Seborrheic Keratosis:basal cell papillomacommon

slow grow

elderly age

well circumscribed, waxy,friable ,greasy,and appear stuck to the skin round to oval, and may be multiple or pigmented

Excision or laser

Epidermis Tumors

Actinic Keratosis:solar keratosis common

slow grow

elderly age

reddish-brown scaly patches in sun exposed areas of the lids and are 3–10 mm in diameter

cryotherapy or curettageExcision for larger lesion

Epidermis Tumors

Keratoacanthoma:It recently was reclassified as alow-grade form of squamous carcinoma.

104 cases per 100,000 in the white population

rapidly grow over a period of2–6 months

elderly age

dome-shaped tumors with distinct borders and a central keratin core.

observation, to cryoapplication, to surgical resection. There have been some reports of spontaneous regression.

Epidermis Tumors

Sebaceous.G Hyperplasia and Adenoma:Hyperplasia and adenoma of the sebaceousglands(zeis ,meibomian,caruncle…)

systemic association with *Muir-Torre syndrome

any age but are more common in young adulthood.

yellowish nodule of the lid

observed, or a simple surgical excision

Sebaceous gland Tumors

*This syndrome is an autosomal dominant condition in which patients with cutaneous sebaceous tumors, basal cell carcinoma, or keratoacanthoma have a high incidence of visceral malignancy, especially colon cancer. Almost 70 % of these patients have a positive family history.

Syringoma:benign tumors of the eccrine sweat glands around the lid and adnexae

common

young females but may present at any age

yellowish small papules that are oftenmultiple and bilateral

observation,excision,Laser

Sweat gland Tumors

TrichoepitheliomaTrichofolliculoma

Trichilemmoma

Pilomatrixoma (calcifying epithelioma of Malherbe)

Hair follicle Tumors

Trichoepithelioma: benign adnexal neoplasm.

The gene involved in the familial form of trichoepithelioma is located on band 9p21

Slow grow

appearing in childhood and gradually increase in number with aging

single or multiple papules or nodules typically are observed on the lid skin and face.The lesions are round, skin-colored, firm papules or nodules that are 2–8 mm in diameter

may be associated with other cutaneous tumors

solitary lesions may be excisedlaser may be used to manage huge cluster lesions

Recurrence of a solitary trichoepithelioma is uncommon

Hair follicle Tumors

Pilomatrixoma: the commonest hair follicle proliferation

composed of islands of basophilic cells surrounding eosinophilic shadow cells

children and young adults and is more common in females

mobile purplish dermal nodule that may have a hard consistency due to calcification

Malignant change is rare

excision

Hair follicle Tumors

Melanocytic Nevus:benign tumor derived from cutaneous melanocytes.

Nevus may be either congenital or acquired. congenital nevus usually appears sometime after birth and shows a very slow growth pattern until puberty. An acquired melanocytic nevus starts developing in early adulthood and may occur anywhere over the eyelid skin.

tumors usually are brownish and thick, and they may range from flat, nonelevated lesions to large nodular pigmented growths in the eyelid margin, over the eyelid skin, or even over the eyebrow

Melanocytic Tumors

Melanocytic Nevus:In the eyelid, two very characteristic varieties have been described:

Kissing nevus, or divided nevus, is a rare form of congenital nevus

Hairy nevus is a dark-colored, often hairy patch of skin present in the periocular region at birth. It may occur along the distribution of the lacrimal drainage system; sometimes it forms a teardrop pigmentation over the periocular regionMelanocytic nevus usually is a benign condition. In very rare situations, the lesion may show a very rapid increase in pigmentation and growth in middle age, especially in sun-exposed areas; in these case, malignant conversion should be suspected

Melanocytic Tumors

Melanocytic Nevus:

Treatment is indicated for cosmesis or for concern about malignancy. Excision should be complete in most cases, with at least a 3 mm margin if melanoma is strongly suspected.

Large eyelid nevi may be a cosmetic problem and require complex and challenging rotational flaps

Melanocytic Tumors

Neurofibroma: in the eyelid and periorbital region, two forms ofpresentation usually are noted:

Plexiform neurofibroma presents as a diffuse and elongated swelling along the lateral aspect of the lid and periorbital region. It may range from a small bulkiness of the lateral upper lid to a mechanical S-shaped ptosis due to the increased weight of the lid. In severe forms, a large fold of skin may occupy the whole lateral side of the face and usually follows the course of the facial nerve trunk. These neurofibromas tend to infiltrate deeper structures, such as fascia, muscle, and bone.

Neural Tumors

Neurofibroma:Neurofibroma nodules are multiple soft lesions ranging from small maculopapular lesions to large nodules or peduncles appearing over the lids, periorbital region, and face. Similar lesions also are seen over the trunk and body. They usually are very slow growing but continue to grow throughout the patient’s life.

Neural Tumors

Neurofibroma:Treatment of the eyelid involvement is limited. The lesions do not respond to radiation therapy. Surgical treatment of ptosis is often temporary since the tumors continue to grow. In some instances, removal of a neurofibroma is necessary to relieve pain.

