lids: lumps & bumps

define lesion 

any damage or abnormal change in tissue 

state and describe the different lesions we will be looking at (3)

• benign lesions - no harmful effect; may be unsightly 

• malignant lesions - infectious, growth, cancerous

• pre malignant lesions - may become malignant

• sn: Many eyelid lesions - most are innocent and innocuous (not harmful) - occasionally find a suspicious lesion - need to recognise it’s abnormal and refer 

state the common benign lesions of the eye (4:3:3) 

MUST know:

• Xanthelasma

• Papilloma - squamous cell papilloma and basal cell papilloma 

• Retention cysts

• Milia

SHOULD know:

• Skin tags

• Haemangioma

• Port-wine stain

EXTRA:

• Dermatitis Papulosa Nigra

• Naevi 

• Cutaneous horn (not always benign - can be pre malignant) 

describe the signs/appearance of Xanthelasma  (3)

• Soft yellowish plaques, variable size

• Usually medial upper and lower eyelids, often bilateral

• Lipid & cholesterol deposits (50% associated with elevated serum lipid levels)

describe the appearance/signs of squamous cell papilloma (6)

• Also known as viral wart

• Human papilloma virus (HPV)

• Common in adults

• Sessile (larger immobile piece) or pedunculated (attached via a stalk)

• Histopathology: excessive convoluted epithelium with central fibrovascular core

• Described as looking like raspberries under magnification

• can be cosmetically removed - reassure patient 

describe the appearance/signs of basal cell papilloma (7)

• Also known as seborrheic keratosis or seborrheic wart

• Very common (90% > 60 yrs)

• Benign, harmless skin growth – build up of skin cells

• Smooth, waxy or warty surface

• Slow growing, not painful or tender

• Flat or raised plaque

• Skin coloured, yellow, grey, light brown, dark brown or mixed colours

describe the appearance/signs of dermatisis papulosa nigra (4) MF

•Multiple small diameter black or dark brown papules - face and neck

•Dark skin colour

•Incidence and number increase with age

•Papules are identical to small seborrheic keratoses

describe the appearance/signs of skin tags (6)

• most common bengin lesion 

• Small, soft, skin coloured growth

• Variable size, shape, colour and number

• Cause unclear - clusters of collagen and blood vessels surrounded by skin / associated with friction when skin rubs together

• can be found on other parts of the body (neck, groin and armpits)

• harmless but secondary treatment can be: freezing, strangulation (ligature), snipping and cauterisation

describe the appearance/signs of the different retention cysts (4)

• Small, round, non-tender cysts - blocked glands 

• Cyst of Zeis - white cheesy (sebaceous) material - occurs on eyelid margin 

• Sebaceous cyst - similar to a cyst of Zeis - can occur anywhere on the skin 

• Cyst of Moll - clear, fluid filled, partially translucent - occurs on eyelid margin 

describe the appearance/signs of Milia (4)

• Tiny superficial white/yellow dome-shaped cysts

• usually multiple - nose, chin & cheeks

• Any age - common in new born babies (40%) - and resolves as the baby grows

• Trapped keratin - near the surface of the skin, derived from hair follicles

describe the appearance/signs of naevi (5)

• Congenital (skin coloured markings which develop before or shortly after birth) OR acquired (benign developmental skin lesions that develop later in life) 

• Pigmented or non-pigmented - may become more pigmented post puberty

• Flat or slightly raised

• +/- hairs, warty surface - can be smooth 

• Malignant transformation is rare

describe the appearance/signs of naevus flammeus (6)

• Port-wine stain - flat red/purple mark on skin 

• Vascular malformation (capillaries under the skin remain dilated) - abnormal development of blood vessels

• Present at birth - may become more prominent with time - about 3 in 1000 children (3F:1M) - refer children for assessment of associations

• 65% on head and neck 

• be aware that - Sturge-Weber syndrome (~8%)* & Glaucoma (~10%)*

• laser treatment is available for cosmetic removal 

describe the appearance/signs of capillary haemangioma (5)

• Strawberry naevus: evident in neonatal period - usually a few weeks after a birth but can be born with them

• Grows in first year then usually regresses by 5yrs

• May be cutaneous, orbital or mixed

• Systemic associations - worth being investigated and aware of but can reassure parents it is harmful

• can occur on upper lid - causing droopy lids - may drop visual axis and affect visual development - press on cornea - rare ! 

explain what the general management/treatment of bengin lesions are (4)

• Monitor & reassure

• consider referral for exclusion of underlying cause - if in doubt refe

• refer if problematical - urgent pathway 2 weeks in NHS for suspiscious lesions 

• Cosmetic excision (60% recur)

state the names of the premalignant lesions to know (2:1)

SHOULD know:

• Actinic Keratosis

• Keratoacanthoma

EXTRA:

• cutaneous horn 

describe the signs/appearance of actinic (solar) keratosis (5)

