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Young Ophthalmologists
Eyelid-Lesion Removal: Seven Important Pearls for the Young Ophthalmologist
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Eyelid lesions are common in everyday practice. Patients commonly present to their eye care provider complaining of a lesion growing near their eye. While many of the lesions are benign in nature, periocular malignancy is common. As such, appropriate documentation and biopsy techniques will lead to better patient outcomes and aid in further treatment, should referral to a subspecialist be required.

Nevus involving eyelid margin
Nevus involving eyelid margin. Note smooth, papillary appearance without destruction of eyelid architecture. Excess cilia actually growing through the eyelid lesion. Surgical excision would be recommended without need for margin control.
Basil cell carcinoma involving the lower eyelid margin
Basal cell carcinoma involving the lower eyelid margin. Note the cicatricial ectropion and loss of eyelid margin architecture. Incisional biopsy should be performed for diagnosis and then subsequent surgical excision with margin control.
  1. Classify the lesion: benign or malignant? It’s important to understand the basic principles to identifying eyelid lesions so that you can pursue appropriate treatment. Benign lesions commonly grow out of normal epithelium or simply displace normal structures, including eyelash follicles. When true destruction has occurred, you must consider malignancy in the differential diagnosis. Many benign lesions are uniform, smooth or papillary, while malignancy commonly exhibits ulceration, bleeding and irregularity.
  2. Decide what kind of biopsy to perform: incisional versus excisional. Typically, when a benign lesion is suspected, patients prefer elimination of the entire growth; in such cases, an excisional biopsy is recommended. Incisional biopsies are performed when malignancy is suspected; the goal of the biopsy is to sample the lesion along an edge, removing a border that includes both normal and abnormal tissue. This border sample may aid in the diagnosis provided by the pathologist.
  3. Provide photodocumentation. Taking external photographs of the lesion, its characteristics and its location provides an important referral point for the provider. These images help you assess accuracy in clinical diagnosis, compared with pathologic diagnosis, and spot a recurrence rather than a new lesion. Appropriate photodocumentation of the lesion for malignancy, also provides an important aid in treatment for the surgical dermatologists and oculoplastic surgeons.
  4. Choose the right type of anesthesia. Topical anesthesia with ointments containing lidocaine, prilocaine or other anesthetics may aid in excision, either with or without additional injectable anesthesia. Diluting injectable lidocaine (by three to four times) or adding sodium bicarbonate to lidocaine will diminish the stinging sensation with infiltration.
  5. Communicate with the pathologist. It is imperative to communicate the clinical diagnosis and any clinical characteristics important for that diagnosis with pathologists evaluating the specimen. If you name a particular clinical diagnosis, the pathologist will commonly spend extra time confirming the presence or absence of cells suggestive of that diagnosis.
  6. Review the pathologist’s diagnosis. Similar to reviewing each imaging study ordered, it is important to review each reported pathologic diagnosis. This quick check allows each practitioner to assess his/her own clinical diagnostic ability and also ensures that you agree with the pathological assessment. Gross abnormalities should be communicated to the pathologist, as errors in the lab may have occurred or the lesions may have required deeper sectioning.
  7. Report to the patient. After following up on each pathology report from the removed lesions, you should notify the patient of the result either in person or via phone call. Document the communication. If the lesion is benign, assess patient satisfaction regarding successful removal. If the lesion is malignant, you should discuss further treatment options, including potential referral to surgical dermatology (for a procedure such as Mohs surgery) or an ophthalmic plastic surgeon.

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About the author: Steven M. Couch, MD, is a board-certified oculofacial plastic and reconstructive surgeon at Washington University in St. Louis. He currently teaches there as an assistant professor of ophthalmology and visual sciences.

 
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