Neural Tumors

Congenital Capillary Hemangioma:one of the most common tumours of infancy

it is three times as common in boys as girls.

It presents shortly after birth as a unilateral, raised bright red lesion.

The lesion blanches on pressure and may swell on crying.There may be orbital extension.

The lesions are composed of a dilated capillary network resembling the surface of a strawberry, hence the name strawberry marks.

Spontaneous involution occurs in most cases; therefore, observation may be appropriate. Usually, 40 % of lesions completely involute by age 4, whereas 80 % completely involute by age 8.

Vascular Tumors

Congenital Capillary Hemangioma:Treatment is indicated principally for amblyopia secondary to induced astigmatism, anisometropia, occlusion or strabismus, and less commonly for cosmesis, optic nerve compression or exposure keratopathy.

The options are:Beta-blockers Oral propranolol is now widely used, and seems most effective in the proliferative stage

SteroidInjection of triamcinolone acetonide (1–2 ml total of 40 mg/ml over several injection sites) or betamethasone (4 mg/ml) into a cutaneous or preseptal tumour is usually effective in early lesions. Regression usually begins within 2 weeks but, if necessary, second and third injections can be given after about 2 months. It is advisable not to inject deeply into the orbit for fear of causing occlusion of the central retinal artery due to retrograde introduction of the suspension. Other complications include skin depigmentation and necrosis, fat atrophy and systemic effects such as adrenal suppression.Oral prednisone (1–2 mg/kg per day given in association with the child’s pediatrician; treatment usually is for months

Laser may be used to close blood vessels in superficial skin lesions less than 2 mm in thickness.

Interferon alfa-2a and vincristine may be used for some steroid-resistant sight-threatening lesions.

radiation

Surgical excision (for debulking; the lesion is not encapsulated, and there is a risk of recurrence )

Vascular Tumors

Nevus Flammeus(Port-Wine Stain)congenital malformation of vessels within the superficial dermis

About 10% have associated ocular or CNS involvement, including Sturge–Weber syndrome.

reddish to purplish discoloration of the skin does not blanch with pressure, most frequently located on the face. It is usually unilateral typically following the distribution of the trigeminal nerve. It usually does not cross the midline.

Different options may be tried, including freezing, surgical removal, local radiation, and tattooing.

Vascular Tumors

Eyelid Varix:consists of an abnormally distended vein, artery, or lymphatic vessel. isolated eyelid varices are rare

these lesions often enlarge on Valsalva maneuver. Patients with the orbital component of varix may present with proptosis or report visual disturbances.

These lesions are difficult to treatLigation of small sections of the varix may achieve the desired cosmetic effect and improve patient comfort.

Vascular Tumors

Cystic lesions

Cyst of Zeis is a small, non-translucent cyst on the anteriorlid margin arising from obstructed sebaceous gland

associated with the eyelash follicle

Cystic lesions

Cyst of Zeis

Cystic lesions

Cyst of Moll (apocrine hidrocystoma) is a small retentioncyst of the lid margin apocrine glands. It appears as a round,non-tender, translucent fluid-filled lesion on the anterior lid

margin

Cystic lesions

Epidermal inclusion cyst is usually caused by implantationof epidermis into the dermis following trauma or surgery. Itis a slow-growing, round, firm, superficial or subcutaneous

lesion containing keratin

Cystic lesions

Sebaceous cyst is caused by a blocked pilosebaceousfollicle and contains sebaceous secretions; the gland orifice

will often be visible. It is only rarely found on theeyelid although it may occasionally occur at the inner

canthus lesion containing keratin

Cystic lesions

Sebaceous cyst

Cystic lesions

Dermoid cyst is usually subcutaneous or deeper and istypically attached to the periosteum at the lateral end of the

brow . It is caused by skin sequestered duringembryonic development

Cystic lesions

Dermoid cyst

Cystic lesions

Traumatic hematomatous cyst

Inflammatory lesions

Pyogenic granuloma is a rapidly growing vascularized proliferation of granulation tissue that is usually antedated by surgery,trauma or infection, although some cases are idiopathic.

Inflammatory lesions

chalazion (meibomian cyst) is a sterile chronic granulomatousinflammatory lesion ( of the meibomian, or sometimes Zeis, glands caused by retained sebaceous secretions.

Miscellaneous lesions

Xanthelasma is a common, frequentlybilateral condition typically affecting middle-aged and elderly

individuals. It is a subtype of xanthoma. Hyperlipidaemia is foundin about one-third of patients

References

• Diagnostic atlas of common eyelid diseases/Jonathan J. Dutton,Gregg S. Gayre, Alan D. Proia 2007• Eyelid Tumors Clinical Diagnosis and Surgical Treatment Second Edition/Jay JustinOlder, Richard J Grostern 2003• Clinical Evaluation and Reconstruction Techniques/ Frank Nesi 2014• Kanski's Clinical Ophthalmology 8th 2016

Thank you for your attention