• Flat scaly lesions, rough skin - multiple 

• Red, pink, brown or skin coloured

• Older age, h/o sun exposure

• May give rise to squamous cell carcinoma

• Occasionally papillomatous or cutaneous horn

treatment/management of actinic (solar) keratosis (3)

• biopsy - sample of it removed to be tested 

• excision

• cautery - burn the skin or flesh of (a wound) with a heated instrument or caustic substance in order to stop bleeding or to prevent infection

describe the signs/appearance of cutaneous horn (4)

•Keratin projection

•Arise from benign, premalignant and malignant lesions

•10% associated with squamous cell carcinoma

•Base is the point of interest - prompt referral to be removed and sent of for biopsy to see for malignancy 

describe signs/appearance of Keratoacanthoma (5)

• Rapidly enlarges (months)

• Regresses or evolves into squamous cell carcinoma - be aware and prompt referral (2 weeks)

• Volcano shaped with keratin plug

• Visually, often difficult to distinguish from BBC or SCC

• Histopathology - arises from hair follicle skin cells

state the malignant lesions to know (1:2:3)

SHOULD know:

• Basal cell carcinoma

good to know:

• Squamous cell carcinoma

• malignant melanoma

EXTRA:

• Sebaceous gland carcinoma

• Kaposi’s sarcoma

• Merkel cell carcinoma

describe the signs/appearance of basal cell carcinoma (5)

• Most common periocular (around the eye/on eyelids) malignancy

• Slow growing, painless, often ulcerated

• Do not metastasise (spread through body) but invade locally

• Change in lid contour/lash redirection or loss - lower lid is most common site

• later cases sometimes pigmented 

state the 3 types of basal cell carcinoma

• Nodular - hard nodule, pearly appearance, abnormal (telangiectatic) vessels

• Ulcerative - as nodular but with raised rolled border surrounding a central ulcer, may bleed

• Sclerosing - flat hardened plaque of thickened skin without surface vascularisation, ill-defined border making it difficult to determine area of involvement

explain the management of BCC (3:2)

Optometric management

• Urgent referral

• Low risk skin cancer

• Photographic documentation

Secondary care

• Surgery

• Histology

describe signs/appearance of squamous cell carcinoma (SCC) (4) 

• May evoke inflammatory response

• symptomatic unlike BCC  - patient concern about lesion, may irritate or itch, may bleed

• Can look similar to BCC but more aggressive

• More likely to metastasise (spread via blood) than BCC

explain management/treatment of SCC (3:2)

Optometric management:

• Urgent referral

• Photographic documentation

Secondary care:

• Surgery

• Histology

describe signs/appearance of malignant melanoma (4)

•Very rare (of the eyelid)

•Can arise de novo or as a malignant transformation of a naevus

•Signs include itching, bleeding, pigmentary changes, increase in size

•50% are non-pigmented

examples of other malignant lesions - extra

how do we distinguish between benign or malignant lesions

• from patient history taking 

• asking key questions 

state risk factors for malignancy (8)

•Prior skin cancer

•FH: skin cancer

•Previous radiation exposure (excessive UV)

•Fair skin

•Older patients

•Acute (suddenly appeared)  > chronic onset

•Increasing in size

•Bleeding/crusting

state some examples of key questions we can ask patients (6)

•How long has the lesion been present?

•Has it enlarged since onset?

•Has the lesion crusted or bled?

•Has the colour changed?

•Any history of skin cancer?

•Any history of significant UV exposure (e.g. lived in a hot climate, outdoor occupation, use of sunbeds)

visual signs of malignant vs benign

Suspicious signs of malignancy	More reassuring signs (benign)
New	Long standing
Increasing in size	Remain static in size
Surface ulceration/induration	Smooth surface - benign do not ulcerate
Neovascularisation - new blood vessels in and around the lesion, bleeding	Does not bleed with minor trauma
Crusts	Doesn’t form adherent crusts
Lid margin changes - destruction of margin, loss of lashes	Does not destroy eyelash follicles (may distort them)
Recurrent infection/inflammation

what i need to know

	Must know	Should know	Good to know
I:   Lumps & Bumps	Common benign lesions Xanthelasma Papilloma Retention cysts Milia Basal cell carcinoma Signs of malignancy	Other benign lesions Skin tags Haemangioma Port-wine stain Premalignant lesions Actinic keratosis Keratoacanthoma	Other malignancies Squamous cell carcinoma Sebaceous gland carcinoma Malignant Melanoma Kaposi’s sarcoma Merkel cell carcinoma
II: Eyelid Infection & Inflammation	Ectropion Entropion Acquired Ptosis Trichiasis	Blepharospasm Twitch Lagophthalmos Floppy eyelid syndrome	Madorosis & Poliosis Lash infestations
III: Positional Abn & Eyelash Disorders	Blepharitis Hordeolum Chalazion	Molluscum contagiosum Herpes zoster ophthalmicus	Impetigo Herpes simplex